HomeMy WebLinkAbout_4130 Horizon DocsHAZARDOUS MATERIALS BUSINESS PLAN CERTIFICATION FORM
For Use by Unidocs Member Agencies or where approved by your Local Jurisdiction
Authority Cited: Health and Safety Code $25503.3(c); tS CCR $2729.5(c)
To: Agency Name: CUPA for San Luis Obispo County and City
Agency Mailing Address: PO Box 1489 San Luis Obispo, 943406
FAX 805-781-4211
Pursuant to Section 25503.3(c) of California Health and Safety Code (HSC), the Hazardous Materials
Business Plan (HMBP) certification described below is hereby submitted for the following facility:
Facility Name:-\
FacilityStreetAddress: QtjO I4Ofl-17;61J t-^j . q. {3 City:
Date of Current HMBP: 17
I certiff that: (Check the appropriate box.)
F I have personally reviewed the Hazardous Materials Business Plan currently on file with your agency and
certiSr that the HMBP is complete and accurate. (See bottom of page for details.) If this facility is subject
to Federal Emergency Planning and Community Right to Know Act (EPCRA) reporting requirements, I
have submitted the following documents with this Certification Form: Unified Program Consolidated Form
(UPCF) Business Activities page; UPCF Business Owner/Operator Identification page with current
signature and date; Hazardous Materials Inventory Statement page(s) with an original signature, photocopy
of an original signature, or signature stamp on each page for all Extremely Hazardous Substances (EHS)
handled at or above their Federal Threshold Planning Quantity (TPQ) or 500 pounds, whichever is less.
or
n Revisions to the Hazardous Materials Business Plan are necessary. The HMBP as revised is complete and
accurate and is being implemented. A copy of the revisions has been electronically submitted or is
enclosed with this Certification along with a signed UPCF Business Owner/Operator Identification page
and UPCF Business Activities page if the HMBP revision include changes to the Hazardous Materials
Inventory Statement.
OWNER/OPERATOR CERTIFICATION: I hereby certify under penalty of law that, based upon my
inquiry of those individuals responsible for obtaining the information reported aboveo I believe that the
submitted information is trueo accurate, and cornplete. I understand that a revised HMBP xn'.rst be
submitted within 30 days of any change in this facility's storage or handling of hazardous materials that
would require updating of the HMBP.
Name of Owner/Operator (Print)Title: GP1
Signature Date: 7
>
The information contained in the HMBP most recently submitted is complete, accurate, and up-to-date; and
There has been no change in the quantity of any hazardous material as reported in the most recently submitted Hazardous Materials
Inventory forms; and
The facility has not begun handling any hazardous material in a HMBP reportable quantity that is not currently listed in the
Hazardous Materials Inventory; and
The most recently submitted HMBP contains the information required by Section 11022 of Title 42 of the United States Code; and
By checking the upper box on this form, you are certifiiing that:
There have been no substantial revision ofthe currentin the that would
uN-039 - 1/1 www.unidocs.org \"\l\[Rev.10/09/07
County of San Luis Obispo . Public Health Department
Environmental Health Services Division
2156 Sierra Way. P.O. Box 1489
San Luis Obispo, California 93406
805-781 -5544 . F AX 805-781 -421 I
Jeff Hamm
Health Agency Director
Penny Borenstein, M.D., M.P.H.
County Health Officer
Public Health Department Director
o,,",,:::1":;f::';ii:;8,';!;f ;
Annual Hazardous Materials Inventory/Business Plan Gertification due 2-26-2010
Who is required to provide the Gertification Form on the back of this paqe?r Businesses who have not been inspected by the Certified Unified Program Agency (CUPA) in 2009. The CUpAis comprised of San Luis Obispo County Environmental Health Services and the San Luis Obispo City Fire
Department.. Businesses who have not provided a new complete or updated Hazardous Materials Business plan to the
CUPA in 2009.
How do I proceed if my Hazardous Materials inventory or Business Plan has not chanqed?. Check the first box on the Certification Form. Fill out the Form. Mail, fax or e-mail the Form to us anO youte Oone.
Keep a copy on site.
How do I proceed if my Hazardous Materials inventory or Business Plan has chanqed?. Check the second box on the Certification Form. Fill out the Form.. Provide updated hazardous materials business plan forms (ldentification Page, lnventory,,site plan) and the
certification Form. Mail, fax or e-mailthe Forms to us. Keep a copy on site.
How do I obtain Hazardous Materials inventory or Business Plan forms?. Download the forms online at http://www.slocounty.ca.gov/health/publichealth/ehs/HazMat.htm. Request a hazardous materials business plan packet to be mailed to you:o Call 805-781-5544 for facilities within the County.o Call 805-783-7774 for facilities within the Gity of San Luis Obispo.
Where do I send the required forms?o All Forms can_b_e e-mailed to crattigan@co.slo.ca.us, faxed to 805-781-4211, or mailed with invoice payment to
P.O. Box 1489 San Luis Obispo, CA 93406
When are forms due?. February 26,2010
Who can I callwith questions regarding Form completion?o The Hazardous Materials lnspector for your facility within the County. Call 805-781-bS44.o The Hazardous Materials lnspector for your facility within the City of San Luis Obispo. Call 805-781-2383
' I '"-j'
HAZARDOUS MATERIALS BUSINESS PLAN CERTIFICATION FORM
For Use by Unidocs Member Agencies or where approved by your Local Jurisdiction
Authority Cited: Health ond Safety Code $25503.3(c); 19 CCR $2729.5(c)
To: Agency Name: San Luis Obispo GounW Environmental Health Services
Agency Mailing Address: PO Box 1489 San Luis Obispo,943406
FAX 805-7814211
Pursuant to Section 25503.3(c) of California Health and Safefy Code (IISC), the Hazardous Materials
Business Plan (HMBP) certification described below is hereby submitted for the following facility:
Facility Name: 5l: p Lu,,\ 1 ,zA t^-r r'\r ) [ lst )( t1
Facility Street Address: Ll l tr C l-\CXa\ ? ( )r-City tA/i L.ur c--, Orir('rr)
Date of Current HMBP:lL /r> c,
I certiff that: (Check the appropriate box.)
I have personally reviewed the Hazardous Materials Business Plan currently on file with your agency and
certiff that the HMBP is complete and accurate. (See bottom of page for details.) If this facility is subject
to Federal Emergency Planning and Community Right to Know Act (EPCRA) reporting requirements, I
have submitted the following documents with this Certification Form: Unified Program Consolidated Form
(UPCF) Business Activities page; UPCF Business Owner/Operator Identification page with current
signature and date; Hazardous Materials Inventory Statement page(s) with an original signature, photocopy
of an original signature, or signature stamp on each page for all Extremely Hazardous Substances (EHS)
handled at or above their Federal Threshold Planning Quantity (TPQ) or 500 pounds, whichever is less.
or
Revisions to the Hazardous Materials Business Plan are necessary. The HMBP as revised is complete and
accurate and is being implemented. A copy of the revisions has been electronically submitted or is
enclosed with this Certification along with a signed UPCF Business Owner/Operator Identification page
and UPCF Business Activities page if the HMBP revision include changes to the Hazardous Materials
Inventory Statement.
OWNER/OPERATOR CERTIFICATION: I hereby certify under penalty of law that, based upon my
inquiry of those individuals responsible for obtaining the information reported above, I believe that the
submitted information is true, accurate, and complete. I understand that a revised HMBP must be
submitted within 30 days of any change in this facility's storage or handling of hazardous materials that
would require updating of the HMBP.
(Print):Vftt-:rlf I l(C( \C/J Title: llGrlSrr)t.,Jf ) 1ta C
\ 1r)
Name of Owner/Operator
Phone: SL{j ZU7- L Signature:v?>. /,&
-Date
6I2_LJ
By checking the upper box on this form, you are certiffing that:
. The information contained in the HMBP most recently submitted is complete, accurate, and up-to-date; and
. There has been no change in the quantity of any hazardous material as reported in the most recently submitted Hazardous Materials
Inventory forms; and. The facility has not begun handling any hazardous material in a HMBP reportable quantity that is not currently listed in the
Hazardous Materials Inventory; and. The most recently submitted HMBP contains the information required by Section I1022 of Title 42 of the United States Code; and
. There have been no substantial revision of the current HMBPin the S that would
LJN-039 - l/l www.unidocs.org Rev. 10/09/07
County of San Luis Obispo . Public Health Department
Environmental Health Services Division
2156 Sierra Way. P.O. Box 1489
San Luis Obispo, California 93406
805-781-5544 . FAX 805-781-4211
Jeff Hamm
Health Agency Director
Gregory W. Thomas, M.D., M.P.H.
County Health Officer
Public Health Depaftment Director
,,,""3i,!i'ri,ffj',f !;Eifr !;f ;
Annual Hazardous Materials lnventory/Business Plan Certification due 12-31-OT
Pursuant to California Health and Safety Code Section 25503.3(c), your hazardous materials
inventory/Business Plan is required to be certified as accurate and submitted to this Agency annually.
The California Environmental Protection Agency has directed our Agency to collect this information
from applicable businesses within San Luis Obispo County.
Businesses that comply with this requirement help to ensure the safety of firefighters and emergency
responders by confirming the accuracy of the hazardous materials inventory and business plan. We
process this information and then provide the data to fire departments within the County.
Who is required to provid e the Certification Form on the back of this paqe?
Businesses who have not been inspected by our Agency in 2007.
Businesses who have not provided a complete or updated Hazardous Materials Business Plan to our Agency in
2007.
When is this Certification Form due to be provided to this Agency?. By December 31,2007
How do I proceed if my inventorv or Business Plan has not changed?. Check the first box on the form. Fill out the certification. Mail, fax or e-mail the form to us. Keep a copy
How do I proceed if my inventorv or Business Plan has changed?
Check the second box on the form. Fill out the certification.
Provide the certification, updated inventory and hazardous materials business plan forms. Mail or e-mailthe form
to us. Keep a copy on site.
a
a
a
How do I obtain the required forms?o Download the forms online at http://www.slocounty.ca.govihealth/publichealth/ehs/HazMat.htm. Call 805-781-5544 and request a hazardous materials business plan packet to be mailed to you
Where can lsend the required forms?. lnventory Certification Forms can be e-mailed to crattigan@co.slo.ca.us, faxed to 805-781-4211, or mailed to
the P.O. Box 1489 San Luis Obispo, CA 93406. Hazardous Materials Business Plan and the Gertification can be e-mailed or mailed.
Who can I call with questions regarding form completion?. The Hazardous Materials lnspectorforAtascadero, North Coast, Santa Margarita. Call805-461-6236o The Hazardous Materials lnspector for other areas within the County. Call 805-781-5544.
ilL.l
)-o3
119 Z-,FORM S _ SAN LI[,
(\TZV BUSINESSOWI\ER/OPERATORIDENTIFICATION
COUNTY CERTIFTED T]NIFIED -AGENCY
2
C:\Documents and Settings\Chris\Desktop\Haz-Mat Owner Operator Form 12-05.DOC 1Jt
L IDENTIFICATION
FACILITYID#l BEGINNINGDATE 100 ENDINGDATE tol
BUSINESS NAME (sm G rAcrLrTY NAME or DBA - Doing Busircs As)
SAN LUIS AMBULANCE SERVICE, INC.
3 tmBUSINESS PHONE
805-543-2626
BUSINESS SITE ADDRESS
4I3O HORIZON LN. SPACE B
l03
l05ZTPCODE
93401SAN LUIS OBISPO
104CITY CA
SIC CODE (a digit #)107DI-'N & BRADSTREET
0s-388-3492
106
COT]NTY
SAN LUIS OBISPO
l08
110BUSINESS OPERATOR PHONE
805-s43-2626
BUSINESS OPERATORNAME
FRANKI. KELTON
l09
II. BUSINESS OWNER
lt2OWNERPHONE
805-543-2626
OWNERNAME
FRANKI. KELTON
lll
OWNERMAILINGADDRESS
PO BOX 954
113
115STATE
CA
ll6ZIPCODE
93406
ll4
SANLUIS OBISPO
CITY
Itr. ENVIROITI,IENTAL CONTACT
lt8CONTACTPHONE
805-543-2626
CONTACTNAME
CHRIS JAVINE
tt7
CONTACT MAILING ADDRESS
PO BOX 954
ll9
tztSTATE
CA
t22ZIPCODE
93406SAN LUIS OBISPO
120CITY
IV. EMERGENCY CONTACTS _sEcoNDARy-.PRIMARY.
lZENAME
CHRIS JAVINE
tz3NAME
TITLE
ON DUTY FIELD SUPERVISOR
t29
OPERATIONS DIRECTOR
tz4TITLE
BUSINESS PHONE 130BUSINESSPHONE
805-543-2626
t25
24-HOURPHONE t26 13124-HOIJRPHONE
PAGER# i CELLPHONE#127 PAGER# /CELLPHONE#l3z
ADDITIONAL LOCALLY COLLECTED INFORMATION:t33
Certification: Based on my inquiry of those individuals responsible for obtaining the information, I certiff under penalty of law that I have personally examined and
am familiar with the information submitted and believe the information is true, accurate, and complete.
NAME OF DOCI]MENT PREPARER
CHRIS JAVINE
135DA]E r ll4
t I nk>c
NAME OF SIGNER (print)
FRANKI. KELTON
136
1
TTTLE oF SIGNER
PRESIDENT/CEO
137
Page-
'5ct''-nt
,r"rxts
')BusinessOwner/Operatorldentification
)
please submit the Business Activities page, the Bustrrcsi Owner/Operator Identifidation page (OES Form 2730), ---i.{azardous Materials - Chemioal 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.
lNotl:-the numberiig of the instruitions follows the data element numbers that are on the UPCF (Unified Program Consolidated Form) pages. These data element
numbers are used
for efectronic submission and are the same as the numbering used in 21 CcR,Appendix C, the Business Section of the Unified Program Data Dictionary.)
please number all pages of your submittal. This helps the Dlpartment of Toxic Substances Control (DTSC) identiS whether the submittal is complete and if any pages
are separated.
t. FACIL5Y ID NUMBER - Irave this blank. This number is assigned by DTSC. This is the unique number which identifies your facility.
3. BUSINESS NAME - Enterthe full legal name of the business.
100. BEGINNING DATE - Enter the beginning year and date of the report. (YYYYI\{MDD)
101. ENDING DATE - Enter the ending year and date of the report. (YYYYMMDD)
102. BUSINESS PHONE - Enter the phone number, area code first, and any extension.
103. BUSINESS SITE ADDRESS - Enter the sfreet address where the facility is tocated. No post office box numbers are allowed. This information must provide a
m€ans to geographically locate tho facility.
104. CITY - Enter the city or unincorporated area in which business site is located.
105. ZIP CODE - Enter the zip code of business site. The extra 4-digit zip may also be added.
106. DUN & BRADSTREET - Enter the Dun & Bradstreet number for the facility. The Dun & Bradstreet number may be obtained by calling (610) 882'7748 ot
by Intemet.
107. SIC CODE - Enter the primary Standard Industrial Ctassificatiorr Code number for primary business activity. NOTE: If code is more than 4 digits' report
only the first four.
l0E. COIJNTY - Enter the county in which the business site is located.
109. BUSINESS OPERATOR NAME - Enter the name of the business operator.
I 10. BUSINESS OPERATOR PHONE - Enter business operator phone numbeq ifdifferent from business phone, area code first and any extension.
I I I . OWNER NAME - Enter name of business owner, if different from business operator.
I12. OWNER PHONE - Enter the business owner's phone number if different from business phone, area code first, and any extension.
I13. OWNER MAILING ADDRESS - Enter the owner's mailing address if different from business site address.
I14. OWNER CITY - Enter the name of the city for the owner's mailing address.
I15. OWNER STATE - Enter the 2-character state abbreviation for the owner's mailing address.
I16. OWNER ZIP CODE - Enter the zip code for the owner's address. The oxtra 4-digit zip may also be added.
I I 7. ENVIRONMENTAL CONTACT NAME - Enter the namo of the person, if different from the Business owner or operator, who receives all environmental
correspondence and will respond to enforcement activity.
I lg. CONTACT pHONE - Enter the phone number, if different from Ownor or Op€rator, at which the environmental contact can bo contacted, area code fint and any
extgnsion.
I19. 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.
l2l. STATE - Enter the 2-character state abbreviation for the environmental contact's mailing address.
122. ZP CODE - Enter the zip code fof the environmental cofltact's mailing address. The extra 4-digit zip may also be added.
I 23 . 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 - Entor the business number for the primary emergency cofltact, 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. Ifit is not the contact's home phone number, then the service answering the phone must be able to immediately contast the individual stated above.
127. PAGER NUMBER - Enter the pager number for the primary emergency contact, if available.
l2g. sECoNDARy EMERGENCY CONTACT NAME - Enter the name of a secondary representative that can be contacted in the event that the primary emergency
contact is not available. The contact shall have FULL facility access, site familiarity, and authority to make decisions for the business regarding incident
mitigation.
129. TITLE - Enter the title of the secondary emergency contact.
130. BUSINESS PHONE - Enter the business telephone number for the secondary emergency contact, area code first, and any extension'
13l. 24-HOUR PHONE - Enter a 24-hour phone number for the secondary gmergency contact. The 24 hour phone number must be one which is answered 24 hours a
day. If it is not the contaot'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 emergenoy contact, if available.
133. ADDmIONAL LOCALLY COLLECTED INFORMATION - This space may be used for DTSC to collect any additional information necessary to me€t the
requirements oftheir individual programs. Contact DTSC, or your local agency for guidance.
134. DATE - Enter the date that the document was sigred. (YYYYMMDD)
135. NAME OF DOCLJMENT PREPARER - Enter the full name of the person who prepared the inventory submiftal information.
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 ofthose individuals responsible for obtaining the information, all the information subntitted is true, accurate and complete.
SIGNATLJRE OF OWNERi OPERATOR OR DESIGNATED REPRESENTATWE - The Business owner/operator, or officially designated representative of the
Owner/Operator, shall sign in the space provided. This sigrature certifies that the sigrrer is familiar with the information submitted and that based on the
signer's inquiry ofthose individuals responsible for obtaining the information it is the signer's beliefthat the submitted information is true, acourate and
complete.
137. TITLE OF SIGNER - Enter the title of the person signing the page.
ii C:\Documents and Settings\Chris\Desktop\Haz-Mat Owner
Operator Form 12-05.DOC 29-Dec-05
Page _l_of 2_
fIDELETE EIREVISE 200
I. FACILITY INFORMATION
3
BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As)
SAN LUIS AMBULANCE SERVICE,INC.
202CHEMICAL LOCATION CONFIDENTI,AL EPCRA
r]YES ENO
CHEMICALLOCATION
EAST WALL INSIDE THE SHOP
201
GRID# (optioul)ff-ro zo4203**y
FACILITY ID #
II. CHEMICALINFORMATION
TRADESECRET EYes
to EPCRA, refer to instructions
206
IfSubject
C}IEMICALNAME
PETROLETIM HYDROCARBON
2{J5
I Yes ElNo
208
EHS*COMMONNAME
WASTE OIL
207
*If EHS is "Yes"' all amounts below must be in lbs.cAs#
N/A
209
FIRE CODE FIAZARD CLASSES (complete if required by cuPA)2IIJ
213
CURIES
212
RADIoAcrrvE Eves ElNoHAZARDOUS MATERTAL TYPE
(Check one item only)Ea.PUFG Eb.NflXTURE EIc.WASTE
2tt
LARGEST CONTAINER: 55 GAL DRUM
215
E a. solrD El b. LIQITID E s. GASPHYSICAL STATE
(Check one item only)
214
FED HAZARD CATEGORIES
(Check all that apply)EtA.FIRE Eb.REACTIVE EC.PRESSURERELEASE Ed'ACUTEIDALTH EE.CHROMCHEALTH
216
220STATE WASTE CODE
22t
2t9ANNUAL WASTE AMOUNT
8OO GALLONS
218MA)OMT]MDAILYAMOUNT
2OO GALLONS
2t7AVERAGEDAILYAMOIJNT
1OO GALLONS i)7DAYS ON SITE:
365Eb.CUBICFEET EC.POUNDS
*IfEHS, amount must be in pounds.
E d. TONSEl a. GALLONS
(Check one item only)
221
UNITSI
trtrn
b. IJNDERGROUNDTANK
c. TANKINSIDEBUILDING
d. STEELDRUM
EI e. PLAS r'1C/NONM.b I ALLIU IJKUM
E r. cau
E g. CARBOY
fl h. str-o
r. OTHER
q. RAILCAR
p. TANKWAGONE l. cYLtrIDER
223
trtrtrntrtr
u r. rlbrK DRTIM
o. TOTEBIN
E a. ABOVE GROUND TANKSTORAGE
CONTAINER J, BAG
k. Box
I m. GLASS BofiLE
E n, PLASTIC BOTTLE
E A. AMBIE}IT N b. ABOVEATIBENT E c. BELOWAMBIENTSTORAGE PRESSURE
224
STORAGETEMPERATURE EA,AMBIENT Eb.ABOVEANBEN|N d, CRYOGEMCn c. BELOWAMBIENT
225
EHS CAS #o/oWT HAZARDOUS COMPONENT (For mixture or waste only)
228
I Yes ElNo
aJo
I 100
226
PETROLEUM HYDROCARBON
227
I Yes DNo
233230
2
231
237
EYes ENo
236234
3
235
241
E Yes [tto
240238
4
239
E Yes ENo
244242
5
243
if trotr-ercitrogeric, or 0.1 o/ocomponents !rc pgent !t Sutcr
ADDITIONAL LOCALLY COLLECTED INFORMATION
FORM I- SAN LUIS OBISPO COUNTY CERTIFTED UNIFIED PROGRAM AGENCY (CI]PA)
CHEMICAL INVENTORY
material or
rK
(
Lt'C:\Documents and Settings\Chris\Desktop\Waste Oil Doc .DOC 29-Dec-05
Page _1_ of_3_Eaon EDELETE EREVISE 200
I. FACILITY INFORMATION
BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As)
SAN LUIS AMBULANCE SERVICE, INC.
3
aouCHEMICAL LOCATION CONFIDENTIAL EPCRA
EIYES ElwoCHEMICAL LOCATION
EAST WALL INSIDE THE SHOP
201
2MGRID# (optional)
.:r- ?
203utc* <oor,y
FACILITY ID #
il. CHEMICALINFORMATION
TRADESECRET EYes ENO
If Subject to EPCRA' refer to instructions
206CHEMICALNAME
PETROLEUM HYDROCARBON
205
I Yes ENo
208
EHS*COMMONNAME
WASTE OIL FILTERS
*If EHS is "Yes", all amounts below must be in lbs.CAS#
N/A
2tJ9
FIRE CODE HAZARD CLASSES (completeifrequiedby cttPA)2to
2t3
CURIES
2t2
RADIOACTIVE E Yes ENoI a, PLIRE E b, IvflffURE E c, WASTE
2tt
HAZARDOUS MATERIAL TYPE
(Check one item only)
LARGEST CONTAINER: 55 GAL DR1JM
215
Ea.SOLID Bb.LIQLID Eo.GASPHYSICAL STATE
(Check one item only)
214
Et a.FrRe E b.REACTIVE E c.PRESSURERELEASE I d.ACUTEIIEALTI{ B e. CHROMCHEALTT{FED HAZARD CATEGORIES
(Check all that apply)
216
220STATEWASTECODE
221
ANNUAL WASTE AMO1JNT
2- 55 GAL DRUMS
219MAXIMUMDAILYAMOUNT
55 GALDRUM
2tEzl'IAVERAGE DAILY AMOUNT
II2- 55 GAL DRUM araDAYS ON SITE:
365Eb.CUBICFEET Eo.POUNDS
*If EHS, amount must be in pounds'
E d. TONSEl a. GALLONS
(Check one item only)
UNITS*
E a. ABOVE GROIJND TANK
E b. IJNDERGROIJNDTANK
I c. TANK INSIDE BUILDING
E d, STEELDRUM
utrtr
f. CAN
g. CARBOY
h. srl.o
tr
trtrn
i. FIBERDRUM
J. BAG
k. Box
I- CYLINDER
E m. GLASS BOTTLE
E n. PLASTICBOTTLE
E o. TOTEBIN
Ip.TANKWAGON
223
r. OTHER
q. RAILCAR
trtr
El e. PLASTIC/NONMETALLIC DRUMSTORAGE
CONTA]NER
$ A. AMBIENT E b. ABOVEANDENT E c. BELOWAMBIENTSTORAGE PRESSI]RE
STORAGETEMPERATURE EA,AMBIENT Ob.ABOVEATBENT E c. BELOWAMBIENT E d. CRYOGENIC
CAS #EHSHAZARDOUS COMPONENT (For mixture or waste only)o/"WT
flYes I No
2ZA
PETROLETIM HYDROCARBONI 100
726
233
E Yes DNo
232230
2
23't
E Yes ENo
236,1<234
3
ul
E Yes ENo
24t)239z3a
4
745
! Yes Et'to
244243242
5
If morc h@rdous componentr tre pBcot at gMacr thatr 17o by weight if non-srcitrogetric' or 0.170 by if qninoSenic, lttrch rddilional shetr of psprr opturing the requircd infomrtion.
ADDITIONAL LOCALLY COLLECTED INFORMATION
If llPCRA. Pleese Sisn Here
246
FORM I _ SAN LUIS OBISPO COUNTY CERTIFIED UNIFIED PROGRAM AGENCY (CUPA)
CHEMICAL INVENTORY
meterial
0*'
14t-/
t/
C:\Docr-rments and Settings\Chris\Desktop\Waste Oil Filter Doc..DOC 29-D ec-05 \ n
ANN'
Page _ of_fIADD DDELETE Enrvtse 200
I. FACILITY INFORMATION
BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As)
SAN LUIS AMBULANCE SERVICE, INC.
202CFIEMICAL LOCATION CONFIDENTIAL EPCRA
E YES ENO
CHEMICAL LOCATION
EAST WALL INSIDE SHOP
201
2UGRID# (optional)J-1
203MAP# (ontioyf
_1-FACILITY ID #
il. CIIEMICAL INFORI\{ATION
TRADESECRET ilYCS XNO
If Subject to EPCRA, refer to instructions
206CFIEMICALNAME
ETHYLENE GLYCOL
205
E Yes ENo
208
EHS*COMMONNAME
WASTE ANTIFREEZE/COOLANT
207
tlf EHS is "Yes", all amounts below must be in lbs,cAs#
107-zt-r
2W
FIRE CODE HAZARD CIASSES (complete if required by cuPA)2to
213
CURTESRADIOACTIVE DYes EINoE a. PURE I b. MIXTIIRE g(". wasre
211
HAZARDOUS MATERIAL TYPE
(Check one item only)
LARGESTCONTAINER 55 GALDRUM
21s
Ea,SOLID EIb,LIQUD Ec,GASPHYSICAL STATE
(Check one item only)
214
FED HAZARD CATEGORIES
(Check all that apply)E a.FIRE EI b.REACTIVE E c,PRESSURERELEASE E d.ACUTEIDALIH E e. CHRONIC}IEALTH
216
STATEWASTE CODE 220
343
ANNUAL WASTE AMOUNT
55 GAL
zt92taMAXIMUMDAILYAMOUNT
55 GAL
zt7AVSRAGEDAILY AMOUNT
25 GAL
222DAYS ON SITE:
365Et.crislcFEet Eo.PouNDS
'IfEIIS, amount must be in pounds.
E o. roNsEl a. GALLONS
(Check one item only)
T]NITS+
E a. ABOVE GROIJND TANK
E b. T]NDERGROUND TANK
E c, TANK INSIDE BUILDING
E d. STEELDRUM
trtrtr
f. CAN
g. CARBOY
h. srl.o
trtrtr
J. BAG
K, BOX
I. CYLINDER
E m. GLASS BOTTLE
E n. PLASTICBOTTLE
E o. TOTE BIN
E p. TANKWAGON
r. OTI{ER
q. RAIL CAR
trtr
E i, FIBERDRUME e. PLASTIC/NONMETALLIC DRUMSTORAGE
CONTAINER
ff a. AMBIENT E b. ABOVEANBENT E c. BELOWAMBIENTSTORAGE PRESST]RE
224
STORAGETEMPERATURE EIA.AMBIENT Nb.ABOVEAMBIENT E c. BELOWAMBIENT E d. CRYOGENIC
225
CAS #EHSo/oWT IIAZARDOUS COMPONENT (For mixture or waste only)
t07-21-l
229
E Yes ElNo
2ZA
ETHYLENEGLYCOL
227
150
226
233
El Yes ENo
23223123t)
2
231
[Yes ENo
236235234
3
?41
E Yes Elto
240239234
4
245
[Yes ENo
244243242
5
ieightiforcinogenic,f,tt8ch8ddi.iond!hetsofpsper€pturin8therequiredinfomrtion.
ADDITIONAL LOCALLY COLLECTED INFORMATION
If EPCRA- Pleese Sisn Here
246
FORM I_ SAN LTIIS OBISPO COUNTY CERTIF'IED UNIFIED PROGRAM AGENCY (CUPA)
CHEMICAL INVENTORY
,,r)
L-/
C :\Docr.rments and Settings\Chris\Desktop\Antifreeze.doc 29-Dec-0529-Dec-05 , ,,.
\JN.,$Q \n\
Hazardt ; Materials lnventory - Ghemical De' liption
you must complete a separate Hazardous Materials lnventory - 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 pdunds, si gallons, 200 cubic feet of gas (calculated at standard temperature and pressure)
iri inJieAerar inresnob fhnnin-g qilantity for Extreniely Hazaidous Substances, whichever is less. Also complete a page for each radioactive material handled over
quantities for which an emergen"c! plan is requireo to 6e adopted pursuant to 10 CFR Parts 30, 40, or 70. The completed inventory should reflect all reportable quanlities
temperature and storage pressuie. j'r.roi", the numberin! of the instrudio;s follows the data element numbero 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 Datja Dic{ionary.) Please
number all pages of your submittal. This helps your CUPA or AA identify whetherlhe submittal is complete and if any pages are separated.
1. FACILITY ID NUMBER - This number is asiigned by the CUPA or AA. This is lhe unique number which identifies your facility.
3. BUSINESS NAME - Enter the tull legal name of the business.
2OO. ADD/DELETEI REVISE - rnAicate irjtre material is being sdded 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 arla where the hazarious maierial is handled. A chemical that is stored at the same pressure and
temperature, in multiple locations wiihin a building,'can be reported on a single page. NOTE: This information is not subject to public disclosure pursuant to HSC
:25506.
202. CHEMTCAL LOCATION CONFTDENTT{L - EPCRA - Ail businesses which afe subject to the Emergency Planning and community Right to Know Act (EPCRA) must
check Ayes= to keep chemical location information @nfdential. lf the business does notwish to keep chemical location information confidential check ANo=.
203. MAp NUMBER - lf a map is included, enter the number of lhe map on which the localion of the hazardous material is shown.
204. GRID NUMBER - lf grid'coordinates are used, enter the grid cooriinates of the map that conespond to the location of the hazardous material. lf applicable, multiple grid
coordinates can be listed.
2oO. CHEMICAL NAME - Enter the proper chemical name associated with the Chemical Abstract Service (CAS) number of the hazardous material. This should be the
lnternational Unionotpure'andAppliedChemistry (IUPAC) namefoundontheMaterial SafetyDataSheet (MSDS). NOTE: lfthechemical isamixture,donot
complete this field; complete the ACOMMON NAME'field instead'
206- TRADE SECRET - Check 'Yes' if lhe information in lhis section is declared a lrade secret, or "No' if it is not-
State requirement lf yes, and business is not subject to EPCRA, disclosure of the designated trade sccfet informaton is bound by HSC e25511 -
Federal requirement ' lf yes, and business is subjia to EPCM, disclosure of the designated Trade Secret information is bound by 40 CFR and lhe business
must submii a Asub$tantiation to Accompany Claims of Trade Secrecy= form (40 CFR 350.27) to USEPA.
207. COMMON NAME - Enter the common name or trade name of the hazardous material or mixture coniaining a hazardous material.
2OB. EHS - Check 'yes" if the hazardous material is an Extremety Hazardous Substance (EHS), as defined in 40 CFR, Part 355, Appendix A. lf the material is a mixture
containing an EHS, leave this section blank and complete the section on hazardous @mponents belo/v.
20g. CAS # - Enter the ChemicalAbstract Service (CAS) numbei for lhe hazardous material. For mixtures, enter the CAS number of the mixture if it has been assigned a
number distinct from its components. if tne hixture 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 CODL HAZARD CLACSE'S - Fire Code Hazard Classes describe to first responders lhe type and level of hazardous materials which a business handles. This
information shall only be provided if the locat fire chief deems it necessary dnd requests ihe CUPA or AA to collect it. A list of the hazard classes and instructions
on how to determine wtriin class a material falls under are included in the appendices of Article 80 of the Uniform Fire Code. lf a material has more than one
applicable hazard class, include all. Contact CUPA or AA for guidance'
21 1. HAzARbbUS MATERIAL TYPE - check the one box that best describes the type of hazardous material: pure, mb(ture or waste. lf waste material, check only that box.
lf mixture orwaste, complete hazardous oomponents section.
212. RADIOACTIVE - Check 'Yes' if the hazardous material is radioac{ive or ANo= if it is not.
213.CUR|ES-lfthehazardousmateriat isradioactive,usethisareatoreporttheactivityincuries. Youmayuseuptoninedigitswithafroatingdecimal pointtoreport
activity in cudes.
214. PHYSICAL Sfnfe - Check the one box that best describes the state in which the hazardous material is handled: solid, liquid or gas.
21b. LARGEST CONTAINER - Enter the total capacity of the largest container in which the material is stored.
material.- Check all and health hazards
the average daily material or mixture each building or
ouiside area. Calculations shall be based on the previous year6 inventory of material reported on this page. Total all amounb and divide by the number of
days the chemical will be on site. lf this is a material that has not previously been present at this localion, the amount
daily
shall be the average daily amount you
project to be on hand
daily amount.
218. MAXIMUM DAILYAMOUNT
during the murse of the year. This amount should be consistent with the units reported in box 221 and should not exceed that of maximum
- Enter the maximum amount of each hazardous material or mixture containing a hazardous material, which is handled in a building or
adjacenyoutside area at any one time over the course of the year. This amount must contain at a minimum last year=s inventory of the material reported on this
page,withthereflectionotidditions,deletions,orrevisionsprojectedforthecurrentyear. Thisamo_untshouldbeconsistentwiththeunitsreportedinbox22l.
219. ANNUAL WASTE AMOUNT - lf the hazardous material being inventoried is a waste, provide an estimate of the annual amount handled.
220. STATE WASTE CODE - lf the hazardous material is a wastq enter the appropriate Califomia 3digit 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. NO-Te lf the material is a
federaly detined Extremely Hazardous Su6dtarice (EHS), all amounts muit bb reported in pounds. lf material is a mixture containing an EHS, report the units that
the material is stored in (gallons, pounds, cubic feet, or tons).
222. DAYS ON SITE - List the total number of days during the year that the material is on site.
22g. STORAGE CONTAINER - Check all boxes ihat describe the type of storage containers in which the hazardous material is stored. NOTE: lf appropriate, you may
choose more than one.
224. STORAGE PRESSURE - Check lhe one box that b€st desclib€s the pressure atwhich the hazardous material is stored.
22S. STORAGE TEMPERATURE - Check the one box that best describes the temperature at which the hazardous material i3 stored.
226. HAZARDOUS COMPONENTS 1-5 (% By WEIGHT) - Enter the percentage weight of the hazardous component in a mixture. lf a range of percentages is available,
report the highest percentage in that range. (Report for components 2 through 5 in 230, 234, 238, and242.)
227. HAZARDOUS CoMpoNENTs 1-6 NAME - wn'en rdpoiting a hazaidous material that is a mixture, list up to five chemical names of hazardous components in that
mb,ture by percent weight (refer to MSDS or, ih the case of trade secrets, refer to manufacturer). All hazardous components in the mixture present at greater
than 1% 6yweight if ndn-cdrcinogenic, or 0.'lo/o by weight ifcarcinogenic, should be reported. lf more than five hazardous components are present above these
percentag6s, yotr may attach an iOoitibnat sheet df papir 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 COMPONENiS 1-s 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 S in 2S2, 236' 24O, and 2M')
229. HAZARDOUS coMpoNENTs 1-s cAs - List the Chbmical Abstract Service (CAS) numbers as related to the hazardous components in the mixture. (Repeat for 2-5.)
246. LOCALLY COLLECTED INFORMATION - This space may be used by the cuPA or AA to collect any additional information necessary to meet the requirements of their
individual programs. Contact the CUPA or AA for guidance.
PHYSICAL HAZARDS HEALTH HAZARDS
Flr€: Flammable Liouids and Solids. Combustible Liquids, Pvrophorics, Oxldizers Acute Health (lmmedlate): Highly Toxic, Toxic, lnitiants, Sensitizers, Corroslves'
other hazardous chemicals with an adverse effect with short term exoosureReictive: Unstable Reactive. Omanic Peroxides, Water Reactive, Radioactive
Pressure Release: Explosives, Compressed Gases, Blasting Agents Chronic Health (Delayed): Carcinogens, olher hazardous chemicals with an
adverse efiect with lonq term exposure
C:\Docurnerrts and Settings\Chris\Desktop\Antifreeze.doc 29-Dec-0529-Dec-05
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FORM M - MAP GRID (see instrucrions)
Scale: 1 inch =Feet
\
Map # 1-
q
A B c D E F G H J K L M N
1 IUOAIB T I
2 2
3 3
4 4
5 5
6 6lnrASI)1 ol L
7 7(^)46111 CJDUJTJT
8 8
I
tryA6lE olLt'tctti;Lg
fucvta>rtf I
l0 10f.5Ds
11
@ 11t:Lfcrftlc4 L
P+l-_l tl.L.
12 (Zole-uP DooL)12
l3 13
14 14
A B c D E F G H J K L M N
ft
2
I
I
I
tp(Business Name:77Date: I CA
nddress: Q I HcYLr Zor-))<
Number of Employees in Facility Depicted Above - Day =Night =
%\"\n
'r) FoRM E -)
SAN LUIS OBISPO COI.'NTY CERTIFIED UNIFIED
PROGRAM AGENCY (CUPA)
EMERGENCY RESPONSE PLAI\I
Or Hazardous Waste Contingency Plan
(see instruction page vii)Date: l2ll9l05
SECTION I-A: BUSINESS IDENTIFICATION DATA
SAN LUIS AMBULANCE SERVICE, INC.
BUSINESSNAME
4130HORZONLN. SPACEB SANLLIIS OBISPO 93401
SITEADDRESS
MECHANIC SHOP
CITY ZIP CODE
805:783-2474
FACILITYIJNIT
PO BOX 954 SANLUIS OBISPO
TELEPHONENUMBER
93406
BUSINESS MAILINC ADDRESS CITY ZIPCODE
Ifyour buslnus hos a license or permitftom any ofthefollowing agencia, please indicde the dmanwnt rramha.
1. Hazardous Materials
Underground Storage #
2. Hazardous Waste
Generator # CAL 0002861 12
Gas Service N/A
Sanitation SANLUISGARBAGE
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. ftrir 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 ntmber of the utility company.
Electric Service PG AND E Telephone # 800-743-5000
Telephone #
Telephone #an< </1 /la?<
Water District TelePhone #
SECTION I-B: OW\ER CERTIFICATION OF DATA (Certif either I or2\
l. This is a finnw run IUTuATED Existing Plan. I have personally examined the information it contains and am familiar with the
operation oithr plun. (If you check either of the above two options, continue to complete the remained ofthe Emergency Response /
Contingency Plan).
2. f] This plan requires no change and is on file with San Luis Obispo County Hazardous Materials Unified Program Agency and does
not need any change. (Ifyou check this section, please proceed direct$ to Form T, the Training Program.)
I certify under penalty of law that the above information is true and accurate'
---t?-oFRANKI. KELTON
PRINTNAME OF OWNEROR OPERATOR
CHRISJAVTNE
DOCUMENIS PREPARED BY
DATE
5
Paoe of
DATE
SECTION RESPONSE PLAI{S
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 notillcation 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 Hazardous Materials Unified Program Agency during business hours @ 80$.781-5544. After
business hours dial 911.
2. The State Office of Emergency Services - (800) 852-7550 or (916) 262-t621.
List the individuals responsible for verifying that these calls have been made and also indicate their position in your company.
FOR VERIF"TING TIIE DIALING OF 911:
FRANKMURPHY SHOP MANAGER
NAME POSITION
Individual responsible for calling San Luis Obispo County Hazardous Materials Unified Program Agency and the State Offrce of
Emergency Services: (Normally the Emergency Coordinator of your business.)
CHRISJAVINE OPERATIONSDIRECTOR
NAME POSmON
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 release ofhazardous materials.
SIERRAVISTAHOSPITAL IOIOMURRAY SANLUISOBISPO 805-543-7600
NAME ADDRESS CITY PHONE
NAME ADDRESS CITY PHONE
C. List the Emergency Coordinato(s) at your facility.
Primary: CHRISJAVINE OPERATIONSDIRECTOR 805-543-2626 805-7844202
NAME
Secondary:
TITLE
FIELD SUPERVISOR
BUSINESS PHONE
805-550-8604
24HRPHONE PAGER#
NAME TITLE BUSINESSPHONE 24}IRPHONE PAGER#
D.Does your business have an on-site emergency response team? f]yes flNo Describe procedures your business will follow in
the event ofa release or threatened release ofhazardous materials.
IN TTM EVENT OF A RELEASE/THREATENED RELBASE, A FIRE OR OTI{ER EMERGENCY, STAFF WILL CALL 91I THEN
EVACUATE TI{E FACILITY By WAy OF TI{E ROLL-UP DOO& IF OPEN, OR Tt{E FRONT DOOR. STAFF
MEET IN TI{E DIRT PARKING AREA WEST OF THE FACILITY
ll
Paoe of
E. Ifyouhaveacutely hazardous '.ffi phnning quantities, L -)v name and address) adjacent neighboring
businesses and residences, schools, hospitals,etc. Include sensitive facitities (schools, hospitals and rest homes) within 1'000 feet
(straightJine distance from your property line). List telephone
phone. Do not list telephone numbers for private residences.
numbers for all businesses; for apartment buildings, list manager's
N/A
x'.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 facillty' What actions
would your business take to reduce accident potentials? Include description ofsafety, storage and containment procedures.
wE sToRE WASTE MOTOROTL AND COOLANT rN REPORTABLE QUANTITIES. BOTH ITEMS ARE STORED IN
APPROPRIATE CONTAINERS WITHCATCHMENT PANS UNDERNEATHIN THE EVENTOFA SPILLORLEAK.
2. Equipment -- List the emergency response equipment at your facility (e.g. fire extinguishing systems, spill control equipment,
decontamination equipment).
Item
THREE (3) FIRE
EXTINGUIS}IERS
3.
Maintenance Procedure
ANNUAL SERVICE
Evacuation - Describe how you will immediatety evacuate your facility. What communications or alarms me used? How will
you operate these during power failure?
LocationUse
EAST, WESTAND
NORTH WALL
FIRE
SUPPRESSION
SHOTILD IT BECOME NECESSARY TO EVACUATE THE FACILITY DUE TO A FIRE OR OTHER EMERGENCY, STAFF WILL
MEMBERS WILL EVACUATE TI{E FACILITY BY WAY OF TI{E ROLL-I.]P DOOR" IF OPEN, OR TIIE FRONT DOOR. STAFF
MEET IN TIIE DIRT PARKING AREA WEST OF THE FACILITY
7
Paoe of
4. Shutdown - Describe the shutdt,'vn for each site or facility
TFM STAFF IMILL TURN OFF TTIE ELECTRICAL SERVICE AND EVACUATE TI{E FACILTTY
5a. Response - Describe what is done to lessen or mitigate the harm or damage to person(s), propefty, or the environment and
prevent the event from getting worse or spreading. What is your immediate response to:
FiTE: CONTROL SMALL FIRES WITH THE FIRE EXTTNGUISFIER. FOR LARGER FIRES STAFF WILL CALL 9I I AND
EVACUATE TTIE FACILITY
Explosion:EVACUATE TTM FACILITY AND CALL 911 FROM AN OFF- SITE TELEPHONE
Spill:CONFINE TTM SPLL TO TI{E SMALLEST AREA POSSIBLE. USE ABSORBENT MATERIAL FOR SMALL SPLLS
AND PLACE IN A DRUM FOR DISPOSAL. FOR LARGE SPILLS, A CLEAN-UP CONTRACTOR WILL BE USED
Earrhquake: TURN OFF ELECTRICAL SERVICE AND EVACUATE TI{E FACILITY.
Major Power Failure: N/A
Flood: TURN OFF ELECTRICAL SERVICE AND EVACUATE THE FACILITY.
b. Is this facility located on a 100-year flood plain? lYes EXo
c. Earthqualre - Iaenti& facility arias and list mechanical or other systems that require immediate inspection or isolation because of
their vulnerability to earthquake related ground motion.
N/A
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: Noti! the Hazardous Materials Unified Program Agency when clean up is complete.
USE SHOPRAGS ANDABSORBENTMATERIALFORSMALL SPLLS AND PLACEINADRUMFORDISPOSAL
FOR LARGE SPILLS, A CLEAN-UP CONTRACTOR WILL BE USED
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.
THEFILECABINET
8
Paoe of
-)
FORM T
SAN LUIS OBISPO COUNTY CERTIFIED UNIFTED
PROGRAM AGENCY (CUPA)
EMPLOYEE TRAINTING PROGRAM Datezl2?7l05
A. Describe the safety training for all employees in the event of a release or threatened release of hazardous materials. This
training shall include, nut 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 the training for all employees that work with or come in contact with hazardous materials/hazardous
waste. Describe how these employees are trained to avoid exposure.
THE SHOP MANAGER, FRANK MURPHY, CONDUCTS NEW HIRE AND AS NEEDED TRAINING FOR ALL SHOP
EMPLOYEES THIS TRAINING CONSISTS OF: ACTIONS TO TAKE lN THE EVENT OF A SPILL, INFORMATION
REGARDING THE HAZARDOUS MATERIALSM/ASTE IN THE SHOP AND PRACTICES THAT LIMIT THE POSSIBILITY
OF A SPILL OR EXPOSURE.
)Summarize fiaining specific to those employees that would respond to a release or threatened release of hazardous materials or
hazardous waste.
THE SHOP MANAGER, FRANK MURPHY, CONDUCTS NEW HIRE AND AS NEEDED TRAINING FOR ALL SHOP
EMpLOyEES. THIS TRAINING CONSISTS OF: USE OF SAFETY EQUIPMENT, MSDS, EVACUATION PROCEDURES'
CLEAN-UP PROCEDURE, THE 911 SYSTEM AND ELECTRICAL SERVICE SHUT-OFF
I
C:\Documents and Settings\Chris\Desktop\Haz Mat Training Shop DOC 12129105
Page- of-
J Indicate frequency and duration of naining for employers that work with or come into contact with hazardous materials/hazardous
waste.
INITIAL HIRE TRAINING IS CONDUCTED PRIOR TO A NEW EMPLOYEE BEGINNING WORK. REFRESHER
IS CONDUCTED ANNUALLY. SAFETY MEETINGS ARE CONDUCTED MONTHLY
4. Describe how your employees access training materials. (E.g., bulletin board, employee newsletter, staffmeetings, etc.)
TRAINING MATERIALS ARE KEPT IN THE FILING CABINET AND HANDED OUT WHEN REQUIRED.
B. List person(s) in charge of training and indicate their quatifications to conduct the training.
THE SHOP MANAGER, FRANK MURPHY. FRANK HAS 40 YEARS EXPERIENCE IN THE AUTO REPAIR FIELD
c.Indicate where training records are kept (Records must document the type of naining duration, completion dates, names and
positions of employees receiving taining and the name(s) of instructors / frainer.)
FILING CABINET
10
C:\Documents and Settings\Chris\Desktop\Haz Mat Training Shop DOC 12129105Page- of-
i
.t
SerErv & HA'z./\RDOUS MATERIAL
TRAINING
Duration ,3 ort,t,.ADate L-4 - o'7
Mech#1
Mech#2
Mech#3
Notes
3 xfcr I
t t^, Bouac'15
?rao^- Ku^tc.
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to
Asbury Environmental Services
9302 Garfield Avenue
South Gate, CA 90280
INVOICE
SAN LUIS AMBULENCE
PO BOX 954
SAN LUIS OBISPO, CA 93406
BILL TO:
lnvoice #:
Date :
PO#:
Terms:
Due Date :
Service Date:
Job#:
Order # :
so #:
Reference :
Salesperson :
130048167
1t6t2006
NET 30
2t5t2006
12t28t2005
16202A03
N496979
Dispatch
ExtendedReferenceDisc. Unit PriceQuantity Description
1.0000
USED OIL / MIXED OILS
WASTE OIL SERVICE CHARGE
0%
a%
0:0000
65.0000
$0.00
$65.00
Sub Total:
lnternational Taxes:
Federal Taxes:
State Taxes:
County Taxes:
City Taxes:
Other Taxes:
Total:
$65.00
Notes:
D
4130 HORIZON LANEEESAN LUIS OBISPO, CA 93401 $0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$65.00,,,)
REMIT PAYMENT TO
FILE 41899
LOS ANGELES, CA 90074-1899J
Foryour convenience, we now accept Visa, Mastercard and American Express!
To make credit card payments please contact the Gredit Department at 562-231-1550
THANK YOU FOR YOUR BUSINESS.
" Asbury Environmental Services
9302 Garfield Avenue
South Gate, CA 90280
II\IVOICE
SAN LUIS AMBULENCE
PO BOX 954
SAN LUIS OBISPO, CA 93406
BILL TO
lnvoice # :
Date :
PO #:
Terms :
Due Date :
Service Date
Job#:
Order # :
so #:
Reference :
Salesperson
130054778
2t112006
NET 30
3t3t2006
1t26t2006
1 61 88406
N51 5952
Dispatch
Reference ExtendedDisc. Unit Price
1.OOOO USED OIL AND GASOLINE FILTERS O o/o 65.0000 $65.00
Sub Total:
lnternational Taxes:
Federal Taxes:
State Taxes:
County Taxes:
City Taxes:
Other Taxes:
Total:
$65.00Notes:
tr
4130 HORIZON LANEtrOSAN LUIS OBISPO, CA 93401 $0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$65.00
REMIT PAYMENT TO
F|LE 41899
LOS ANGELES, CA 90074-1899
For your convenience, u/e now accept Visa, Mastercard and American Express!
To make credit card payments please contact the Credit Department at 562-231-1550.
THA,NK YOU FOR YOUR BUSINESS.
,_-a)
o
Asbury Environmental Services
9302 Garfield Avenue
South Gate, CA 90280
II\IVOICE
SAN LUIS AMBULENCE. SAN155
PO BOX 954
SAN LUIS OBISPO, CA 93406
lnvoice # :
Date:
PO#:
Terms :
Due Date :
Job#:
Order # :
Reference :
Salesperson :
BL Batch#:
1 30061 643
03/01 /2006
Net 30 Qays
03/31 /2006
DISPATCH
320
EA WASTE OIL SERVICE CHARGE $65.00 $6s.00
200 EA $0.00 $0.00USED OIL / MIXED OILS
$65.00
Service Orde# : N51S6S1 Service Order Date:
Manifest# i 24A223411 Manifest Date :
Notes :4130 HORIZON LANE, , SAN LUIS OBISPO, CA 93401
2t2',2006
REMIT PAYMENT TO:
FILE 41899
LOS ANGELES, CA 90074.1899
Sub Total :
State Taxes :
County Taxes :
Total :$65.00
For your convenience, we now accept Visa, Master Card, and American Express!
To make credit card payments please contact the Credit Department at (562) 231-1550
THANK YOU FOR YOUR BUSINESS-
-\
Asbury Environmental Services
9302 Garfield Avenue
\ South Gate, CA 90280
INVOICE
SAN LUIS AMBULENCE,.SAN1 55
PO BOX 954
SAN LUIS OBISPO, CA 93406
BILL TO
lnvoice # :
Date :
PO #:
Terms:
Due Date :
Job#:
Order # :
Reference :
Salesperson
BL Batch#:
130074255
04t24t2006
Net'30'Days
05t24t2006
DISPATCH
House Account
820
EA WASTE OIL SERVICE CHARGE $65.00 $65.00
200 EA $0.00 $0.00USED OIL / MIXED OILS
Sub Total :
State Taxes :
County Taxes :
Total :
$65.00
$0.00
$0.00
Service Orde# : NS1237g Service Order Date :
Manifiest# : 2SO595SO Manifest Date :
Notes : 4130 HORIZON LANE, SAN LUIS OBISPO, CA 93401
4nn006
REMIT PAYMENT TO:
F|LE 41899
LOS ANGELES, CA 90074-1899
$65.00
For your convenience, we now accept Visa, Master Card, and American Express!
To make credit card payments please contact the Gredit Department at (562) 231-1550
THANK YOU FOR YOUR BUSINESS.
Asbury Environmental Services
9302 Garfield Avenue
South Gate, CA 90280
II\TVOICE
SAN LUIS AMBULENCE,- SAN155
PQ BOX 954
SAN LUIS OBISPO, CA 93406
BILL TO:
lnvoice # :
Date:
PO #:
Terms:
Due Date :
Job#:
Order#:
Reference:
Salesperson :
BL Batch#:
130074254
04t24t2006
Net 30 Days
05t2412006
DISPATCH
House Account
819
Quantity UOM Description Unit Price Extended
50 EA ETHYLENE GLYCOL SOLUTIONS $1.30 $65.00
Sub Total :
State Taxes :
Gounty Taxes :
Total
$65.00
$0.00
$0.00
Service Orde#: N512378 Service Order Date :
Manifest#: 25060037 Manifest Date:
Notes : 4130 HORIZON LANE, SAN LUIS OBISPO, CA 93401
4n/2006
REMIT PAYMENT TO:
FtLE 41899
LOS ANGELES, GA 90074.1899
$65.00
For your convenience, we now accept Visa, Master Card, and American Express!
To make credit card payments please contact the Credit Department at (562) 231-1550
THANK YOU FOR YOUR BUSINESS.
Asbury Environmental Services
9302 Garfield Avenue
South Gate, CA 90280
II\TVOICE
SAN LUIS AMBULENOE - SAN155
PO BOX 954
SAN LUIS OBISPO, CA 93406
BILL TO:
lnvoice # :
Date :
PO #:
Terms:
Due Date :
Job#;
Order # :
Reference :
Salesperson
BL Batch#:
1 30076336
05/01/2006
Net30 Days
05/31/2006
DISPATCH
House Account
870
EA USED OIL AND GASOLINE FILTERS $65.00 $65.00
Sub Total :
State Taxes :
County Taxes :
Total
$65.00
$0.00
$0.00
SeMce Orde# i N512747 Service Order Date:
Manifiest# : Manifest Date:
Notes : 4130 HORIZON LANE, SAN LUIS OBISPO, CA 93401
4t13t2006
REMIT PAYMENT TO:
FILE 41899
LOS ANGELES, CA 90074-1899
$65.00
For your convenience, we now accept Visa, Master Card, and American Express!
To make credit card payments please contact the Credit Department at (562) 231-{550
THANK YOU FOR YOUR BUSINESS.
Asbury Environmental Services
9302 Garfteld Avenue
South Gate, CA 90280
IT\[vOICE
SAN LUIS AMBULENCE - SAN155
PO BOX 954
SAN LUIS OBISPO, CA 93406
BILL TO:
lnvoice # :
Date :
PO #:
Terms :
Due Date :
Job#:
Order#:
Reference ;
Salesperson
BL Batch#:
1 3008431 8
06/06/2006
Net 30 Days
07/06/2006
DISPATCH
House Account
1,144
Quantity UOM DescriPtion Unit Price Extended
EA WASTE OIL SERVICE CHARGE $55.00 $55.00
175 EA USED OIL/ MIXED OILS $0.00 $0.00
Sub Total
State Taxes
Gounty Taxes
Total :
$55.00
$0.00
$0.00Service Orde#: N530640 SeMce Order Date :
Manifest# : . 25060026 Manifest Date :
Notes : 4130 HORIZON LANE, SAN LUIS OBISPO, CA 9340'l
5t25t2006
REMIT PAYMENT TO:
FILE 41899
LOS ANGELES, CA 90074-{899
$55.00
For your convenience, we now accept Visa, Master Card, and American Express!
To make credit card payments please contact the Credit Department at (562) 231-1550
THANK YOU FOR YOUR BUSINESS.
Asbury Environmental Services
9302 Garfield Avenue
South Gate, CA 90280
INVOICE
SAN LUIS AMBULENCE - SAN155
PO BOX 954
SAN LUIS OBISPO, CA 93406
lnvoice # :
Date ;
PO #:
Terms :
Due Date :
Job#:
Order # :
Reference :
Salesperson
BL Batch# :
1 3008781 1
06/1 9/2006
Net 30 Days
07t19t2006
DISPATCH
'House Account
1,237
Quantity ...- .*.UOM *,.. Description -Extended.---
50 EA ETHYLENE GLYCOL SOLUTIONS $1.30 $65.00
Servlce Order#: Nb36516 Servlce Order Date:
Manifest# : 2b060047 Manifest Date :
Notes : 4130 HORIZON LANE, SAN LUIS OBISPO, CA 93401
6t9t2006
REMIT PAYMENT TO:
FILE 41899
LOS ANGELES, CA 90074-1899
Sub Total :
State Taxes :
Gounty Taxes :
Total :
$65.00
$0.00
$0.00
$65.00
For your convenience, we now accept Visa, Master Card, and American Express!
To make credit card payments please contact the Credit Department at (562) 231-1550
THANK YOU FOR YOUR BUSINESS.
*1
Asbury Environmental Services
9302 Garfield Avenue
South Gate, CA 90280
II\IVOICE
SAN LUIS AMBULENCE. SAN155
PO BOX 954
SAN LUIS OBISPO, CA 93406
BILL TO:
lnvoice # :
Date :
PO #:
Terms:
Due Date :
Job#:
Order#:
Reference :
Salesperson
BL Batch#:
1300975't 5
08t02t2006
. , Net 30 Days
09/01/2006
DISPATCH
House Account
1495
EA WASTE OIL SERVICE CHARGE $45.00 $4s.00
200 EA $0.00 $0.00USED OIL / MIXED OILS
Sub Total :
State Taxes :
CountyTaxes:
Total :
$45.00
$0.00
$0.00
Servlce Order# : Ns39146 Service Order Date :
Manifest# : 25190122 Manifest Date :
Notes : 4130 HORIZON LANE, SAN LUIS OBISPO, CA 93401
7t2012006
REMIT PAYMENT TO:
FILE 41899
LOS ANGELES, CA 90074.1899
$45.00
For your convenience, we now accept Visa, Master Card, and American Express!
To make credit card payments please contact the Gredit Department at (562) 231-1550
THANK YOU FOR YOUR BUSINESS.
Asbury Environmental Services
9302 Garfield Avenue
South Gzte, CA 90280
II\TVOICE
SAN LUIS AMBULENCE - SAN155
PO BOX 954
SAN LUIS OBISPO, CA 93406
BILL TO:
lnvoice # :
Date :
PO #:
Terms :
Due Date :
Job#:
Order # ;
Reference :
Salesperson
BL Batch# :
130102837
08t23t2006
Net 30 Days
09t22t2006
0
DISPATCH
House Account
1 658
Quantity UOM DescriPtion Unit Price Extended
55 EA ETHYLENE GLYCOL SOLUTIONS $1.ss $85.25
Sub Total
State Taxes
County Taxes
Total :
$85.25
$0.00
$0.00
Service Orde# : N536277 Service Order Date :
Manifest# : 25180236 Manifest Date:
Notes : 4130 HORIZON LANE, SAN LUIS OBISPO, CA 93401
8t15t2006
REMIT PAYMENT TO:
FILE 41899
LOS ANGELES, CA 90074.1899
$85.25
For your convenience, we now accept Visa, Master Card, and American Express!
To make credit card payments please contact the Gredit Department at (562) 231-1550
THANK YOU FOR YOUR BUSINESS.
Asbury Environmental Services
9302 Garfield Avenue
South Gate, CA 90280
II\IvOICE
SAN LUIS AMBULENCE. SAN155
PO BOX 954
SAN LUIS OBISPO, CA 93406
BILL TO:
lnvoice # :
Date:
PO#:
Terms:
Due Date :
Job#:
Order#:
Reference :
Salesperson
BL Batch#:
130103207
08t24t2006
Net 30 Days
09t23t2006
0
DISPATCH
House Account
1 666
Quantity UOM Description Unit Price Extended
1EA USED OIL AND GASOLINE FILTERS $65.00 $65.00
Service Order# : N539478 Service Order Date :
Manifest#: Manifest Date :
Notes:4130 HORIZON LANE, SAN LUIS OBISPO, CA 93401
8t17t2006
REMIT PAYMENT TO:
FILE 41899
LOS ANGELES, CA 90074-1899
Sub Total :
State Taxes :
County Taxes :
Total
$65.00
$0.00
$0.00
$65.00
For your convenience, we now accept Visa, Master Card, and American Express!
To make credit card payments please contact the Credit Department at (562) 231-1550
THANK YOU FOR YOUR BUSINESS.
t: v..
Asbury Environmental Services
9302 Garfield Avenue
South Gate, CA 90280
II{VOICE
SAN LUIS AMBULENCE - SAN155
PO BOX 954
SAN LUIS OBISPO, CA 93406
BILL TO:
lnvoice # :
Date :
PO #:
Terms :
Due Date :
Job#:
Order # :
Reference :
Salesperson
BL Batc*r#:
1 301 I 0235
09t28t2006
Net 30 Days
10t28t2006
0
DISPATCH
House Acepunt
2067
Quantity UOM DescriPtion Unit Price Extended
1EA WASTE O]L SERV'CE CHARGE $45.00 $45.00
210 EA USED OIL/ MIXED OILS $0.00 $0.00
Sub Total :
State Taxes :
County Taxes :
Total
$4s.00
$0.00
$0.00
$eMce Order#: N536405 SeMce Order Date :
Manlfest# : oOOSBS714JJK Manlfest Date :
Notes : , 4130 HORIZON LANE, SAN LUIS OBISPO, CA 93401
9t14t2006
REMIT PAYMENT TO:
FILE 41899
LOS ANGELES, CA 90074.1899
$45.00
For your convenience, we now accept Visa, Master Card, and American Express!
To make credit card payments please contact the Gredit Department at (562) 231-1550
THANK YOU FOR YOUR BUSINESS.
Asbury Environmental Services
9302 Garfield Avenue
South Gate, CA 90280
Ii\IvOICE
SAN LUIS AMBULENCE - SAN155
PO BOX 954
sAN LU|S OBTSPO, CA 93406
BILL TO:
lnvoice # :
Date :
PO #:
Terms :
Due Date :
Job #:
Order # :
Reference :
Salesperson
BL Batch#:
1 301 1 6925
10/30/2006
Net 30 Days
11t29t2006
0
DISPATCH
House Account
2383
Unit Price Extended
lEA WASTE OIL CHARGE $45.00 $45.00
2OO EA USED OIL / MIXED OILS $0.00 $o.oo
Service Order#
Manifest#
Notes:
N555308 Service Order Date : 1012012006
000S22903JJK Manifest Date :
4130 HORIZON LANE, SAN LUIS OBISPO, CA 93401
Sub Total :
State Taxes :
County Taxes :
Total :
$45.00
$0.00
$0.00
$45.00
REMIT PAYMENT TO:
FtLE 41899
LOS ANGELES, CA 90074-1899
For your convenience, we now accept Visa, Master Card, and American Express!
To make credit card payments please contact the Credit Department at (562) 231-1550
THANK YOU FOR YOUR BUSINESS. Page 1 of 1
Asbury Environmental Services
9302 Garfield Avenue
South Gate, CA 90280
INVOICE
SAN LUIS AMBULENCE - SAN155
PO BOX 954
SAN LUIS OBISPO, CA 93406
lnvoice # :
Date :
PO#:
Terms :
Due Date :
Job#:
Order # :
Reference :
Salesperson
BL Batch# :
1 301 1 8656
111O7120A6
Net 30 Days
12107t2006
U
DISPATCH
House Account
2481
. E USED OIL AND GASOLINE FILTERS $6s.00 $65.00
Sub Total
State Taxes
County Taxes
Total :
$65.00
$0.00
$0.00
Service Order# : N525327 Service Order Date :
Manifest# : .Manifest Date :
Notes : 4'130 HORIZON LANE, SAN LUIS OBISPO, CA 93401
10t26t2006
REMIT PAYMENT TO:
FtLE 41899
LOS ANGELES, CA 90074.1899
$6s.00
For your convenience, we now accept Visa, Master Card, and American Express!
To make credit card payments please contact the Credit Department at (562) 23f -1550
THA.NK YOU FOR YOUR BUSINESS.Page 1 of 1
Environmental Health Services
(805) 781-5544
P.O. Bor 1'f89
2156 Sierra Way
San Luis Obispo, CA 93406
Otyol-
san luls rgffiispo
Flre Department (805) 781-7380
2160 Santa Barbara Avenue
San Luls Obispo CA 93.101-5240
CERTIFIED UNIFIED PROGRAM AGENCY (CUPA)
HAZARDOUS MATERIALS INSPECTION FORM EFW data
entry by:1.rt
FACILITY NAME:
ADDRESS:
n
H
EHS
"'TFE
AGENCY
Routine
Reinspectlon
n Gomplaintn otner
PHONE:
PROGRAMS INSPECTED:! Buslness Plan Ftt Generator E usr El acr Ecaurnp
fl Eusiness Plan F,"Generator D usr E rcr Ecx-rnpREtNsPEcfloN REoutneo:
I H*o I YES
\'!
Date
Time:
YES NO N/AntrMnn,m.trr4
Mr n,pn n
tr
n
un
n
!
ln
\
w, i\,ffi,/l
BPOI
BPO2
Bm3
TROI
TRO2
EROl
ERO2
ATOl
AT02
BUSINESS PLAN
Business plan is complete, current, & available during inspection (HSC 25503.5, Title 19 CCR2729)
Inventory of hazardous materials is complete (HSC 25504, Title 19 CCR2729)
Site layouUfacility maps are accurate (HSC 25504;-Title 19 CCR 2729)
TRAINING PLAN
Facility has appropriate training program (Title 19 CCR2732 & 22 CCR 66265.16',
Training documentation is maintained on site for current personnel (Title 19 CCR 2732 & 22 CCR
66265.16)
EMERGENCY RESPONSE PLAN
Contingency plan is complete, updated, and maintained on site (HSC 25504, Title 19 CCR 2731 & 22
ccR $ 6626s.s3/54)
Facility is operated and maintained to prevenVminimize/mitigate fire, explosion, or release of
hazardous materialVwaste constituents to the environment. Maintains all required or appropriate
equipment including an alarm and communications system (Title 19 CCR 273f & 22 CCR 66265.31-.43)
ABOVEGROUND PETROLEUM STORAGE TANK ACT
SPCC Plan is reviewed and certified by a registered engineer within last 5 yrs. (40 CFR f f2.5(b))
SPCC Plan is maintsined on site or nearest field oflice. (HSC 25270)
COMMENTS Go to http://www.slopublichealth.org/environmentalhealth/hazardous-materials.htm. to obtain forms to comply with BP01-BP03, TROl
GPS Coordinates: Latitude: deg min-decimal min Longitude: d"" *n-decimal min
FACILITY REP:INSPECTOR:
C:\DOCU \Temp\c.lotus.notes.data\l_lnspection Form Page 1.doc 24-Jan-06
'i
:.t I
i
i")
HAZARDO
ADDRESS:',jl,'' j r'i'i"!
US WASTE GENERATOR
Total generated/month
FACILITY NAM
EPA ID NUMBER:
Tiered Permit:
Treatment
Equipment:
Lbs or gals
(average)
CA Waste oil: j/'' Solvents:
Antifreeze: ;..' ' Others:
YES NO N/AE.EE
tr
a
vrol.#
GTOl
GTO3
GTO4
GTO5
GTO6
GTOT
GTO8
GTO9
GTTO
GT11
GT12
GT13
GT14
GT15
GT16
GT17
GTTE
GT19
GT2O
GT21
GT22
GT23
EPA ID NO/PERMITS
Generator has an EPA ID number to treat, store, dispose, transport or transfer hazardous waste (Title
22CCR566262.12) If Not, Call (800) 618-6942 to obtain your CAL EPA ID number.
HAZARDOUS WASTE DETERMINATION
Hazardous waste determination conducted (Title 22 CCR $66262.11)
flown knowledge lanalysis Eother
'fiazardous waste analysis/test records are kept for at least 3 years (Title ?2 CCR $66262.40.(c))
DISPOSAL/TRANSPORTATION
Hazardous wastes were transported and/or disposed to a facility with an EPA ID NO. and permit or
authorization from DTSC (HSC $25189.5' Title 22 CCRE66262.L2)
flmilkrun Llother
Hazardous wastes are shipped with manifest (Title22 CCR $66262.20)
Manifests and/or receipts are properly completed/retained by generator for 3 years (Title 22 CCR
966263.4U 66262.23)
STORAGE AND MANAGEMENT OF CONTAINERS/TANKS
$azardous wastes are accumulated on site as follows (Title 22 CCR 566262.34)
_ E, SO days if waste generated per month is greater than or equal to lffi kg (220 lbs.)
['ttO days if waste generated per month is less than 100 kg (see note)
AZIO days if waste generated pcn month is less than 100 kg and transported more than 200 miles (see
note)
Note: Applies only if hazardous waste accumulated on site never exceeds 6000 kg(13,2fi) lbs.)and no
acutely/extremely hazardous waste over lkg(2.2|bs.) is held on site for over 90 days.
Hazardous waste "satellite" collection is managed properly (complete labeling/accumulation time/S5'gal
or l-qt limit) (Title 22CCR $66262.34(c))
Ignitabte or reactive wastes are located 15 m (50 feet) from facility's property line (Title 22 CCR
s6626s.t76)
Containers of hazardous waste are properly labeled (includes appropriate date, "HAZARDOUS
WASIE,t'waste composition/physical state, hazardous properties, name/address of generator) (Title2?
ccR $66262. 31, 66262.34',)
Containers/tanks containing hazardous wastes are in good condition/handled to minimize release or '
reaction(Title22CCR$66265.1711.191,66265.177(c))
ContainerVtankMiners are compatible with waste stored or transferred (Title22 CCR$66265.172)
Containers storing hazardous wastes are closed/sealed (Title22 CCR $66265.173)
Weekly inspection of areas where hazardous waste containers are stored is conducted
(T itle 22 C CRS 66265. I 74)
Daily inspection of all tank systems is conducted and documented (Title 22 CCR 566265.195),
Empty containers or inner liners greater than 5 gal has date when emptied and are managed properly
within one year of date emptied (Title 22 CCR $66261.7 (f))
RECYCLABLE WASTE
Used oil is managed as hazardous waste until recycled (includes proper labeling, storage, etc) (HSC
$2s2s0.4)
Used oil lilters for recycling are managed properly (drained of free flowing liquid, stored in closed
rainproof container, labeled "drained used oil filters," and transferred for metal reclamation) (Title22
ccR$ 66266.130)
Spent lead-acid batteries are being properly stored and transferred offsite under manifest or bill of
lading for recycling, reuse' or reclamation (Title22 CCR $66266.81)
Solvent$other recyclable materials are managed as hazardous wastes until recycled (Title 22 CCR
$66266.3)
SOURCE REDUCTION: For facilities generating >12,000 kg./yr. of hazardous waste on site.
Generator is subject to SB14 and has prepared and retained current source reduction documents or is
able make them available to the inspector within (5) days. (HSC s25244.19,25244.21)
Source Reduction Evaluation and Plan contains the following five elements:
certification, amounts of wastes generated, process description, block diagrams, and implementation
schedule of selected source reduction measures. (HSC 925244.19')
,tr,
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C:\DOCUME-1\Repro\LOCALS-1\Temp\c.lotus.notes.data\2--HazardousWasteGenerator.doc 20-Jul-04 20-Jul-04
l
Environmental Health Services
(805) 781-ss44
P.O.Box 1489
2156 SienaWav
San Luis Obisoo. CA 93406
CERTIFIED UNIFIED PROG
HAZARDOUS MATERIAL
Time:
fiHt$-o$$ru
Date: 02/01/2007
Fire Dspartrnent (805) 781-7380
2160 Santa Barbara Avenue
San Luis Obistro CA 93401-5240
RAM AGENCY (CUPA)
INSPECTION FORM
GPS Goordinates: Lonqtitude: 120.6658500000
YES NO N/A
8trtr
8trtr
8trtr
BPOl
BPO2
BPO3
TROl
TRO2
EROI
ERO2
ATOI
ATO2
COMMENTS Goto
GPS Coordinates: Latitude : 35.241 42O00Q0
BUSINESS PLAN
Business ptan is complete, current, available during inspection (HSC 25503.5, Title 19 CCR2729)
Inventory of hazardous materials is complete (HSC 25504, Title 19 CCR2729)
Site layout/facility maps are accurate (HSC 25504' Title 19 CCR2729)
TRAINING PLAN
Facility has appropriate training program (Title 19 CCR 2732 & 22 CCR 66265.16)
Training documentation is maintained on site for current personnel (Title 19 CCR 2732 & 22 CCR)
6626s.16
EMERGENCY RESPONSE PLAN
contingency plan is complete, updated, and maintained on site (HSC 25504, Title 19 CCR273I &22
ccR s 6626s.s3/s4)
Facility is operated and maintained to prevent/minimwelmitigap fire, explosion, or release of
hazardous materials/waste constituents to the environment. Maintains all required or appropriate
equipment including an alarm and communications system (Iitle 19 CCR 2731& 22 CCR
ABOVE GROUND PETROLEUM STORAGE TANK AGT
SPCC Plan is reviewed and certified by a registered engineer within last 5 yrs' (40 CFR 1f2'5(b))
SPCC Plan is maintained on site or nearest field office' (HSC 25270)
lo obt in foms lo comply with BP01-8P03' TRol and ER01
tr
tr
tr
tr
Facility Name: SAN LUIS AMBULANCE SERVICE Aqencv
EEHS
trCITY FIRE
lnspection Tvpe
trRoutine
trReinspection
uComplaintSite Address: 4130 HORIZON LN #B
SAN LUIS OBISPO, CA 93405
Phone
Facility lD: FA0007203
PROGRAMS INSPECTED:EHazmat EHW Generator trUST trAGT trCalARP trTPE
REINSPECTION REQUIREDT EHazmat EIHW Generator trUST T]AGT trCalARP trTPE
PERMISSION TO INSPECT: Inspections may involve obtaining photographs, reviewing and copying
records, and determining compliance with adopted codes.
GRANTED BY (NAME/TITLE): Title: TECHNICIAN Name:
INSPEGTOR: PETER HAGUE FACILITY REP GENE BOUNDS
FACILITY NAME: SAN LUIS AMBUI-ANCE SERVICE
HAZARDOUS WASTE GENERATOR
VIOL. # EPA ID NO/PERMITS
SOURCE REDUCTION:For facilities generating >12,000 kg./yr. of hazardous waste on site'
G'122 Generator is subject to SB14 and has prepared and retained current source reduction
documents or is able make them avaitable to the inspector within (5) days. (HSC $25244,19'
GT23 Source Reductioh Evaluation and Plan contains the following five elementsscertillcation,
amounts ofwastes generated, process description, block diagrams, and implementationschedule
ofselected source reduction measures' (HSC S25244.19)
ADDRESST 4130 HORIZON LN #B
sAN LUIS OBISPO, CA 93405
YES N N/A
tr
INSPECTED BY: PETER HAGUE DAtrEi02/0112007
FACILITY NAME: SAN LUIS AMBULANCE SERVICE
3
ADDRESS: 4130 HORIZON LN #B
SAN LUIS OBISPO, CA 93405
Certification: I certify under penalty of perjury that this facilify has complied with the corrective actions listed on this
inspection form.
Signature of Owner/0perator:Title:Date: _
Date: 01/18/2006
N/A
tr
tr
tr
I
Environmental Health Services
(80s) 78 l-5544
P.O.Box 1489
2156 Sierra Way
San Luis Obispo. CA 93406
BPOl
BPO2
BPO3
TROl
TRO2
EROl
ERO2
ATOl
ATO2
\,
cltyol
san u,$s o8rsp
Fire Department (805) 781-7380
2160 Santa Barbara Avenue
San Luis Obispo CA 93401-5240
CERTIFIED UNIFIED PROGRAM AGENCY (CUPA)
HAZARDOUS MATERIAL INSPECTION FORM
Time:
BUSINESS PLAN
Business plan is complete, current, available during inspection (HSC 25503.5' Title 19 CCR2729)
Inventory of hazardous materials is complete (HSC 25504, Title 19 CCR2729)
Site layout/facility maps are accurate (HSC 25504' Title 19 CCx-2729)
TRAINING PLAN
Facility has appropriate training program (Title 19 CCx-2732 & 22 CCR 66265.16)
Training documentation is maintained on site for current personnel (Title 19 CCR2732 & 22 CCR)
66265.t6
EMERGENCY RESPONSE PLAN
Contingency plan is complete, updated, and maintained on site (HSC 25504' Title 19 CCR273l & 22
ccR s 6626s.s3/s4)
Facility is operated and maintained to prevent/minimize/mitigate fire, explosion, or release of
hazardous materials/waste constituents to the environment. Maintains all required or appropriate
equipment including an alarm and communications system (Title 19 CCR 2731& 22 CCR
ABOVE GROUND PETROLEUM STORAGE TANK ACT
SPCC Plan is reviewed and certified by a registered engineer within last 5 yrs. (40 CFR I12.5(b))
SPCC Plan is maintained on site or nearest field office. (HSC 25270)
NO
tr
tr
tr
o
tr
YES
tr
tr
tr
tr
tr
tr
tr
tr
u
tr
tr
CO M M ENTS Go to t ttp,ll*.slopublichoalth.org/snvironmontelhoalth/hazardous-mat€rials.htm to obtain forms to comply with BPOI-BP03, TROI and ERO'l
GPS Coordinates: Latitude: 35.2414200000 GPS Goordinates: Longtitude: 120.6658500000
Facility Name: SAN LUIS AMBULANCE SERVICE Agencv
trEHS
trCITY FIRE
lnspection Tvpe
trRoutine
trReinspection
trComplaintSite Address: 4130 HORIZON LN #B
SAN LUIS OBISPO, CA 93405
Phone
Facility lD: FA0007203
PROGRAMS INSPECTED:trHazmat trHW Generator trUST trAGT trCalARP trTPE
REINSPECTION REQUIRED trHazmat trHW Generator trUST trAGT trCa|ARP trTPE
PERMISSION TO INSPECT: Inspections may involve obtaining photographs, reviewing and copying
records, and determining compliance with adopted codes.
GRANTED BY (NAME/TITLE): Title: Name:
INSPEGTOR: AARON LA BARRE FACILITY REP: Chris Javine
FACILITY NAME: SAN LUtS A1(BULANCE SERVTCE
l
HAZARDOUS WASTE GENERATOR
ADDRESS 4130 HORIZON LN #B
SAN LUIS OBISPO, CA 93405
Lbs or gals (average)EPA II)
NUMBER:
cAL000286112 Total generated/month
Waste Oil:
Antifreeze:
Solvents:
Others:
YES NO N/A VIOL. #tr tr GT01
tr GT03
tr GTO4
E GTO5
D GTO6
tr GT07
tr cros
EPA ID NO/PERMITS
Generator has an EPA ID number to treat, store, dispose, transport or transfer hazardous
waste (Title 22CCR$66262.12) lf not, Call (800) 618-6942 to obtain your CAL EPA ID
number
HAZARDOUS WASTE DETERMINATION
Hazardous waste determination conducted (Title22 CCR $66262.1f)
Eown knowledge Elanalysis Dother
Hazardous waste analysis/test records are kept for at least 3 years(Title 22 CCR $66262.a0.(c)
DISPOSAL/TRANSPORTATION
Hazardous wastes were transported and/or disposed to a facility with an EPA ID NO. and permit or
authorization from DTSC (HSC $25189.5,Tit\e22 CCR $66262.12)
Emilkru n AF.S Eother
Ilazardous wastes are shipped with manifest (Title 22 ccR s66262.20)
Manifests and/or receipts are properly completed/retained by generator for 3 years (Title 22 CCR
s66263.421 66262.23',t
STORAGE AND MANAGEMENT OF CONTAINERSITANKS
Hazardous wastes are accumulated on site as follows (Title22 CCR 566262'34)
tr90 days if waste generated per month is greater than or equal to 100 kg. (220 lbs.)
tr180 days if waste generated per month is less than 100 kg (see note)
tr270 days ifwaste generated per month is less than 100 kg and transported more than 200
miles (see note)
Note: Applies only if hazardous waste accumulated on site never exceeds 6000kg(13'200 lbs)
and noacutely/extremely hazardous waste over lkg Q.2lbs.) is held on site for over 90 days.
Hazardous waste "satellite" collection is managed properly (complete labeling/accumulation
time/55-sal or l-qt limit) (Title 22 CCx. $66262.34(c))
Ignitable or reactive wastes are located 15 m (50 feet) from facility's property line (Title 22
ccR $6626s.176)
Containers ofhazardous waste are properly labeled (includes appropriate
date,"HAZARDOUS WASTE," waste composition/physical state, hazardous properties,
name/address of generator) (Title 22 CCR $66262.3l, 66262.34)
Containers/tanks containing hazardous wastes are in good condition/handled to minimize the
release or reaction ('l itle 22 CCR $66265. I 7 10.19 1,66265.L7 7 (c))
Containers/tanks/liners are compatible with waste stored or transferred (Title 22 CCR
F66265.r721
Containers storing hazardous wastes are closed/sealed (Title 22 CCR $66265.173)
Weekly inspection of areas where hazardous waste containers are stored is conducted (Title 22
ccRs6626s.174)
Daily inspection of all tank systems is conducted and documented (Title 22 CCR $66265.195)
Empty containers or inner liners greater than 5 gal has date when emptied and are managed
properly within one year of date emptied (Title 22 CCR $66261.7 (f))
RECYCLABLE WASTE
Used oil is managed as hazardous waste until recycled (includes proper labeling' storage, etc)
(HSC $2s2s0.4)
Used oil filters for recycling are managed properly (drained of free flowing liquid' stored in
closed rainproofcontainer, labeled ttdrained used oil filters,t' and transferred for metal
reclamation) (Title 22 CCRS 66266.130)
Spent lead-acid batteries are being properly stored and transferred offsite under manifest or
bill of lading for recycling, reuse' or reclamation (Title 22 CCR $66266.81)
Solvents/other recyclable materials are managed as hazardous wastes until recycled (Title22
ccR a66266.3)
tr
tr
tr
tr
tr
tr
tr
tr
n
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
E GTO9
tr GT10
tr GTII
tr GTI2
tr GT13
tr GTr4
D GT15
tr GT16
tr GT17
tr tr Grls
tr tr cr19
tr tr GT20
tr tr GTzt
INSPECTED BY: AARON LA BARRE DATE: ovrgt2oo6
FACILITY NAME: SAN LUIS AMoTJLANCE SERVICE
YES
tr
tr
'l
ADDRESS: 4130 HORIZON LN #B
SAN LUIS OBISPO, CA 93405
HAZARDOUS WASTE GENERATOR
NO N/A VIOL. # EPA ID NO/PERMITS
SOURCE REDUCTION:For facilities generating >12,000 kg./yr. of hazardous waste on site.
tr tr GT22 Generator is subject to SB14 and has prepared and retained current source reduction
documents or is able make them available to the inspector within (5) days. (HSC 525244.19'
tr tr GT23 Source Reduction Evaluation and Plan contains the following five elements:certification,
amounts of wastes generated, process description, block diagrams, and implementationschedule
ofselected source reduction measures. (HSC 525244.19)
INSPECTED BY: AARON LA BARRE DATE: outt/2006
FACILITY NAME: SAN LUIS /'-?ULANCE SERVICE ADDRF^\4130 HORIZON LN #B
SAN LUIS OBISPO, CA 93405
SUMMARY OF OBSERVATIONSNIOLATIONS
No violations ofunderground storage tank, hazardous materials, or hazardous waste laws/regulations were discovered.
SLO CUPA greatly appreciates your efforts to comply with all the laws and regulations applicable to your facility.
Violations were observed/discovered as listed below. All violations must be corrected by implementing the corrective action
listed by each violation. Ifyou disagree with any ofthe violations or corrective actions required, please inform the CUPA
in writing.
ALL VIOLATIONS MUST BE CORRECTED WITHIN 30 DAYS OR AS SPECIFIED. CUPA must be informed in
writing with a certification that compliance has been achieved. A false statement that compliance has been achieved is a
violation of the law and punishable by a fine of not less than $2,000 or more than $25,000 for each violation. Your facility
may be reinspected any time during normal business hours.
You may request a meeting with the Program Manager to discuss the inspection findings and/or the proposed corrective
actions. The issuance of this Summary of Violations does not preclude the CUPA from taking administrative, civil, or
criminal action.
FACILITY NAME: SAN LUIS AMBULANCE SERVICE ADDRESS: 4130 HORIZON LN #B
SAN LUIS OBISPO, CA 93405
PE NO
VIOLATIONS
VIOL. NO VIOL. TYPE CORRECTIVE ACTION REQUIRED
INSPECTION COMMENTS:
On site with Frank Kelton todav. All items have been complied with.
INSPECTED BY: AARON LABARRE
DATE: out\tzoo6
NAME OF FACILITY REP: Chris Javine
SIGNATURE OF FACILITY REP:
Certification: I certify under penalty of perjury that this facility has complied with the corrective actions listed on this
inspection form.
Signature of Owner/Operator:Title:Date:
Environmental Health Services
(805) 781 -5544
P.O. Box 1489
2156 Sierra Way
San Luis Obispo, CA 93406
Date: /z- /45
gHtff"n,,po
Fire Department (805) 781-7380
2160 Santa Barbara Avenue
San Luis Obispo CA 93401-5240
CERTIFIED UNIFIED PROGRAM AGENCY (CUPA)
HAZARDOUS MATERIALS INSPECTION FORM EFW data
entry by:
ADDRESS:
FACILITY NAME:
e Reinspection
Complaint
Other
utineEHS
AG DEPT
CITY FIRE
PHONE:! acr flcnmnp{n* Generator n usr.Z-Business PlanPROGRAMS INSPEGTED:
n usr n rcr Icnmnen Business Plan I nw Generator- NO rx VeS'--\REINSPECTION REQUIRED:
PERMISSION TO INSPEGT: lnspections may involve obtaining photographs'reviewino andA,-iuo ""ru3ii:r?'^"odetermininq compliance with adopted codes. GRANTE D BY (NAME/TITLE):
Time:
N/An
Itnn
F
NOtr
H
H
t
YESInn
TT
tr
BPOl
BPO2
BPO3
TROl
TRO2
EROl
RR02
ATOl
ATO2
BUSINESS PLAN
Business plan is complete, current, & available during inspection (HSC 25503.5, Title 19 CCR2JZ9)
Inventory of hazardous materials is complete (HSC 25504, Title 19 CCR2729)
Site layouUfacility maps are accurate (IISC 25504' Title 19 CCR2729)
TRAINING PLAN
Facility has appropriate training program (Title 19 CCR2732 & 22 CCR 66265.16)
Training documentation is maintained on site for current personnel (Title 19 CCR2732 & 22 CCR
66265.16)
EMERGENCY RESPONSE PLAN
Contingency plan is complete, updated, and maintained on site (HSC 25504' Title 19 CCR273L & 22
ccR s 66265.s31s4)
Facitity is operated and maintained to prevenUminimize/mitigate fire, explosion, or release of
hazardous materials/waste constituents to the environment. Maintains all required or appropriate
equipment including an alarm and communications system (Title 19 CCR 2731 & 22 CCR 66265.31-
.43\
ABOVEGROUND PETROLEUM STORAGE TANK ACT
SPCC Plan is reviewed and certified by a registered engineer within last 5 yrs. (40 CFR 112.5(b))
SPCC Plan is maintained on site or nearest field office. (HSC 25270)
c
COMMENTS GotO
e
GPS Coordinates:
to obtain to comply with BP01-BP03, TR01 and ER01
FACILITY REP:
v-U l/VL-s
CT
mtn
INSPECTOR:
C:\DOCUME-1\fiepro\LOCA[S-1\Temp\c.lotus.noies.daia\'l*lnspection Form Page 1.doc 13'Jun-05
mln
FACILITY NAME L ADDRESS
HAZARDOUS WASTE GENERATOR
L,A
Lbs or gals
(average)EPA ID NUMBER:
Tiered Permit:
Treatment
Equipment:
E]CESw lcnser lcr lrnn Waste oil:
Antifreeze:
Total generated/month:
Solvents:
Others:
YES NO N/AZ, E- E E-
VIOL.#
GTOl
GTO3
GT04
GTO5
GTO6
GTOT
GTOS
GTO9
GTlO
GT11
GT12
GT13
GT14
GT15
GT16
GTIT
GTI8
GT19
GT20
GT2I
GT22
GT23
EPA ID NO/PERMITS
Generator has an EPA ID number to treat, store, dispose, transport or transfer hazardous waste (Title
22CCR566262.12) If Not, Call (800) 618-6942 to obtain your cAL EPA ID number.
HAZARDOUS WASTE DETERMINATION
Hazardous waste determination conducted (Title 22 CCR 566262.11)
Wownknowledge lanalysis nother
Hazardous waste analysis/test records are kept for at least 3 years (Title 22 CCR $66262.40.(c))
DISPOSALITRANSPORTATION
Hazardous wastes were transported and/or disposed to a facility with an EPA ID NO. and permit or
authorization from DTSC (HSC $25189.5, Title 22 CCR 966262.12)
!mitkrun nother
Hazardous wastes are shipped with manifest (Title22 CCR $66262.20)
Manifests hnd/or receipts are properly completed/retained by generator for 3 years (Title 22 CCR
866263.421 66262.23)
STORAGE AND MANAGEMENT OF CONTAINERS/TANKS
Hazardous wastes are accumulated on site as follows (Title 22 CCR $66262.34)
n gO Oays ifwaste generated per month is greater than or equal to 100 kg (220 lbs.)
n fSO days if waste generated per month is less than 100 kg (see note)
Z ZIO days if waste generated per month is less than 100 kg and transported more than 200 miles (see
note)
Note: Applies only if hazardous waste accumulated on site never exceeds 6000 kg(13,200 lbs.)and no
acutely/extremely hazardous waste over lkg(2.2 tbs.) is hetd on site for over 90 days.
Hazardous waste ,,satellite" collection is managed properly (complete labeling/accumulation time/55-gal
or l-qt limit) (Title22 CCR $66262.34(c))
Ignitable or reactive wastes are located 15 m (50 feet) from facility's property line (Title 22 CCR
s6626s.176)
Containers of hazardous waste are properly labeled (includes appropriate date, "HLZARDOUS
WASTE," waste composition/physical state, hazardous properties, narne/address of generator) (Title22
ccR $66262.3 l, 66262.34)
Containers/tanks containing hazardous wastes are in good condition/handled to minimize release or
reaction (Title 22 CCR $66265.17 ll.l9l, 66265.177 (c))
Containers/tanks/liners are compatible with waste stored or transferred (Title 22 CCR$66265.172)
containers storing hazardous wastes are closed/sealed (Title 22 CCR $66265.173)
Weekly inspection of areas where hazardous waste containers are stored is conducted
(T itre 22 C CRS66265.174)
Daily inspection of all tank systems is conducted and documented (Title 22 CCR $66265.195)
Empty containers or inner liners greater than 5 gal has date when emptied and are managed properly
within one year of date emptied (Title 22 CCR $66261.7 (f))
RECYCLABLE WASTE
Used oil is managed as hazardous waste until recycled (includes proper labeling, storage, etc) (HSC
$2s2s0.4)
Used oil filters for recycling are managed properly (drained of free flowing liquid, stored in closed
rainproof container, labeled "drained used oil filters," and transferred for metal reclamation) (Title22
ccR$ 66266.130)
Spent lead-acid batteries are being properly stored and transferred offsite under manifest or bill of
lading for recycling, reuse' or reclamation (TitleZ2 CCR $66266.81)
Solvents/othe" r."y.lublu materials are managed as hazardous wastes until recycled (Titte 22 CCR
s66266.3)
SOURCE REDUCTION: For facilities generating >12,000 kg./yr. of hazardous waste on site.
Generator is subject to SB14 and has prepared and retained current source reduction documents or is
able make them available to the inspector within (5) days. (HSC 525244.19,25244.21)
source Reduction Evaluation and Plan contains the following five elements:
certification, amounts of wastes generated, process description, block diagrams, and implementation
schedule ofselected source reduction measures. (HSC 525244.19)
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FACILITY NAME
5,L,C .
SUMMARY OF OBSERVATIONS/VIOLATIONS
l--.l No violations ofunderground storage tank, hazardous materials, or hazardous waste laws/regulations were discovered.
SLO CUPA greatly appreciates your efforts to comply with all the laws and regulations applicable to your facility.
V Violations were observed/discovered as listed below. All violations must be corrected by implementing the corrective action listedt-4) by each viotation. If you disagree with any of the violations or correctivfl"i:ivydtay: inform the CUPA in writing.
ALL VTOLATTONS MUST BE CORRECTED WTTHIN 30 DAyfdR AfSpn-clFmo. cupA must be informed in writing with a
certification that compliance has been achieved. A false statem€nt that compliance has been achieved is a violation of the law and
punishable by a fine if not less than $2,000 or more than $25,000 for each violation. Your facility may be reinspected any time
during normal business hours.
you may request a meeting with the Program Manager to discuss the inspection findings and./or the proposed corrective actions.
The issuance of this Summary of Violations does not preclude the CUPA from taking administrative, civil, or criminal action.
NUMBER MINOR CORRECTIVE ACTION REQUIRED
)
VIOLATIONS
2
MAJOR
,{xy7X
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a
COMMENTST t
lnspected
Date:
By:Facility Rep Name:
Signature:
Sign the certilication below and mail this form to the CUPA inspector after all corrective actions have been Retain a copy for r
Certification: I certify under penalty of perjury that this facitity has complied with the correctiYe actions listed on this
inspection form.
Signature of Owner/Operator:Title:Date:
I!]ASTER FIIE RECOHD {MFR} INPUTAJ.EDATE FORM *rfl ENIEnEn
K
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it
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CREATE NgrV MFR RECORD {,App. a€cned}
'SPTTIGE CURRENT MFR RECORD
RELEASFFAN CK TO PFitnf fiep attaci,ecl
CH.ANGE OF OU/NERSHIP tApp. araci:ecl
IT.IACTffETE fulFR
CLOSE (DELETE MFR
ASSIGN FEE CODE #
{;''ANGE E.CODE.=]
CFiAI\GE ELEVI # _
CHANGE RISK CATECORY
SUP. DIST. f,fl:,"
JN,iL;i
"= l\26
C}TANGE CUBRETIT MFR IIIFOfiIIIIATION TO:
FIAZARD O US IIJIATERI.AI-S SPECIFIC:
Number of,. Materials
Number of Wa,ste Su'earns -?t
Nurnber of Tanks
e ueut *nurEt>'t
6 L,-L /-
LABEL{NFo: [.]-New
Color Code
Site Aditress:
Site Name:,
[ 1 Conected
comp. #
-
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Reviewed bi gnru,an:
Supe:rvisor ' I i
Requested b1c
Dat* -
InprJf E'ftered hfi
Copy ic:
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ECCCiT-vC:-:'.CC,1iStClii!r\iFCC€::i?riEf'5CF3iS€a1E=ii-*iF=E:€C '-:*=i€
Environmental Health Services Division(805) 781-ss44P.O. Box 14892156 Sierra WaySan Luis Obispo, CA 93406TIIIS PERMIT IS ISSUED FOR TIIE FOLLOWING:FA: FA0006596BRLINDAGE-B ONE CONCRETE PUMPING4130 HORZON LN #CSAN LTIIS OBISPO, CA 93401VALID FROM DATE: 01/01/2005VALID TO DATE: 1213112005CERTIF'IED T]NIFIED PROGRAM AGENCYFire Department (805) 781-73802160 Santa Barbara AvenueSan Luis Obispo, CA 93401-5240ffiffi"ffiilspsft(l,) '.r ..{.t. .'.,;,AUTHORIZATION IS GRANTED F'OR THE FOLLOWING:0726 PROOIO3OO HAZARDOUS MATERIALS HANDLER I-4I126 PR00l030l WASTE GENERATOR (l - 5 waste streams)OWNER:BRUNDAGE-BONE CONCRETE PUMPING4130 HORZON LN #CSAN LUIS OBISPO CA 93401aCURTIS A. BATSON, RE.H.S. :DIRECTOR. ENVIRONMENTAL HEALTH SERVICESWOLFGANG KNABE, CHIEFCITY OF SAI\ LUIS OBISPO FIRE DEPARTMENTTHIS AUTHORIZATION/PERMIT TO OPERATE IS NONTRANSFERABLE AI\D MUST BE POSTED ON-SITE IN A CONSPICUOUS PLACE.THIS OPERATING PERMIT WITH ALL CONDITIONS AND ATTACIIMENTS,INCLI]DING MOIYITORING PLANS, SHALL BERETAII\-ED AT TIIE FACILITY AT ALL TIMES.
BRT]'NDAGE-B ONE CONCRETE PUMPINGPage: 2Facility Identification Number: FA0006596CERTIFIED UMFIED PROGRAM AGENCY (CUPA)PERMIT CONDITIONSIn order to maintain the Permit to Operate, the permit holder must comply with the following provisions of related laws conceming management of hazardous materials. Anyviolation of the conditions may be causefor revocation of the Permit/Authorization to Operate:a. Hazardous Materials Busindss Plan Program: California Health and Safety Code, Division 20, Chapter 6.95, Article I and Title 19 Califomia Code of Regulations.s. Hazardous Waste Generator Program: California Health and Safety Code, Division 20, Chapter 6.5, Articles 1-13, Section 25100 et seq., and Title22, California Code ofRegulations, Chapter 20.e. Aboveground Petroleum Storage Tanks (AGT) Spill Prevention Countermeasure Control (SPCC) Plans: Califomia Health and Safety Code, Division 20, Chapter 6.67 and 40The Permit to Operate is to be maintained on-site and is valid for a period of one year
Environmental Health Services Division(80t 78r-ss44P.O. Box 14892156 Sierra WaySan Luis Obispo, CA 93406TIIIS PERMIT IS ISSUED FOR TITE FOLLOWING:FACILITY: FA0006596. BRUNDAGE-BONE CONCRETE PUMPING4130 HORTZON LN #CSAN LUIS OBISPO. CA 93401VALID FROM DATE: 0110112004VALID TO DATE: 1213t12004ffiffi"o*ilspoCERTIFIED UNIFIED PROGRAM AGENCYFire Department (805) 781-73802160 Santa Barbara AvenueSan Luis Obispo, CA 93401-5240AUTHORIZATION IS GRANTED FOR THE FOLLOWING:0726 PROOIO3OO HAZARDOUS MATERIALS HANDLER 141126 PR0010301 WASTE GENERATOR (l - 5 waste streams)OWNER:BRI.'NDAGE-B ONE CONCRETE PUMPING4I3O HORZON LN #CSAN LUIS OBISPO CA 9340IIcuRTrs A. BATSON, R.E.H.S.DIRECTOR ENVIRONMENTAL IIEALTH SERVICESft(WOLFGANG KNABE, CHIEFCITY OF SAI\ LT]IS OBISPO FIRE DEPARTMENTTHIS AUTHORIZATION/PERMIT TO OPERATE IS NONTRANSFERABLE AND MUST BE POSTED ON.SITE IN A CONSPICUOUS PLACE.THIS OPERATING PERMIT WITH ALL CONDITIONS AND ATTACHMENTS,INCLUDING MONITORING PLANS, SHALL BERETAINED AT TIIE FACILITY AT ALL TIMES.
BRTINDAGE-BONE CONCRETE PUMPINGPage: 2Facility Identification Number: FA0006596CERTIFIED T]NIFIED PROGRAM AGENCY (CUPA)PERMIT CONDITIONSIn order to maintain the Permit to Operate, the permit holder must comply with the following provisions of related laws concerning management of hazardous materials. Anyviolation of the conditions may be causefor revocation of the Permit/Authorization to Operate:a.HazardousMaterialsBusinessPlanProgram: CaliforniaHealthandSafetyCode,Division20,Chapter6.g5,ArticlelandTitlelgCaliforniaCodeofRegulations.s. Hazardous Waste Generator Program: California Health and Safety Code, Division 20, Chapter 6.5, Articles l-13, Section 25100 et seq., and Title22, Califomia Code ofRegulations, Chapter 20.e. Aboveground Petroleum Storage Tanks (AGT) Spill Prevention Countermeasure Control (SPCC) Plans: California Health and Safety Code, Division2},Chapter 6.67 and40The Permit to Operate is to be maintained on-site and is valid for a period of one year
0E/28/2001 04 51 FAX
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lflUUtTvwr
\
HAZARI}OUS MATERIALS BUSINT,SS PLAN CERTIFICATION SORM
Fer Use W Uttidoes h/enbet 4te,ireF,|r ot'*lrz*.aWs,tcd bryovEL&*.1#dte4on
tWtu'nyeffi tfdhsd*Fyf,a*gttJt3.3fg;Jf ff f Wg&,
To: Agutcy Name:San Luis Obisoo Countv Environmental Health Seilicos
PCLEopI4ESSe+tunObbpo; 94i!$g-
ffixtos:tt{421t
Pursucnl to Sectlon 25503.3(c) of CrUfornia Hcdth rnd Safety Code (IISC), rhe ltutrsslour trliletashlsi
Bu rinerr Phn (IIMBP) gcdficatiou dcEcribed below is hcrEbta crhnirlrd fer tb'cfeihttb* f$Ii\
F*i*itr+lrmr
Facilig SuectAddrgs$-
Drte of Cunent HMBP:
c
4f-3"Or- F{-R*an>^.f-.[-.*..1.a f C- -'- -
I certi& thal: (Check the approprtate bix.)
{n*"pcrsonally ,r"i.*A the Hazartlous MaterialsBrxiness?lan currently on file withlyoru aggncy and
ceiliry that tht HIvtBPlS COmptcte and accwate . 6aC b:otrcm of page for details.) If this faciliry is subjeet'i
to Fedcral Emeraency Ptanning and Community Right to Know Act @TCRA) pp.orliqgre.quiremeatr,.,l
havc submitted the foltowing d6cumens with rhls Certificarion porm: tinitisd PiograeConsoiid"r.O:om)
ruPCEI Rusiness Aclivities pagE UPeE-Business. Owney'Operalor ldeilificntion.page..witb-ctr*en\
signatrue and date;llazardols MsFidslnventory $tat+mcnr+sge(s){ii$ ansdgind signiflruc; phetoeoBy i
of a*.,origi@. sump+eacb page'.for all- Exacmely Haaadous$ubsames{Dll$\
lrandled at or-aborrc"theit fedsal Tfircfuldfid'ng@itytT?Q) otJfopormds, wtiichwerisJess.
gt--
tr Revisions to the.llszaratous Matefials Business Plan are neccssary. The I{MBP as revised is complete and
accurate and is being implCrnented. A copy of the revisions has, becn electronically submined or is
enclosed with this Certification along With a siged UPCF Business Ownerlop-eretor tdcntilication-gagq
and UPCF Business Activities page if thc HMB} rcvisiotr jsslude.lbsnges-lo thF-Hazardous Mrrcrids \
lnventory.$tafenent.
OWNER/OPERATOI CERTIFICATK)N: I hereby eerti.$ undor penahy of lsw theg brued upoD.Ey
in au,iry of thos e indiriduele rcsppusihle for ohtaining. the information
rubmltted iufonnrlion is lrue, rccurrtr; rnd coughte; Ilradcrtsarl tJrel r r+viocd IIMBP
urunil*eaqlilhiE30O*ygoernf.-c.brngc bthir frsiliryl+sle;rgo+'-hildliilg.o$lrraar{araaicrialrt}rt
-+orrH,roquhalpdltiltt oF*efi il3il
Name of Orvner/Operatsr (Print):-i)r*r.ro r., ?."k-TitlEi
Pho'.:@ Sisoatil' s, == t Rl,F"D*e:
Rtv, to,Ot/ltt
conrqincd in the HMBP moit rcccnrly submined is completo, sceurnte. aod up-to'dstc; .nd. Thsrc has bcqn no chrngc in ttrc quanrlry of ury hazudous matcrial as reponed ln lhc rnosl recently submined Hazardoru Materials
- 'l1rc facility lnsrottEguntmffiguytrwdors marcriul in al{ilfBP reponab'le quantiry ihat is not cunendy listed in he
' Thc rnost recently subsdthd HMBPcsntalu Sa inbmationrcquircdny-Scuion I +022of Tirlo 42 ofrireUnited Snbrtoile; rnil
By the upper boxo this fonn, yoruercri$ingrla:
th-aaimgntFIFIBF
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tt).4")
\ {-., FoRM s-sAN LUIS oBISPo couNTY cER
BUSINBSS OWNER/OPERATOR IDENTIFICATION
TIFIED UNIFIED PROGRAI\{ AGENCY
I. IDENTIFICATION
l0:BUSINESS PHONE3
{t (';
BUSINESS NAME (same ro TACILITY NAME or DBA - Doing Busin*s Ar)
BUSINESS SITE ,C
- (--<t it,i (c:irl-
,l
[-P.. 11i z<r' ', L-:+ u' E'
CA
ZIP CODE
{ 3yc. {
105
f,;r r. Lr-lt s O D4'.
1:tt-,
104CIry
108
TORPHONEBUS
Li:;
BOPERATORNAME
L..eris C'(t
il. BUSINESS OWNER
ll2OWNER PHONEOWNERNAME
R".. ,-.Jo. a- -
!' t)tjc' u e Lf.. i tt tl, €-'i t- t-t,-
lll
rVtkl)ii.t( fr-
ll3
<\ I /rL'agOWNER MAILING ADDRESS
*c:,(LtZr-r1 Ll L-*g
115STATE
/-l(A ZIP CODE
Q3+c t
CITY
l:-'qor Lu-.s d,t5.*f.,.
l14
ilI. ENVIRONMENTAL CONTACT
118CONTACT PHONE
Fcrs StS- >'2P t-CONTACTNAME
t5')t t": g ('-,t sz L" kt.
I l'1
I l9
A(*CONTACT MAILING ADDRESS
4fct t*f-*er ?-zr !J L;+r..*re-
121STATE
Cil'
ZIP CODEcl3ye I
CITY
I;tlr. Lo*'s e {,tr'.(,
t20
o
W. EMERGENCY CONTACTS -SECONDARY--PRIMARY-
128
&'lr+y
(2.,--i"
NAME
<:*-,Jll \-J
TITLE
Srai*g_s"ilt-.:1,,"r- l,'t
NAME
TITLE
U\k
t!\4
f--r*., f.= C, a=,fA*
BUSINESS PHONEtcs 5\5 €?zY u
130
Sr,S 5.{ S :fzg G
BUSINESS PHONE 125
l3l24.HOUR PHONEt2624-HOURPHONE
PAGER # / CELL PHONE #l]2PAGER # / CELL PHONE #121
ADDITIONAL LOCALLY COLLECTED INFORMATION:lll
penalty oflarv personally examined and1theinformation,thoseof individuals responsibleonBasedmy
andbelardeveinformationthersaccurate,witlraf information*re bmitted bue,complete.5Ufamiliam
DAIE i\/i'+ L, q
I t- |
lJ4 135
.r1 I-\ l.)a
OFIGNATEDOROF
TITLE OF l3'1
rZ,€-I
naUl Of SIGVIR (p'lnr)
I\I -/( itr\r S i?r"sL
136
/o"304/ o 7ab
ilu 0
C,F\
Mr(,-\t*t/
O :\DOC UM E NT\J etfp\FORMS\B us jness P lan Forrns\FRM-S. DO ()r
Business Owner/Operator Identifi cation
Please submit the Business Activities page, the Business Owner/Operator Identification page (OES Form 2730), and Hazardous Materials - Chemical Description
pages (OES Form2731) for all hazardous materials inventory submissions. For the inventory to be considered complete
tlis page must be signed by the appropriate individual.
(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
forelectronicsubmissionandarethesatneasthenumberingusedin2T CCR,AppendixC,theBusinessSectionoftheUnifiedProgramDataDictionary.)
Pleasenumbera.ll pagesofyoursubmiftal. Thishelpsthe DepartmentofToxicSubstancesControl (DTSC)identifuwhetherthesubmittal iscompleteandifanypages
are separated,
3. BUSINESS NAME - Enter the full legal name of the business.
l. BUSINESS PHONE - Enter the phone number, area code first, and any extension.
2. BUSINESS SITE ADDRESS - Enter the street address where the facility is iocated. No post offce 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. ZP 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.
1 09. BUSINESS OPERATOR NAME - Enter the name of the business operator.
I i0. BUSINESS OPERATOR PHONE - Enter business operator phone number, if different from business phone, area code firs! ard any extension.
ll1. OWNERNAME-Enternameofbusinessovmer,ifdifferentfrombusinessoperator.
I12. OWNER PHONE - Enter the business owner's phone number if different from business phone, area code first, and any extension.
I i3. 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.
I 15. OWNER STATE - Enter the 2+haracter state abbreviation for the owner's mailing address.
I 16. OWNER ZIP CODE - Enter the zip code for the owner's address. The extra 4-digit zip may also be added.
I 17. ENVIRONMENTAL CONTACT NAME - Enter the name of the person, if different from the Business Owner or Operator, who receives all environmental
conespondence and will respond to enforcement activity.
I18. 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.
I 19. CONTACT MAILING ADDRESS - Enter the mailing address where all environmental contact conespondence shoutd be sent, if different from the site address.
120. CITY - Enter the name of the ciry for the environmental contact's mailing address.
121 . STATE - Enter the 2-character state abbreviation for the environmental contact's mailing address.
122. ZP CODE - Enter the zip code for the environmental contact's mailing address. The extra 4-digitzip 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 facilify access, site familiarity, and authorify to matr<e decisions for the business regarding incident
mitigation.
124. TITLE - Enter the title of the primary emergency contact.
125. BUSINESSPHONE-Enterthebusinessnumberfortheprimaryemergencycontact,areacodefirs!andanyextensions.
126. Z4-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. PACER NUMBER - Enter the pager number for the primary emergency contact, if available.
128. SECONDARY EMERGENCY CONTACTNAME - Enter the name of a secondary representative that can be contacted in the event that the primary emergency
contact is not available. The contact shail have FULL facility access, site familiarity, and authoriry to make decisions for the business regarding incident
mitigation.
129. TITLE - Enter the title of the secondary emergency contact.
I 30. BUSINESS PHONE - Enter the business telephone number for the secondary emergency contact, area code firs! 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 contactrs 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. (rrYYMMDD)
135. NAME OF DOCUMENT PREPARER - Enter the full name of the person who prepared the inventory submittal information.
136. NAME OF SIGNER - Enter the full printed name of the person signing the page, The signer certifies to a familiadty with the informarion submined and that
based on the signer's inquiry ofthose individuals responsible for obtaining the information, all the information submined is Eue, accurate and complete.
SIGNATURE OF OWNER/ OPERATOR OR DESIGNATED REPRESENTATIVE - The Business Owner/Operator, or officially designated representative of t6e
Owner/Operator, shall sign in the space provided. This signature certi{ies that the signer is familiar with the information submitted and that based on ttre
signer's inquiry ofthose individuals responsible for obtaining the information it is the signer's beliefthat the submitted information is true, accurate and
complete.
137. TITLE OF SIGNER - Enter the title of the person signing the page.
O:\DOCUMENT\Jefip\FORtvlS\Business Ptan Forms\FRM-S.DOC 1 1 -Dec_02
l
FORM I - SAN LUIS OBISPO COUNTY CERTIFIED UNIFIED PROGRAM AGENCY (CUPA)
CHEMICAL INVENTOR.Y
(one page per material per building or arca)
B'enn floprcre En-rvrse 200
I. FACILITY INFORMATION
BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business| "--:-.)
-{At.[- - a*-r-i-\<:r/ -.-.'
_)1 1-a,1,,-ti,-UL
CHEMICAL LOCATION
<"'l t ' .t)-.)bl1 |
r 201 CLIEMICAI LOCATION CONFIDENTIAL EPCRA 202
N YES BN6
l, ::.', I
f';;-. I
203MAP#t:FACILITY ID #
(Agency usc only)
204GRID#'2
-,)
il. CHEMICAL INFORMATION
CFIEMICAL NAME
[lr"t\v I -r. ,.in GV'cr' L I f_'t1{r,,,- dzLr.rr.r L(
205 TRADE SECRET D Yes El'fo
IfSubject to EPCRA, refer to instructions
206
COMMONNAME
i-A, i'. i "l-;.1 /.\trT-r fr<e'2",t'
I 207I 208
EHS*! Yes E+{d
E'-i'z-i t
209CAS#*If EHS is "Yes", all amounts below must be in lbs.
CODE HAZARD CLASSES (Complete if required by CIIPA)210FIRE
1t2
RADIoACTTVE Dves DNowdoro2ll
IL{ZAITDOUS IVIATERIAL TYPE
(Check one item on)y)fl a.PURE E b.]\dXTtlRE
2t3
CURIES
A6-.uqunPTrySICAISTATE E C, GASE a. SOLD(Check one item only)
214 5sLARGEST CONTAINER
215
216
E a. FIRE E b. RTACTTVE E c. PRTSSLTRE RELEASE E d-. e.CUrs rnerrH E-tfrm.OmC i[nrrnFED HAZARD CATEGORIES
(Check all that apply)
?18MAXIMUM DAILY AMOUNT
s5
ANNUAI WASTE AMOUNT
3 cr<>
2t9AVERAGE DAILY AMOLTNT
t--ra:
STATE WASIE CODE
'2;, )'3
220
y'. a. GAILONS E b. CLIBICFEET D c.POUNDS
*If EHS, amount mut be in pounds.
! o. roNs
(Check one item only)
?2t
T]NTTS'DAYS ON SITE:222
I a. ABOVE GROLIND TANK
! b, IJNDERGROLIND TANK
I c.JANK INSIDE BUiLDING
E4TSTEEL DRUM
f] i. FIBER DRTM
tr j. BAG
n k. Box
E I. CYLINDER
223
r. OTHER
q. RAIL CARo. TOTE BIN
p. TANK WAGON
Itrtrtr!tr
STORAGE
CONTA]NER
D m. GLASS BOTTLE
E n. PLASTIC BOTTLE
D e. PLASTIC/NONMETAILIC DRLjM
fl r can
s. CARBOY
h. SILO
I A. AMBIENT E b, ABOVEAI,{BIENT fl c. BELOWAMBIENTSTORAGE PRESSIJRE
224
STORAGE TEMPERAruRE E A. AMBIENT tr b, ABOVE AMBIENT E c, BELOW AMBIENT D d. CRYOGEI'IIC
I{AZARDOUS COMPONENT (For mixture or waste only)EHS96WT CAS #
-/'Ll Yes |-rlNoI€r.'f,1+'11 Lrte .-1-LJ f ,.<:L
141
LU I l-t\
EYes ENo
232270
1
231it
2f4
3
235 236
[Yes ENo
239 240
[Yes DNo
2JE
4
243
EYes nNo
244242
)
245
ADDITIONAL LOCALLY COLLECTED INFORMATION 246
If
f\/t-.
O:\DOCUMENT"rJefip\FORlvlS\Business Plan Forrns\FRM-l.DOC 1 1 -Dec-02
Form I - San Luis Obispo County Certified Unified Program Agency - Ghemical lnventory
you must complete a separate Hazardous Matenals lnventory- Chemical Description page for each hazardous material (h2'ardous substances and hazardous waste) that
you handle at your facility in aggregate quantities equal to or greater than 500 pounds, 55 gallons, 200 cubic teet of gas (calculated at standard temperature and pressure) or
ihe 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 1 0 CFR Parts 30, 40, ot 70. The completed inventory should reflect all reporlable quantities of hazardous
and storage pressure. (Note: the numbering of the instruclions follows lhe data element numbers that are on the UPCF pages. These data element numbers are used for
electroniclubmission and are lhe same as the numbering used in 27 CCR, Appendix C, the Business Sestion of the Unified Program Data Diclionary.) Please number all
pagesofyoursubmittal. ThishelpsyourCUPAorAAidenlifywhetherthesubmittal iscompleteandifanypagesareseparated.
3. BUSINESS NAME - Enter the full legal name of the business.
200. ADD/DELETE/ REVISE - lndicate if the matedal is being added to the inventory, deleted hom 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 informalion is not subject to public disclosure pursuant lo HSC
Section 25506
202. CHEMTCAL 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 contidential. lf the business does not wish to keep chemical localion information confidenlial check No.
203. MAp NUMBER - lf a map is included, enter the number of lhe map on which the location of lhe ftaza;lsss material is shown.
204. GRID NUMBER - lf grid coordinates are used, enter the grid coordinates of the map that mnespond to the location of lhe he-'rdous material. lf applicable, muliiple grid
coordinates can be listed.
20S. CHEMICAL NAME - Enter the proper chemical name associated with the Chemical Abstract Service (CAS) number of the hazardous material. This should be the
lntemational Union of Pure and Applied Chemistry (IUPAC) name found on the Material Safety Data Sheet (MSDS). NOTE: lf the chemical is a mixture, do not
complete this field; complete lhe COMMON NAME field instead.
206. TRADE SECRET - Check Yes if the intormation in lhis section is declared a kade secret, or No if it is not.
State requirement: lf yes, and business is not subject to EPCRA, disclosure of the designated trade secret information is bound by HSC Section 2551 I .
Federal requirement: lf yes, and business is subject to EPCM, disclosure of the designated Trade Secret information is bound by 40 CFR and the business must
submit a Substanliation to Accompany Claims of Trade Secrery form (40 CFR 350.27) to USEPA.
207. COMMON NAME - Enter lhe crmmon 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 detined in 40 CFR, Part 355, Appendix A. lf the material is a minure
containing an EHS, leave this section blank and complete the section on hazardous components below.
20S. CAS # - Enter the Chemical AbstEct 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. lf the mixture has no CAS number, leave lhis column blank and report lhe CAS numbers of the individual ftazafu6gg
components in the appropriate seclion below.
210. FIRE CODE HAZARD CTASSES - Fire Code Hazard Classes describe to first responders the type and level of hazardous materials which a business handles. This
information shatl 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. lf a material has more than one
applicable hr72rd class, include all. Coniact CUPA or AA for guidance.
21 1 . HAZARDOUS MATERLCL TYPE - Check the one box that best describes the type of hazardous material: pure, mixture or waste. lf waste material, check only that box.
lf mixture or waste, comPlete hazardous components section.
212. RqDIOACTIVE - Check Yes if the hazardous material is radioac{ive or No if it is not.
213.CUR|ES-lfthehazardousmaterial isradioaciive,usethisareatoreportlheactivityincuries. Youmayuseuptoninedigitswithafloatingdecimal pointtoreport
activiiy in curies.
214. PHYSICAL STATE - Check the one box lhat best describes the state in which lhe hazardous material is handled: solid, liquid or gas.
container in which the material is stored.215. LARGEST CONTAINER - Enter the total capacity of the
216. FE CATEGORIES -the and heallh hazards associated with the hazardous material.
NT - Calculate the average hazardous material or mixture containing a hazardous material,or
outside area. Calculations shall be based on the previous yeais inventory of material reported on this page. Total all daily amounts and divide by lhe number of
days the chemical will be on site. lf this is a material that has not previously been present at this localion, 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 lhat 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
adjacenUoutside area at any one time over the course of the year. This amount must conlain at a minimum last yea/s inventory of the material reported on this
pa'ge, with the reflection of additions, deletions, or revisions projected for the cunent year. This amount should be consistent with the units reported in box221.
21 9. ANNUAL WASTE AMOUNT - lf the hazardous material being inventoried is a waste, provide an estimate of the annual amount handled.
220. STATE WASTE CODE . lf the hazardous material is a waste, enter the appropriate Califomia 3-digit hazardous waste code as listed on the back of the Uniform
Hazardous Waste Manifest.
221.UNlTS-Checktheunitofmeasurethatismostappropriateforthematerial beingreportedonthispage: gallons,pounds,cubicfeetortons, NOTE:lfthematerial isa
federally delined Extremely Hazardous Substance (EHS), all amounts must be reported in pounds. lf material is a mixlure containing an EHS, report the units that
the material is stored in (gallons, pounds, cubic feet, ortons).
222. DAYS ON SITE - List the total number of days during the year that the material is on site.
223. STOMGE CONTAINER - Check all boxes that describe the type of storage containers in which the hazaldous material is stored. NOTE: lf appropriate, you may
choose more than one.
224. STOMGE PRESSURE - Check the one box that best describes the pressure at which the hazardous material is stored.
225. STORAGE TEMPEMTURE - 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 militure. lf a range of percentages is available,
reportthehighestpercentageinthatrange, (Reportformmponents2throughSin230,234,238,and242.)
227. HAZARDOUS COMPONENTS 1-5 NAME - When reporting a hazardous matedal that is a minure, list up to live 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
thanl%byweightifnon-carcinogenic,or0.l%byweightifcarcinogenic,shouldbereported. lfmorethantivehazardouscomponentsarepresentabovethese
percentages, you may attach an additional sheet of paper to capture the required information. When reporting waste miltures, mineral and chemical composition
should be listed. (Reportforcomponents 2 through 5 in 231, 235'235' and 243.)
228. HAZARDOUS COMPONENTS 1-5 EHS -CheckYes if thecomponentof the mixture isconsidered an Extremely Hazardous Substance asdefined in 40 CFR,
Part 355, or No if it is not. (Report for components 2 through 5 in 232' 236' 240' and 2M.)
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 spac€ may be used by the CUPA or AA to collect any additional information necessary to meet the requirements of their
individual programs, Contact the CUPA or AA for guidance.
7
HEALTH HATARDSPHYSICAL HATARDS
-Fire: Flammable Liquids and Solids, Combustible Liquids, Pyrophorics, qI4EeIs Acute Health (lmmecliate): Highly Toxic, Toxic, lnitants, Sensitizers, Conosives,
other hazardous chemicals with an adverse effecl with short term exoosureneactive: Unstable Reaclive, Orqanic Peroxides, Water Reactive,Radioactive
Chronic Health (Delayed): Carcinogens, other hazardous chemicals with an
adverse effect with long term exposure
pressure netease: Explosives, Compressed Gases, Blasting Agents
O:\DOCUMENT\Jeffp\FORMS\Business Plan lnstructions\Frm-i-in.doc 8-Aug-02
FORMI-SAN LUIS OBISPO COUNTY CERTIFIED UNIFIED PROGRAM AGENCY (CUPA)
CHEMICAL II{\{EI\TORY
(one page per material per building or area)
Eano EDELETE NREVISE 200
I. FACILITY INFORMATION
.'i F.*-./ Il"tr t;* .3-i ' t 1 c:. -t- rt (-
3BUSINESSBusiness As)
. , 4f
202CFIEMICAL LOCATION CONFIDENTIAL E?CRAEvss trNoCHEMICAI LOCATION 40t
f
MAP#2UGRID#
flFiii
F*r:::-l
li$FACILITY ID #
(Agcncy sc only)
II. CHEMICAL INFORMATION
TRADESECRET n Yes INo
If Subject to EPCRA, refer to instructions
206C}trMICAINAME.
hl,l Jn,r, r, .,, , *e'L 205
208
EHS*E Yes flNot.)i r (.--
201
*If EIIS is 'Yes", all amounts below must be in lbs.*/*
209CAS#
FIRE CODE HAZARD CLASSES (Complac if rcquircd bv CtjPA)210
Ev"s ffNoRADIOACTTVE
213
CURIES}IAZARDOUS MATERIAL TYPE
(Check one item only)Sa. rln-r E b. N4DrruRE Kc. wesrs
2tL
55 r.li $*- i:ii-i,';.!.{
2t5
LARGEST CONTAINERE a. soLID H,u. uQuto El c. GASPI{YSICAL STATE
(Check one item only)
d,. Tn E b. REACTTVE E c. PRESSTIRE RELEASE E d. ACI.TTE HEALTH E e. CHROMC HEALTH
zt6
FED TIAZARD CATECORIES
(Check all that apply)
STATE WASTE CODE 220zt9ANNUAL WASTE AMOUNT
"7 lr','\ r'',.:- Lt \-) v
ZIEMAXIMUMDAILY AMOUNT
Z ,ot>
zllAYERAGEDAN YAMOUNT
?) ,"
ON SITE:fl d. roNS
(Check one item only)
r. OTHER
q. RAIL CAR
I p.TANKWAGON
22l
UNTTST
lp
trtrtrn
GALLONS
E h" sLo
rlf EHS, amount Est b€ in
m.BOTTLEa. ABOVE GRO{JND TANKSTORAGE
CONTAINER EJ.BAG
E k. Box
E I. CYLINDER
f. CAN
s. CARBOY
El b.CUBICFEET E c.POUNDS
n. PLASTIC BOTTLE
o. TOTE BINf] b- UNDERGROUND TANK
D e . TANK INSIDE BUILDING
,P(. srerr onur,,r
["emrrvr Eb.ABovEArlcIENr El c.BELOWAMBIENTSTORAGE PRESSURE
{ a.*mmm E b.ABovEA}aENr E c. BELOW AMBIENT E d. CRYoGENTCSTORAGE TEMPERATURE
zzs
EHS CAS #I{AZARDOUS COMPONENT (For mixture or waste only)%wT
il,/nt 729?24
[Yes (t'to?woo{!,",,*'.'d::r.,E-tn4*elAa *ttr{iiL/' I'r, t
a6
EYes ENo
232 23323l230
2
EYes [No
236 23'7234
3
235
EYes DNo
240 24t239?38
4
245
EYes ENo
244243242
5
by wcigbt if qrcjDogcnic, tttrch additiood theE
Please S
ioforEetioD.ol plPcr
Here
morc hgrdou cooponc!t3 2rc pl*trt at gEtcr thru l% by wcigh( if
ADDITIONAI LOCALLY COLLECTED INFORMATION
v
O:\DOCUMENT\Jeffc\FORItllS\Business Plan Forms\FRII-i.DOC 1 1 -Dec-C2
Form I - San Luis Obispo Gounty Certified Unified Program Agency - Chemical lnventory
You must complete a separate Hazardous Materials lnventory - Chemical Dessiption page for each hazardous material (hazardous substances and haTardous waste) that
you handle at your facllity in aggregate quanlities 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 HaTardous Substances, whichever is less. Also complete a page for each Edioactive material handled over quantites
for which an emergency plan is required to be adopted puBuant to 10 CFR Parts 30, 40, or 70. The completed inventory should refleci all reportable quantities of hazardous
materials at your facility, reported separately fr each building or ouFide adjacent area, with separate pages for unique occunences of physical state, storage temperature
and storage pressure. (Note: the numbering of lhe instructjons follows he data element numbers lhat 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
pagesofyoursubmittal. ThishelpsyourCUPAorAAidentirywhetherthesubmittal iscompleteandifanypagesarcseparated.
3. BUSINESS NAME - Enter the tull legal name of the business.
200- ADD/DELETS REVISE - lndicate if he material is being added to the inventory, deleted from the inventory, or if he information previously submifted 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 heTirdous 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 informatjon is not subject to public disclosure pursuant to HSC
Section 25506.
202. CHEMICAL LOCATION CONFIDENTIAL - EPCRA - All businesses which are subjeci to the Emergency Planning and Community Right to Know Act (EPCRA) must
check Yes to keep chemical location information confidential. lf the business does not wish to keep chemical location informabon confidential check No.
203. MAP NUMBER - lf a map is included, enter he number of the map on which lhe location of the hazardous material is shown.
204. GRID NUMBER - lf grid coordinates are used, enter lhe grid coordinates of the map that conespond to lhe location of ttre ha7'rdous material. I applicable, multjple grid
coordinates can b€ listed.
205. CHEMICAL NAME - Enter the proper chemical name associated with the ChemicalAbst-act Service (CAS) number of the h2Tardous material. This should be the
lntemational Union of Pure and Applied Chemistry (IUPAC) name found on the Material Safety Data Sheet (MSDS). NOTE: lf the chemical is a minure, 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 lf yes, and business is not subject to EPCRA, disclosure of the designated trade se$el information is bound by HSC Section 2551 1.
Federal requirement lf 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 S€crecy form (40 CFR 350.27) to USEPA.
207. COMMON NAME - Enter lhe common name or trade name of $e ha"ardous material or mixture containing a haTardous material.
208. EHS - Check Yes if lhe hazardous material is an Extremely Hazardous Subsbnce (EHS), as defined in 40 CFR, Part 355, Appendix A, lf the material is a mixture
containing an EHS, leave this section blank and complete the section on hazardous componenis b€low.
209. CAS # - Enter the Chemical Absfact Service (CAS) number for lhe hazardous material. For mixtures, enter the CAS number of ttte mixture if it has been assigned a
number distinct from its components. lf the mixture has no CAS number, leave lhis column blank and report the CAS numbers of the individual h.?ardous
components in the appropriate section b€low.
210. FIRE CODE HAZARD CLASSES - Fire Code Haard Classes describe to first responders he type and level of hazardous materials whieh 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 iL A list of ths ilazeld classes and insbucljons
on how to determine which class a material falls under are inc.luded in the appendices of Article 80 of the Uniform Fire Code. lf a material has more than one
applicable hazard dass, include all. Conhd CUPA or AA for guidance.
211. HAZARDOUS MATERIAL TYPE - Check the one box that best describes the type of ha'erdous material: pure, mixture or lvaste. lf lvaste material, check only hat bo)c
lf mixure or waste, complete hazardous components section.
212. MDIOACTIVE - Check Yes if the ha-ardous material is radioac{ve or No if it is nol
213. CURIES - lf the ha.ardous material is radioactive, use this area lo report the activity in curies. You may us€ up to nine digits wilh a floating decimal point to report
activity in curies.
214. PHYSICAL STATE - Check he one box that best describes the sbte in which the h2Tardous material is handled: solid, liquid or gas.
21 5. LARGEST CONTAINER - Enter the lotal capacity of the container in which the material is stored.
and health h2Tards associated wlth the
avera9e amount of the hatardous material or mbdure contarning a hazardous material, in each
the number of
amount you
proiect to be on hand during the course of the year. This amount should be consistent wilh the units reported in box221 and should not exceed that of maximum
daily amount.
218. MAXIMUM DAILY AMOUNT - Enter the maximum amount of each hazardous material or mixture conbining a hazardous material, which is handled in a building or
adjacenuoutsideareaatanyonetimeoverthecourseoftheyear. Thisamountmustcontainataminimumlastyeaisinventoryofthematerial reportedonhis
page, with the reflection of additions, deletions, or revisions projected for the cunent year. This amount should be consistent with the unils reported in box 221 .
219. ANNUAL WASTE AMOUNT - lf the haTerdous material being inventoried is a waste, provide an estimate of the annual amount handled.
220. STATE WASTE CODE - lf he ha.ardous material is a waste, enter the appropriate Califomia 34igit hazardous waste code as listed on the back of the Uniform
Ha'ardous Waste Manifesl
221 . UNffs - Check the unit of measure that is most appropriate for the matedal being reported on this page: gallons, pounds, cubic feet or tons. NOTE: lf the material is a
federally defined Extremely HrTardous Substance (EHS), all amounts must be reported in pounds. lf material is a mixture containing an EHS, report the units that
the material is stored in (gallons, pounds, cubic teet, or tons).
222. DAYS ON SITE - List the tolEl number of days during the year lhat the material is on site.
223. STORAGE CONTAINER - Check all boxes that describe the type of storage containers in which the hazardous material is stored. NOTE: lf appropriate, you may
choose more than one.
224. STORAGE PRESSURE - Check the one box that best describes the pressure at which the ha"ardous material is stored.
225. STORqGE TEMPEMTURE - Check the one box lhat best describes the temperature at which the h2?ardous material is stored.
226. HAZARDOUS COMPONENTS 1-5 (% BY WEIGHT) - Enter he percentage weight of the hazardous component in a mixture. lf a lange of percenbges is available,
report the highest percentage in that range. (Report for components 2 lhrough 5 in 230, 234, 238, and 242.)
227. HAZARDOUS COMPONENTS 1-5 l.lAME - When reportjng a hazardous material lhat is a mixture, list up to five chemical names of ha'ardous components in that
mixture by percent weight (refer to MSDS or, in lhe case of t'ade secrets, refer to manuhctureo. All lazaldess mmponents in the mixure present at greatet
lJ:lanl%byweightifnon-carcinogenic,or0.l%byweightifcarcinogenic,shouldbereported. lfmorethanfivehazardouscomponenlsarepresentabovethese
perc€ntiages, 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 he component of the mixture is considered an Extremely Hazardous Substance as defined in 40 CFR,
Part35S,orNoifitisnol (Reportforcomponents2lhrough5in232,236,24o,and2M.)
229. HAZARDOUS COMPONENTS 1-5 CAS - List the Chemical Abstract Service (CAS) numbers as related to the hazardous componenls in the mixture. (Repeat for 2-5.)
246. LOCALLY COLLECTED INFORMATION - This spac€ may be used by the CUPA or AA to collect any additional information necessary to meet the requirements of their
individual programs. contactthe CUPA orAA forguidance.
outside area. Calculations shall be based on the previous yea/s inventory of material reported on this page. Total all daily amounts and divide
days the chemical will be on site. lf this is a material lhat has not previously been present at lhis location, lhe amount shall be the average daily
PHYSICAL HAZARDS HEALTH HATARDS
Fire: Flammable Liouids and Solids, Combustible Liquids, Pvrophorics, oxidizers
Reactive: Unstable Reactive, Orqanic Peroxides, water Reaclive, Radioactive
Acute Healti (lmmediate): H'ghlyToxic, Toxic, lnitants, SensitizeG, Conosives,
other hazardous chemicals wilh an adveGe effect with short term exDosure
Pressure Release: Explosives, Compressed Gases, Blasting Agents chronic Health (Delaye{l): caronogens, other hazardous chemicals with an
adverse efiect with lonq term exposure
/.l.\n^^l ll/tENlT l^4^\traDl\;1q\Q'rciaace Pl.n inc:/r'^;i^F-Itr.h i ;^ r{^^ a,A,r,
Ll
FORM I _ SAN LUIS OBISPO COUNTY CERTIFIED UNIFIED PROGRAM AGENCY (CUPA)
CHEMICAL INVENTORY
(one material b or
tlormre ERevrse
I. FACILITY INFORMATION
B USINESS NAME (Same as FACILIry NAME or DBA
,..'t - Doing Business As)3
i
V\",1. r'1 (A{r. L f i/, !'t!{s ,lr y',t'.,,L i''',,r.1 r t-
CHEMICAL LOCATION
I r':)rl
LOCATION 202
Dyes trNo
FACILITY ID #
(Agency use only)
t, .-_._ II '1: irl
lli;, ll
I l:.'.1
I MAP#203
,i
204
2
il. CHEMICAL INFORMATION
CHEMICAINAME 205
{)*{Y#sL,\
TRADESECRET I Yes Rfot 206
If Subject to EPCM, refer to instructions
COMMONNAME 207
1'^:r-' \,j ' *. .L--' I L:\Ei '
208
EHS*E Yes Etqo
CAS#209
, l"; i f':;; : '"3 *If EHS is "Yes", all amounts below must be in lbs.
FIRE CODE IIAZARD CLASSES (complere if requted by cupA)zl0
HAZARDOUS MATERI-AL TYPE { a. runr I b. MxruRE fl c. WASTE(Check one item only)RADIOACTTE Eves ffwo
2t3
CURIES
PHYSICAL STATE 214
(Check one item only)E a. SoLID I b. LIQUD fic. cAS
2t5
LARGESTCOI.TTATNER 2za
FED IIAZARD CATEGORTES I A. FIRE N b. REACTIVE }/ C. PRESSURE RELEASE E d. ACI..TTE HEALTH fI C. CHROMC HEALTH
?16
(Check all that apply)
AVERAGE DAILY AMOUNT 217'W uyo
MAXIMUM D{LYAMOUNT 2t8 ANNUAI WASTE AMOUNT 2t9 STATE WASTE CODE
UNTTS*
(Check one item only)
fl a. GAILONS Q u. cuerc rEEr E c. PoLTNDS
*If EHS, amount mut be in pounds.
I d. ToNS 221 DAYS ON SITE:
4t 4clp>
STORAGE
CONT{NER
E a. ABOVE GROUND TANK
E b. T'NDERGROUND TANK
De.i, FIBER m. GLASS BOTTLE
trtr
c, TANK INSIDE BUILDING
d. STEEL DRUM
f- CAN
g. CARBOY
n j.BAc
fl k. Box
"E'1.
cylnrnrn
E n. PLASTIC BOTTLEfl o. rOTE BIN
E p. TANK wAGoN
n r. OTHER
E q, RAIL CARE h, sILo
STORAGE PRESSLIRE E a. AMBIENT fi t. anoveewmvr fl c. BELOW AMBIENT 224
STORAGE TEMPERATURE ffa. arvonn"r E b. ABOVE AT,GIEI.I-I D c. BELOW AMBIENT I d. CRYoGEI.UC
%v/T FIAZARDOUS COMPONENT (For mixture or waste only)EHS CAS #
226
I \ i"- ', n.Jr..
I t-ri- t'u
228flYes E No "1-l t 2+L{
230
2
231
EYes DNo
233
2f4
3
235 236fl Yes flNo 231
238
4
239 240
EYes DNo
5
243 2MI Yes flNo
If more herdous components aE pEient at gE.ter th2n I 7. by weight if non-cercinogenic, or 0.attsch additional shcts pap.r the rcquired if, formrtion.
ADDITIONAL LOCALLY COLLECTED INFORMATION
Here
(.l-
I
O:\DOCUMENfrJeffp\FORMS\Business Plan Forrg*\FRM-l.DOC 1 1 -Dec-02
Form I - San Luis Obispo Gounty Certified Unified Program Agency - Chemical lnventory
you must complete a separate Hazardous Materials lnventory - chemical Description page for each hazardous material (hazardous substiances and hazardous waste) that
v* n"nai"
"t iour Facility in aggregate quantities equal to or greater than 5oo pounds, 55 gallons, 2oo cubic feet of gas (calculated at standard ternperature and pressure) or
the federal threshold planning q"riiiiV ii,i gxr.-ely Hazarooirs substances, whichever is less. Also complete a page for each radioactive material handled over quantities
ioi*r,iCrranemergenryptanis'requiiedtobeadopiedpursuanttol0cFRParts30,40,orT0. Thecompletedinventoryshouldreflectall reportablequantitiesofhazardous
and storage pressure.
-
(Note: the nlmberirig of the instrudidns 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 th'e numbering used in 27 CCR, Appendix C, the Business Section of the Unified Program Data Dictionary.) Please number all
p"d"i y"ri irUritt"t. fnir tr"tps your CUPA or AA id6ntify whether the submittal is compleie and if any pages are separated.
3. BUSINESS NAME - Enter the full legal name of the business'
200. ADD/DELETE/ REVISE - tndicate if ihe material is being added to the inventory, deleted from the inventory, or if the information previously submitted is being revised.
NOTE: you may choose lo leave this blank if you resubmit your entire inventory annually.
201. CHEMICAL LOCATION - Enter the building or outside/ adlacent arba where the hazardous material is handled. A chemical that is stored at the same pressure and
temperature, in munif te ncaton" *iinin a building, 'can be reported on a single page. NOTE: This information is not subiect to public disclosure pursuant to HSC
Section 25506.
202. CHEMICAL LOCATION CONFIDENTL\L - 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. lf the business does not wish to keep chemical localion information confidential check No.
203. MAp NUMBER - lf a map is included, enter the number of the map on which.the location of the hazardous material is shown.
ioa. cnro NUMBER - lf grid coordinates are used, enter the grid coordinates of the map that conespond to lhe location of the hazardous matedal. lf applicable, multiple grid
coordinates can be listed.
2oS. CHEMICAL NAME - Enter the proper chernical name associated with the Chemical Abstract Service (CAS) number of the hazardous material. This should be the
lntemational Union of pure and Applied chemistry (lUpAC) name found on ihe Material Safety Data Sheet (MSDS). NOTE: lf the chemical is a minure, do not
complete this field; complete the COMMON NAME field instead'
206. TRADE SeCngf - Check Yes if the information in this seclion is declared a trade secret, or No if it is not
state requirement lf yes, a;; ousiness is noi subject to EpcRA, disclosure of the designated trade secret information is bound by Hsc section 2551 1.
Federal iequirem"ni'' itl"i, i"J uusiness is suuji:,ct to EPCRA, disclosure of the designated Trade secret information is bound by 40 cFR and the business must
submit a Substantiation io Accompany Claims of Trade Secrecy form (40 CFR 350.27) to USEPA
207. COMMON NAME - Enter ihe 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. lf the material is a mixture
containing an EHS, leave this section blank and complete the seclion on hazardous components below.
209. cAS # - Enter the cnemicaienstraa Service (GAS) numbei for the hazardous material. For mixtures, enter the cAs number of the mixture if it has been assigned a
number distinct from its components. ir tne mi*ture has no cAS number, leave lhis cplumn blank and report the cAS numbers of the individual hazardous
components in the appropriate section below.
210. FIRE CODE HAZARD Cr_nssEs - Fire code Hazard classes describe to first responders the type and level of hazardous materials which a business handles. This
information snatt onty u-e prwiJeo irte jocat nre chief deems it necessary and requests the CUPA or M to collect it. A list of the hazard classes and inslruc'tions
on how to determine whiih class a mat6rial falls under are included in the appendices of Article 80 of the Uniform Fire code lf a material has more than one
applicablehazardclass,includeall. ContaclCUPAorAAforguidance rr,..^-.a-'^.A;^r ^h6211. HAZARDOUS MATERAL rypE - check the one bOX that best describes the type of hazardous material: pure, mixture or waste' lf waste material' check only that box.
lf mixture or waste, complete hazardous components seclion'
212. RADIOACTIVE - Check Yes if lhe hazardous material is radioaclive or No if it is not.
213.cuRlES-lfthehazardousmateriat isradioactive,usethisareatoreporttheactivityincuries. Youmayuseuptoninedigitswithafloatingdecimal pointtoreport
214.
215.
216.
activity in curies.
PHYSICAL STATE - Check the one box lhat best describes the slale in which the hazardous material is handled: solid, liquid or gas'
LARGEST CONTAINER - Enter the total of the largest container in which the material is stored.
associated with thealllhe
YAMOU average of the hazardous or containing a or adjacenU
outside a rea. Calculations shall be based on the previous yeads inventory of matenal reported on this page. Total all daily amounts and divide by lhe number of
days the chemical will be on site. lf 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 inboxz2l and should not exceed lhat of maximum
217
daily amount.
218. MAXIMUM DAILY AMOUNT - Enter the maximum amount of each hazardous matedal or mixture containing a hazardous material, which is handled in a building oI
adjacenyoutside area at any one time over the course of the year. This amount must contain at a minimum last yea/s invenlory of the material reported on this
pa'ge, wiflr the refleclion of idditions, deletions, or revisions p'rojected for the cunent year. This amor.rnt should be consistent with the units reported in box 221 .
219. ANNUAL-WASTE AMOUNT - lf the hazardbus material being inventoried is a waste, provide an estimate of the annual amount handled'
220- STATE WASTE CODE - lf the hazardous material is a wastel enter the appropriate califomia 3-digit hazardous waste code as listed on the back of the Uniform
Hazardous Waste Manifesl.
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: lf the material is a
federally defined Extremely Hazardous Substance (EHS), ail amounls must be reported in pounds. lf material is a mixture containing an EHS, report the units that
the material is stored in (gallons' pounds, cubic feet, or tons)'
222. DAYS ON SITE - List the toial number of days during the year that the material is on site.
223. STOMGE CONTATNER - Check all boxes ihat desiribe ihe type of storage containers in which lhe hazardous material is stored. NOTE: lf 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 lhe hazardous material is stored-
iig. ieznnoous coMpoNENls r -i ti" ev wgfGHT) - Enter the percentage weight of the hazardous component in a minure. lf a range of percentages is available,
reportthehighestpercentageinthatrange. (Reportformmponents2through5in230,234,238,and242.)
227. HAzARDouS coMpoNENTS 1-6 NAME - wtien riporting a hazaidous material that is a mixture, list up to five chemical names of hazardous components in lhat
mixture by percent weight (refer io MSDS or, in the case of trade secrets, refer lo manufacturer). All hazardous components in the mixture present at greater
than 1 % by weight ir no-n-carcinogenic, or 0,1 % by weight if carcinogenic, should be repoded. lf more than five hazardous components are present above these
percentages, you may attach an additional sheet of pa-per to capture the require-d.information. when reporting waste mixtures, mineral and chemical composition
itrouU OJ lis6d. (Report for components 2 through 5 in 231' 235' 239, and 243')
228. HA7ARD6US cOMpoNENiS 1-s EHS - check yes if t-he component of the mixture is considered an Exlremely Hazardous Substance as delined in 40 cFR,
Part355,orNoifitisnot. (Reportforcomponents2throughSin232'236,240,and2M.)
229. HAZARDOUS COMPONENTS 1-5 CAS - List the chemical Abstract service (cAS) numbers as related lo 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 lhe requirements of their
individual programs. Contact the CUPA or AA for guidance'
HEALTH HAZARDSPHYSICAL HAZARDS
ffilids, Combustible Ljquids, Pyrophorics, Oxidizers Health
oiher
lnitants,
with an adverse effecl
effec{ wilh
other anChronic
termExploslves, uotllPl esseu ud5e5 AgentsReleasePressure
O:\DOCUMENT\Jeffp\FORMS\Business Plan lnstructions\Frmli-in.doc 8-Aug-02
FORM I _ SAN LUIS OBISPO COUNTY CERTIFIED UNIFIED PROGRAM AGENCY (CUPA)
CHEMICAL II\IIIENTORY
or area)material buildi
6no flnrlrre EREVISE 200
I. FACILITY INFORMATION
BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As)
I +- rFSrq.',1*\(u4,{L dcr rrg". LSrtr:
CHEMICAL LOCATION
E YES
CONFIDENTIAL
FACILITY ID #
(Agcncy uc only)
It:'.*
t'ili
li"ri'fl Hr-s
I x03rVAP#p 2UGRID#
IL CIMMICAL INFORMATION
CHEIvIICALNAME
'-QeT\c {-€,., , ,. lJ'i !-y 1,q'4p 1i,*t-\
20s TRADESECRET EYes EI
If Subject to EPCRA, refer to instructions
206No
COMMONNAME
LUfr 'ir-e d), L-I t ,r. 6:-'(-tns
20'l
E Yes E ttoEHS*
208
N/a
I 209CAS#*If EHS is 'Yes', all amounts below must be in lbs.
FIRE CODE HAZARD CLASSES (conpldc if requir.d by cuPA)210
E a. PURE E b. I,ID{TLIRE F(c. w,+srr
ztt}IAZARDOUS MATERIAL TYPE
(Check one item only)
212.
EI v.. (NoRADIOACTIVE CI]RIES
D a, SoLID fl u. uQun E c. GAS
P}rySICAI. STA]3
(Check one item only)
zt4 55I.ARGEST CONTAINER
2t5
FED TIAZARD CATEGORIES
(Chmk all that apply)p.a. rrnr E b. REAcrrvE I c. PRESSURE RELEASE ,.k(a. ACtm rreerrn ,(.. crm.oNrc HEALTH
217AVERAGE DAILY AMOUNT56 2t8MAXIMTIM DA]LY AMOUNT
I 0',-i
2t9ANNUAL WASTE AMOUNT
/ !{t;6
STATE IYASTE CODE
'z-?- r
220
lS{. cerr-oNs E b. CUBICFEET tr c.POUNDS
*It EHS, amount mut be in pounds,
zztE d. TONS
(Check one item only)
UNTTSI DAYS ON SITE:
7-l Ea'1J\e J
223
r. OTHER
q. RAIL CAR
El n. PLASTIC BOTILE
o" TOTE BIN
p. TANK WAGON
trtr trtrtrtrntr
tri FIBERDRUM Ll rn. GI-ASS BOTTLEfl a. ABOVE GROUND TANK
Eq. STEELDRUM El l. cyLbrDER
STORAGE
CONTAINER b. UNDERGROUND TANK
c. TANK INSIDE BUILDING
j.BAG
K. BOX
! C. PLASTICNONIVIETALLIC DRUM
fl f. cAN
s. CARBOY
h. srl.o
U{arrmmrr Eb.ABovEAMBTENTSTORAGE PRESSURE E c. BELOW AMBIENT
U{*tt* E b.ABovEA}aENrSTORAGE TEMPERATURE D c. BELOWAMBIENT E d. CRYOGEMC 225
%wr F{AZARDOUS COMPONENT (For mixture or waste only)EHS CAS #
226t loo%Te+ rnle<'r,'y1'r*. *.t,r:t: r,',/igrlv.J ! Yes Eho
228 rt/*229
?30
2
231 232
flYes E No
!34
3
235 236I Yes ENo
13'l
238
4
239
! Yes ENo
240
5
243
[Yes ENo
244
cDmpontDt! .rc pEsut .a gEtcr tbr! 17. by w.ight if Don{1rcinogrnic, 0r 0.1./. by atEch additio!al !hea of pepcr qpluritrgmorc
ADDITIONAL LOCAILY COLLECTED INFORMATION 246
{L
O:\DOCUMENl,Jeffp\FORlrrlS\Business Ptan Forms\,FRf,i-i.DOC 1 1 -Dec-A2
Form t - San Luis Obispo County Certified Unified Program Agency - Ghemical lnventory
you must complete a separate Hazardous Materials lnventory - Chemical DescripUon page for each hazardous material (h2Tardous substances and ha?.rdous waste) that
you handle at your facility in aggregate quantiiles equal to or greater than 500 pounds, 55 gallons, 200 cubic feet of gas (calculated at siandard temperature and pressure) or
ihe federal tt'rirst'otO plahning quantjty for Exbemely HaTardous Substances, whichever is less. Also complete a page for each radioactve material handled over quantities
for which an emergency plan-is required to be adopied pursuant to 10 CFR Parts 30, 40, or 70. The completed inventory should reflect all reportable quantjues of hazardous
and storage pressure.
- (Note: lhe numberirig of the instructions follows the data element numbers that are on the UPCF pages. These data element numbers are used for
elecroniciu'bmission and are the same as the numbering used in 27 CCR, Appendix C, the Business Section of the Unified Progrdm Data Dic,tionary.) Please number all
pages of your submittal. This helps your CUPA or AA identiry whether the submittal is complete and if any pages are separated.
3. BUSINESS NAME - Enter the tull legal name of the business'
200. ADD/DELETS REMSE - lndicate 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 - Enier the building or outside/ adjacent area where the hazardous material is handled. A chemical that is stored at lhe same pressure and
temperature, in multjple 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. CHEMTCAL LOCATION CONFIDENTTAL - EPCRA - All businesses which are subject to the Emergencry Planning and community Right to Know Act (EPCRA) must
check yes to keep chemical location information confidential. lf the business does not wish to keep chemical locatjon information confidential check No.
203. MAp NUMBER - lf a map is included, enter lhe number of the map on which the location of the fiaza;sloss material is shown.
iol. e nf O NUMBER - lf grid bordinates are used, enter the grid coordinates of the map that corespond to the location of the hazardous material. lf applicable, multiple grid
coordinates can be listed.
205. CHEMICAL NAME - Enter the proper chemical name associated with lhe Chemical Abstract Service (CAS) number of the h2'zrdous material. This should be the
lntemational Union of pure and Applied Chemistry (IUPAC) name found on the Material Safety Data Sheet (MSDS). NOTE: lf the chemical is a mixture, do not
complete this field; complete the COMMON NAME field instead.
206. TRADE SECRFI - Check Yes if lhe infonnation in this sedion is declared a trade secret, or No if it is nol
State requirement lf yes, and business is not subject to EPCRA, disclosure of the designated trade secret information is bound by HSC Section 25511-
Fedenl iequiremenL'lf yes, and business is subjA to EPCRA, disclosure of lhe designated Trade Secret information is bound by 40 CFR and the business must
submit a Substanliation io Accompany Claims of Trade Secrecy form (40 CFR 350.24 to USEPA
207. COMMON NAME - Enter ihe common name or b.ade name of the h?'2rdous material or mixture mntiaining a hazardous material.
ioa. EFIS - Cneck yes if lhe lazrpfl6ss material is an Extremely Hazardous Substance (EHS), as defined in 40 CFR, Part 355, Appendix A. lf the material is a mixture
conlaining an EHS, leave this section blank and complete lhe section on hazardous components below.
209. CAS # - Enter ihe Chemical Abstrast Service (CAS) number fi3r the hazardous matedal. For mixtures, enter the CAS number of the mixture if it has been assigned a
number distinct ftom its components. * the mixture has no CAS number, leave this column blank and report the CAS numbers of the individual hazardous
components in the appropriate sedion belo '.
210. FIRE CODL HAZARD CUSsfs - 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 iL A list of lhe hazard class€s and instructions
on how to determine wtriitr ctass a material ialls under are included in the appendices of Article 80 of lhe Uniform Fire Code. lf a material has more than one
applicable h272rd class, include all. Contact CUPA or AA fror guidance.
21 1. HAZARbbUS MATERIAL fipE - Check the one box that best describes the type of harrrclsve rnslsrial: pure, mixture or waste. lf waste rnaterial, check only hat box
lf mixture or waste, complete hazardous componenb section.
212. RADIOACTIVE - Check Yes if the hazardous material is radioactive or No if it is nol
213. CURIES - lf lhe hazardous material is radioactive, use this area io report the activity in curies. You may use up to nine digits wilh a floaung decimal point to report
214. PHYSICAL STATE - Check
ac{vity In curies.
lhe one box that best describes the state in which the hazardous material is handled: solid, liquid or gas.
21 5. LARGEST CONTATNER - Enter lhe total capacity of the conlainer in which the material is stored.
with the hazardous216. FEDEML TEGORIES describe the
217 - Calculate avelzlge amount of lhe or mixture containing a hazardous or
outside area. Calculauons shall be based on the previous yeafs inventory of material reported on lhis page. Total all daily amounb and divide the number of
days the chemical will be on site. lf lhis is a material that has not previously been present at this location, the amount shall be he average daily amount you
proiect to be on hand during the course of lhe year. This amount should be consistent with the units reported in box221 and should not exceed that of maxmum
daily amount
218. MAXMUM DAILY AMoUNT - Enter the maximum amount of each hazardous material or mixture containing a hazardous material, which is handled in a building or
adjacenUoutside area at any one time over lhe course of the year. This amount must contain at a minimum last yea/s inventory of the material rercrted on this
paie, with the reflection of idditions, deletions, or revisions pro.iected for the cunent year. This amount should be consistent with the units reported in box 221.
219. ANNUAL-WASTE AMOUNT - lf the hazardous material being inventoried is a waste, provide an estjmate of lhe annual amount handled.
220. STATE WASTE CODE - lf the hazardous material is a wastq enter lhe appropriate Califomia 3digit haTardous waste code as listed on the back of the Uniform
HeTardous Waste Manifesl
221. UNITS - Check the unit of measure that is most appropriate fr3r lhe material being reported on this page: gallons, pounds, clbic feet or tons' NOTE: lf the material is a
federally defined F-xtiemely H"zardous Su6itance (EHS), all amounts must be reported in pounds. lf material is a mixture coniaining an EHS, report the units that
the material is stored in (gallons, pounds, cubic feet, or tons).
222. OAYS ON SITE . List the total number of days during lhe year lhat the material is on site.
223. sToRqGE CONTAINER - Check all boxes that describe ihe type of storage containers in which the hazardous material is stored. NoTE: lf appfopriate, you may
choose more than one.
224. STOMGE PRESSURE - Check the one box that best describes the pressure at which the hazardous material is stored.
225. sToMcE TEMPEMTURE - 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 percenbge weight of the hazardous component in a mixture. lf a range of percenhges is available,
report the highest percentage in that range. (Report for components 2 through 5 in 230, 2U,238, and242.)
227. l-tczARtioUS coMpoNENTS 1--5 1.1,4ME - wnlen nipoitlng a hazaidous material that is a mixture, list up to five chemical 1361s5 ef ftaza;{ous components in lhat
mixture by percent weight (refer to MSDS or, in the bse of trade secrets, refer to manufacturer). All hazardous components in he mixture present at greater
tiran 1% by weight if nin<ircinogenic, or 0.1% by weight if carcinogenic, should be reported. lf more than five haT2rdous components are present above these
percentages, you may attach an idditional street bf paper to capturi tne required informaUon. 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 coMpoNENiS 1-5 EHS - check yes if tie mmponent of the mixture is considered an Extremely Hazardous Subsbnc€ as defined in 40 cFR,
Part 355, or No if it is nol (Report for components 2 through 5 in 232, 236, 240, and 244.)
229. HAZARDOUS COMPONENTS 1-5 CAS - List lhe chemicat Abstract service (cAS) numbers as related to the haT,rdous components in the mixture. (Repeat for 2-5')
246. LOCALLY COLLECTED INFORMATTON - This space may be used by the cuPA or AA to collect any additional information necessary to meet the requirements of their
individual programs. Contac;t the CUPA or AA for guidance
HEALTH HATARDSPHYSICAL HAZARDS
an adverse efrec{ with short
Acute Health
olherWater
Chronic Health (Delayed): Carcinogens, other hrTardous chemicals with an
adverse effecl with lonq term exposure
Gases, Blastingre Release:
C:\DOCUMENTJei,io\FORMS',Business Plan lnstruciions\Frm-i-in.Ccc 8-Aug-C2
FORM I_ SAN LUIS OBISPO COUNTY CERTIFIED UNIFIED PROGRAM AGENCY (CUPA)
CHEMICAL II\\IEI{TORY
(one paee per material per building or area)
NADD flogt-ere NREVISE ?00
L FACILITY INFORMATION
BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As)
3,*,n,irr4.6 .'t1'', c (,1t;'","'" !'r'':' ,jit''(--'fi'4.1 (
l
CHEMICAL LOCATION CONFIDENTIAL EPCRA
n vEs WoCFIEMICAI LOCANON
*'r-b f
201
?03MAP#
l+irtl.'r!;::l
2D4GRID#FACILITY ID #
(Agcncy uc only)
II. CHEMICAL INFORMATION
CT{EMICAINAME
f* erl T'r' r F'.-: i-1,
205 TRADE SECRET Lf Yes F"No
IiSubject to EPCRA, refer to instructions
206
?08
EHS*nyes !Nolc.v i-'r'{6nrff
COMMON NAME 201
*If EHS is *Yes", all amounts below musl be in lbs.'-i Lr flrI L{ -. 6 ."tj - d-_
209CAS#
FIRE CODE TIAZARD CLASSES (Complac if rcqubcd by ctrPA)210
RADIOACTIVE tlYes ENo
2r3
CURIESI{AZARDOUS MATERIAL TYPE
(Check one item only){ruu fI b. }VDTTURE D c. WASTE
2Ll
fi /l<>I.ARGEST CONTAINERE a. SoLrD n b. LIQUID Et ces
zt4
PTrySICAL STATE
(Check one item only)
E ".
rrnr E b. REAcrrvE EI{. pngssunr RELEASE E d. ACtm HEALTH ! e. CHRONIC HEATfiI
2t6
FED }IAZARD CATEGORIES
(Check all tlrat apply)
2IEMAXIMUM DAILY AMOUNT
?>c:
219ANNUAL WASTE AMOUNT STATE WASTE CODE 220
'13:'
2t'7A\GRAGE DAILY AMOUNT
ll0
22l DAYS ON SITE:E d. TONSI a. GALLONS
fl j.BAG
E K, BOX
Etfn-nrorn
m.a-
fTINTIS'
one item only)
E b. CttBIC FEET E'c. POUNDS
rlf EHS, amount mut be in pounds
E f. cAN
E s. CARBOY
tr h. sn-o
223
E r. OTIIER! q. RAIL CAR
N b. UNDERGROUND TANK
E c, TANK INSIDE BIIILDING
E d. STIEL DRUM
fl n. PLASTIC BOTTLE
n o. TOIE BIN
n p. TAI{KWAGON
STORAGE
CONTAINER
E A. AMBIENT E{ESOYE A]UBTNT E C. BELOW AMBIENTSTORAGE PRESSLIRE
STORAGETEMPERATURE g{.A]VIBMTi Eb.ABOVEAI/IBE}IT I c. BELOW AMBIENT E d. CRYOGEMC
EHS CAS #%wT HAZARDOUS COMPONENT (For mixfure or waste only)
E Yes tr'd;"'l,S^ .l'{# - -lu6l lD*,gl, ,'",I, r ;-,.d i' (--
227
UYes lNo
232EI2t0
2
lYes flNo
?36 23'7
3
E5
EY.r fltto
240238
4
739
I Yes flNo
244 2.45243242
5
U mon bsrdous componatt! an prelt at Fr:icr thra 17. by wcigbt if non-urcioogcoic, or 0.1 7. by wcigbr if urcioogedic. rtt cb additioDd rhab ol p2per ce pturinE thc Eq uirtd info rmatioo,
ADDITIONAI LOCALLY COLLECTED INFORMATION
If EPCRA, PIease Siqn Here
246
v O:\DOCUMENTTJeffT\FORMS\Business Plan Forrns\FRLI-i.DOC 1 1 -Dec-A2
Form I - San Luis Obispo County Ceftified Unified Program Agency - Ghemical lnventory
You must complete a separate Hazardous Materials lnvenlory - Chemical Desqiption page for each hazardous material (heTardous substances and ha2ardous waste) that
you handle at your facility in aggregate quantiiies 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 Edioactjve material handled over quantibes
for which an emergency plan is required to be adopted pursuant to 10 CFR Parts 30, 40, or 70. The completed inventory shouid reflect all reportable quantities ef hazadsug
and storage pre-ssure- (Note: the numbering of the instsuciions follows the data element numbers lhat are on the UPCF pages. These data element numbers are used for
electronic submission and are the same as the numbenng used in 27 CCR, Appendix C, the Business Section of the Unified ProgEm Data Dictionary.) Please number all
pages of your submitial. This helps your CUPA or AA identjfy whether the submittal is complete and if any pages are separated.
3. BUSINESS NAME - Enter the tull legal name of the business.
200. ADD/DELETE/ REVISE - lndicate 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 lo leave this blank if you resubmit your entire inventory annually.
201. CHEMICAL LOCATION - Enler the building or outside/ adjacent atea where the ha-ardous material is handled. A chemical that is stored at he same pressure and
tempeiature, in multiple locations wihin a building, can be reported on a single page. NOTE: This information is not subject to public disclosure pursuant io HSC
Sestion 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 iniormation confidential. lf lhe business does not wish to keep chemical location information confidential check No.
203. MAP NUMBER - lf a map is included, enter the number of the map on which the location of ths hazadsgs material is shown.
204. GRID NUMBER - lf grid coordinates are used, enter the gdd coordinates of the map that conespond to lhe location of he hazardous matedal. lf applicable, multiple grid
coordinates can be listed.
205. CHEMICAL NAME - Enter he proper chemical name associated wilh the Chemical AbsFact Service (CAS) number of the haza1fl6ss 631s6a1. This should be the
lntemational Union of Pure and Applied Chemistry (IUPAC) name found on the Material Safety Data Sheet (MSDS). NOTE: lf the chemical is a mixture, do not
complete this field; complete the COMMON NAME field instead.
206. TMDE SECRET - Check Yes if the information in lhis section is dedared a trade secret, or No if it is noL
State requiremenl lf yes, and business is not subject to EPCM, disclosure of the designated trade secret information is bound by HSC Section 25511.
Federal requirement lf yes, and business is subjecl to EPCRA, disclosure of the designated Trade Secret informatjon is bound by 40 CFR and lhe business must
submit a Substantiatjon to Accompany Claims of Trade Secrecry form (40 CFR 350.27) to USEPA.
207. COMMON NAME - Enter the common name or trade name of the hrT2rdous material or mixture containing a h2Tardous material.
208. EHS - Check Yes if lhe haza rdous material is an Extremely Ha'ardous Substance (EHS), as defined in 40 CFR, Part 355, Appendix A. lf the material is a mixture
containing an EHS, leave this section blank and complete the section on hazardous componenb belom.
209. CAS # - Enter the Chemical AbsFact Service (CAS) number for the heT2rdous material. For mixtures, enter the CAS number of tfre mixture if it has been assigned a
number distinct from its componenb. lf 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 descdbe to first responders lhe type and level of hazardous materials which a business handles. This
information shall onty be provided if the local fire chief deems it necessary and requests lhe CUPA or AA to collect it A list of the haTard classes and instructjons
on how to determine which class a material blls under are included in the appendices of Article 80 of the Uniform Fire Code. lf 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 lraste. lf waste material, check only hat bor
lf mixture or waste, complete ha"ardous components section,
212. MDIOACTME - Check Yes if the ha7^rdous material is radioactive or No if it is nol
213. CURIES - lf the hazardous material is radioactive, use lhis area to report the aciivity in dries. You may use up lo nine digits with a floating decimal point to report
activity in curies.
214. PHYSICAL STATE - Check the one box that best describes the sbte in which the hazardous material is handled; solid, Iiquid or gas.
21 5. LARGEST CONTAINER - Enter the lotal capacity of the largest container in which the material is stored.
HAZARD CATEGORIES - C and heallh ha2ards associated with material.
AVERAGE DAILY the average material or mixture containing a material, in each
outside area. Calculations shall be based on the previous yea/s inventory of material reported on this page. Total all daily amounts and number of
days the chemical will be on site. If this is a material that has not previousty 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 lhe maximum amount of each ha'ardous material or mixture containing a hazardous material, which is handled in a building or
adjacenvoutrside area at any one time over the course of the year. This amount must contain at a minimum last yea/s inventory of the material reported on this
page,withlhereflectionofadditions,deletjons,orrevisionsprojectedforthecunentyear. Thisamountshouldbeconsistentwiththeunitsreportedinbox22l.
219. ANNUAL WASTE AMOUNT - lf the heTirdous material being inventoried is a waste, provide an estimale of lhe annual amount handled.
220. STATE WASTE CODE - lf lhe hazardous material is a waste, enter the appropriate Califomia 3-digit heTardous waste code as listed on the back of the Uniform
Hazardous Waste Manifesl
221 . UNrS - Check the unit of measure hat is most appropriate for he material being reported on this page: gallons, pounds, cubic feet or tons. NOTE: lf the material is a
federally denned Effemely Ha'ardous Substrance (EHS), all amounts must be reported in pounds. lf matenal is a mixture containing an EHS, report the units that
the material is stored in (gallons, pounds, cubic feet, or tons).
U2. OAYS ON SITE - List the total number of days during the year ihat the material is on site.
23. STORAGE CONTAINER - Check all boxes thai describe the type of storage conlainers in which the hazardous material is stored. NOTE: lf appropriate, you may
choose more than one.
224. STOMGE PRESSURE - Check the one box that best describes the pressure at which the hazardous material is stored.
225. STOMGE TEMPEMTURE - Check the one box that best describes the temperature at which the hazardous material is stored.
226. HqZARDOUS COMPONENTS 1-5 (% BY WEIGHT) - Enter the percentage weight of the hazardous component in a mixture. lf a range of percenbges is available,
report the highest percentiage in that range. (Report for components 2 through 5 in 230, 234, 238, and 242.)
227. I-IAZARDOUS COMPONENTS 1-5 MME - When reporting a hazardous material lhat is a mixture, list up to five chemical names of haTardous components in that
mixture by percent weight (refer to MSDS or, in the case of bade secrets, refer to manuhcturer). All ha'ardous mmponents in the mixfure present at greater
than 1 % by weight if non-carcinogenic, or 0.1% by weight if carcinogenic, should be reported. lf morc than five hrTrrdous components are present above these
pei'e€ntages, you may attach an additional sheet of paper to capture the required information. When reporting waste mixtures, mineral and chemical composition
should be listed. (Reportforcomponents 2 through 5in231,235,239, 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 nol (Report for componenis 2 through 5 in 232, 236, 240, and 244.)
229. HAZARDOUS COMPONENTS 1-5 CAS - List the Chemical Abstract SeNice (CAS) numbers as related to the htTardous 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 additjonal information nec€ssary to meet the requirements of their
individual prog€ms. Contact the CUPA or AA foi guidance.
PHYSICAL HATARDS HEALTH HATARDS
Fire: Flammable Liouids and Solids. Combustible Liauids. Pvroohorics, Oxidizers Acute Health (lmmediate)r Highly Toxic, Toxic, lnitants, Sensitizers, Conosives,
other ha-adous chemicals with an adverse efiec-t with short term exposureReactive: Unstable Reactive. Oroanic Peroxides, Water Reactive, Radioactive
Pressure Release: Explosives, Compressed Gases, Blastjng Agents Chronic Health (Delayed): Carcinogens, other hazardous chemicals with an
adverse effect with lonq term exoosure
O:\DOCU|viENT',Jeifo\FORliStBusiness Plan insiruciionstFrm-i-in.dcc 8-Auq-C2
,")
BO5-45A298 ?PJorr 16
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04 O1:41p BBCr
r r i r 3_ !'4I i-5 il- 9 !,F. ,r-F v u La ltusso ConcreLe Co lnc q/:iuur
San Luis Obispo Gounty Certified Unified Program Agency
FORM M - MAP GRID (s ee instructions)
Scale:1 inch Feet
MaP #
ra65qb
Jool **
/
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t-D E F G t{
A.B f ,*u"n'1
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O:\DOCUMENTUeffp\FORMS\Business Plan Foms\FRM'M DOC 12/1 1 /02
,\
FORM E
SAN LLIIS OBISPO COUNry CERTIFIED LINIFIED
PROGRAM AGENCY (CTIPA)
EMERGENCY RESPONSE PLAN
Or Hazardous Waste Contingency Plan
Date:6qI \i.
SECTION I-A: BUSINESS IDENTIFICATION DATA
.\rr*u-'?",Cu"..'.1-)
T'LLI
.i!
v\in L-
BUSINESS NAME
,t c\t
SITE ADDRESS
[z(
I /,
tL\ \-r{r Xl E L-clr.\Ll-t is
CITY
ctz G(
ZIP CODE
Lir,, [titnt -lPsrt,-,tt
{-1
FACILITY LINIT
[-(: -'t)L
TELEPHONE NLMBER
Hi,rztz-c *l L-ns-,el + c-.)cL Lri i *r a+ci
BUSINESS MAILING ADDRESS CITY ztr coDE
Ifyour businas hw a licerue or permitfrom any of thefollauing agencia, please indicaefie doctment namber.
l. Hazardous Materials
Underground Storage #
2. Hazardous Waste
Generator #
u /,,3. Air Pollution Conbol
Disnict#9c'f 'lh q Z.t
._L,lt . Lcrz 4. Responding Fio D.pj_. f&Permit# -'>t4 l-Iru.- yo'{ 5V 5^ r,'LQLc;ZVC *?.
Please provide the following information as it pertains to your business and its location. You are not required to noti$ 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 faciiity. List the name and phone number of the utiiity company.
Electric Service ?C a Telephone + f-ocl ?y 3 * Sr:c,a
Gas Service 1../A Telephone #
sanitation Sl.u.'. L...Telephone #Ecs -Svs cltr"7s"
Water District tJttq Telephone #
SECTION I-B: OWNER CERTIFICATION OF DATA (Certify either I or 2)
1. This is a EiVpW Plan IUPDATED Existing PIan. 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. tr 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 directiy to Form T, the Training Program.)
T certifli under penaily of law that the above information is tme and accurate
lJ "'r.*- F-.6C+mt-\"fu vgnt tltJat
PRINTNAME OF OWNER OR orffo*
'l',3 \(L) IL
aro*nf* "
,}.*.i-"Q.,tl
o'ote r
I cl'
*-t:
-f-i'r n . (
DOCLIN4ENTS PREPARED BY DATE
o+
SIGNATURE
1
SECTION tr: EMERGENCY RESPONSE PLANS AND PROCEDIIRES
Note: Completeall sections of this EmergencyResponse Procedure below. Use of terms such as'N/A" QtlotApplicable) will not be accepted.
A. FIRE, SPILL, OR RELEASE: The fire code requires immediate notification through dialing 911, by whoever first sights the
incidenl In the event of release or spill of hazardous materials, you must also notify:
l. San Luis Obispo County Certified Unified Program Agency during business hours @ 805-781-5544. After business hours
dial 9L1.
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 matle and also indicate their position in your company.
FORVERIF^TING TI{E DIALING OF 911:
O,.s'z-L*?8r.".^.f.. l'V\€,02
NAME POSMON
krdividual responsibie for calling San Luis Obispo County Certified Unified Program Agency and the State Office of Emergency Services:
fNormally the Emergency Coordinator of your business.)
\,ES
NAME
VL
POSmON
B. List the local emergencY medical facilities that will be used by your business in the event ofan accident or injury caused by a reiease
or release of hazardous materials.
lqrl
ADDRESSNAME
NAME
CITY
?6s- s+z- L5q.z
PHONE
PHONE
8o.s 132 ^aqa"3cL.4,tt- z-
ADDRESS
S'
CITY
C. List the Emergency Coordinator(s) at your facility.
Primary:{gai Svsg 7y 6
Secondary: 5Tfriv1 M
BUSINESS PHONE
#oS 51P,f KLtb
NAME TITLE 24 HRPHONE PAGER#
*,NLet
NAME TITLE BUSINESS PHONE 24 HRPHONE PAGER#
D. Does your business have an on-site emergency response team? fVes EF.{o Describe procedures your business will follow in the
event of a release or threatened release ofhazardous materials.
V)t(w
s ctvr vt
At ,U(acl
t ,*e - dr+t t t t1 *fl'V
,VCs (
1
E. If you have acutell' hazardous materials above threshold planning quantities, list fty 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 properfy line). List telephone numbers for all businesses; for apartrnent 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 reguiations. 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 potentiais? Inciude description of safety, storage, and containment procedures.
Ci ,... i,r'1 iL h Lt)"l L-ete lt
d.,-rui,,\.J"3i l/
c Lr Itr'iC.{ 6. C- i.J-dtt'ie cr( .'(^rl s.a ,".J.
'F4 uvr ia
2. Equipment - List the emergency response equipment at your facility (e.g. fire extinguishing systems, spill control equipment
decontamination equipment).
Item
FtzL
E
<ln
r-. A i,
he-s, l,hl-K,
Maintenance Procedure
5'F-".V t i a'
'iZa- St"*.1-
S.-+:.xz- 1 E-;ra,- d,irc\ r.e- q''rl.:-t:
3. Evacuation -- Describe how you wili immediately evacuate your facility. Where are the designated meeting locations?
What commurications or alarms are used? How will you operate these during power failure?
Use Location
lnlgr t thr.ofitaLonrvzL-
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4. Shutdown -- Describe the procedures to shutdown the facility in case of an emergency
*{- r+*' F t/\T14t -AltA-N
f*let \ Vnsutv'e -mfA'f -fhg F-LerTTl,tr-a.L .t.r,J ,f*-:*.r,r-r,rzvl't"-r\S
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des 4 h=,3,2 rr.,rWA/0
5a. Response - Describe what is done to lessen or mitigate the harm or damage done to person(s), propety, or the environmen! and to
prevent the event from getting worse or spreading. What is your immediate response to:
Fire:fl-t\Ltsn
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b. Is this facility located on a 100-year flood plain? lVes ,XINo
c. Earthquake - Identify facility areas and iist mechanical or other systems that require immediate inspection or isolation because of
their wlnerability to earthquake related ground motion.
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6. Clean-Up - How do you handle the complete process of cleaning up and disposing of hazardous material releases at your facility?
Note: Notify the Certified Unified Program Agency when clean up is
$+oft,\r\-rLL lvL Yt4
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G. Location - Your business is required to keep a copy of the Business Plan and related Material Safery Data Sheets (MSDS) on-site.
Describe where this information is located.
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4
FORM T
SAN LTIIS OBISPO COI.N{TY CERTIFIED UNIFIED
PROGRAM AGENCY (CLIPA)
EMPLOI'EE TRAINING PROGRAM Date
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
coyer familiarization with the facility's hazard communication program and Emergency Response Plan/Contingency PIan.
1. Summarize the haining for all employees that work with or come in contact with hazardous materiais/hazardous wastes. Describe how
these employees are trained to avoid exposure.
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2. Summarize training specific to those empioyees that would respond to a release or tlreatened release of hazardous materials or
hazardous waste.
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3. Indicate frequency and duration of training for employees that work with or come into contact with hazardous materials/hazardous
waste.
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4. Describe how your employees access taining materials. @.g., bulietin board, employee newsletter, staffmeetings, etc.)
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B. List person(s) in charge of training and indicate their qualifications to conduct the training.
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C. Indicate where training records are kept. @ecords must document the type of taining, duration, completion dates, names and
positions of employees receiving taining and the name of instuctor/trainer')
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cfty ofsn luls ont$po
FIRE DEPAflTMENT
?160 Sants B8rbara AvBnue' Sen Lus Obttpo, G4 El4tt-Fa4e' flfl 5 I 7Et'7480
"tir-rrnfsJ t# lcrt,lce "
VIA OVERNIGHT SERVICE, SIGNATURE REQUIRED
5t19/2009
BRUNDAGE-BONE CONCRETE PUMPING
BRUNDAGE-BONE CONCRETE PUMPING
4130 HORIZON LN #C
SAN LUIS OBISPO, CA 93401
FA#: FA0006596
FACILITY ADDRESS: 4130 HORIZON SAN LUIS OBISPO
NOTICE OF VIOLATION
Our records indicate that you have failed to conect the listed violations by the assigned
deadline date. You must take appropriate action as directed, not later than 06/03/2009, to
avoid further enforcement action. Enforcement action includes, but is not limited to, a
chargeable reinspection, administrative enforcement, and civil or criminal prosecution. Within
20 days of the date of this letter, initial each violation below that you have corrected, sign the
statement certifying compliance, and retum the signed copy to SLOFD with any requested
supporting documentation.
lf the listed violations have not been corrected, and you have not returned this form with any
requested supporting documentation by the deadline, you will be scheduled for an Office
Hearing at City Fire Station #1,2160Santa Barbara Avenue, San Luis Obispo, CA on
une 22 200 at 1:30 PM to discuss required corrective actions, timetables for completion,
and potential penalties. lf you have conected the listed violations and retumed this letter,
please call me at (805) 781-7383 to cancelthis hearing. lf you do not send in the certification
and you do not appear as scheduled, you may be assessed a fine or refened to the Office of
the District Attorney for prosecution.
,.\
)
BRUNDAGE-BONE CONCRFI C PUMPING
NOTICE OF VIOLATION
511912009
PAGE 2
Date of Violation
5t12t09
Violation Code: BP01 PE: 0762 Original Comply By Date: 5/17/og
Violation Text: BUSINESS PLAN WAS NOT COMPLETE, CURRENT ANDiOR AVAILABLE DURING
INSPECTTON
(HSC 25503.5, TITLE L9 CCR2729)
Comments: Facility to eiiirer updaie complete Business Plan or reduce chemicai inventory tielow ilueshold ievels
3 55-gallon drums of lube oil along with approx. 200 gallons of waste oil and I 55-gallon drum of waste antifreeze
are stored at the site. No labels on any of the containers indicating contents. Deadline to remove or update
documentation is 5 /3 | /09 .
Violation Correction Text: IMMEDIATELY TAKE NECESSARY ACTION TO ENSURE THAT TI{E
BUSINESS PLAN IS COMPLETE AND AVAILABLE ON SITE. IMPLEMENT A PROCEDURE TO ENSURE
THAT Trm PLAN IS UPDATED AS REQUIRED BY IIEALTH At{D SAITETY CODE SECTION 25503.5 AND
TITLE 19 CALIFORNIA CODE OF REGULATIONS SECTION 2729. FAILURE TO CORRECT THIS
VIOLATION BY TT{E DATE SPECIFIED IN THIS REPORT MAY RESULT IN CTVIL AND/OR CRIMINAL
PENALTIES OF UP TO $2,OOO PERDAY PER VIOLATION, AND/OR THE PENALTIES DESCRIBED IN TIIE
CAI{EALTF{& SAFETY CODE SECTION 25515.
Date of Violation:
5n2ta9
Violation Code: BP02 PE: 0762 Original Comply By Date: A17log
Violation Text: INVENTORY OF HAZARDOUS MATERIALS WAS NOT COMPLETE (HSC 25504, TITLE
19 CCP.2729)
Comments: Business Plan documents not updated to reflect current chemical inventory storage. Last updates
l2lIOlOT when facility was located at 4130 #C, next door.
Violation Correction Text: IMMEDIATELY COMPLETE TI{E INVENTORY OF HAZARDOUS MATERIALS
AND TMPLEMENT A PROCEDURE TO ENSURE THAT TFIE INVENTORY OF HAZARDOUS MATERIALS IS
UPDATED (AS TNVENTORY CITANGES) AS REQUTRED BY r{EALTH AND SAFETY CODE SECTION 2ss04
AND TITLE 19 CALIFORMA CODE OFREGULATIONS SECTTON2'729. FAILI]RE TO CORRECT THIS
VIOLATION BY TIIE DATE SPECIFIED IN TIIIS REPORT MAY RESULT IN CTVIL AND/OR CRIMINAL
PENALTIES OF UP TO $2,OOO PER DAY PER VIOLATION, AND/OR TI{E PENALTIES DESCRIBED IN TIIE
CA I{EALTTI & SAFETY CODE SECTION 25515.
Date of Violation:
5t12tO9
Violation Code: BP03 PE: 0762 Original Gomply By Date: 5/17/og
Violation Text: SITE LAYOUT/FACILITY MAPS ARE NOT ACCURATE (HSC 25504, TITLE 19 CCR
272e)
Comments: Business Plan map is outdated as facitty moved operations next door to an unimproved lot without
utilities.
Violation Gorrection Text: IMMEDIATELYPREPARE SITELAYOUTIFACILITYMAPS ACCORDINGTO
I{EALTH A}ID SAITETY CODE SECTION255O4 AND TTTLE 19 CALIFORMA CODE OF REGIILATIONS
SECTION 2729 OR CORRECT TIIE SITE LAYOLN/FACILITY MAPS FOR ACCURACY. FAILURE TO
CORRECT THIS VIOLATION BY TIIE DATE SPECIFIED IN THIS REPORT MAY RESULT IN CIWL AND/OR
CRIMINAL PENALTIES OF IJP TO $2,OOO PER DAY PER VIOLATION, AND/OR THE PENALTTES
DESCRIBED IN TIM CA IIEALTTI & SAFETY CODE SECTION 25515.
BRUNDAGE.BONE CONCRETE PUMPINb
NOTICE OF VIOLATION
5/1912009
PAGE 3
Date of Violation:
5t12t09
Violation Gode: ER01 PE: 0762 Original Comply By Date: 5l17log
Violation Text: CONTINGENCY PLAN IS NOT COMPLETE, KEtrI UPDATED, OR MAINTAINED ON SITE
(HSC 2s504, TITLE 19 CCF.273L TmLE 22 CCP.662s.s3ls4)
Comments: Contingenry Plan reflects site layout, exiting, and hazards of building next door before operations were
re-located to an unimproved lot next door.
Violation Correction Text: IMMEDIATELY COMPLETE. UPDATE AND MAINTAIN CONTINGENCY
PLAN ON SITE. IMPLEMENT A PROCEDURE TO ENSURE THAT TI{E CONTINGENCY PLAN IS KEPT
CURRENT AND ON SITE. FAILURE TO CORRECT THIS VIOLATION BY TT{E DATE SPECIFIED IN THIS
REPORT MAY RESULT IN CTVIL AND/OR CRIMINAL PENALTIES OF IJP TO $2,OOO PER DAY PER
VIOLATION, AND/OR TI{E PENALTIES DESCRIBED IN TI# CA IIEALTH & SAFETY CODE SECTION
255t5.
Date of Violation:
5t12t09
Viofation Code: ER02 PE: 0762 Original Comply By Date: 5l17log
Violation Text: HAZARDS OF FIRE, E)(PLOSION, ORRELEASE OF IIAZARDOUS MATERIALSAVASTE
ARE NOT MINIMIZED AND/OR EQUIPMENT TS MISSING OR IMPROPERLY MAINTAINED (TITLE 19
CCR273T, TITLE 22 CCR6625.3I-.43)
Gomments: Two open top containers were noted at the site. One contained waste oiVwater, the other contained
floor sweep contaminated with hydrocarbons and water. Additionally, there were mrmerous quart, gallon, f gallon
containers of paint related materials such as reducer, oil based paint, and latex paint. These materials are to be
properly disposed of by a hazwaste hauler or by disposal at the Small Business HazWaste Facility at Cold Canyon
Landfill - disposal receipt to be presented to SLO City Fire W 5/3I/09.
ViOIAtiON COTTection Text: IMMEDIATELY DEVELOP AN OPERATIONS AND MAINTENANCE PLAN
THAT PREVENTSA4INIMZES/]V{ITIGATES FIRE, E)(PLOSION OR RELEASE OF IIAZARDOUS WASTE TO
TI{E ENVIRONMENT, AND ENSURES TI{AT TTIE REQI]IRED EQIIIPMENT (INCLIJDING AN ALARM AND
COMMUMCATIONS SYSTEM) IS IN PLACE AND OPERATIONAL. IMPLEMENT A SYSTEM TO T'PDATE
OPERATIONS AND MAINTENANCE TO ENSURE TTMY ARE CONSISTENT WTTH CURRENT RELEASE
IIAZARDS. FAILURE TO CORRECT TFtrS VIOLATION BY TIIE DATE SPECIFIED IN THIS REPORT MAY
RESULT IN CIVIL AND/OR CRIMINAL PENALTIES OF UP TO $2,OOO PER DAY PER VIOLATION, AND/OR
TIIE PENALTIES DESCRIBED IN TIfi CA IIEALTH & SAFETY CODE SECTION 255T5.
AFTER CORRECTION. CONTACT INSPECTOR FOR A REINSPECTION TO VERIFY COMPLIANCE.
t--\
BRUNDAGE-BONE CONCREI tr PUMPING
NOTICE OF VIOLATION
511912009
PAGE 4
Date of Violation:
5t12t09
Violation Gode: TR01 PE: 0762 Original Gomply By Date: 5/17log
Violation Text: FACILITY LACKS APPROPRIATE TRAINING PROGRAM (TITLE 19 CCR 2732,TITLE 22
ccR 6626s. 16)
Comments: Annual training for employees handling hazardous materials, hazardous waste must be conducted with
topics such as personai protective equipment, safety equipment, spiii prevention anci ciean-up, an<i emergency
evacuation noted.
Violation Correction Text: IMMEDIATELY DEVELOP AN APPROPRIATE TRAINING PROGRAM AND
IMPLEMENT APROCEDURE TO ENSURE TIIAT THE TRAININGPROGRAM IS UPDATED TO INCLUDE
ANY CIIANGES IN OPERATIONS. FAILURE TO CORRECT THIS VIOLATION BY THE DATE SPECIFIED IN
TIIIS REPORT MAY RESULT iN CIVIL ANDiOR CRIMINAL PENALTIES OF UP TO $2,OOO PER DAY PER
VIOLATION, AND/OR TIIE PENALTIES DESCRIBED IN TI{E CA I{EALTH & SAFETY CODE SECTION
2s5ts.
Date of Violation
5t12tO9
Violation Code: TR02 PE: 0762 Original Comply By Date: 5l17llg
Violation Text: TRAINING DOCUMENTATION FOR CURRENT PERSONNEL IS NOT MAINTAINED ON
SITE. (ITTLE 19 CCR 2732,TYfi,8 22 C8.6626s.r6)
Comments: Documentation of employee training to be kept on site or at closest office location for review by
inspector.
Violation Correction Text: IMMEDIATELY PREPARE TRAINING DOCUMENTS ACCORDING TO TITLE
19 CALIFORNIA CODE OF REGULATIONS SECTION 2732 AND TITLE 22 CALIFORMA CODE OF
REGULATIONS SECTION 66265.16 AND LOCATETRAININGDOCUMENTATIONON SITE. FAILURETO
CORRECT THIS VIOLATION BY TIIE DATE SPECIFIED IN THIS REPORT MAY RESI]LT IN CIVIL AND/OR
CRIMINAL PENALTIES OF UP TO $2,OOO PER DAY PER VIOLATION, AND/OR TIIE PENALTIES
DESCRIBED IN TI{E CA T{EALTI{ & SAFETY CODE SECTION 25515.
Date of Violation:
5t12t09
Violation Code: GT01 PE: 1176 Original Gomply By Date: 5/17109
Violation Text: GENERATOR DOES NOT HAVE AN EPA ID NUMBER TO TREAT, STORE, DISPOSE,
TRANSPORT OR TRANSFERHAZARDOUS WASTE CITTLE 22 CCR66262.12)
Comments: Generator did not have a current EPA ID # for current location at 4130 Horizon Lane, an unimproved
lot without utilities. Obtain a Temporary EPA ID # to clean up haz. waste stored on site or obtain a permanent
number if you wish to continue operations at this site.
Violation Correction Text: IMMEDIATELY OBTAIN AN EPA ID NIJMBER TO TREAT, STORE, DISPOSE,
TRANSPORTORTRANSFERHAZARDOUS WASTE. THEFINEFORTHIS VIOLATIONIS ANINITIAL
PENALTY OF UP TO $25,000, AND TIIEN AN ADDITIONAL TWO PERCENT OF TI{E INITIAL PENALTY
PERDAY TIMREAFTER.
"l
BRUNDAGE-BONE CONCRFI tr PUMPING
NOTICE OF VIOLATION
511912009
PAGE 5
Date of Violation:
5t12tO9
Violation Gode: GT11 PE: 1176 Original Comply By Date: 5117/Og
Violation Text: CONTAINERS OFHAZARDOUS WASTE ARENOTPROPERLYLABELED (INCUDES
APPROPRI-,4.TE DATE, 'HAZARDOUS WASTE" WASTE COMPOSITION/PIIYSICAL STATE, HAZARDOUS
PROPERTIES, NAME/ADDRESS OF GENERATOR) Crr[-E 22 CCR66262.34, TITLE 22 CCR66262.31)
Comments: Waste containers were not properly labeled as to contents or with a hazardous waste label. Correct
immediately.
Violation Correction Text: IMMEDIATELYBEGIN TO PROPERLY LABEL ALL CONTAINERS OF
HAZARDOUS WASTE. IMPLEMENT APROCEDURE TO ENSURE THAT ALL CONTAINERS OF
HAZARDOUS WASTE ARE PROPERLY LABELED. TI{E FINE FOR THIS VIOLATION IS AN INITIAL
PENALTY OF UP TO $25,000, AND THEN AN ADDITIONAL TWO PERCENT OF THE IMTIAL PENALTY
PERDAY TI{EREAFTER.
Date of Violation:
5t12t09
Violation Code: GT14 PE: 1176 Original Comply By Date: 5117/Og
Violation Text: CONTAINERS HOLDING/STORINGHAZARDOUS WASTES ARENOT CLOSED/SEALED
(TTTLE 22 CCP. 6626s.r7 3)
Gomments: Two waste oil containers were noted with no lids or any way to securely store the waste oil so as to
prevent spillage. Dispose of haz. waste immediately or transfer contents to another secure container.
Violation Gorrection Text: IMMEDIATELY CLOSE AND SEAL ALL CONTAINERS HOLDING/STORING
HAZARDOUS WASTES. IMPLEMENT A PROCEDURE TO ENSURE THAT ALL HAZARDOUS WASTE
CONTAINERS WILL BE KEPT TIGHTLY CLOSED AND SEALED. TI{E FINE FOR THIS VIOLATION IS AN
INTI]I,AL PENALTY OF IIP TO $25,000, AND TI{EN AN ADDITIONAL TWO PERCENT OF TTM INTTIAL
PENALTY PER DAY TI{EREAFTER.
AFTER CORRECTION, CONTACT INSPECTOR FOR A REINSPECTION TO VERIFY COMPLIANCE.
Date of Violation:
5t12t09
Violation Code: GT16 PE: 1176 Original Gomply By Date: 5l17log
Violation Text: DAILY INSPECTION OF ALL TANK SYSTEMS IS NOT CONDUCTED AND DOCUMENTED
(TTTLE 22 CCR 6626s. 19 s)
Comments: Site is used as work load determines, so daily inspections are not conducted. Make a determination if
operations at this site will continue to generate hazardous waste, and manage site accordingly.
Violation GoTTection Text: IMMEDIATELY BEGIN INSPECTIONS AT LEAST ONCE EACH OPERATING
DAY OF ALL TANK SYSTEMS AND DOCUMENT, IN TI{E OPERATING RECORD, TI{E FOLLOWING:
OVERFILL/SPILL CONTROL EQTIIPMENT; ANY ABOVEGROUND PORTIONS OF TIIE TANK; DATA THAT
PROVES TIIE TANK SYSTEM IS OPERATING ACCORDING TO ITS DESIGN; AREA IMMEDIATELY
SIIRROIINDING EXTERNAL PORTIONS OF TI{E TANK AND SECONDARY CONTAINMENT; CATHODIC
PROTECTION SYSTEMS; AND FOR UNCOVERED TANKS, THE LEVEL OF WASTE IN T}IE TANK.
IMPLEMENT A MANAGEMENT SYSTEM TO ENSURE THAT DAILY INSPECTIONS ARE CONDUCTED
AND THAT TTIE RESULTS ARE LOGGED. TI{E FINE FOR THIS VIOLATION IS AN INMAL PENALTY OF
UP TO $25,000, AND TI{EN AN ADDMONAL TWO PERCENT OF TIIE INMAL PENALTY PER DAY
TI{EREAFTER.
,-,,
I
BRUNDAGE-BONE CONCRET E PUMPING
NOTIGE OF VIOLATION
511912009
PAGE 6
Date of Violation:
5t12t09
Violation Gode: GT18 PE: 1176 Original Comply By Date: 5l17log
Violation Text: USED OIL IS NOT MANAGED AS HAZARDOUS WASTE LINTIL RECYCLED (INCLUDES
PROPERLABELING, STORAGE, ETC.) (HSC 2s250.4)
Gomments: Used oil is not managed as a hazardous waste as noted above with storage violations'
Violation Correction Text: IMMEDIATELY MANAGE USED OIL AS A I{AZARDOUS WASTE UNTIL IT IS
RECYCLED. IMPLEMENT A PLAN TO ENSURE TTIAT USED OIL WLL CONTINUE TO BE MANAGED AS
A HAZARDOUS WASTE. TFM FINE FOR THIS VTOLATION IS AN INTIIAL PENALTY OF UP TO $25,000,
AND TT{EN AN ADDITIONAL TWO PERCENT OF T}IE INTTIAL PENALTY PER DAY THEREAFTER
AFTER CORRECTION, CONTACT INSPECTORFOR A REINSPECTION TO VERIFY COMPLIANCE.
Date of Violation:
5t1409
Violation Code: GT19 PE: 1176 OriginalGomply By Date: 5l17l0g
Violation Text: USED OIL FILTERS FORRECYCLING ARE NOT MANAGED PROPERLY (DRAINED OF
FREE FLOWING LIQUID, STORED IN CLOSED RAINPROOF CONTAINER LABELED UDRAINED USED OIL
FILTERS," AND TRANSFERRED FOR METAL RECLAMATIO}I) (TITLE 22 CCR66266.I3O)
Gomments: Filters for used oil not labeled as such.
Violation Correction Text: IMMEDIATELY BEGIN PROPERLY MANAGING USED OIL FILTERS TIIAT
ARE TO BE RECYCLED. TIIE FINE FOR THIS VIOLATION IS AN IMTIAL PENALTY OF UP TO $25,000,
AND THEN AN ADDITIONAL TWO PERCENT OF T}IE IMTIAL PENALTY PERDAY TIIEREAFTER.
AFTER CORRECTION, CONTACT INSPECTORFOR A REINSPECTION TO VERIFY COMPLIANCE.
Date of Violation
5t12109
Violation Code: GT08 PE: 1176 OriginalComply By Date: 5/17l0g
Violation Text: FIAZARDOUS WASTES WERE ACCUMULATED ON-SITE IMPROPERLY (TruLE 22 CCR
66262.34)
Comments: Accumulation of hazardous waste exceeds state limits of 90 days, 180, or 270 based on monthly total of
waste generated.
Violation Conection Text: IMMEDIATELY CIIANGE OPERATIONS SO TI{AT TIIE ON-SIE
ACCUMULATION OF IIAZARDOUS WASTE CONFORMS TO TI{E REQUIREMENTS OUTLINED IN TITLE
22 CCR 66262.34 AND IMPLEMENT A PROCEDURE TO ENSURE THAT WASTE ACCUMULATION MEETS
TIIE MINTMUM REQUIREMENTS rN TrTLE 22 CCR66262.34. Ti{E FINE FOR THIS VIOLATION IS AN
INNIAL PENALTY OF UP TO $25,000, AND TI{EN AN ADDMONAL TWO PERCENT OF TTIE INITIAL
PENALTY PER DAY THEREAFTER.
BRUNDAGE-BONE CONCRET tr PUMPING
NOTICE OFVIOLATION
lf you have questions regarding this notice, please contact me at (805) 781-7383.
511912009
PAGE 7
\F.r^*A ,r.n
D. Kerry Boyle, Hazardous Materials Coordinator
City of San Luis Obispo Fire Department
Program: SLO CITY- WASTE GENERATOR (1-5 waste streams)
I hereby certify, under penalty of law, that the initialed violations, listed above, have been
corrected. I understand that a chargeable reinspection may be eonducted to venf;r compliance
Signature Title Date
Report 9602
Environmental Health Services
(805) 781-ss44
P.O. Box 1489
2156 Sierra Way
clty
san
oI
lur rg
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s
San Luis cA 93406
San Luis Obispo CA 93'101-5240
CERTTFIED UNiFiruU rKUGr(AM AGT]NCY (CUPA)
DOUS MATERIALS INSPECTION FORM EFW data
entry by:Date:
Time
YES N/A
n
n
NO"
w,*
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@
g
Q'
n
trIn
trn
u
T
BP{I1
Bm2
BPO3
TROl
TRO2
EROl
ERO2
BUSINESS PLAN
Business plan is compleie, current, & available during inspection (HSC 25503.5, Title 19 CCR2729)
Inventory of hazardous materials is complete (HSC 25504, Title 19 CCR 2729)
Site layouUfacility maps are accurate (HSC 25504, Title 19 CCR2729)
TRAINING PLAN
Facility has appropriate training program (Title 19 CCR2732 & 22 CCR ffi265.16'l
Training documentation is maintqined on site for current personnel (Title 19 CCII2732 & 22 CCR
66265.16)
EMERGENCY RESPONSE PLAN
Contingency'plan is complete, updated, and maintained on site (HSC 25504, Title 19 CCR273I & 22
ccR $ 6626s.s3/54)
Facility is operated and maintained to prevenUminimize/mitigate fire, explosion, or release of
hazardous materials/waste constituents to the environment. Maintains all required or appropriate
equipment including an alarm and communications system (Title 19 CCR 273f & 22 CCR 66265.31-.43\
ABOVEGROUND PETROLEUM STORAGE TANK ACT
SPCC Plan is reviewed and certified by a registered engineer within last 5 yrs. (40 CFR 1f2.5(b))
SPCC Plan is maintained on site or nearest field office. (HSC 25270)
vl AT0r:--'hJ Aro2
Go to http:l/www
, {UNTAISd II T,FACILIrrr NAME: / :TLJ
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ADDRf l, /,* {Jfr 4.?t
"AGENGY,ffi
CITY FIRE
ry
Routine
Reinspection
f] ottrer
n Complaint
PHoft'E; '"'
H "* cenerator fl usr l--'l,AGT Ecer-nnpPROGRAMS INSPEGTED:Buslness Plan
E rcr flcnunptr NO trYES E Bueinese Plan & t* cenerator fl usrREINSPECTION REOUIRED:
COMMENTS .htm, to obtain forms to with BPOl-BP03 TROI andER0l
mtn
F'ACILITY REP:
GPS Coordinates: Latitude:
INSPECTOR:
E*1 ALS-1 \Temp\c. lotus. notes.data\1 ion doc 24-Jan-06
mm
1T!ar {^'61 lidi\:r'r 1 ::r'jF ^aar.--1!ri;anr lF;r.r[ Ti .1 ;:i] iJl. .l lt r
i"\ i'FACILITY NAME
EPAIDNUMBER:
Tiered Permit:
Treatment
Equipment:
HAZARDOUS WASTE
CESQT
generated/mo nth, ii/t'ii
oil: d;'/' Solvents:
Antifreeze:
Lbs or gals
(average)
YES NO., N/AnEIn
E/'!
n
n
!
un
E'
tr
tr""
un
tr
tr
E'""
#"'L
@'n
tr'-
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ntrE'""E-n nr Ern
GTO3
GT04
GTO5
GTO6
GTOT
w'"" n GTOS
GTO9
GTlO
GTl1
GT12
GT13
GT14
GTI5
GT16
GT17
GT18
GT19
! E-''
GT2O
GT21
vrol.#
GTOl
GT22
GT23
EPA ID NO/PERMITS
Generator has an EPA ID number to treat, store, dispose, transport or transfer hazardous waste (Title
22CCR566262.12) If Not, Call (800) 618-6942 to obtain your CAL EPA ID number.
HAZARDOUS WASTE DETERMINATION
Hazardous waste determination conducted (Title22 CCR 566262.11)
Ebwn knowledge flanalysis f]other i
Hazardous waste analysidtest records are kept for at least 3 years (Title 22 CCR $66262.40.(c))
DISPOSAL/TRANSPORTATION
Hazardous wastes were transported and/or disposed to a facility with an EPA ID NO. and permit or
authorization from DTSC (HSC $25189.5' Title ?2 CCR 566262.12)
lmilkrun Eother
Hazardous wastes are shipped with manifest (Title 22 CCR $66262.20)
Manifests and/or receipts are properly completed/retained by generator for 3lyears (Title 22 CCR
s66?,63.421 66262.23)
STORAGE AND MANAGEMENT OF CONTAINERS/TANKS
Hazardous wastes are accumulated on site as follows (Title22 CCR $66262.34)
E gO aays if waste generated per month is greater than or equal to 100 kg (220 lbs.)
I fSO days if waste generated per month is less than lfi) kg (see note)
I ZIO days if waste generated per month is less than 100 kg and transported more than 200 miles (see
note)
Note: Applies only if hazardous waste accumulated on site never exceeds 6fiX) kg(13'2fi] lbs.)and no
acutely/extremely hazardous waste over lkg(2.21bs.) is held on site for over 90 days.
Hazardous waste "satellite" collection is managed properly (complete labeling/accumulation time/S5-gal
or l-qt limit) (Title 22 CCx. $66262.34(c))
Ignitabte or reactive wastes are located 15 m (50 feet) from facility's property line (Title 22 CC,R
s6626s.176',)
Containers of hazardous waste are properly labeled (includes appropriate date, "IIAZARDOUS
WASTE," waste composition/physical state, hazardous properties, name/address of generator) (fitle 22
ccR $66262. 31, 66262.34)
ContainerVtanks containing hazardous wastes are in good condition/handled to minimize release or '
reaction(Title22CCR$66265.1711.191'662ri5.177(c))
ContainerVtankMiners are compatible with waste stored or transferred (Title22 CCRS66265.172)
Containers storing hazardous wastes are closed/sealed (Iitle?2 CCR S66265.f73)
Weekly inspection of areas where hazardous waste containers are stored is conducted
(Titte 22 C CR$ 66265. 1 74)
Daily inspection of all tank systems is conducted and documented (Title 22 CCR $66265.195),
Empty containers or inner liners greater than 5 gal has date when emptied and are managed properly
within one year of date emptied (Title 22 CCR 566261.7 (f))
RECYCLABLE WASTE
Used oil is managed as hazardous waste until recycled (includes proper labeling, storage' etc) (HSC
$2s2s0.4)
Used oil filters for recycling are managed properly (drained of free flowing liquid, stored in closed
rainproof container, labeled "drained used oil frlters,tt and transferred for metal reclamation) (Title22
ccRs 66266.130)
Spent lead-acid batteries are being properly stored and transferred offsite under manifest or bill of
lading for recycling, reuse, or reclamation (Title 22 CCR $66266.81)
SolventVother recyclable materials are managed as hazardous wastes until recycled (Title 22 CCR
s66266.3)
SOURCE REDUCTION: For facilities generating >12,fi)0 kg./yr. of hazardous waste on site.
Generator is subject to SB14 and has prepared and retained current source reduction documents or is
able make them available to the inspector within (5) days. (HSC 52524/,.19,2524/,.21)
Source Reduction Evaluation and Plan contains the following five elements:
certification, amounts of wastes generated, process description, block diagrams, and implementation
schedule of selected source reduction measures. (HSC 925?4.19)
trn
n
tr
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n
n
n
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C:\DOCUME-1\Repro\LOCALS-1\Temp\c.lotus.notes.data\2*Hazardous Waste Generator.doc 20-Jul-04 20-Jul-04
D
SUMMARY OR OBSERVATIONSNIOLATIONS
No violetions of underground tank, hezardous meterials, inventory, and hrzardous waste lews' reguletions, end requirements were
discovered. SLO CUPA greatly appreciates your efforts to comply with sll the laws and regulations applicable to your facility.
Violetions were observed/discovered as listed below. All violations must be corrected by implementing the corrective action listed by each
violation. If you disegree with any of thc violations or proposed action, pleese inform us in writing.
ALL VIOLATIONS MUST BE CORRECTED WITHIN 30 DAYS OR AS SPECIFIED. CUPA must be informcd in writing certifying
that comptiancc has been rchieved. A false statement that complirnce has been rchievcd is a violetion of thc hw rnd punishable by r fine
of not less then $2,(Xl0 or more then $25,000 for each violetion. Your facility may be reinspected rny time during normel business hours.
You mry rcquest a meeting with the Progrem Menegcr to discuss the inspection findings end/or proposefl corrcctive ections. The
issurnce of this Summrry of Violations does not prccludc CUPA from trking edministretive, civil, or criminel rction rs e result of the
violrtions notcd or that hrve not been corrected within the time specified.
MINOR ACTION REQUIRED
VIOLATIONS
MAJOR
i
NUMBER
4
'..,1,
.,:. i..i.
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-:-L
-
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-
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;.":
--'
' 4j:
!,:,,1
COMMENTS:
Facility Rep Name:
Signature:
Inspected By:
Date:
O:\DOCUMENT\Jeffp\FORMS\lnspection forrns\CUPA irrspection forms.doc 1 o-Sep-01
Date: 12/0912005
Environmental Health Services
(80s) 781-ss44
P.O.Box 1489
2156 Siena Way
San Luis Obispo. CA 93406
BPOI
BP02
BPO3
TROl
TRO2
EROl
ERO2
ATOl
ATO2
z-- \
)$tyst
sanlrlls ffia#w
Fire Department (805) 781-7380
2160 Santa Barbara Avenue
San Luis Obispo CA 93401-5240
CERTIFIED UNIFIED PROGRAM AGENCY (CUPA)
HAZARDOUS MATERIAL INSPECTION FORM
Time:
BUSINESS PLAN
Business plan is completg curren! available during inspection(HSC 25503.5' Title 19 CCR2729)
Inventory of hazardous materials is complete(Hsc 25504' Title 19 CCR2729)
Site layouUfacility maps are accurate(HSC 25504, Title 19 CCR2729)
TRAINING PLAN
Facility has appropriate training program (Title 19 CCR 2732 & 22 CCR 66265.16)
Training documentation is maintained on site for current personne(Title l9 CCR 2732 & 22 CCR)
66265.16
EMERGENCY RESPONSE PLAN
Contingency plan is completq updated, and maintained on site(HSC 25504, Title 19 CCR273l &22
ccR s 6626s.s31s4)
Facility is operated and maintained to prevenfminimize/mitigate fire, explosion, or release of
hazardous materialVwaste constituents to the environment Maintains all required or appropriate
equipment including an alarm and communications systern(Title 19 CCR 2731& 22 CCR
YES NO N/A
trtrtrtrtrtrtrtrtr
tr
u
tr
tr
D
tr
ABOVE GROUND PETROLEUM STORAGE TANK ACT
SPCC Plan is reviewed and certified by a registered engineer within last5 yrs. (40 CFR I12.5(b))
SPCC Plan is maintained on site or nearest field office (HSC 25270)
COMMENTS Co to f,ttp,ll*.slopublichealth.org/environmentalhealtlilhazardous-materials.htm to obtain forms to comPly with BP01-BPo3, TRO1 and ER0'l
GPS Goordinates: Latitude: 35.2415500000 GPS Goordinates: Longtitude: 120.6661100000
J
Facility Name: BRUNDAGE-BONE CONCRETE
PUMPING
Aqency
trEHS
trCITY FIRE
lnsoection Tvpe
trRoutine
trReinspection
trComplaintSite Address: 4130 HORIZON LN #C
SAN LUIS OBISPO, CA 93401
Phone: (805)545-8286
Facility lD: FA0006596
PROGRAMS INSPECTED trHazmat trHW Generator trUST trAGT trCalARP trTPE
REINSPECTION REQUIRED:trHazmat trHW Generator trUST trAGT trCalARP trTPE
PERMISSION TO INSPECT: Inspections may involve obtaining photographs, reviewing and copying
records, and determining compliance with adopted codes.
GRANTED BY (NAME/TITLE): Title: Steve May Name:
INSPECTOR: AARON LA BARRE FACILITY REP: Steve May
FACILITY NAME: BRUN DAGF\BON E CONCRETE PUMPING ADDRItS:
)
4130 HORIZON LN #C
SAN LUIS OBISPO, CA 93401
EPA ID
NUMBER:
cAL000230170
HAZARDOUS WASTE GENERATOR
Total generated/month:
Waste Oil:
Antifreeze:
Solvents:
Others:
Lbs or gals (average)
YES NO N/Atrtrtr VIOL. #
GTOl
EPA ID NO/PERMITS
Generator has an EPA ID number to treag store, dispose, transport or transfer hazardous
waste (Title 22CCRS66262.12)If not, Call (800) 618-6942 to obtain your CAL EPA ID
number
HAZARDOUS WASTE DETERMINATION
Hazardous waste determination conducted(Title 22 CCR $66262.11)
Eown knowledge Eanalysis Eother
Hazardous waste analysiVtest records are kept for at least3 years(Title 22 CCR $66262.a0'(c))
DISPOSAL/TRANSPORTATION
Hazardous wastes were transported and/or disposed to a facilify with an EPA ID NO. and permit or
authorization from DTSC (HSC $25f89.5,Titl,e22 CCR $66262.12)Emilkru@tr
Hazardous wastes are shipped with manifest (Title22 CCR $66262.20)
Manifests and/or receipts are properly completed/retained by generator for 3 years (Title 22 CCR
s66263.42t 66262.23)
STORAGE AND MANAGEMENT OF CONTAINERS/TANKS
Hazardous wastes are accumulated on site as follows(Title 22 CCR566262.34)
tr90 days if waste generated per month is greater than or equal to100 kg' (220 lbs.)
tr180 days if waste generated per month is less than 100 kg (see note)
tr270 days if waste generated per month is less than 100 kg and transported more than200
miles (see note)
Note: Applies only if hazardous waste accumulated on site never exceeds6000kg(13'200 lbs)
and noacutely/extremely hazardous waste over 1kg (2.2 lbs.) is held on site for over 90 days.
Hazardous waste "satellite" collection is managed properly(complete labeling/accumulation
time/55-gal or l-qt limit) (Title 22 CCx- $66262.34(c))
Ignitable or reactive wastes are located 15 m (50 feet) from facility's property line (Title 22
ccR $6626s.176)
Containers of hazardous waste are properly labeled(includes appropriate
date,"HAZARDOUS WASTE," waste composition/physical state, hazardous propertieg
n a m e/add ress o f gen erator) (T itle 22 CCR S66262. 31, 66262.3 4)
Containers/tanks containing hazardous wastes are in good conditiolhandled to minimize the
release o r reaction (T itle 22 CCR $66265. 17 10.19 l'66265,17 7 (c))
ContainerVtanks/liners are compatible with waste stored or transferred(Title 22 CCR
Q6626s.1721
Containers storing hazardous wastes are closedsealed (Title22 CCR S66265.173)
Weekly inspection of areas where hazardous waste containers are stored is conducted(Title 22
ccR$66265.174)
Daily inspection of all tank systems is conducted and documented(Title 22 CCR 566265'195)
Empty containers or inner liners greater than5 gal has date when emptied and are managed
properly within one year of date emptied (Title22 CCR $66261.7 (f))
RECYCLABLE WASTE
Used oil is managed as hazardous waste until recycled(includes proper labeling storage, etc)
(HSC $2s2s0.4)
Used oil filters for recycling are managed properly(drained of free flowing liquid, stored in
closed rainproofcontainer, labeled "drained used oil filters," and transferred for metal
reclamation) (Title 22 CCRS 66266.130)
Spent lead-acid batteries are being properly stored and transferred offsite under manifest or
bill of lading for recycling reuse' or reclamation ("Iitle 22 CCR $66266'81)
Solvents/other recyclable materials are managed as hazardous wastes until recycled(Title 22
ccR 066266.3)
tr
tr
tr
tr
tr
tr
tr GT03
tr GTO4
tr GTOs
tr GT06
tr GT07
D GTOs
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
D
tr
tr
tr
GTO9
GTlO
GTl1
GTl2
GT13
GTl4
GT15
D GTl6
tr GT17
tr GTls
tr GTI9
tr GT2O
tr GT21
tr
tr
tr
tr
INSPECTED BY: AARON LA BARRE DATE: 12t09t2005
a
FACILITY NAME: BRUNDAGE.OONE CONCRETE PUMPING
YES
tr
tr
"lADDRESo: 4130 HORIZON LN #C
SAN LUIS OBISPO, CA 93401
HAZARDOUS WASTE GENERATOR
NO N/A VIOL. # EPA ID NO/PERMITS
SOURCE REDUCTION:For facilities generating >12,000 kg./yr. of hazardous waste on site
tr tr GT22 Generator is subject to SB14 and has prepared and retained current source reduction
documents or is able make them available to the inspector withi(S) days. (HSC 525244.L9,
tr tr cT23 Source Reduction Evaluation and Plan contains the following five elementscertilication'
amounts of wastes generated, process description, block diagrams, and implementationschedule
ofselected source reduction measures (HSC $25244.19)
INSPECTED BY: AARON LA BARRE DATE: t2/o9t2oo5
FAclLlry NAME: BRUNDAT-)BONE CONCRETE PUMPING ADDP ")S:4130 HORIZON LN #U
SAN LUIS OBISPO, CA 93401
SUMMARY OF OBSERVATIOI\S/VIOLATIONS
No violations of underground storage tank hazardous materialq or hazardous waste lawVregulations were discovered.
SLO CUPA greatly appreciates your efforts to comply with all the laws and regulations applicable to your facility
Violations were observed/discovered as listed below. All violations must be corrected by implementing the corrective action
listed by each violation Ifyou disagree with any ofthe violations or corrective actions require{ please inform the CUPA
in writing.
ALL VIOLATIONS MUST BE CORRECTED WITHIN 30 DAYS OR AS SPECIFIED. CUPA muSt bE iNfOrMEd iN
writing with a certification that compliance has been achieved A false statement that compliance has been achieved is a
violation of the law and punishable by a fine of not less than$2,000 or more than $25,000 for each violation Your facility
may be reinspected any time during normal business hours
You may request a meeting with the Program Manager to discuss the inspection findings andor the proposed corrective
actions. The issuance of this Summary of Violations does not preclude the CUPA from taking administrativpcivil' or
criminal action.
FACILITY NAME: BRUNDAGE-BONE CONCRETE PUMPING ADDRESS: 4130 HORIZON LN #C
SAN LUIS OBISPO, CA 93401
PE NO
1126
VIOLATIONS
VIOL. NO VIOL. TYPE
GTOT
CORRECTIVE ACTION REQUIRED
IMMEDIATELY BEGIN PROPERLY COMPLETING MANIFESTS AND
RETA|N|NG THEM FOR A MINIMUM OF THREE (3) YEARS.
IMPLEMENT A PROCEDURE TO ENSURE THAT MANIFESTS ARE
PROPERLY COMPLETED AND THAT THEY ARE PROPERLY
RETAINED.
AFTER CORRECTION, CONTACT INSPECTOR FOR A
REINSPECTION TO VERIFY COMPLIANCE.
Provide manifests for 2004 and 2005.
1126 GT14 IMMEDIATELY CLOSE AND SEAL ALL CONTAINERS
HOLDING/STORING HAZARDOUS WASTES. IMPLEMENT A
PROCEDURE TO ENSURE THAT ALL HAZARDOUS WASTE
CONTAINERS WILL BE KEPT TIGHTLY CLOSED AND SEALED.
AFTER CORRECTION, CONTACT INSPECTOR FOR A
REINSPECTION TO VERIFY COMPLIANCE.
1126 GT17 IMMEDIATELY BEGIN DATING ALL CONTAINERS AND LINERS
(FROM CONTAINERS THAT ARE GREATER THAN FIVE (5)
GALLONS) WHEN THEY ARE EMPTIED AND ENSURE THEY ARE
MANAGED PROPERLY WITHIN ONE (1) YEAR OF BEING
EMPTIED. IMPLEMENT A PROCEDURE TO ENSURE THAT
CONTAINERS AND LINERS ARE PROPERLY DATED AND
MANAGED.
AFTER CORRECTION, CONTACT INSPECTOR FOR A
REINSPECTION TO VERIFY COMPLIANCE.
4 unused 55 gallon drums on site.
INSPECTION COMMENTS
INSPECTED BY: AARON LA BARRE DATE: t2togt2oos
FAclLlw NAME: BRUNDAGrPNE CONCRETE PUMPING ADDRET\4130 HORIZON LN #C
SAN LUIS OBISPO, CA 93401
INSPECTED BY: AARON LA BARRE
DATE: r2/o9t2oos
NAME OF FACILITY REP: Steve May
SIGNATURE OF FACILITY REP:
: I certify under penalty of perjury that this facility has complied with the corrective actions listed on this
form.
of Owner/Operator:Title:Date:
Environmental Health Services
(805) 781 -5544
P.O. Box 1489
2156 Sierra Way
San Luis Obispo, CA 93406
r\
)
gHff"ffinspo
Fire Department (805) 781-7380
2160 Santa Barbara Avenue
San Luis Obispo CA 93401-5240
CERTIFIED UNIFIED PROGRAM AGENCY (CUPA)
HAZARDOUS MATERIALS INSPECTION FORM
Date:
Time:'tl-l 4 EFW data
entry by:
FACILITY NAME:AGENCY
E- EHsn nc DEPT! crrY F|RE
INSPECTION TYPE
-
Ll Routine
fl Reinspection
n Gomplaintn otner
AADDRESS
IPHONE:
PROGRAMS INSPECTED:-p6usiness Plan ffi* Generator fl usr E ncr ncnmnp
R Er NsPEcrro N REQ u I aeo= lw{o t] YES ! Business Plan I Hw Generator n usr n rcr Ecr-nnp
PERMISSION TO INSPECT: lnspections may involve obtaining photographs,
determininq compliance with adopted codes. GRANTED BY (NAME/TITLE):
and records,
YES -trwW
w
W
nn
NO N/A
BUSINESS PLAN
Business plan is complete, current, & available during inspection (HSC 25503.5, Title 19 CCR2729)
Inventory of hazardous materials is complete (HSC 25504' Title 19 CCR2729)
Site layouUfacility maps are accurate (HSC 25504, Title 19 CCR2729)
TRAINING PLAN
Facility has appropriate training program (Title 19 CCR 2732 & 22 CCR 66265.16)
Training documentation is maintained on site for current personnel (Titte 19 CCR2732 & 22 CCR
6626s.L6)
EMERGENCY RESPONSE PLAN
Contingency plan is complete, updated, and maintained on site (HSC 25504' Title 19 CCRn3l &22
ccR $ 6626s.53154)
Facility is operated and maintained to prevenUminimize/mitigate fire, explosion, or release of
hazardous materials/waste constituents to the environment. Maintains all required or appropriate
equipment including an alarm and communications system (Titte 19 CCR 2731 & 22 CCR 66265.31'
.43)
ABOVEGROUND PETROLEUM STORAGE TANK ACT
SPCC Plan is reviewed and certified by a registered engineer within last 5 yrs. (40 CFR 112.5(b))
SPCC Plan is maintained on site or nearest field office. (HSC 25270)
n
n
BPOl
BPO2
BPO3
TROl
TRO2
EROl
ERO2
ATOl
ATO2
nn
COMMENTS
GPSCoordinates: Latitude:mtn mtn
F'ACILITY REP:INSPECTOR:
C:\DOCUME-1\Repro\LOCA.L$-1\Temp\c"lotus.notes.data\l,,lnspection Form Page 1.doe 20'Jul-04
aFACILITY NAME
'np,c.mNUMBER:
Tiered Permit:
Treatment
Equipment:
A
HAZARDOUS WASTE GENERATOR
a a Total generated/month:
CESQT Waste oil: Solvents:
Antifreeze: Others:
L_
Lbs or gals
(average)
d
YES- NO N/Af,E'E-
K T IW tr T
w
yz
GTO3
GTO4
GT05
GTO6
GTOT
GT08
GTO9
GTlO
GTl1
GT12
GT13
GT14
GT15
GT16
GT17
GT18
GT19
W cr2o
I Gr2t
VIOL. #
GTOl
GT22
GT23
EPA ID NO/PERMITS
Generator has an EPA ID number to treat, store, dispose, transport or transfer hazardous waste (Title
22CCR566262.12) If Not, Call (s00) 61s-6942 to obtain your cAL EPA ID number.
HAZARDOUS WASTE DETERMINATION
Hazardous waste determination conducted (Title22 CCR $66262.11)
nown knowledge f]analysis nother
Hazardous waste analysis/test records are kept for at least 3 years (Title 22 CCR $66262.40.(c))
DISPOSAL/TRANSPORTATION
Hazardous wastes were transported and/or disposed to a facility with ID NO.permit or
for 3 years (Titte 22 CCR
s66263.421 66262.23)
STORAGE AND MANAGEMENT OF CONTAINERS/TANKS
Hazardous wastes are accumulated on site as follows (Title22 CCR $66262.34)
n gO aays if waste generated per month is greater than or equal to 100 kg (220 lbs.)
n fSO days ifwaste generated per month is less than 100 kg (see note)
JZZO days if waste generated per month is less than 100 kg and transported more than 200 miles (see
note)
Note: Applies only if hazardous waste accumulated on site never exceeds 6000 kg(13'200 lbs.)and no
acutely/extremely hazardous waste over lkgQ.2lbs.) is held on site for over 90 days.
Hazardous waste ',satellite" collection is managed properly (complete labeling/accumulation time/55-gal
or l-qt limit) (Title22 CCR $66262.34(c)
Ignitable or reactive wastes are located 15 m (50 feet) from facility's property line (Title 22 CCR
s6626s.176)
Containers of hazardous waste are properly labeled (includes appropriate date, "HLZLRDOUS
WASTE,', waste composition/physical state, hazardous properties, name/address of generator) (Title22
ccR $66262.3 l, 66262.34)
Containers/tanks containing hazardous wastes are in good condition/handled to minimize release or '
reaction (T itle 22 C CR $ 66265. l7 | I .19 l, 66265.17 7 (c))
Containers/tanks/liners are compatible with waste stored or transferred (Title 22 CCRS66265.172)
containers storing hazardous wastes are closed/sealed (Title22 CCR $66265.173)
Weekly inspection of areas where hazardous waste containers are stored is conducted
(Title 22 CCR$66265. 174)
Daily inspection of all tank systems is conducted and documented (Title 22 CCR $66265.195),
Empty containers or inner liners greater than 5 gat has date when emptied and are managed properly
within one year of date emptied (Title 22 CCR 566261.7 (f))
RECYCLABLE WASTE
Used oil is managed as hazardous waste until recycled (includes proper labeling, storage, etc) (HSC
s252s0.4\
Used oil filters for recycling are managed properly (drained of free flowing liquid' stored in closed
rainproof container, labeled "drained used oil filters," and transferred for metal reclamation) (Title 22
ccR$ 66266.130)
Spent lead-acid batteries are being properly stored and transferred offsite under manifest or bill of
lading for recycling, reuse' or reclamation (Title22 CCR $66266.81)
Solvents/other recyclable materials are managed as hazardous wastes until recycled (Titte 22 CCR
$66266.3)
SOURCE REDUCTION: For facilities generating >12,000 kg./yr. of hazardous waste on site.
Generator is subject to SB14 and has prepared and retained current source reduction documents or is
able make them available to the inspector within (5) days. (HSC 525244.19,25244.21)
source Reduction Evaluation and Plan contains the following five elements:
certification, amounts of wastes generated, process description, block diagrams, and implementation
schedule ofselected source reduction measures. (HSC $25244.19)
u
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n
u
F
"d
{
Wtr
C:\DOCUMH-1\Hepro\LOCALS-1\Temp\c.lotus.notes.cJata\2-HazardousWasteGenerator.doc 20-Jul-04 20-Jul-04
fl*a fuz ^/*sL/e
OF OBSERVATTONS/VIOLATIONS
kl ./*" violations of underground storage tank, hazardous materials, or hazardous waste laws/regulations were discovered.
\ Sl,O CUpA greatty appreciates your efforts to comply with alt the laws and regulations applicable to your facility.
Violations were observed/discovered as listed below. All violations must be corrected by implementing the corrective action listed
by each violation. If you disagree with any of the violations or corrective actions required, please inform the CUPA in writing.
ALL VIOLATIONS MUST BE CORRECTED WITHIN 30 DAYS OR AS SPECIFIED. CUPA MUSt bC iNfOTMCd iN WTitiNg With A
certification that compliance has been achieved. A false statement that compliance has been achieved is a violation of the law and
punishable by a fine of not less than g2,000 or more than $25,000 for each violation. Your facility may be reinspected any time
during normal business hours.
you may request a meeting with the Program Manager to discuss the inspection findings and/or the proposed corrective actions.
The issuance of this Summary of Violations does not preclude the CUPA from taking administrative, civil, or criminal action.
NUMBER
VIOLATIONS
MINOR MAJOR CORRECTIVE ACTION REQUIREI)
COMMENTS
lnspected By:
Date:
ility Rep
Sign the certification below and mail form to the CUPA inspector after all corrective actions completed. Retain a copy for your records.
of perjury that this facility has complied with the
Title:Date:
corrective actions listed on thisCertification: I certify under
inspection form.
Signature of Owner/Operator :
A:\Summary lnspection'Form.doc 23-Jun-04
Division of Envirc entaf HealE
(80s) 781-ss44
P.O. Box 1489
2156 Sierra Way rSan Luis Obispo, CA 93406
Department of Aericulture/Measurement
Standards (80s) 781-s910
2156 Sierra Way Suite A rSan Luis Obispo, CA 93401
City of San Luis Obis
Fire Department (805) 781-7380
2160 Santa Barbara Avenue
San Luis Obisno CA 93401-5240
Utilities Department r (805) 781-7215
879 Morro Street r San Luis Obispo, CA 93401
o
CERTIFIED UNIFIED PROGRAM AGENCY (CUPA)
HMARDOUS MATERIALS INSPECTION FORM EFW data
entry by:Date:
Time
lt tT laj
?
FACILITY ID NO:
FACILITY NAME:
ADDRESS:o
'13']N:('vis Ol'
INSPECTION TYPE
El Routine
I Reinspection
n Complaint
n ottt"t
AGENCY
EI nnn! ncDEPrn crrv prnp
E crrv urILrrIES
PHONE:! usr n ncr I Tiered PermittingEl Hw ceneratorffi Business PlanPROGRAMS INSPEC
n usr n lcr ! Tiered PermittingE Hw Generatorn Business PlanETNO tr YESREINSPECTION REQUIRED:
reviewing and copying records, and determining complianceON TO INSPECT: Inspections may involve
codes. GRANTED BY
YES
COMMENTS:
N/A
Tnn
IT
NO
M
wa
ntr
K
n
,)
('
I
1
I
BPOl
BPO2
BPO3
TROl
TRO2
EROl
ERO2
BUSINESS PLAN
Business plan is complete, current, & available during inspection (HSC 25503.5, Title 19 CCR2729)
lnventory of hazardous materials is complete (HSC 25504, Title 19 CCR2729)
Site layouVfacility maps are accurate (HSC 25504, Title 19 CCR2729)
TRAINING PLAN
Facility has appropriate training program (Title 19 CCR 2732 & 22 CCF{ 66265.16)
Training documentation is maintained on site for current personnel (Title 19 CCR2732 & 22
ccR 66265.16)
EMERGENCY RESPONSE PLAN
contingency plan is complete, updated, and maintained on site (HSC 25504' Title 19 CCR
2731 &22 CCR $ 66265.53/s4)
Facility is operated and maintained to prevenVminimize/mitigate fire, explosion, or release of
hazardous waste to the environment. Maintains all required or appropriate equipment
including an alarm and communications system (Title 19 CCR273L & 22 CCR 66265,31-,43)
INSPECTOR:FACILITY REP:
'or* 10{11 rev 1 0:\llcCUMINT\Je{fp\FORMS\lnspeetion forms\CLJPA inspection fcrms.cioc 10-$ep-01
FACILITY NAME:DATE: ]l O7' INSPECTOR:
HAZARDOUS WASTE GENERATOR
7o
CA
Treatment EquiPment:
EPA ID
NUMBER:
Tiered Permit:
L
Lbs or gals
(average)Totaf generatedlynth
Waste oil: \/
Antifreeze:
Solvents:
Others:
YES NO N/AEE'E'vIoL. #
GTOl
GT03
GTO4
GTO5
GTO6
GTOT
GTOS
GTO9
GTIO
GTII
GT12
GT13
GT14
GTI5
GTI6
GTIT
GTIS
GTI9
GT2O
GT2T
EPA ID NO/PERMITS
Generator has an EPA ID number to treat, store, dispose, transport or transfer hazardous waste (Title
22CCR66262.t2) If Not, Call (800) 618-6942
HAZARDOUS WASTE DETERIVIINATION
Hazardous waste determination conducted (Title22 CCR 66262'll)
Eoton knowledge lanalYsis Dother
Hazardous waste analysis/test records are kept for at least 3 years (Title 22 CCR 66262.40.(c))
DISPOSAL/TRANSPORTATION
Hazardous wastes were transported and/or disposed to a facility with an EPA ID NO. and permit or
authorization from DTSC (HSC 25189'5'Title22 CCR66262.12)
pmilkrun service Eother S
Hazardous wastes are with manifest (Title 22 CCR
Manifests and/or receipts are properly completed/retained by generator for 3 years (Title 22 CCR
66263.42t 66262.23)
STORAGE AND MANAGEMENT OF CONTAINERS/TANKS
Hazardous wastes are accumulated on site as follows (Title22 CCR66262.34\
I gO Oays ifwaste generated per month is greater than or equal to 100 kg (220 lbs.)
! fgO Oays ifwaste generated per month is less than 100 kg (see note)
flZlOdays if waste generated per month is less than 100 kg and transported more than 200 miles (see
note)
Note: Applies only ifhazardous waste accumulated on site never exceeds 6000 kg(l3200 lbs.)and no
acutely/extremely hazardous waste over I kg (2.2 lbs.) is held on site for over 90 days'
Hazardous waste,.satellite" collection is managed properly (complete labeling/accumulation time/55-gal
or l-qt limit) (Title 22 CCR66262.34(c\)
tgnitable or reactive wastes are located 15 m (50 feet) from facility's property line (Title 22 CCR
66265.176)
Containers of hazardous waste are properly labeled (includes appropriate date, "HAZARDOUS
WASTE,'waste composition/physical state, hazardous properties, name/address of generator) (Title22
ccR66262.34)
Containers/tanks containing hazardous wastes are in good condition/handled to minimize release or
reaction (T itle 22 CCR 66265. I 7 I l.l9 l, 66265.17 7 (c\)
Containers/tanks/liners are compatible with waste stored or transferred (Title22 CCR66265.172\
containers storing hazardous wastes are closed/sealed (Title22 CCR 66265.173)
Weekly inspection ofareas where hazardous waste containers are stored is conducted
(Title 22 CCR 66265. I 74)
iaily inspection of all tank systems is conducted and documented (Title 22 CCR 66265'195)
Empty containers or inner liners greater than 5 gal has date when emptied and are managed properly
within one year of date emptied (Title 22 CCR 66261.7 (0)
RECYCLABLE WASTE
Used oil is managed as hazardous waste until recycled (includes proper labeling, storage, etc) (HSC
25250.4',
Used oil filters for recycling are managed properly (drained of free flowing liquid, stored in closed
rainproofcontainer, labeled .,drained used oil filters," and transferred for metal reclamation) (Title22
ccR 66266.130)
Spent lead-acid batteries are transferred offsite under manifest or bill oflading for recycling' reuse' or
reclamation (Title 22 CCR 66266.81)
Solvents/other recyclable materials are managed as hazardous wastes until recycled (Title 22 CCR
66266.3)
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SUMMARY OR OBSERVATIONSNIOLATIONS
- No violations of underground tanlq hazardous materials, inventory, and hazardous waste laws, regulations, and requirements wereL-r discovered. SLO CUpA greatly appreciates your efforts to compty with all the laws and regulations applicable to your facility.
Violations were observed/discovered as listed below. All violations must be corrected by implementing the corrective action listed by each
violation. If you disagree with any of the violations or proposed action, please inform us in writing.
ALL VIOLATIONS MUST BE CORRECTED WITHIN lg DAYS OR AS SPECIFIED. CUPA must be informed in writing certifying
that compliance has been achieved. A false statement that compliance has been achieved is a violation ofthe law and punishable by a line
of not lesi than $2,000 or more than $25,000 for each violation. Your facility may be reinspected any time during normal business hours.
you may request a meeting with the Program Manager to discuss the inspection findings and/or proposed corrective actions. The
issuanciof this Summary olviol"tiont does not preclude CUPA from taking administrative, civil, or criminal action ss e result of the
violations noted or that have not been corrected within the time specified.
NUMBER
Blgl:-el
EROI
VIOLATIONS
MINOR MAJOR
7e!:@
CORRECTIVE ACTION REQUIREI)
,/
,,/
-/
COMMENTS:
Inspected By:
Date:
Facility Rep Name:
Signature:
ropro ll27 r€v 1 O:\DOCUMENT\Jeffp\FORMS\lnspectiorr forrns\CUPA inspection fortns.doc 1 0-Sep-01
..'..'' ,"-)
City of San Luis Obispo
Fire Department
John Callah?n, Fire Chief
2160 Santa Barbara Ave.
San Luis Obispo, CA 9340I
(805) 7 8I-7 380 lrmnruoxr;
t/ (805) 543-801! lrax)
FAX COVER SHEET
To:
Fax:
From: San Luis Obispo City Fire Department
Sender's Name )
Date:
You should have received f n , pages (including this cover sheet).
If you do not received all of the pages, or any of the pages are illegible, then please contact
the sender at (805) 781-7380 o
(1vl-1f(3
COMMENTS:
r FAX (805) 543-8019.
, f/z rML, f/r.k4,e I
tr,,,"Hwu&meffi;,d
(
)
The information contained in this FAX message is PRIVILEGED-CONFIDENTIAL
INFORMATION intended only for the use of the individual or entity named above. If the
reader of this message is not the intended recipient, you are hereby notified that any
dissemination, distribution or copy of this communication is strictly prohibited. If you have
received this communication in error, please immediately notify us by telephone and return
the original message to us at2160 Santa Barbara Ave., San Luis Obispo, CA 93401-
Thank
FORMS-SANLII.
BUSINESS OWNER/OPERATOR IDENTIFICATION
COTINTY CERTIF'MD TINIFIED AGENCY
I. IDENTIFICATION
ENDING DATE 101IBEGINNING DATE 100FACILITY ID#
102BUSINESS PHONEBUSINESS NAME (saru ro TACILITY NAME or DBA - Doing Business As)3
BUSINESS SITE ADDRESS 103
CA
ZIP CODE 105104CITY
SIC CODE (a digit #)107106DUN & BRADSTREET
108
COUNTY
110BUSINESS OPERATOR PHONEBUSINESS OPERATOR NAME 109
tr. BUSINESS OWNER
112OWNER PHONElllOWNER NAME
113
OWNER MAILING ADDRESS
ll6ZIP CODESTATE115114CITY
m. EI\TVIRONMENTALCONTACT
118CONTACT PHONEtt7CONTACT NAME
119
CONTACT MAILING ADDRESS
ZIP CODE t22STATE12tr20CITY
Iv. EMERGENCY CONTACTS -SECONDARY--PRIMARY.
r28NAME123NAME
t29TITLEt24TITLE
130BUSINESS PHONEBUSINESS PHONE t25
13t24-HOUR PHONE24.HOUR PHONE 126
PAGER#ICELLPHONE#t32
PAGER # I CELL PHONE #121
ADDITIONAL LOCALLY COLLECTED INFORMATION
133
those individuals responsible for obtaining the information,I certiff under penalty of law that I have personally examined and
am familiar with the information submined and believe the information is true, accurate, and complete
Certification: Based on my inquiry of
DATE 134 NAME OF DOCUMENT PREPARER 135
SICNATURE OF OWNER/OPEMTOR OR DESIGNATED REPRESENTATIVE
t!7OF SIGNERr36NAME OF SIGNER (print)
2
Page- of-A:\FRM-S.DOC 06/01/00
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A
I
5 r,t
FedEx Express
Customer Support Trace
3875 Airways Boulevard
Module H,4th Floor
Memphis, TN 381 16
U.S. Mail: POBox727
Memphis, TN 38194-4643
Telephone: 901 -369-3600
06/1 6/2006
Dear Customer:
The following is the proof of delivery you requested with the tracking number 855965317964.
Delivery lnformation:
Status:
Signed for by:
Service type:
Delivered
.RANDY Y
Standard Envelope
Delivery location
Delivery date:
4130 HORIZON
May 26, 2006 10:29
Shipping Information
Tracking number:
Recipient:
RANDY JORDAN
KEN'S BODY SHOP
4130 HORIZON LN D
93401 US st-O
85596531 7964
Thank you for choosing FedEx Express
FedEx Worldwide Customer Service
1 .800.GoFedEx 1 .800.463.3339
Ship date:
Shipper:
SCOTT MILNER
SAN 93401 US
May 25, 2006
SAN LUIS OBISPO GOUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SERVICES
(805) 781-5557 FAX: (805) 781'4211
2156 Sierra Way - P.O. Box {489,San Luis Obispo, California 93401
Facsimile Gover Sheet
Confidentiality Notice: The information in
recipients named below. lt may contai
is intended only for the use of the desig
n protected health information and/or confidential personal
information. lf the person receiving this facsimile is not a named recipient or the employee or agent
responsible to deliver it to a named recipient, do not read, use, disseminate, distribute, or copy this
communication. lf you receive this facsimile message in error, please immediately notify us by telephone
and return the ori lme to us at address via the U.S. Postal service.
Date:
To:
From:
Subject:
May 24,2006
Steve May
Scott Milner
Outstanding Violations from 12109105 lnspection
Fax: 545-8298
Number of pages including cover page: 5
Comments: Provide copies of your waste disposal documentation to
this office from 2004-2006 for your waste oil/filters/solvent, etc.
After all the violations on the enclosed inspection report have been
corrected sign and return the compliance certification at the bottom of
the enclosed inspection report.
"1
r,",ivlsloN INPUT/UPDATE Fo\'*h
X
I]
II
il
I]
tI
tl
I]
CREATE NEW RECORD (App. aftached)
CHANGE CURRENT RECORD
CHANGE OF OWNERSHIP (App. attached)
TEMPORARI LY I NACTIVATE FACI LITY
CLOSE FACILITY
FACILITY # 6Sq(-
PROGRAMX O*An \630o
PE O72G / t lZLe Fn I o3o \
{nm
CHANGE CURRENT INFORMATION TO:iJ
HAZARDOUS MATERIALS SPECIFIC:
Number of Materials J
Number of Waste Streams a
Number of Tanks 6
.6P,r^1 ^ lo6*l
@ t*r ;na G
c.tatl 5-ef f 6 #1",
3/ro /04 n Vl' I \-.r-,^eol
LABEL INFO: pd ruew [ ] Gorrected
Site Address: +,30 l]o';,^,,, hno #c-
Site Name: B*",!ry- *lo".* C^.,.b Punol,, 'hc"
t'y J
Reviewed by linitiat;:
Supervisor t I
Requested by:
Date:
lnput Entered by:
Date:
tlrt
/
,7,a
OtherCopy to
O:\DOCUMENT\Forms\GENERALIIVIFRFILF.OOC 27 -F eb-C2
Corrnt]rf San Luis Obispo . p.rl Ic Health Department
Env ir onment aI H e alth S erv i c e s
2156 SierraWay . P.6, Box 1489
San Luis Obispo, California 93406
(805) 781-5544 . FAX (805) 781-4211
G r e go ry' liffii' H P,,iY ifil;
Public Health Director
Curtis A. Batson, R.E.H.S.
Director
December 22,2003
Brundage Bone
Steve May
P.O. Box 1269
San Luis Obispo, CA93406
NOTICE OF VIOLATION
Re: Hazardous Materials Business Plan
California Health and Safety Code $25503.5 requires facilities handling hazardous materials at
or above the reportable quantities of 55 gallons of a liquid, 500 pounds of a solid, 200 cubic feet
of a compressed gas, or any amount of hazardous waste, to submit a Business Plan and Inventory
Forms to this office. Hazardous materials include, but are not limited to, gasoline, diesql,
propane, compressed gasses, etc. Hazardous wastes include, but are not limited to, waste oil,
arfiifteeze, solvents, paint, etc.
I conducted an inspection of your facility on November 7,2003, at which time you were
instructed to prepare and provide a business plan to this office. As of this date, our office has not
received your Business Plan or Inventory Forms. Pursuant to HSC $25514 (a), any business
which fails to provide the required Business Plan and Inventory Forms is civilly liable for as
much as two thousand dollars ($2,000) for each day of the violation.
This office must receive the enclosed Business Plan and Inventory Forms within the next thirty
days or an administrative enforcement order may be issued to your facility which will impose the
above referenced civil penalties of as much as two thousand dollars ($2,000) for each day of the
violation.
If you have questions, please contact me at (805) 781-5557
Sincerely,
,(itrtul^
Scott Milner
Environmental Health Specialist III
Hazardous Materials Section
County of San Luis Obispo gHff"ffispo iEnvironmental Health Services
(805) 781'5544
P.O. Box 1489
2156 Sierra Way
San Luis Obispo, CA 93406
Fire Department (805) 781-7380
2160 Santa Barbara Avenue
San Luis Obispo CA 93401-5240
CERTIFIED UNIFIED PROGRAM AGENCY (CUPA)
HAZARDOUS MATERIALS INSPECTION FORM
EFW data
entry by:nli
Datez ll t ,i i,lr
FACILITY
;I
ADDRESS:
Result Gode: _70
Action Code: _32 37 33 1
Othern Complaint
Routine
AGENCYn rts
N AG DEPT
l-.]'ctrY FtREr
PHONE:
flcemneI HW Generator [] usr ! aerBusiribss Plan/ v$ *'pXdcnAMS rNsPEgIeo
fl ner ncnlnnp! HW Generator n usrnNO,fi YESu--.1'I Business
{
PlanREINSPECTION REQUIRED:
PERMISSION TO INSPEGT: lnspections may involve obtaining photographs, reviewing and copying records,
determinins compliance with adopted codes. GRANTED BY (NAM
and
Time:
YES
t''
! -/,.
N/Antrn
cosntrtr
NOn
ntr n trtrtr u tr
n
n
BPOl
BPO2
BPO3
TROl
TRO2
EROl
ERO2
ATOl
ATO2
BUSINESS PLAN
Business plan is complete, current, & available dqring inspection (HSC 25503.5' Title 19 CCF.272I)
Inventory of hazardous materials is complete (HSC 25504, Title L9 CCR2729)
Site layout/facility maps are accurate (HSC 25504, Title 19 CCR2729)
TRAINING PLAN
Facility has appropriate training program (Title 19 CCR2732 & 22 CCR 66265,16)
Training documentation is maintained on site for current personnel (Title 19 CCR2732 &22 CCR
6626s.16)
EMERGENCY RESPONSE PLAN
Contingency plan is complete, updated, and maintained on site (HSC 25504, Title 19 CCR273I & 22
ccR s 6626s.s3ts4)
Facility is operated and maintained to prevent/minimize/mitigate fire, explosion, or release of
hazardous materials/waste constituents to the environment. Maintains all required or appropriate
equipment including an alarm and communications system (Title 19 CCR 2731 &22 CCIi66265.31-
.43)
ABOVEGROUND PETROLEUM STORAGE TANK ACT
SPCC Plan is reviewed and certified by a registered engineer within last 5 yrs. (40 CFR 112.5(b))
SPCC Ptan is maintained on site or nearest field office' (HSC 25270)
Go to http://www to obtain fonns tro comply with BP01-8P03, TR01 and ER01
GPS Coordinates: Latitude: _deg
INSPECTOR:
) f' ,t'' .t' t'// ,' ,!,i' \l 1../ !,..' )
nun mln
_ACILITY REP:
decimal min
Gounty of San Luis ObisPo cty-o$
salr lus sffiw
. ili ;.'1,,:l:ll -.1..:r;i;
:: -:' :ri.r; l:r-:: :j :i;l:l i
Environmental Health Services
(805) 781-5544
P.O. Box 1489
2156 Sierra Way
San Luis Obispo, CA 93406
Fire Department (805) 781'7380
2160 Santa Barbara Avenue
San Luis Obispo CA93401-5240
CERTIFIED UNIFIED PROGRAM AGENCY (CUPA)
HAZARDOUS MATERIALS INSPECTION FORM
EFW data
entry by:
t4
Date: ,
Time:
YES NO COS NiA
yE.fl
{a
ytr
,F
if,
,E
uE''n
uu!
ntr
trn nnn n
Dtr
BUSINESS PLAi\
Business plan is complete, current, & available during inspection (HSC 25503.5, Title 19 CCR2729)
Inventory of hazardous materials is complete (Hsc 25504, Title 19 CCR2729)
Site layoutifacility maps are accurate (HSC 25504' Title 19 CCR2729)
TRAINING PLAN
Facility has appropriate training program (Title 19 CCR2732 & 22 CCR 66265.16)
Training documentation is maintained on site for current personnel (Title 19 CCR2732 & 22 CCR
6626s.16)
EMERGENCY RESPONSE PLAN
Contingency plan is complete, updated, and maintained on site (HSC 25504, Title 19 CCR273I &22
ccR $ 6626s.531s4)
Facility is operated and maintained to prevent/minimize/mitigate fire, explosion, or release of
hazardous materials/waste constituents to the environment. Maintains all required or appropriate
equipment including an alarm and communications system (Tiue 19 CCR 2731 & 22 CCR 6626531-
.43)
ABOVEGROUND PETROLEUM STORAGE TANK ACT
SpCC plan is reviewed and certified by a registered engineer within last 5 yrs. (40 CFR U2.5(b)
SPCC Plan is maintained on site or nearest field office. (HSC 25270)trnNI
BPOl
BPO2
BPO3
TROl
TRO2
EROl
ERO2
ATOl
ATO2
Result Gode:
-70 -80 -90Action Code:
-32 _37 -33 -31
E
Reinspectionn otner
Routine
Complaint
FACI AGENCY
fl EHS
PHONE:
NAME:
S:
iJ
DEPT
FIRECITY
fl acr ncnmnp! Hw Generator n usrn Business PlanPROGRAMS INSPECTED:
!cnmnen usr n aer! HW GeneratorI Business Plann NO IYESREINSPECTION REQUIRED:
reviewing and coPYing records, andERMI
n
obtainvolve lntNSPECT ng hotogp raphs,TO maytoNnspections
codes. GRANTED BYliance with
COMMENTS Goto
GPS Coordinates: Latitude:
-deg
t
to obtain forms to comply with BP01-BP03, TR01
FACILITY REP:
min Longitude:
tl\,]
i\ r,i,r
II
t
i'i t i: t1i
mln
INSPECTOR:
{,{
Report # MFR1
Pag #: 1)
Dale run 112015 2:12:30PM
Run by: kboyle
.COUNTY OF SAN LUIS OBISPO
acility lnformation as of 611112015
Record Selection Criteria: F-acility lD: F40007202
o,t", br// t/t'
t 1 TNFORMATTON CYIA
Requested by:
NGE
I ] UPDATE UST INF
t I closE FACILITY
OWNER FILE INFO
Owner lD: OW0007317
Owner Name: .}AJegg,+en
Owner DBA:
Owner Address: 4130 HORIZON LN #D
sAN LUIS OBISPO, CA 93401
Home Phone: 805-543-5450
Work Phone: 805-543-5450
Mailing Address: 4130 HORIZON LN #D
SAN LUIS OBISPO, CA 93401
t ] NEW FACILITY RECORD
{,k'IOWNERSHIP CHANGE; [ ] Business [ ] Property [ ] Tank
' I IUPDATE BILLING INFORMATION
New Owner lD:
New Name:
New DBA:
New Address:
New Home Phone:
New Work Phone:
New Mailing Address:
Care of:New Care of:
FACILITY FILE INFORMATION
FacilitY lD: FA00O72O2
FacilitY Name: KEN'S BODY SHOP
Phone:
Mailing Address:
Care of:
CERS ID:
Location Code:
BOS District:
4130 HORIZON LN #D
SAN LUIS OBISPO, CA 93401
805-543-5450
4130 HORIZON LN #D
SAN LUIS OBISPO, CA 93401
HAZARDOUS MATERIALS COMPLIANCE
1 0438960
31 -HAZ MATCOASTAL
New lD:
New Name:
New Site Address:
New Phone:
New Mailing Address:
New Care of:
APN:
SIC Code:
ACCOUNTS RECEIVABLE FILE IN
Account lD: AR0015253
Mail lnvoices io: Account
Account Name: WOOD, JEFF
Account Balance as of 6/1 1/2015: $0.00
Program/Element and Descripiion
FORMATION
vlnffi-New Account lD:
Mail lnvoices to: Owner / Facility / Account
(Circle One)
UST(s)
Transfer
Program to (Circle One)
0762 - SLO CITY-HAZARDOUS MATERIALS HANDLER 1.4
Last Activity: 1 112512013 - REGULAR INSPECTION
1176 - SLO CITY- WASTE GENERATOR (1-5 waste streams)
Last Activity: 061 1 01201 5 - REG U LAR I NSPECTION
Record lD Employee lD and Name
PROO1,1150 EEOOOO5IO - KERRY BOYLE
PR00,11151 EEOOOO51O - KERRY BOYLE
Status
.-Itctive
Active
Linked
YN
YN AI
t ] CREATE NEW FILE FOLDER
t ] UPDATE EXISTING FILE FOLDER LABEL
UPDATE NEXT INSPECTION DATE:Date: I I
Copy to: File Other:
HAZARDOUS MATERIALS SPECIFIC:
Number of Materials
Number of Waste Streams
Number of Tanks (list
ca pacity/compa rtment)
PE
Entered
Comments:
Date:
rtFlll-,
i3 J i"j
l
coUttw oF sAN LUls oBlsPo
Facility lnformation as of 612612024
Report #: MFR'I
Page #: 1
INFORMATION CHANGE
CLOSE FACILITY AS OF: Date: I I
I UPDATE BILLING INFORMATION
I UPDATE UST INFO (sys, type, capacity, etc.)
Requested by:Dale:612612024
[ ]Property [ ]TankftffilsinessERSHIP CHANGE:t I NEW FACILITY RECORD
t
OWNER FILE INFORMATION
Owner lD: OW00073'17 New Owner lD:
New Name:OwnerName: WADE BROWN ft)frr'dI bilq
Owner DBA New DBA:
New Address:OwnerAddress: 4130 HORIZON LN #D
SAN LUIS OBISPO, CA 93401
Home Phone: 805-543-5450 New Home Phone:
New Business Phone:
New Mailing Address:
Business Phone: 805-543-5450
Mailing Address: 4130 HORIZON LN #D
sAN LUIS oBlsPo, cA 93401
Care ofl
Email:
New Gare of:
New Emaih
ESTAB FILE I ON
Establishment lD: FAO007202 New Establishment lD:
New CERS lD:
New Name:
CERS lD: 10438960
Establishment Name: KEN'S BODY SHOP F --*>l1
Site Address:4130 HORIZON LN #D NewAddress
sAN LUls oBlsPo. cA 93401
Phone: 805-543-5450 New Phone:
New Email:Email:z@o
arr:rraM!LINKED
EEOOOOs17 - MATHESON BLISS
EEOOOOs17 - MATHESON BLISS
Account lD:ARO015253
Mailing a661gs5;4130 HORIZON LN #D
sAN LUIS OBISPO, CA 93401
Account Balance*: *as ol 612612O24: $0.00
Active
r
PE:
Last Activity:11n5r2}13 - REGULAR INSPECTION , EE0000510: BOYLE
Last Activity:oSlOSl?o23 - REGUTAR INSPECTION , EE0000s17: BLISS
o
Account Name:WOOD, JEFF V larU
& Pe: Numberofwa8testreams: L PE:lt?Q
New Mailing Address:
Discount Code:
[Activate I Change I lnactvate]
N:CUPA
Number of Tanks (list capaclty/compartment below):Number ol Materlals:
HANDLER 1.4
New Gare of:
Discount Eligible?
Care of :
Discount Eligible? Yes
New Account lD:
New Account Name:
lnactive lActivate I Change I lnactvate]
PRO01 11 51 1 1 76 - SLO CITY- WASTE GENERATOR (1-s wasle streams)
Update CERS?Yes No (lf yes, forward to CERS admin)
pRool1150 0762 - sLo CIrY-HAZARDOUS
I CREATE NEW FILE
] UPDATE EXISTING FILE LABEL
t ] UPDATE NEXT INSP ECTION DATE: Date: ---J-t-I I RETURN FILE TO:
to: File Other:
Gomments:
Date:Entered
\rU4q 'r"
Ut9''8k
,L5rV
cz u-:l'tu
Q- -u;{t
./ttu (z
\bq\
t.N,vFa-otqtt7vt-a.A^4 htor\ouu &**Orco'&a-ty'b?+tu\,u<(e'<.tr{S'r.ht.}al.*-v\At-wa^)b h*aJ ?u {ce,t/tt"A!1 J qtLL/r'bof-L/^A e\-li ("i II qVD4Qa)v 14
l,/5o pi--^,,trt 1(a
Lv
COUNrv OF SAN LUIS OBISPO
Faci lnformation as of 612612024
Report#: MFR1
Page #: I
Dale:612612024 Requested by:
[ ]Property I lTankffirsinesstlUPDAIE BI LLING INFORMATION
I I UPDATE UST INFO (sys, type, capacity, etc.)
IP CHANGE:
CLOSE FACILITYAS OF: Dale: -J-l-
t I NEW FACILITY RECORD
I I TNFORMATION CHANGE
OWNER FILE IN FORMATION
Owner lDr OW0007317
(rod*lrt bil.aOwnerName: WADEBROWN
Business Phone: 805-543-5450
Home Phone: 805-543-5450
sAN tuls oBlsPo, cA 93401
Owner Address: 4130 HORIZON LN #D
Owner DBA:
New Home Phone:
New Business Phone:
New Mailing Address:
New Gare of:
New Email:
Care of:
Email:
New Owner lD:
New Name:
NEW DBA:
New Address:
Mailing Address: 4130 HORIZON LN #D
SAN LUIS OBISPO, CA 93401
MENT
sAN LUIS OBISPO, CA 93401
zoo o
s SHOP ttF
NawAddress:Site Address:4130 HORIZON LN #D
Phone: 805-543-5450
Email:
New Phone:
New Email:
New Establishment lD:
New CERS lD:
New Name:
Establishment lD:
CERS ID:
Establishment Name:
EEOOOO517 - MATHESON BLISS
EEOOO0517 - MATHESON BLISS Active
PR0011150 0762-sLo CIW-HAZARDOUS MATERIALS HANDLER 1 -4
[Activate I Change I Inactvatel
LastActivity: 1112512013 - REGULAR INSPECTION , EE0000510: BOYLE
LastAclivity: OglO3l2O23 - REGULAR INSPECTION , EE0000517: ELISS
lnactive lActivate I Change I lnactvate]
PRoo11151 1176 - SLO CITY- WASTE GENEMTOR (1-5 waste
Account lD:AR0015253
Mailing a{d1s3e;4130 HORIZON LN #D
SAN LUIS OBISPO, CA 93401
r'.o
Account Name:WOOD, JEFF V ..aAU
New Mailing Address:
Oiscount Code:
New Gare of:
Discount Eligible?
Care of:
Discount Eligibb? Yes
Account Balance': ffi So.oo
New Account lD:
New Account Name:
2 pe: U?<t Number of Tanks (list capacity/compartment below):
Update CERS?Yes No (lf yes, forward to CERS admin)PE:
Number of Malerlal*PE: Number of Waste Streams:
[ ] CREATE NEW FILE
[ ] UPDATE EXISTING FILE LABEL
[ ] UPDATE NEXT INSPECTION DATE; Date: --) t
[ ] RETURN FILE TO:
Comments:'r
t"v h*z
t,rV6
a.\aFa,ot vtRtt7pt/t.7{^CIo l"/f\a,uu {+*OQ.o4a-5/(r.?.t tuUu44uurfJa^X''U,,to"Ak ?tr"u/,^/t 9!1 .t q52-o Jtu)f4 bo3\-5/^d-r5t,^r{-(2CLF{VD4 (Qa,t v(5o(a-l>'a.ra-trs
to: File Other:Date:Entered
COUNTY OF SAN LUIS OBISPO
1
Facility lnformation as of 612612021
Report #: MFRI
Page #: 1
Dale:612612024 Requested by:
t I NEW FACTLTTY RECORD
[ ] TNFORMATION CHANGE
+"A closr FAC|L|TYAS oF: Date: I I\'
t@wr\ERSHIP CHANGE 1)frrsiness [ ] Property [ ] Tank
[ ] UPDATE BILLING INFORMATION
[ ] UPDATE UST INFO (sys, type, capacity, etc.)
OWNER FILE INFORMATION
Owner lD: OW0007317 New Owner lD:
New Name:OwnerName: WADEBROWN h bo)
Owner DBA New DBA
New AddressOwnerAddress: 4130 HORIZON LN #D
SAN LUIS OBISPO, CA 93401
Home Phone: 805-543-5450 New Home Phone:
New Business Phone:
New Mailing Address:
Business Phone: 805-543-5450
Mailing Address: 4130 HORIZON LN #D
SAN LUIS OBISPO, CA 93401
Care of:
Email:
New Care of:
New Email:
ESTABLISHMENT FILE IN
Establishment lD: FA0007202 New Establishment lD:
New GERS lD:
New Name:
CERS lD:10438960
Establishment Name: KEN'S BODY SHOP F _>lt
Site Address: 4130 HORIZON LN #D New Address:
SAN LUIS OBISPO, CA 93401
Phone: 805-543-5450 New Phone:
New Email:Email:u-a\200 0
LINKED PROGRAM
PROO11150 0762 - SLO CITY.HAZARDOUS MATERIALS HANDLER 1.4
LastActivity: 1112512013 - REGULAR INSPECTION , EE0000510: BOYLE
EEOOOO517 - MATHESON BLISS lnactive lActivate I Change I lnactvatel
PR00111 51 1176 - SLO CITY- WASTE GENEMTOR (1-5 waste streams)
LastActivity: O8lo3l2o23 - REGULAR INSPECTION, EE0000517: BLISS
EEOOOOs17 . MATHESON BLISS Active lActivate I Change I lnactvatel
BILLING CO INFORMATION
Account lD: AR001 5253 New Account lD:
New Account Name:Account Name:WOOD, JEFF V _aO^
Mailing tr61d1s55;41 30 HORIZON LN #D New Mailing Address:
SAN LUIS OBISPO, CA 93401
Gare of:
Discount Eligible? Yes
New Gare of:
Discount Eligible?
r'"ovl
Discount Code:
Account Balance*: *as of 612612024: $0.00
CUPA
Number of Materials: L pe: Number of Waste Streams:
Update CERS?Yes No (lf yes, forward to CERS admin)
)_pe: tt?<+ Number of Tanks (list capacity/compartment below):
PE:
[ ] CREATE NEW FILE
[ ] UPDATE EXISTING FILE LABEL
[ ] UPDATE NEXT INSPECTION DATE: Date:
[ ] RETURN FILE TO:
Comments:
? b ^-:+ o{eo^'{2 rlo't'^'r
srvvll 1 lal-*itrv
,h,v/v\ tv
AP '*r czv'-*lu
r. -6 tt 5<
tlEntered by:Date:Copy to: File Other:
FORM I _ SAN LUIS OBISPO COUNTY CERTIFIED UNIFIED PROGRAM AGENCY (CUPA)
CHEMICAL INVENTORY
EADD EDELETE EREVISE
I. FACILITY INFORMATION
BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business AO KEN'S BODY S HOP
CHEMICAL LOCATION CONFIDENTIAL EPCRA
r]YES ENo
CHEMICALLOCATION MAP 1, PAINT SHOP
GRID#FACILITY ID #
(Agency use only)
F 40007202 MAP#
il. CHEMICAL INFORMATION
TRADESECRET EYes ENo
IfSubiect to EPCRA, refer to instructions
.HEMICAL'^" IVASTE pAr NT/DI RTy rH I NNER
EHS*!Yes DNo
COMMON NAME WASTE PAINT/DIRTY TH INNER
*If EHS is "Yes", all amounts below must be in lbs.
CAS#
FIRE CODE HAZARD CLASSES (Complete if required by criPA)
RADIOACTIVE Eves ENo CIJRIESE A. PURE E b. MIXTURE EI C, WASTEHAZARDOUS MATERIAI TYPE
(Check one item only)
LARGESrcoNro'** 55.0E A, SOLID E b. LIQUID E C, GASPHYSICAL STATE
(Check one itern only)
EI A, FIRE E b, ruICTTVE E C. PRESSLIRE RELEASE E d. ACUTE HEALTHFED HAZARD CATEGORIES @ e. CHRONIC HEALTH(Check all that apply)
ANMJAL WASTE AMOUNT STATE WASTE CODE
01
AVERAGE DAILY AMOUNT
1.5
MAXIMUM DAILY AMOUNT
3.0
DAYSoNtttt' 365.0! u. cwrc nrrT E c. PoUNDS
*If EHS, amount must be in pounds,
E d. roNSI a. GALLONS
(Check one item only)
UNITS*
E a. ABOVE GROUND TANK
trtr EI.CYLINDER Ep.TANKwAGoNE d, STEEL DRT'M
STORAGE
CONTAINER I q, RAIL CAR
E r. OTHER
E i.FIBERDRT'M E M, GLASS BOTTLE
J. BAG
K. BOX
n, PLASTIC BOTTLE
o, TOTE BIN
b. UNDERGROUND TANK
c, TANK INSIDE BUILDING
E e, PLASTIC/NONMETALLIC DRUM
E f, CAN
g. CARBOY
h, SILO
[I a, AMBIENT E U. ASOVP ANBTENT E c. BELOWAMBIENTSTORAGE PRXSSURE
STORAGETEMPERATURE S A, AMBIENT E b. AIOVEE]\4BICNT E d. CRYOGENICfl c. BELOWAMBIENT
EHS CAS #Y"WT HAZARDOUS COMPONENT (For mixture or waste only)
! ves [No25.0I PAINT SLUDGE
lves lNo70.0
2
LACQUER THINNER
E Yes fl llo3TOLUENE, XYLENE
ACETONE lYes ENo4
[Yes [No5
If more hazardous components Ire present at greater than I 9/. by weight if non-carcinogenic, or 0.1yo by weight if carcitrogenic, attach additional sheets of p{per capturing the reqtrired information.
ADDITIONAL LOCALLY COLLECTED INFORMATION
If EPCRA. Please Siqn Here
::01 |,/iI fi){; fJ'l l8j.,$urJ6* !rt3d era*1sn$\stl]}isr\!1}afx-LN?} Jn?L){:}i1'l.)laeJ t#= uSul talms{sucsrn"4sutoes} g;gg dVW - lfit tllgedd*ue'* ure;6o.t6 pa1;lun pa$firo3 &uns3 c fi*slnf u?S(\-/n* ilt _f :aleflausN scaul€ngf-tY r".rtLlll'?t{dltL"r 'i, -lI lf, :ssarPPVO = iq$tN}; = {,ag - anoqY P*1rrdaff ,{llpaer, utseadqduS Js JaqunN2; tVSt{ -?t:rvs ?"t?rI}\l* )*]a\ 11rle!l5-.lj3!rl!{'4? J-r t"d ?)deF$ -, rd'gJ}'tJ.>:'11.l {stvu,|;* r'r,$ A{i,:1}t*l,c-tvfH.}J3a!3*,*,-$"rr*grjp,tlrt l4ti h "i1, r-(f 3 3l|tC ' .8, ir('t * ' * rl Vil / -r 3"iL{ wri tr 73"'l 1,\ ',^lr'U{J ]/f^rnrtU. }qi {} I q; '-Y! {! r-tr.lol hc, q} }1 nw* T-} -}?td S ' hkttr-*q ?J.5v s J {'itttJ t:q-lV.iEtrtiJ '{,gtt?tziVl f {VVrc; S.,rtr"*rtr!!t} ,trtclr$1"J)L*z,(.,,,,u0l01,"4.L.tr.:76$8t"eJ$l\-tIts;l3_€+-Lscfi. ill'u \:/i:-tj_a.)$*ptI7t,ltn-lXIHfrJ3fi3avt# oEti{
PROGRAM CONSOLIDATED
FACILITY INFORMATION
BUSINESS ACTIVITIES.
Page 1 of
I. FACILITY IDENTIFICATION
EPA ID # (Hazardous Waste Only)2FACILITY ID #
(Agency Use Only)F A 0 0 0 7 2 0 z
BUSINESS NAME (Same as DBA-Doing Business As)Name
BI]SINESS SITEADDRESS 4130 HORIZON LN #D 103
CA ZIP CODE 1051BUSINESS SITECITY SAN LUIS OBISPO 104
II. ACTIVITIES DECLARATION
NOTE: If you check YES to any part of this list'
please submit the Business Owner/Operator Identification page.
Of the UPCFIf Yes, please complete these pagesDoes your faciliW
fl ves
HAZARDOUS MATERIALS
INVENTORY_ CHEMICAL
DESCRIPTION
A. HAZARDOUSMATERIALS
Have on site (for any purpose) at any one time, 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 applicable Federal threshold
quantity for an extremely hazardous substance specified in 40 CFR Part 355,
Appendix A or B; or handle radiological materials in quantities for which an
emersencv plan is required pursuant to l0 CFR Parts 30. 40 or 70?
Ivns Coordinate with your local agency
responsible for CalARP.
B. REGULATED SUBSTANCES
Have Regulated Substances stored onsite in quantities greater than the
threshold quantities established by the California Accidental Release
prevention Program (CalAM)?
UST FACILITY (Fomerly swRcB Form A)
UST TANK lone page per tank) (Formerly Form B)nves
C. UNDERGROUND STORAGE TANKS (USTS)
Own or operate underground storage tanks?
NO FORM REQUIRED TO CUPAS! vas
D. ABOVE GROUND PETROLEUM STORAGE
Own or operate ASTs above these thresholds:
Store greater than 1,320 gallons ofpetroleum products (new or used) in
aboveground tanks or containers.
!YES
! vrs
I vrs
I vrs
IvEs
I vas
!vrs
! vas
EPA ID NUMBER - provide at the toP of
this page
RECYCLABLE MATERIALS REPORT
(one per recycler)
ON.SITE HAZARDOUS WASTE
TREATMENT _ FACILITY
ON-SITE HAZARDOUS WASTE
TREATMENT - UNIT (one page perunit)
CERTIFICATION OF FINANCIAL
ASSURANCE
REMOTE WASTE / CONSOLIDATION
SITE ANNUAL NOTIFICATION
HAZARDOUS WASTE TANK
CLOSURE CERTIFICATION
Obtain federal EPA ID Number, file
Biennial Report (EPA Form 8700-
13A/B), and satisff requirements for
RCRA Large Quantity Generator.
See CUPA for required forms.
Recycle more than 100 kg/month of excluded or exempted recyclable
materials (per HSC 25143.2)?
Treatment subject to financial assurance requirements (for Permit by Rule and
Conditional Authorization)?
Consolidate hazardous waste generated at a remote site?
Need to report the closure/removal of a tank that was classified 4S
hazardous waste and cleaned on-site?
Generate in any single calendar month 1,000 kilograms (kg) (2,200 pounds) or
more of federal RCRA hazardous waste, or generate in any single calendar
month, or accumulate at any time, I kg (2.2 pounds) of RCRA acute hazardous
waste; or generate or accumulate at any time more than 100 kg (220 pounds) of
spill cleanup materials contaminated with RCRA acute hazardous waste.
Household Hazardous Waste (HHW) Collection site?
Treat hazardous waste on-site?
E. HAZARDOUS WASTE
Generate hazardous waste?
1I
I
F. LOCALREQUIREMENTS
(You rnay also be required to provide additional infonnation by your CUPA or local agency )
l5
&d(/
UPCF Rev. (1212007)
&FORM S-SAN
It\5 0
COUNTY CERTIFIED UNIFIED
OWIYER/OPERATOR IDENTIFICATION
T\Jeffp\FORMS\Business Plan Forms\FRM-S' DOC 1 1 -Dec-02
AGENCY
,..
O:\DOCUfI/EN
6v iJ \-NA- l\r,t\otr ,^r/
T. trNENTIFICATION
{.fCI
BUSINESSNAME(same a FACIUTY NAME or DBA - Doing Businas As)
11
*DOdli
SITE
tlf*)c)A N
CA 73+ot
CODE104
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AIJ il0-S USNTSS OPERATOR PHONE
_sA rn E
il. BUSINESS OWNER
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OWNERNAME h Art\-\nR"n sr
ttzolhiER.
q t-l 3EAG aou (-
M. ENVIRONMENTAL CONTACT
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117
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ry. EMERGENCY CONTACTS -SECONDARY--PRIMARY-
NAME
gRJ5er\)NAME
124
8o
ICELL #
PAGER
t21
ADDITIONAL
133
COLLECTED INFORMATION :
examinedpenaltycertiSforonofthosemyCertifiandaccurate.complete.isinformationthe true,andsubmitted believeinformationthefamiliaralnwith
OR Qn*lo
NAME
N
DATE/- /7 0
FJE{L-}A}.}Ato
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FORM I _ SAN LUIS OBISPO COUNTY CERTIFIED UNIFIED PROGRAM AGENCY (CT]PA)
CHEMICAL INVENTORY
material 2rea
Dnop EDELETE flRsvtse 200
I. FACILITY INFORMATION
')
BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As)
EPCRA
D ves filNo
20tLOCA
FACILITY ID#
(Agercy wc only)
II. CHEMTCAL INFORMATION
fo EPCRA' rcfer to instructions
2fi6
If Subject
NoYesTRADENAME
'f
D Yes FNoEHS*
201NAME
*If EHS is *Ycs", all amounts bclow must be in lbs-
(Completc if required by CUPA)
CURIES
212
RADIOACTIVE Dv"t $NoHAZARDOUS MATERIAL TYPt
(Check one item onlY)flc. wesrEE a. PLIRE b. MIXTURE
LARGEST CONTAINER i.[*ruPHYSICAL STATE
(Check one item onlY)fl a. soLID pu.uOuno E c. GAS
2t4
FED HAZARD CATEGORIES
(Check all lhat aPPIY)sa. rmr D b. REACTIVE fl c. pRESSURE RELEASE Ffo. ecrrre HEALTH E e- cHROMC HEALTH
2t6
STAANNUALAMOI.JNI
t a Gnitosl
StoF
SITE:n d-roNsfi a. GALLONS
(Check one item only)
T'NITS*.If EHS, amount must be in
E U. CtmtC Fgrr D c. POUNDS
nnF
b. TINDERGROTJNDTANK
c. TANKINSIDEBUILDING
d. STEEL DRUM
Dtrn
r. OTHER
q. RAILCAR
j.
k.
t.
m-DRIIMe.Ta.
CONTAINER trn CYLINDER
nn
BAG
BOX
E h. srlo
E n. PLASTIC BOTTLEf. CAN
g. CARBOY o. TOTE BIN
p. TANK WACON
{ ".
nr"ramrr El b. ABovE AN4BIEbrr fl c. BELOW AMBIENT
STORACE PRESSI]RE
224
STORAGETEMPERATURE [". en1tsn}n fl b' ABovE AIIBENI E d. CRYOGEMCD c. BELOWAMBIENT
CAS #EHSHAZARDOUS COMPONENT (For mixture or waste only)o/"WT
Eves ElNouEes%273
f] Yes EI]t"y aE/u
230
2
237
E ves SNo
236
afo234
3
ffves fiNoTovug4N
flYes tlNo
?44
5
or 0.lolr bY rddition.l prpcr
fioft toepoDclts arc pffint rl guter rhr! 17. bY
246
ADDITIONAL LOCALLY COLLECTED INFORMATION
O:\DOCUMENTr.lefiprFORMS\'Business Plan FonnsiFRM-I DOC 11-Dec-02 t,\f'\c,
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A B c D E F G H J K L M N
San Luis Obi'-ap County Gertified Unified Program
FORM M - MAP GRID (see instructions)
Scale 1 inch = Lo Feet
'-\rn"y
Mao #
Date: /* 30'-OleBusiness Name:Si"toil
3.roF*d& t?onJ ,-n-! .S" L.s. c.4Address: 4l 3C
2 Night = Oin Facility DePicted Above - DaY =Number of EmPloYees
\,)A'
O.\DOCUIJIENnJeflp\FORMS1BusinessPlanForms\FRM-M.DCC1'?n1iA2
,) FORME a
SAN LUIS OBISPO COLINTY CERTIFIED I.}NIFIED
PROGRAM AGENCY (CUPA)
EMERGENCY RESPONSE PLAN
Or Hazardous Waste Contingency Plan
Date:
SECTION I-A: BUSINESS IDENTIFICATION DATA
Kg,..)s &rOV Sno P
BUSINESSNAME
CITY ZIP CODE
SITEADDRESS
ffcs 5ilJ3^:-4,fo
TELEPHONE NUMBERFACILITYUNIT
5 K YV\E
CITY ZIP CODE
BUSINESS MAILING ADDRESS
If your businas has a license or permilfrom any ofthelollowing agencia, please indicae the dostment namben
I. Hazardous Materials
Underground Storage #
3. Air Pollution Conuol
District#
4. Responding Fire DePt
& Permit#
Telephone #
U
,1,o. {o"h
8rs 5' ' 5i .1 -rlgtLT
2. Hazardous Waste
Crenerator #
Electric Service
Gas Service
Sanitation
Water District
P G, AL
PA
LO 0
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. fttir information is provided ibr yo* reference and to assist emergency response personnel in responding to a
hazardous materiais emergency at your faciliry. List the name and phone number of the utility company.
goc- "{b- f,oOO
drs
e
r{ln Telephone #
Telephone #
Telephone #
n-l l..tfig A,ILS$.GE
l^r LLL
SECTION I-B: OWNER CERTIFICATION OF DATA (Certify either I or2\
l. This is a gflNrw rlan IUTDATED Existing plan. I have personally examined the information it contains and am familiar with the
;pr;;;;frh" prun. lirvou rireck either of the af,ove rwo options, continue to complete the remainder of the Emergency Response /
Contingency Plan).
t. - ifi;lan requires no change and is on file with San Luis obispo counry cerified Unified Program Agency and does not need any
cnar[e. (If you check &is section, please proceed directly to Form T, &e Training Program')
I certifr under penalty of law that the above information is true and accurate.
0{OAr\)2 a
DATE
1-
DATE
PRINT NA,VE OF OWNER OR OPERATOR
5A 'qe
l-
DOCUMENTS PREPAR.EDBY
O:\DOCUMENT\Jeffp\FORMS\Business Plan FormsiFRM'E DOC 08/08/02
SECTIONII: EMERGENCT RESPONSE pLANs AF{D PR()C?DT'RES
NoE: CmoH. rfi s.cdm of rhir Sm.rgency R.spoora hsdur bctw. Uoc of lcrms such r9 "hr/A" (Not AppllcrblE witl not be acc.p.rd.
A' FIR'E SPU& OR RELEASE: The lirc code require imnediare notificorion through dialing 9l l, by wbocver ft*t sfhtr thciocid$t In the event of rcleare or spill of bszrrdous naterlab, you nusl also notif :
I' San Luir Obispo County Ccrtlfrod Uniftcd Progrtn agEncy'duriog buslnes bours @ fi)A7Ot-SE4,l. After bnsi.gs hourcdill 9lt.
2- Tbe sate olricc of Emcrgorcy scrvtcc$ - (sOo) tsL7s50 or (916) 262-162l.
Lisl tte indivlluals nspoosiblc for veri$ing thrt thcst catb hsvc been nede lnd sbo Indicrte tLeir pcition io your coupany.
rdR rrynrrynvc rlm DrALrNGoFell:
NAI'G m$n(n{
IndividEl rrsponsiblc for calling sen L11s obispo Cornty certificd Uni6ed Program AgEncy aod the slarc office of Emeqenqy Seryices:(Norrnally tLc Emeqancy Cocrdinshr of ),uur bwin€ss,)
s t S nrate
N^ldE rsma{
B.List thc locel eurcrgcacy modical ficiliries rh"t will bc used by yorr busfutess in the event ofsn accidem or injrry carspd by a releaseor tlueaErod rclcase of hazardgus mdfiials.
Et\ S".*rrD A*-r /Yt AO.ra'rn.t^R$.s. A. O.5-?? -8ddo
ADrnt$s CTTY I|{ONE
NA'{D
NAIVG ADDITSS
5i
crfY PrlollP
C, Lisr rhe Efnergarcy Coordinatc(s) ar pw facility.
Primert4
NAt\,lE NTLE BIJSINESS PHOIIE 2. HR P}I{TNE ,AGERT
Secondery: [r / A
xa/rE TITLE EUSINES$ PHONE 2.HRPHq.E PACEn !
D.Does yorrr brrsiness have an on-sitc cmtrgency rtsponrc rcnm? flves ffiNo Dcscribe procedues )our business will follow in treevcnt of a rrlcase or thrratened release of hszrdous matcrials.
Au t^PnolEES he6 -o^r*ot -Tn. Er,i", =F fr-tF Kvrn,&_*
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Itlttt9988 EE:t8 9844/ZZ/98za 39vd dOHSAOOSSNS>|
2
E. Ifyouhave acutely hazardous ma.*-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 aparfinent buildings, list managefs
phone. Do not list telephone numbers for private residences.
l:o N] 0'"r A 0p {./
F,. Briefly describe your standard operating procedures in the event ofa release or threatened release ofhaeardous materials'
Emergency response procedurei must
"o*pry
*itrt a[ 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 accidenlpotentials? lnclude description of safety, storage' and containment procedures'
t\.)
2. Equipment - List the emergency response equipment at your facility (e.g. fire e*inguishing systems,spill control equiPment
decofiamination equiPment),
Item
IA
EXT'tl€.t/rS
LL
ABgocgep"f
g?s? AiF Kr
fz c.S NAEMfi
I €0
Maintenance Procedure
the designated meeting locations?
failure?3. Evacuation - Describe how you will immediately evacuate your facility' Where are
What communications or alarms are used? How will you operate these during power
LocationUse
ia.rAr i( lN qHnFFIQF 4CNTflOL
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4. Shutdown - Describe the procedures to shutdown the facility in case of an emergency
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5a. Response - Describe what is done to lessen or mitigate the harm or damage done to person(s), property, or the environmeng and to
prevent the event from getting worse or spreading. What is your immediate response to:
Fire:
Explosion:
Spill: Cor.j t: r
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Earthquake:
Major Power Failure:a
Flood:il.q-r
b. Is thh facility located on a 100-year flood plain? flyes FVoc. Earthquake - Identifu facility areas and list mechanical or other systems that require immediate inspection or isolation because of
their vulnerability to ealthquake related ground motion.
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6. Clean-Up - How do you handle the complete process of cleaning up and disposing of hazardous material releases at your facility?
Note: Notify the Certified Unified Program Agency when clean up is complete.
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G. Location - Your business is required to keep a copy of the Business Plan and related Material Safety Data Sheets (MSDS) on-site.
Describe where this information is located.
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4
FORM T
SAN LI.NS OBISPO COLINTY CERT'TPIED LTNIFIED
PROGRAM AGENCY (CrtPA)
EMPLOYEE TRAININ G PROGRAM Date: / - Z?-t)b
A. Describe the safety training for all employees in the event of a release or threatened release of hazardous materials' This
training shall inctude, but not be limited to the foltowing: new employee training, annual training and safety meetings which
cover familiarization with the facility's hazard communication program and Emergency Response Plan/contingency Plan'
l. Summarize the training for all employees that work with or come in contact with hazardous materials/hazmdous wastes' Descnlbe how
these employees are trained to avoid exposure.
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2. Summarize training specific to those employees that would respond to a release or threatened release of hazardous materials or
hazardous waste.
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lndicate frequency and duration of training for employees that work with or come into contact with hazardous materials/hazardous
waste.
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4. Describe how your employees access training materials. (E.g., bulletin board, employee newslefier' staffmeetings' etc')
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B. List person(s) in charge of training and indicate their quatilications to conduct the training'
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c.Indicate where training records are kepl (Records must document the type of training, duration, completion dates' names and
positions of employees receiving training and the name of instructor/fainer')
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Winston H. Hickox
Agency Secretary
ealifornia Environmenlal
Protection Agency
Department of Toxic Substances Control
Edwin F. Lowry, Director
1001 I Street, P.O. Box 806
Sacramento, California 958 1 2-0806
EPA lD Number lssued
Location Address:
4130 HORIZON LN
SAN LUIS OBISPO
Gray Davis
Governor
November 17,2OO3
cA 934010000
ATTN: VINCE PELLEGRINI
KEN'S BODY SHOP
4130 HORIZON LN
SAN LUIS OBISPO CA 93401
PERMANENT RECORD . DO NOT DESTROY
YOUR CALIFORNIA EPA INENTIFICATION NUIItrBER I$:
cA1000276374
This is to acknowledge that a permanent California Environmental Protection Agency ldentification (EPA lD)
Number has been assigned to your place of business.
An EPA lD Numher r.s assigned to a person or business at a specific sife. ft ,b only valid for the
tocation and person or business to which it was assigned. tf your business has muttipte
generation sifes, each sife musf have its own unique number. lf you stop handling hazardous
waste, move your husiness, change ownership, change mailing address, or change the type or
amount of waste you handle, you must notify the Department of loxic Substances Control
immediately. If your business has moved, your EPA lD Number must be canceled. A new
number must be obtained for your new location if you continue to generate hazardous waste.
This EPA lD Number must be used for all manifesting, record keeping, and reporting requirements. Please retain
this notice in your files.
Department of Toxic Substances Corrtrol
Office of Environmental lnformation Management
Generator lnformation Services Section
Telephone:(g16) 255-1136 or California Only Toll-free Number:(800) 618-6942
Operator'slnitials: SBouzard
version: July 2001
"The energy challenge lacing Califomia is real. Every Califomian needs lo take immediate action to reduce energy consumption. For a lisi
of simple ways you can reduce demand and cut your energry costs, see our web-site at urww.dtsc.ca.gov."
{F Prinled on Recycted paper
. KEN'S BODY SHOP
NOTICE OF VIOLATION
FA#: FA0007202
lf you have questions regarding this notice, please contact me at (805) 781-5544.
AARON LA BARRE
Environmental Health Specialist
Program: HAZARDOUS MATERIALS HANDLER l-4
I hereby certify, under penalty of law, that the initialed violations, listed above, have been corrected. I
understand that a chargeable reinspection may be conducted to verify compliance.
Owuueru /p- /f ^ Otr-
natu Title Date
5t24t2006
PAGE 5
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COUNTY.6SAN LUISotrsFoEnvironmental Hea'li .!4ees_(80$ 781-55442156 Siefta Wav Ste. BSan Luis Obispo. CA 93401eng@eo-s/o-eg-us-slacountv.aov/ehsFire Department.l lija) i;l,rla llr.::;tr:l Arert{te. ,j.rn 1.";is i;li:Gr-: {1,1 !:1.1i: l:f .iril1!:5.i $ I /3Ll{}',1:r: rl',,r::.iCERTIFIED UNIFIED PROGRAM AGENCY (CUPA}Regulated Facility lnspection FormFacility generates <27gallmonth. Facility will be moved to CESQG category,g Violations were observed/discovered as listed below. All violations must be corrected by implementing the correctiveaction listed by each violation. lf you disagree with any of the violations or corrective actions required, please inform theCUPA in writing.. ALL VTOLATTONS ,ltusf BE CORRECTED WITHIN 30 DAyS OR 45 SPECTFIED CUPA must be infarmed in writing wtth a ceftificationthat compliance has been achieved. A false statement that camplianee has been achieved ,s a wolation of the law and punishable by aftne of up to $70,0A0 for each violation. Your factlity may be reinspected any time dunng normal busr'ness hours.. You may request a meeting wtth the Program Manager to drscuss the inspection findings ancl/or the proposed corrective actions. Therssuance of thts Summary af Violations does not preclude the CUPA from taktng admrnistrative, ctvtl, or criminal action.STATEMENT OF COMPLIANCECertilication: I certify under penalty of periury that this facility has complied with the corrective actions listed onthis inspection form.ljtle:DateSignature of Owner/Operatorm No violations of underground storage tank, hazardous materlals, or hazardous waste laws/regulations were discovered.SLO CUPA greatty appreciates your eflorts to comply with all the laws and regulations applicable to your facility.SUMMARY OF FINDINGSPERMTSS/ON IO INSPECT: tnspections may involve obtaining photographs, reviewing and copying records, and determininlcompliance with adopted codes.SignatureReceived By: Jose Valdonvinoslnspected By: Matheson BlissDate: 08fl.412025Title:ManagerGranted By: Jose ValdonvinosPermit Number:PR0022575gUST0HW Generator0HazmatReinspection RequiredOTPEgcalARPgASTOUSTEHW GeneratorFHazmatPrograms lnspected:OTPEBCaIARPgASTlnspection TvpeX Routinen Other il Change of Ownershipu Reinspection EI Chargeable! ComplaintE Secondary Containment TestingAqencv0EHS ECity FireEstablishment lD: FA0016945Serial Number: DA7821-568CERS lD: 10438960Date: OBll-412025City: SAN LUIS OBISPOSite Address: 4130 HoRlzoN LN #DZip:93401-Phone:(805) 543-5450EStAbIiShMENt NAME: CUSTOM CRAFT AUTOBODY
Date:0612612024/ctty o[ san Luts oBlspoFIRE DEPARflTEilT2160 Silta EarbaE Avilus'Sd Lub Obbpo,CA 93401-5210'(805) 781-7380"Ctturtesy & Service"CERT|FTED UNIFIED PROGRAM AGENCY (CUPA)HAZARDOUS MATERIAL INSPECTION FORMTime:COUNTYbSAN LUISOBISPOPERMISSION TO INSPECT: lnspections may invotve obtaining photographs, reviewing and copying records, anddetermining compliance with adopted codes.trTPEtrCalARPtrAGTtrUSTEHW GeneratortrHazmatREINSPECTION REQUIRED:trTPEtrCalARPtrAGTtrUSTtrHW GeneratorDHazmatPROGRAMS INSPECTED:Facility Name: CUSTOM CRAFT AUTOBODYAqencvtrEHStrctry FrRElnspection TvoetrRoutinetrReinspectiontrChargeable ReinspectiontrChange of OwnershiptrComplainttrSecondary Containment TestingEChargeable Secondary Containment TestinlSite Address: 4130 HORIZON LN #DSAN LUIS OBISPO, CA 93401Phone: (805)543-5450Facility lD: FA0016945 CERS lDSerial Number: DARGDNGQINOtrtrYEStrtrtruN/A VIOL. #tr BPOIBPO2BPO3TROlTRO2EROlERO3BUSINESS PLANBusiness plan complete, current, available during inspection and submitted electronically (HSC 25505,25508(aXl); 19 cCR 2651)lnventory of hazardous materials is complete and submitted electronically (HSC 25505(aX1), 25506,25508(aX1), 19 CCR 2652,26541Site tayouU facility maps are accurate and submitted electronically (HSC 25505(a)(2)' 25508(a)(1), 19 CCR26521TRAINING PLANFacitity has appropriate training program, submifted electronically (HSC 25505(a)(4), 25508(aXl), 1gCCR2659, 22CCR66265.16)Training documentation is maintained on site for current personnel (HSC 25505(a)(4), 22CCR66265.16)EMERGENCY RESPONSE PLANEmergency response/contingency plan complete, current, submitted electronically, maintained onsite(HSC 25505(aX3), 25508(aX1), 1gCCR 2658, 22CCR 66265.52-.54)Secondary containment is installed and sufficiently impervious to discharges. ICHSC 25270.4.5;40 CFR112.8(cX2)IGENERAL EH VIOLATIONSEnvironmental Health fees paid. ICBPC 17200, Local Ordinance]ntrtrtrtrtrtrFE01GPS Goordinates: LatitudeGPS Coordinates: Longtitude:INSPECTOR: MATHESON BLISSFACILITY REP: Jaime
FAGtLtTy NAME: CUSTOM CR4' 'AUTOBODY ADDRESS:( '30 HORIZON LN #DSAN LUIS OBISPO, CA93401HAZARDOUS WASTE GENERATORYEStrtrtrBtrntrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrGT16GT17ntrtrtrDntrtrNO N/A VIOL. #tr tr GT01GTO3GTO4GTO5GTO6GTO9GTlOGT11GT12GT13GT14GT15EPA ID NO/PERMITSGenerator has an EPA lD number to treat, store, dispose, transport or transfer hazardous waste (22CCR 66262.1 2) lf not, Call (800) 618-6942 to obtain your CAL EPA lD numberHAZARDOUS WASTE DETERMINATIONHazardous waste determination conducted (22 CCR 66262'111Eown knowledge tranalysis DotherHazardous waste analysis/test records are kept for at least 3 years(22 CGR 66262.40.(c))D ISPOSAUTRANSPORTATIONHazardous wastes disposed of at an authorized location (HSC 25189.5, 25201(al, 22 CCR 66262j12lFacility utilizes a registered hazardous waste transporter, and hazardous wastes shipped with amanifest (HSC 25160. 25163(a); 22 CCR66262.20,66263'41)trmiltrotherManifests and/or receipts are properly completed/retained by generator for 3 years (22 CCR 66262.23,66262.40(a))STORAGE AND MANAGEMENT OF CONTAINERS/TANKSHazardous wastes are accumulated on site as follows: ( HSC 25123.3 (bxly(dy(hxl);22 CCR 66262'34(d))fl90 days if waste generated per month is greater than or equal to 1000 kg' (2200 lbs.)tr180 days if waste generated per month is less than 1 000 kg (see note)tr270 days if waste generated per month is less than 1000 kg and transported more than 200 miles (seenote)Note: Applies only if hazardous waste accumulated on site never exceeds 6000k9(13,200 lbs) and noacutely/extremely hazardous waste over 'lkg(2.2|bs.) is held on site for over 90 days.Hazardous waste "satellite" collection is managed properly (complete labeling/accumulation timdSS-galor 1-qt limit) (22 CCR 66262.34(e))lgnitable or reactive wastes are located 15 m (50 feet) from facility's property line (22 CCR 66262.34(aXl),66265.1 76)Containers of hazardous waste are properly labeled (includes appropriate date,"HAZARDOUS WASTE,"waste compositiodphysical state, hazardous properties, name/address of generator) (22 GCR 66262'31,66262.34(f))Containersitanks containing hazardous wastes are in good condition/handled to minimize the releaseor reaction (22 CCR 66262.34;22 CCR 66265.17'l-.179, 66265.177(c))Containers/tanks/liners are compatible with waste stored or transferred (22 CCR 66262.34, 66265'1721Containers storing hazardous wastes are closed/sealed (22 GGR 66262.34, 66265.173)Weekly inspection of areas where hazardous waste containers are stored is conducted (22 CCR66262.34,66265.174)Daily inspection of all tank systems is conducted and documented (22 CCR 66262.34, 66265.195)Empty containers or inner liners > 5 gal has date when emptied and are properly managed within oneyear of date emptied (22 CCR 66261.7(f))RECYCLABLE WASTEUsed oil is managed as hazardous waste until recycled (includes proper labeling, storage, etc) (HSC25250.4',)Used oil filters for recycling are managed properly (drained of free flowing liquid, stored in closedrainproof container, labeled "drained used oil filters," and transferred for metal reclamation) (Tille 22ccRs 66266.130)Spent lead-acid batteries are being properly stored and transferred offsite under manifest or bill oflading for recycling, reuse, or reclamation (22 CCR 66266.81)Solvents/other recyclable materials are managed as hazardous wastes until recycled (22 CCR 65266.2)SOURCE REDUCTION:For facilities generating >12,000 kg./yr. of hazardous waste on site.Generator is subject to SB14 and has prepared and retained current source reduction documents or isable make them available to the inspector within (5) days. (HSC 25244.'191.211.22;22 CCR 67100.7/.8)Source Reduction Evaluation and Plan contains the following five elements:certification, amounts ofwastes generated, process description, block diagrams, and implementationschedule of selectedsource reduction measures. (HSC 25244.191.21,22 CCR 67100'5/7/.8)Hazwaste Contingency Plan prepared, current, submitted to the CUPA, maintained onsite. (22GCR66262.34(aX4), 66265.51 -.54)Employees trained upon hire, annually; training records maintained at facility as required (22 CCR66262.34(a)(4), 66265.1 6)Facility is operated and maintained to prevenUminimize/mitigate fire, explosion, or release ofhazardous materials/waste constituents to the environment. Maintains all required or appropriateequipment including an alarm and communications system (22 CCR 66265.31-.37)trDtrGTO7trtrncT08trDtrutrntrtrtrtrtrtrtrtrtrGT18GT19GT2OGT21GT22GT23GT24GT25ERO2trEtrtrtrtrtrtrtrtrtrtrtrtrtrtrtr
SUMIVI, TY OF OBSERVATIONSVIO( TIONStr No violations of underground storage tank, hazardous materials, or hazardous uiaste laws/regulations were discovered.SLO CUPA greatly appreciates your efforts to comply with all the laws and regulations applicable to your facility'tr Violations were observed/discovered as listed below. All violations must be corrected by implementing the correctiveaction listed by each violation. lf you disagree with any of the violations or corrective actions required, please inform thCUPA in writintrALL VTOLATTONS MUST BE CORRECTED WITHIN 30 DAYS OR AS SPECIFIED. CUPA must be informed in writing with acertification that compliance has been achieved. A false statement that compliance has been achieved is a violation ofthe law and punishable by a fine of not less than $2,000 or more than $25,000 for each violation. Your facility may bereinspected any time during normal business hours.you may request a meeting with the Program Manager to discuss the inspection findings and/or the proposed correctiveactions. The issuance of this Summary of Violations does not preclude the CUPA from taking administrative, civil, orcriminal action.FACILITY NAME: CUSTOM CRAFT AUTOBODYADDRESS: 4130 HORIZON LN #DSAN LUIS OBISPO, CA 93401VIOLATIONSVIOL. NO CORRECTIVE ACTION REOUIREDINSPECTION COMMENTS:INSPECTED BY: MATHESON BLISSDATE:06t26t2024NAME OF FACILITY REP: JaimeSIGNATURE OF FACILITY REP:STATEMENT OF COMPLIANCECertification: I certify under penalty of perjury that this facility has complied with the corrective actions listed onis inspection form.Sig nature of Owner/Operator:-Title:- Date
COUNTYb SAN LUISOBISPO,']EnvironmentalHea(r rvicesl(Bos) 781-5s44lP.o.Box 14sg12156 Sierra Wav Ste. BiSan Luis Obisoo. CA 934061Ia'clty o1 san luls oBlspoFIR€ DEPARTMEilT2160 Sdta Barba6 Avfilo'San Lob 0btspo,CA 93401-5210'{8{F) 7gt-7380"Cotrtesy & Service"Date: 08/03/2023CERTTFTED UNTFIED PROGRAM AGENCY (CUPA)HAZARDOUS MATERIAL INSPECTION FORMTime:PERMISSION TO INSPECT: lnspections may involve obtaining photographs, reviewing and copying records, anddetermining compliance with adopted codes.trTPEtrCa|ARPtrAGTtrUSTtrHW GeneratortrHazmatREINSPECTION REQUIRED:trTPEtrCalARPtrAGTtrUSTEIHWGeneratortrHazmatPROGRAMS INSPECTED:Facility Name: KEN'S BODY SHOPAgencytrEHStrCITY FIRElnsoection TvoetrRoutinetrReinspectiontrChargeable ReinspectiontrChange of OwnershiptrComplainttrSecondary Containment TestingtrChargeable Secondary Containment TestinlSiteAddress:4130 HORIZON LN #DSAN LUIS OBISPO, CA 93401Phone: (805)543-5450Facility lD: FA0007202 CERS lD: 10438960Serial Number: DAQVSM579YES NA MtrtrtrBUSINESS PLANBusiness plan complete, current, available during inspection and submitted electronically (HSC 25505'25508(aX1); tg ccR 2651)lnventory of hazardous materials is complete and submitted electronically (HSC 25505(a)(1)' 25506,25508(aX1), 19 CCR 2652,26541Site tayouU facility maps are accurate and submifted electronically (HSC 25505(a)(2)' 25508(aXl)' 19 CCR26521TRAINING PLANFacitity has appropriate training program, submitted electronically (HSC 25505(aX4), 25508(aX1), l9CCR2659, 22CCR66265.16)Training documentation is maintained on site for current pensonnel (HSC 25505(aX4), 22CCR66265'16)EMERGENCY RESPONSE PLANEmergency response/contingency plan complete, current, submitted electronically, maintained onsite(HSC 25505(aX3), 25508(aXl), lgcCR 2658, 22CCR 66265.52-.54)Secondary containment is installed and sufficiently impervious to dlscharges. ICHSC 25270.4.5;40 CFR112.8(cX2)lGENERAL EH VIOLATIONSEnvironmental Health fees paid. ICBPC 17200, Local OrdinancelGPS Goordinates: Latitude: 35.2413200000GPS Coordinates: Longtitude: 120.6656500000vtoL. #BPOltrtrBPO2BPO3TROlTRO2EROlERO3trtrtrtrtrtrtrFE01trtrtrtrtrtrINSPECTOR: MATHESON BLISSFACILITY REP: Wade Brown
FACILITY NAME: KEN'SADDRESS:/!HAZARDOUS WASTE GENERATOREPA ID NO/PERMITSGenerator has an EPA lD number to treat, store, daspose, transport or transfer hazardous wasle (22CCR 66262.12) lf not, Call (800) 618-6942 to obtain your CAL EPA lD numberHAZARDOUS WASTE DETERMINATIONHazardous waste determination conducted (22 CCR 66262.11)Eown knowledge tranalysis trotherHazardous waste analysis/test records are kept for at least 3 years(22 GCR 66262.40.(c))DISPOSA IJTRANS PORTATIONHazardous wastes disposed of at an authorized location (HSC 25189.5, 252O1(a1,22 CCR 66262.121Facility utilizes a registered hazardous waste transporter, and hazardous wastes shipped with amanifest (HSC 25160. 25163(a)r 22 CCR 66262.20,66263.41)trmiEotherWade BrownManifests and/or receipts are properly completed/retained by generator for 3 years (22 CCR 66262.23,66262.40(a))STORAGE AND MANAGEMENT OF CONTAINERS/TANKSHazardous wastes are accumulated on site as follows: ( HSC 25123.3 (bxly(dy(hxl); 22 CCR 66262.34(d))tr90 days if waste generated per month is greater than or equal to 1000 kg. (2200 lbs.)8N180 days if waste generated per month is less than 1000 kg (see note)tr270 days if waste generated per month is less than 1000 kg and transported more than 200 miles (seenote)Note: Applies only if hazardous waste accumulated on site never exceeds 6000k9(13,200 lbs) and noacutely/extremely hazardous waste over 1kg(2.2|bs.) is held on site for over 90 daysHazardous waste "satellite" collection is managed properly (complete labeling/accumulation time/S5galor 1-qt limit) (22 CCR 66262.34(e))lgnitabte or reactive wastes are located 15 m (50 feet) from facility's property line(22 CCR 66262.34(axl),6626s.176)Containers of hazardous waste are properly labeled (includes appropraate date;'HAZARDOUS WASTE,"waste composition/physical state, hazardous properties, name/address of generator) (22 CCR 66262.31,66262.34(fl)Containe'rs/tanks containing hazardous wastes are in good conditiory'handled to minimize the releaseor reaction (22 CCR 66262.34;22 CCR66265.171-'179, 66265.177(c))Containersltanks/liners are compatible with waste stored or transfered (22 CCR 66262.34,66265.1721Containers storing hazardous wastes are closedlsealed(22 CCR 66262.34, 66265.173)Weekly inspection of areas where hazardous waste containens are stored is conducted (22 CCR66262.34,66265.174)Daily inspection of all tank systems is conducted and documented (22 GCR 66262.34,66265.195)Empty containers or inner liners > 5 gal has date when emptied and are properly managed within oneyear of date emptied (22 CCR 6626r.7(f))RECYCLABLE WASTEUsed oil is managed as hazardous waste until recycled (includes proper labeling, storage, etc) (HSG25250.41Used oil filters for recycling are managed properly (drained of free flowing liquid, stored in closedrainproof container, labeled "drained used oil filters," and transferred for metal reclamation) (fille 22ccRs 66266.130)Spent leadacid batteries are being properly stored and transferred offsite under manifest or bill oflading for recycling, reuse, or reclamation (22 CCR 66266.81)Solvents/other recyclable materials are managed as hazardous wastes until recycled (22 CCR 66266.2)SOURCE REDUCTION:For facilities generating >12,000 kg./yr. of hazardous waste on site.Generator is subiect to SB14 and has prepared and retained current source reduction documents or isable make them available to the inspector within (5) days. (HSC 25244.19121/,.22:'22 CCR 67100.7/.8)Source Reduction Evaluation and Plan contains the following five elements:certification, amounts ofwastes generated, process description, block diagrams, and implementationschedule of selectedsource reduction measures. (HSC 25244.191.2'1,22 CCR 67100.5nl.8)Haanvaste Gontingency Plan prepared, current, submitted to the CUPA, maintained onsite. (22CCR66262.34(aX4), 66265.51 -.54)Employees trained upon hire, annually; training records maintained at facility as required (22 CCR66262.34(aX4), 66265.1 6)Facility is operated and maintained to prevenUminimize/mitigate fire, explosion, or release ofhazardous materials/waste constituents to the environment Maintains all required or appropriateequipment including an alarm and communications system (22 CCR 66265.31-37)BODY SHOP,.-'4130 HORIZON LN #D)AN LUIS OBISPO, CA93401YEStrtrtrtrtrBtrtrGTO7trtrtrcTogN/A VIOL. #tr GTOIGTO3GTO4GTO5GTO6GTO9GTlOGTl1GT12GTI3GT14GTISGTI6GT17GT18GTI9GT2OGT21GT22GT23Gf24GT25ERO2Ngtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtr8trtrtrntrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtr8trtrtrtrtrtrtrtrtrtrtrtrntrtrtrtrtr
Btrs u M trt/\RY oF oBs ERVATION SV|OI-\TIONSNo violations of underground ( age tank, hazardous materials, or hazardo[ .laste laws/regulations were discovered.SLO CUPA greatly appreciates your efforts to comply with all the laws and regulations applicable to your facility'Violations were observedldiscovered as listed below. All violations must be corrected by implementing the correctiveaction listed by each violation. lf you disagree with any of the violations or corrective actions required, please inform thCUPA in writinqALL VTOLATTONS MUST BE CORRECTED WITHIN 30 DAYS OR AS SPECIFIED CUPA must be informed in writing with acertification that compliance has been achieved. A false statement that compliance has been achieved is a violation ofthe law and punishable by a fine of not less than $2,000 or more than $25,000 for each violation. Your facility may bereinspected any time during normal business hours.you may request a meeting with the Program Manager to discuss the inspection findings and/or the proposed correctiveactions. The issuance of this Summary of Violations does not preclude the CUPA from taking administrative, civil, orcriminal action.FACILITY NAME: KEN'S BODY SHOPADDRESS: 4130 HORIZON LN #DSAN LUIS OBISPO, CA 93401VIOLATIONSVIOL. NO CORRECTIVE ACTION REQUIREDINSPECTION COMMENTS:Items marked N/A not reviewed during inspectionINSPECTED BY: MATHESON BLISSDATE:08t03t2o23NAME OF FAGILIW REP: Wade BrownSIGNATURE OF FACILITY REP:STATEMENT OF COMPLIANCECertification: I certify under penalty of perjury that this facility has complied with the corrective actions listed onis inspection form.Signature of OwnTitle:-Date:
COUNTY.6SAN LUISOBISPOervices{'ctty cir-'san Lurs oBrspoFnE 0EPARTllEllT2160 Sola BarbaE Avsu6'Ss Lub Obhpo, CA 9340J-5210'1805) 7gl-7380"Courtesy & Service"Date0211012022GERTTFTED UNTFTED PROGRAM AGENCY (CUPA)HAZARDOUS MATERIAL INSPECTION FORMTime:PERMISSION TO INSPEGT: lnspections may involve obtaining photographs, reviewing and copying records, anddetermining compliance with adopted codes.trTPEtrCa|ARPtrAGTDUSTtrHWGeneratortrHazmatREINSPECTION REQUIRED:trTPEtrCa|ARPtrAGTtrUSTtrHW GeneratortrHazmatPROGRAMS INSPECTED:Facility Name: KEN'S BODY SHOPAoencv lnsoection TypetrEHS trRoutineECITY FIRE trReinspectiontrChargeable ReinspectiontrChange of OwnershiptrComplainttrSecondary Containment TestingtrChargeable Secondary Containment TestinlSite Address: 4130 HORIZON LN #DSAN LUIS OBISPO, CA 93401Phone: (805)543-5450Facility lD: FA0007202Serial Number: DALXJ0460NOEtrYEStrtrtrtrN/A V!OL. #tr BPO1BPO2BPO3TROlTRO2EROlERO3BUSINESS PLANBusiness plan complete, current, available during inspection and submitted electronically (HSC 25505,25508(aXl); 19 CCR 26s1)lnventory of hazardous materials is complete and submitted electronically (HSC 25505(a)(1), 25506,25508(aX1), 19 CCR 2652,26541Site layouU facility maps are accurate and submifted electronically (HSC 25505(aX2), 25508(aXl), '19 CCR26521TRAINING PLANFacility has appropriate training program, submitted electronically (HSC 25505(aX4), 25508(aX1), 'l9CCR2659, 22CCR66265.16)Training documentation is maintained on site for current personnel (HSC 25505(aX4), 22CCR66265.16)EMERGENCY RESPONSE PLANEmergency response/contingency plan complete, current, submitted electronically, maintained onsite(HSC 25505(aX3), 25508(aX1), 19CCR 2658, 22CCR 66265.52-.54)Secondary containment is installed and sufficiently impervious to discharges. ICHSC 25270.4.5;40 CFR112.8(cX2)lGENERAL EH VIOLATIONStr tr tr FE01 Environmental Health fees paid. ICBPC 17200, Local OrdinancelGPS Coordinates: Latitude: 35.241 3200000GPS Coordinates: Longtitude: 120.6656500000trtrtrEtrtrINSPECTOR: MATHESON BLISSFACILITY REP: Wade Brown
YES N9 N/ABtrtrFACILITY NAME: KEN'S BoDy'qHoPvroL. #GTOlGTO3GTO4GTOSGTO6EtrtrGTO7tr tr EI cTosGTO9GTlOGTIIGT12GTl3GTl4GTl5GT16GT17GTISGTI9GT2OGT21GT22GT23GT24GT25ERO2ADDRESP-4130 HORIZON LN #DSAN LUIS OBISPO, CA93401HAZARDOUS WASTE GENERATOREPA ID NO/PERMITSGenerator has an EPA lD number to treat, store, dispose, transport or transfer hazardous waste (22CCR 66262.12) lf not, Gall (800) 618-6942 to obtain your CAL EPA lD numberHAZARDOUS WASTE DETERMINATIONHazardous waste determination conducted (22 CCR 66262.111Eown knowledge tranalysis trotherHazardous waste analysis/test records are kept for at least 3 years(22 CCR 66262.40.(c))D I S P OSA UTRA N S P O RTATIO NHazardous wastes disposed of at an authorized location (HSC 25189.5, 252011a1,22CCR66262.121Facility utilizes a registered hazardous waste transporter, and hazardous wastes shipped with amanifest (HSC 25160. 25163(a): 22 CCR 66262.20.66263.41)trmilkruEotherOwnerManifests and/or receipts are properly completed/retained by generator for 3 years (22 CCR 66262.23,66262.40(a))STORAGE AND MANAGEMENT OF CONTAINERS/TANKSHazardous wastes are accumulated on site as follows: ( HSC 25123.3 (bxly(dy(hxl); 22 GCR 66262.34(d))tr90 days if waste generated per month is greater than or equal to 1000 kg. (2200 !bs.)tr180 days if waste generated per month is less than '1000 kg (see note)8tr270 days if waste generated per month is less than 1000 kg and transported more than 200 miles (seenote)Note: Applies only if hazardous waste accumulated on site never exceeds 6000k9(13,200 lbs) and noacutely/extremely hazardous waste over 1kg(2.2|bs.) is held on site for over 90 days.Hazardous waste "satellite' collection is managed properly (complete labelinglaccumulation time/55galor 1-qt limit) (22 CCR 66262.34(e))lgnitable or reactive wastes are located 15 m (50 feet) from facility's property line (22 CCR 66262.34(axl),66265.176)Containers of hazardous waste are properly labeled (includes appropriate date,"HAZARDOUS WASTE,"waste compositior/physical state, hazardous properties, name/address of generator) (22 CCR 66262.31,66262.34(fl)Gontainers/tanks containing hazardous wastes are in good conditiory'handled to minimize the releaseor reaction (22 CCR 66262.34;22 CCR 66265.171-!179, 66255.177(c))Gontainersltanks/liners are compatible with waste stored or transferred (22 CCR 66262.34 ,66265.1721Gontainers storing hazardous wastes are closed/sealed (22 CCR 66262.34,66265.173)Weekly inspection of areas where hazardous waste containers are stored is conducted (22CCR66262.34,66265.174)Daily inspection of all tank systems is conducted and documented (22 CCR 66262.34,66265.195)Empty containerc or inner liners > 5 gal has date when emptied and are properly managed within oneyear of date emptied (22 CCR 66261.7(0)RECYCLABLE WASTEUsed oil is managed as hazardous waste until recycled (includes proper labeling, storage, etc) (HSC25250.41Used oil filters for recycling are managed properly (drained of free flowing liquid, stored in closedrainproof container, labeled "drained used oil filters," and transferred for metal reclamation) (Title 22ccRs 66266.130)Spent lea&acid batteries are being properly stored and transferred offsite under manifest or bill oflading for recycling, reuse, or reclamation (22 CCR 66266.81)Solvents/other recyclable materials are managed as hazardous wastes until recycled (22 GCR 66266.2)SOURCE REDUGTION:For facilities generating >12,000 kg./yr. of hazardous waste on site.Generator is subject to SB14 and has prepared and retained currentsource reduction documents or isable make them available to the inspector within (5) days. (HSC 25244.191.2'|.122;22CCR 67100.7/.8)Source Reduction Evaluation and Plan contains the following five elements:certification, amounts ofwastes generated, process description, block diagrams, and implementationschedule of selectedsource reduction measures. (HSC 25244.191.21.22 CCR 67100.5fll.8)Hazwaste Contingency Plan prepared, current, submitted to the CUPA, maintained onsite. (22CCR66262.34(aX4), 66265.51 -.54)Employees trained upon hire, annually; training records maintained at facility as required (22 CCR66262.34(aX4), 66265.1 6)Facility is operated and maintained to prevenUminimize/mitigate fire, explosion, or release ofhazardous materials/waste constituents to the environment. Maintains all required or appropriateequipment including an alarm and communications system (22 CCR 66265.31-37)trtrtrtrtrtrtrtratrtrtrtrtrEtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtr
SUM}" \RY OF OBSERVATIONSVIQ' qTIONSNo violations of undergrornd -.or"g" tank, hazardous materials, or hazard6*- waste laws/regulations were discovered.SLO CUPA greatly appreciates your efforts to comply with all the laws and regulations applicable to your facility.tr Violations were observed/discovered as listed below. All violations must be corrected by implementing the correctiveaction listed by each violation. lf you disagree with any of the violations or corrective actions required, please inform thCUPA in writintrALL VTOLATTONS MUST BE CORRECTED WITHIN 30 DAYS OR AS SPECIFIED CUPA must be informed in writing with acertification that compliance has been achieved. A false statement that compliance has been achieved is a violation ofthe law and punishable by a fine of not less than $2,000 or more than $25,000 for each violation. Your facility may bereinspected any time during normal business hours.You may request a meeting with the Program Manager to discuss the inspection findings and/or the proposed correctiveactions. The issuance of this Summary of Violations does not preclude the CUPA from taking administrative, civil, orcriminal action.FACILITY NAME: KEN'S BODY SHOPADDRESS: 4130 HORIZON LN #DSAN LUIS OBISPO, CA 93401VIOLATIONSVIOL. NO CORRECTIVE ACTION REOUIREDINSPECTION COMMENTS:Continue to take small quantities of hazardous wastes to landfill through lntegrated Waste ManagementAuthority hazardous waste takeback program. Transfer small amount of used oil observed by carport into aclosed, labeled container.INSPECTED BY: MATHESON BLISSDATE:02/1U2022NAME OF FACILITY REP: Wade BrownSIGNATURE OF FACILITY REP:STATEMENT OF COMPLIANCE: I certify under penalty of periury that this facility has complied with the corrective actions listed oninspection form.nature ofTitle:- Date:-
COUNTYb SAN LUISOBISPO,acrty o[ san Luls oBtspoFIRE DEPARTMENT2160 Santa B..ban Avsuo r Sil Lub Oblepo, CA 93401-5210 ' (8(F) 781-7380"Courtesy & Service"Date:0210412020CERTTFTED UNTFTED PROGRAM AGENCY (CUPA)HMARDOUS MATERIAL INSPECTION FORMTime:PERMISSION TO INSPECT: lnspections may involve obtaining photographs, reviewing and copying records, anddetermining compliance with adopted codes.Title: Shop Manager--a-rJhGRANTED BY (NAME/TITLE): Name: Tom WitmerREINSPECTION REQUIRED:trUSTtrHW GeneratortrHazmattrTPEtrCalARPtrAGTPROGRAMS INSPECTEDtrUSTEHW GeneratortrHazmattrTPEtrCa|ARPI]AGTtrEHS trRoutinetrClry FIRE trReinspectiontrChargeable ReinspectiontrChange of OwnershippzflComPlainttrSecondary Containment TestingtrChargeable Secondary ContainmentFacility Name: KEN'S BODY SHOPlnsoection TvoePhone: (805)543-5450Site Address: 4130 HORIZON LN #DSAN LUIS OBISPO, CA 93401Facility lD: FA0007202Serial Number: DAHECCHHNNOtrtrtrtrtrtrYEStrtrtrtrtrutrtrtrN'A VIOL. #tr BP01BPO2BPO3TROlTRO2EROlERO3BUSINESS PLANBusiness plan complete, current, available during inspection and submitted electronically (HSC 25505, 25508(a)(1); 19 cGR 2651)tnventory of hazardous materials is complete and submitted electronically (HSC 25505(aX1), 25506, 25508(aXl)'19 CCR 2652,26541Site layouU facility maps are accurate and submitted electronically (HSC 25505(aX2), 25508(aXl), 19 CCR 2652)TRAINING PLANFacility has appropriate training program, submitted electronically (HSC 25505(aX4), 25508(aX1), 19CCR 2659,22CCR66265.16)Training documentation is maintained on site for current personnel (HSC 25505(aX4), 22CCR66265.16)EMERGENCY RESPONSE PLANEmergency response/contingency plan complete, current, submifted electronically, maintained onsite (HSC25505(aX3), 25508(a)(1), l9CCR 2658, 22CCR 66265.52-.54)Secondary containment is installed and sufficiently impervious to discharges. ICHSC 25270.4.5;40 CFR 112.8(c)(2)lGENERAL EH VIOLATIONStr tr tr FE01 Environmental Health fees paid. ICBPC 17200, Local Ordinance]GPS Goordinates: Latitude: 35.241 3200000GPS Coordinates: Longtitude: 120.6656500000INSPECTOR: KERRY BOYLEFACILITY REP: Tom Witmer
FACILITY NAME: KEN'S BODY//( )P ADDRESS:i gO HORIZON LN #DSAN LUIS OBISPO, CA 93401HAZARDOUS WASTE GENERATOREPA ID NO/PERMITSGenerator has an EPA lD number to treat, store, dispose, transport or transfer hazardous waste (22 GCR66262.121lf not, Call (800) 618-6942 to obtain your CAL EPA lD numberHAZARDOUS WASTE DETERMINATIONHazardous waste determination conducted (22 CCR 66262.111trown knowledge tranalysis trotherHazardous waste analysis/test records are kept for at least 3 years(22 CCR 66262'40'(c))D IS POSA UTRA N S P ORTATIO NHazardous wastes disposed of at an authorized location (HSC 25189.5, 22 CCR 66262.121Facility utilizes a registered hazardous waste transporter, and hazardous wastes shipped with a manifest (HSC25160, 25163(a); 22 CCR 66262.20,66263.41)trrilkrun_ trotherManifests and/or receipts are properly completed/retained by generator for 3 years (22 CCR 66262.23,66262.40(a))STORAGE AND MANAGEMENT OF CONTAINERS/TANKSFl,azardous wastes are accumulated on site as follows: ( HSC 25123.3 (hXl)/(bXl); 22 CCR 66262.34)tr90 days if waste generated per month is greater than or equal to 1000 kg' (2200 lbs.)tr180 days if waste generated per month is less than 1000 kg (see note)tr270 days if waste generated per month is less than 1000 kg and transported more than 200 miles (see note)Note: Applies only if hazardous waste accumulated on site never exceeds 6000k9(13,200 lbs) and noacutely/extremely hazardous waste over 'lkg(2.2|bs.) is held on site for over 90 days.Hazardous waste "satellite" collection is managed properly (complete labeling/accumulation timd5S-gal or 1-qtlimit) (22 cGR 66262.34(e))lgnitable or reactive wastes are located 15 m (50 feet) from facility's property line (22 CCR 66262.34(a)(1)'66265.176)Containers of hazardous waste are properly labeled (includes appropriate date,"HAZARDOUS WASTE," wastecompositiory'physical state, hazardous properties, name/address of generator) (22 CCR 66262.31, 66262'34(f))Gontainers/tanks containing hazardous wastes are in good conditiory'handled to minimize the release or reaction(22 CCR 66262.34;22 CCR 66265.17'l-179, 66265.177(c))Containers/tanks/liners are compatible with waste stored or transferred (22 CCR 66262.34,66265.172)Containers storing hazardous wastes are closed/sealed (22 CCR 66262'34,66265.173)Weekly inspection of areas where hazardous waste containers are stored is conducted (22 CCR 66262.34,66265.174)Daily inspection of all tank systems is conducted and documented (22 CCR 66262.34,66265.195)Empty containers or inner liners > 5 gal has date when emptied and are properly managed within one year ofdate emptied (22 CCR 66261.7(0)RECYCLABLE WASTEUsed oil is managed as hazardous waste until recycled (includes proper labeling, storage, etc) (HSC 25250'41Used oil filters for recycling are managed properly (drained of free flowing liquid, stored in closed rainproofcontainer, labeled "drained used oil filters," and transferred for metal reclamation) (Title22 CCRS 66266.130)Spent leadacid batteries are being properly stored and transferred offsite under manifest or bill of lading forrecycling, reuse, or reclamation (22 CCR 66266.81)Solvents/other recyclable materials are managed as hazardous wastes until recycled (22 CCR 66266.2)SOURCE REDUCTION:For facilities generating >12,000 kg./yr. of hazardous waste on site.Generator is subject to SB14 and has prepared and retained current source reduction documents or is able maktthem available to the inspector within (5) days. (HSC 25244.19/.211'22:'22 CCR 67100'7/8)Source Reduction Evaluation and Plan contains the following five elements:certification, amounts of wastesgenerated, process description, block diagrams, and implementationschedule of selected source reductionmeasures. (HSC 25244.1 I 1.21, 22 CCR 671 00.7/.8)Hazwaste Contingency Plan prepared, current, submitted to the CUPA, maintained onsite. (22CCR 66262'3a(aXa),66265.51-.54)Employees trained upon hire, annually; training records maintained at facility as required (22 CCR 66262'34(a)(a)66265.16)Facility is operated and maintained to prevenUminimize/mitigate fire, explosion, or release of hazardousmaterials/waste constituents to the environment. Maintains all required or appropriate equipment including analarm and communications system (22 CCR 66265.31-.37)YEStrtrtrtruNg N/A VIOL. #tr D GT01GTO3GTO4GTO5GTO6trtrtrGT07trtrtrGT08GTO9GTlOGT11GT12GT13GT14GT15trtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrntrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrDtrtrGTl6GT17GT18GTl9GT2OGT21GT22GT23GT24GT25ERO2trtrtrtrtrtrtrtr
/SUMM^IY OF OBSERVATIONSVtol\ ;toNStr No violations of underground storage tank, hazardous materials, or hazardous waste laws/regulations werediscovered. SLO CUPA greatly appreciates your efforts to comply with all the laws and regulations applicable to yourfacility.tr Violations were observed/discovered as listed below. All violations must be corrected by implementing thecorrective action listed by each violation. lf you disagree with any of the violations or corrective actions required,please inform the CUPA in writingALL VIOLATIONS MUST BE CORRECTED WITHIN 30 DAYS OR AS SPECIFIED CUPA must be informed in writing witha certification that compliance has been achieved. A false statement that compliance has been achieved is a violationof the law and punishable by a fine of not less than $2,000 or more than $25,000 for each violation. Your facility maybe reinspected any time during normal business hours.You may request a meeting with the Program Manager to discuss the inspection findings and/or the proposedcorrective actions. The issuance of this Summary of Violations does not preclude the CUPA from takingadministrative, civil, or criminal action.FACILITY NAME: KEN'S BODY SHOPADDRESS: 4130 HORIZON LN #DSAN LUIS OBISPO, CA 93401VIOLATIONSVIOL. NO CORRECTIVE ACTION REOUIREDINSPECTION COMMENTS:On site to discuss a complaint from an anonymous source. Allegation is that red paint particles are comingfrom an ineffective filter system and poor exhaust system or possibly spray painting outside the spray booth.Air flow was good through the filters and no evidence of painting outside. We discssed Stormwater PollutionPrevention and the importance of spill prevention and immediate clean up if there were to be a spill. Alsodiscussed the importance of Employee training. Unable to document any violations. Called SLO Co. APCDand discussed findings. No further action required.INSPECTED BY: KERRY BOYLEDATE:0204t2020NAME OF FACILITY REP: Tom WitmerSIGNATURE OF FACILITY REP:-a-WSTATEMENT OF COMPLIANCEGertification: I certify under penalty of perjury that this facility has complied with the corrective actions listed onthis inspection form.Signature ofTitleDate
i''County of San Luis Obispo':i,:!;:,,i,',::ilj: :li.tdr3/--IcltV-orsan utsEnvironmental Health Services(805) 781-5544P.O. Box 14892156 Sierra WaySan Luis Obispo, CA 93406ffiryFire Department (805) 781-73802'160 Santa Barbara AvenueSan Luis Obispo CA 93401-5240CERTIFIED UNIFIED PROGRAM AGENCY (CUPA)HAZARDOUS MATERIALS INSPECTION FORMEFW dataentry byrDut":!,,', ,lQlr4 L)Time:may involve obtaining photographs, reviewing and copying records, andNAMcodes. GRANTED BYERMISSION TO INSPECTce withlntREINSPECTION REQUIRED:! Business Plan4*o I YESn eer! usr! ttw GeneratorIcnmnen Business PlanPROGRAMS INSPECTED:n ecrn usrn nw Generatorncnmnp-t v./ t/ )PHONE:ADDRESSFACILITY NAMEEHSAG DEPTCITY FIREResult Code: _70 _80 _90Action Code: _32 _37 _33 -31ComplaintutineTYPEReinspectionOtherYES NO COS!n n!n nntr nnnntr!TN/ABUSINESS PLANBusiness plan is complete, current, & available during inspection (IISC 25503.5' Title 19 CCR2729)Inventory of hazardous materials is complete (HSC 25504' Title 19 CCR2729)Site layout/facility maps are accurate (HSC 25504' Title 19 CCR2729)TRAINING PLANFacility has appropriate training program (Title 19 CCx^2732 & 22 CCR 66265.16)Training documentation is maintained on site for current personnel (Title 19 CCR2732 & 22 CCR66265.t6)EMERGENCY RESPONSE PLANContingency plan is complete, updated, and maintained on site (IISC 25504' Title 19 CCR273I & 22ccR $ 6626s.s3/s4)Facility is operated and maintained to prevent/minimize/mitigate fire, explosion, or release ofhazardous materials/waste coirstituents to the environment. Maintains all required or appropriateequipmentincludinganalarmandcommunicationssystem(Title19CCR2731 &22CCR6626531'.43)ABOVEGROUND PETROLEUM STORAGE TANK ACTSPCC Plan is reviewed and certified by a registered engineer within last 5 yrs. (40 CFR 112.5(b))SPCC Plan is maintained on site or nearest field office. (HSC 25270)BPOlBPO2BPO3n!nTROlTRO2EROlERO2ATOlATO2COMMEDITS GotoGPSINSPECTOR:Nt'Aobtainto comply with BPpl -BP03, TR01and ER0lLatitude: -degmin decimal min Longitude:-deg--min-decimal minF'ACILITY REP:vid,w:tn r;,;l\,fli'l!4ra'df" i*tui,firttla:l *-'r,.t/,,i ,//$aeltu'/) 'i1I/itvt"t",tiil
fIIEnvironmental Health'sc, vices(805) 781-5544P.O.Box'14892156 Siena Way Ste. BSan Luis Obispo. CA 93406clty o[ san Lurs oBr$poFIRE OEPARII.IENT2'160 Silla BarbaE Avsuo'Sil Lub Obbpo, CA 93101-52,10'{0{F}781-7380"Courtesy & Service"Date: 1212012019GERTTFTED UNTFTED PROGRAM AGENCY (CUPA)HAZARDOUS MATERIAL INSPECTION FORMTime:COUNTY.6 SAN LUISOBISPOPERMISSION TO INSPEGT: lnspections may involve obtaining photographs, reviewing and copying records, anddetermining compliance with adopted codes.Title: OwnerGRANTED BY (NAME/TITLE): Name: Wade BrownREINSPECTION REQUIRED:trCa|ARPtrAGTtrUSTEHW GeneratortrHazmatT]TPEPROGRAMS INSPEGTED:trCa|ARPtrAGTtrUSTtrHWGeneratortrHazmattrTPEtrEHS trRoutineECITY FIRE trReinspectiontrChargeable ReinspectiontrChange of OwnershiptrComplainttrSecondary Containment TestingtrChargeable Secondary ContainmentFacility Name: KEN'S BODY SHOPlnsoection TvpePhone: (805)543-5450Site Address: 4130 HORIZON LN #DSAN LUIS OBISPO, CA93401Facility lD: FA0007202Serial Number: DAMH3QM97YES NO N/AtrtrtrBUSINESS PLANBusiness plan complete, current, available during inspection and submitted electronically (HSC 25505, 25508(a)(1); 19 GGR 2651)lnventory of hazardous materials is complete and submitted electronically (HSG 25505(a)(1), 25506, 25508(aXl),19 CCR 2652,26541Site layouU facility maps are accurate and submitted electronically (HSC 25505(aX2), 25508(aXl), 19 GCR 2652)TRAINING PLANFacility has appropriate training program, submitted electronically (HSC 25505(aX4), 25508(aX1), {9CCR 2659,22CCR66265.16)Training documentation is maintained on site for current peeonnel (HSC 25505(aX4), 22CCR66265.16)EMERGENCY RESPONSE PLANEmergency response/contingency plan complete, current, submifted electronically, maintained onsite (HSC25505(a)(3), 25508(aXl), lgCCR 2658, 22CCR 66265.52-.54)Secondary containment is installed and sufficiently impervious to discharges. ICHSC 2527O.4.5;40 CFR 112.8(c)enGENERAL EH VIOLATIONStr tr tr FE01 Environmental Health fees paid. ICBPC 17200, Local Ordinance]GPS Coordinates: Latitude: 35.241 3200000GPS Goordinates: Longtitude: 120.6656500000vtol. #BPOlBPO2BPO3TROlTRO2EROlERO3trtrtrtrtrtrtrtrtrtruINSPECTOR: KERRY BOYLEFACILITY REP: Wade Brown
FACILITY NAME: KEN'S BODY { )Pi'ADDRESS: i .30 HORIZON LN #D' -aN LUIS OBISPO, CA 93401HAZARDOUS WASTE GENERATOREPA ID NO/PERMITSGenerator has an EPA lD number to treat, store, dispose, transport or transfer hazardous waste (22 CCR66262.121lf not, Gall (800) 618-6942 to obtain your CAL EPA lD numberHAZARDOUS WASTE DETERMINATIONHazardous waste determination conducted (22 CCR 66262.11)trown knowledge tranalysis DotherHazardous waste analysis/test records are kept for at least 3 years(22 CCR 66262.40.(c))D IS POSA UTRA NS P O RTATIO NHazardous wastes disposed of at an authorized location (HSC 25189.5, 22 CCR 66262.121Facility utilizes a registered hazardous waste transporter, and hazardous wastes shipped with a manifest (HSC25160, 25163(a); 22 CCR 66262.20, 66263.41)trmilkrun trotherManifests and/or receipts are properly completed/retained by generator for 3 years (22 CCR 66262.23,66262.40(a))STORAGE AND MANAGEMENT OF CONTAINERS/TANKSHazardous wastes are accumulated on site as follows: ( HSC 25123.3 (hXl)/(bX1); 22 CCR 66262.34)tr90 days if waste generated per month is greater than or equal to 1000 kg. (2200 lbs.)tr180 days if waste generated per month is less than 1000 kg (see note)tr270 days if waste generated per month is less than 1000 kg and transported more than 200 miles (see note)Note: Applies only if hazardous waste accumulated on site never exceeds 6000k9(13,200 lbs) and noacutely/extremely hazardous waste over 1kg(2.21bs.) is held on site for over 90 daysHazardous waste "satellite" collection is managed properly (complete labeling/accumulation time/55-gal or 1-qtlimit) (22 CCR 66262.34(e))lgnitable or reactive wastes are located 15 m (50 feet) from facility's property line (22 CCR 66262.34(a)(1),66265.176)Containers of hazardous waste are properly labeled (includes appropriate daIe,"HAZARDOUS WASTE," wastecomposition/physical state, hazardous properties, name/address of generator) (22 CCR 66262.31, 66262.34(0)Containersltanks containing hazardous wastes are in good conditiodhandled to minimize the release or reaction(22 CCR 66262.34; 22 CCR 66265.'17'l-|179, 66265.177(c))Gontainers/tanks/liners are compatible with waste stored or transferred (22 CCR 66262.34, 66265.172)Containers storang hazardous wastes are closed/sealed (22 GCR 66262.34,66265.173)Weekly inspection of areas where hazardous waste containerc are stored is conducted (22 CCR 66262.34,66265.174)Daily inspection of all tank systems is conducted and documented (22 CCR 66262.34,66265.195)Empty containers or inner liners > 5 gal has date when emptied and are properly managed within one year ofdate emptied (22 CCR 66261.7(D)RECYCLABLE WASTEUsed oil is managed as hazardous waste until recycled (includes proper labeling, storage, etc) (HSC 25250.4,Used oil filters for recycling are managed properly (drained of free flowing liquid, stored in closed rainproofcontainer, labeled "drained used oil filters," and transferred for metal reclamation) (Title22 CCRS 66266.130)Spent leadacid batteries are being properly stored and transferred offsite under manifest or bill of lading forrecycling, reuse, or reclamation (22 CCR 66266.81)Solvents/other recyclable materials are managed as hazardous wastes until recycled (22 CCR 66256.2)SOURCE REDUGTION:For facilities generating >12,000 kg.[r. of hazardous waste on site.Generator is subject to SB14 and has prepared and retained current source reduction documents or is able makrthem available to the inspector within (5) days. (HSC 25244.1912'|1.22; 22 CCR 67100.7/8)Source Reduction Evaluation and Plan contains the following five elements:certification, amounts of wastesgenerated, process description, block diagrams, and implementationschedule of selected source reductionmeasures. (HSC 25244.1 9/ 2'1, 22 CCR 67 I 00.7/8)Hadaste Contingency Plan prepared, current, submitted to the CUPA, maintained onsite. (22CCR 66262.34(aX4),66265.51-.54)Employees trained upon hire, annually; training records maintained at facility as required (22 CCR 66262.34(aX4)66265.16)Facility is operated and maintained to prevenUminimize/mitigate fire, explosion, or release of hazardousmaterials/waste constituents to the environment Maintains all required or appropriate equipment including analarm and communications system (22 CCR 66265.31-.37)YEStrtrBEtrN/Atrtrtrtrtrtrvtol. #GTOlGTO3GTO4GTO5GTO6GTOTNOtrtrtrtrtrBtrtrGTO8GTO9GTIOGT11GT12GTl3GT14GTI5GTl6GTl7GT18GT19GT2OGf21GT22GT23GT24GT25ERO2trEtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrBtrtrtrtrtrtrtrtrtrtrtrBtr
a-'\suMMf ' 'Y OF OBSERVATIONSVIO( --IONStr No violations of underground storage tank, hazardous materials, or hazardous waste laws/regulations werediscovered. SLO CUPA greatly appreciates your efforts to comply with all the laws and regulations applicable to yourfacility.tr Violations were observed/discovered as listed below. All violations must be corrected by implementing thecorrective action listed by each violation. lf you disagree with any of the violations or corrective actions required,please inform the GUPA in writingALL VTOLATTONS MUST BE CORRECTED WITHIN 30 DAYS OR AS SPECIFIED CUPA must be informed in writing witha certification that compliance has been achieved. A false statement that compliance has been achieved is a violationof the law and punishable by a fine of not less than $2,000 or more than $25,000 for each violation. Your facility maybe reinspected any time during normal business hours.You may request a meeting with the Program Manager to discuss the inspection findings and/or the proposedcorrective actions. The issuance of this Summary of Violations does not preclude the CUPA from takingadministrative, civil, or criminal action.FACILITY NAME: KEN'S BODY SHOPADDRESS: 4130 HORIZON LN #DSAN LUIS OBISPO, CA 93401VIOLATIONSVIOL. NO CORRECTIVE ACTION REOUIREDGT11 IMMEDIATELY BEGIN TO PROPERLY LABEL ALL CONTAI/VERS OF HAZARDOUS WASTE. IMPLEMENT APROCEDIJRE IO ENSURE THAT ALL CONTAINERS OF HAZARDOUS WASTE ARE PROPERLY LABELED.MIJST INCLIJDE APPROPRIATE DATE, "HAZARDOUS WASTE', WASTE COMPOSITION/PHYSICAL STATE,HAZARDOUS PROPERTIES, NAME/ADDRESS OF GENERATOR. THE FINE FOR THIS VIOLAI'ON /S ANINITIAL PENALW OF UP TO $25,000, AND THEN N{ ADDITIONAL TWO PERCENT OF THE INITIAL PENALWPER DAY THEREAFTER.INSPECTION COMMENTS:HazWaste label was missing from hazwaste container. A new label was filled out and placed on container,violation corrected same day All else ok..INSPECTED BY: KERRY BOYLEDATE: 1z2ot2o19NAME OF FACILITY REP: Wade BrownSIGNATURE OF FACILITY REP:STATEMENT OF COMPLIANCErtification: I certify under penalty of perjury that this facility has complied with the corrective actions listed oninspection formnature of Owner/Operator:- Title:- Datei-
Gounty of San Luis ObisPoBnvironmental Health Services(805) 781 -5s44P.O. Box 14892156 Sierra WaySan Luis Obispo, CA 93406Fire Department (805) 781-73802160 Santa Barbara AvenueSan Luis Obispo CA 93401-5240r:;:lr:ii!ii:i:;i,r:::1&d5cltyq-sAn lulssryoCERTIFIED UNIFIED PROGRAM AGENCY (CUPA)HAZARDOUS MATERIALS INSPEGTION FORMEFW dataentry by:";rl{l##lArnISSION TO INSPECTwithntmay involve obtaining photographs,iewing and copying records, andcodes. GRANTED BYREINSPECTION REQUIRED:lm'NO NYESn usrt-,1.,4 t* Generatorn Business Planncnmnpn rerPROGRAMS INSPECTEDF "* Generatorn Business Planflcnlnnp! aern usrPHEFACILITY NAMEADDRESS:AGENCYn rnsn nc DEPTyErcnvFIREComplaint I Other-Result Code: _70 -80 -90Action Code: 32 37 33 31ReinspectionRoutineYES NO COSntr nnn nnn trtrntr!N/ABUSINESS PLANBusiness plan is complete, current, & available during inspection (HSC 25503.5' Title 19 CCR2729)Inventory of hazardous materials is complete (HSC 25504' Title 19 CCR2729\Site layout/facility maps are accurate (HSC 25504, Title 19 CCR2729)TRAINING PLANFacility has appropriate training program (Title 19 ccR2732 & 22 CCR 66265.16\Training documentation is maintained on site for current personnel (Title 19 CCR2732 &22 CCR66265.16\EMERGENCY RESPONSE PLANContingency plan is complete, updated, and rnaintained on site (HSC 25504' Titte 19 CCR273I & 22ccR s 6626s.s3/s4\Facility is operated and maintained to prevent/minimize/mitigate fire, explosion, or release ofhazardous materials/waste constituents to the environment. Maintains all required or appropriateequipment including an alarm and communications system (Title 19 CCR 2731 & 22 CCR 66265.31-.43)ABOVEGROUND PETROLEUM STORAGE TANK ACTSPCC Plan is reviewed and certified by a registered engineer within last 5 yrs. (40 CFR 112.5(b))SPCC PIan is maintained on site or nearest field office. (HSC 25270)BPOlBPO2BPO3TROlTRO2trtrntrtrtrIitiEROlERO2ATOlATO2nGohttp://wwwGPS Coordinates: Latitude:to obtainto qomply with BP0l-BP03, TR01 and ER01min Longitude:-deg--minINSPECTOR:degmrndonimalFACILITY REP:decimalmrn
COUNTYb SAN LUISOBISPOe'crty o[ san lurs oBtspoFIRE DEPAR'IIE'IT2160 Sdla garbaa Avduo'Sd Llls Obbpo, CA 9340'l-52,40 ' {8{}5) 781-7380"Courtesy & Service"Date: 1210512018CERTTFTED UNTFTED PROGRAM AGENCY (CUPA)HMARDOUS MATERIAL INSPECTION FORMTime:PERMISSION TO INSPECT: lnspections may involve obtaining photographs, reviewing and copying records, anddetermining compliance with adopted codes.GRANTED BY (NAME/TITLE): Name: Wade BrownTitle: Owner-\trTPEtrCalARPtrAGTtrUSTtrHW GeneratortrHazmatREINSPECTION REQUIRED:trTPEtrCa|ARPtrAGTtrUSTEHW GeneratortrHazmatPROGRAMS INSPECTED:Facility Name: KEN'S BODY SHOPAoencvtrEHStrCITY FIRElnsoection TvoetrRoutinetrReinspectiontrChargeable ReinspectiontrChange of OwnershiptrComplainttrSecondary Containment TestingtrChargeable Secondary ContainmentTestingSiteAddress:4130 HORIZON LN #DSAN LUIS OBISPO, CA 93401Phone: (805)543-5450Facility lD: FA0007202Serial Number: DAWBLVHV4YES NO N/Atrtr8BUSINESS PLANBusiness plan complete, current, available during inspection and submitted electronically (HSC 25505, 25508(a)(1); 19 ccR 2651)lnventory of hazardous materials is complete and submifted electronically (HSC 25505(axl), 25506, 25508(a)(1),19 CCR 2652,26541Site layouU facility maps are accurate and submitted electronically (HSC 25505(a)(2), 25508(aX1), 19 CCR 2652)TRAINING PLANFacility has appropriate training program, submitted electronically (HSC 25505(a)(4), 25508(aXl), l9CCR 2659,22CCR66265.16)Training documentation is maintained on site for current personnel (HSC 25505(a)(4), 22CCR66265.16)EMERGENCY RESPONSE PLANEmergency response/contingency plan complete, current, submitted electronically, maintained onsite (HSC25505(aX3), 25508(a)(1), lgccR 2658, 22CCR 66265.52-.54)Secondary containment is installed and sufficiently impervious to discharges. ICHSC 25270.4.5;40 CFR 112.8(c)(2flGENERAL EH VIOLATIONStr tr tr FE01 Environmental Health fees paid. ICBPC 17200, Local Ordinance]GPS Goordinates: Latitude: 35.241 3200000GPS Coordinates: Longtitude: 120.6656500000vtol. #BPOltrtrtrtrtrtrtruutrtrutrtrtrtrBPO2BPO3TROlTRO2EROlERO3INSPECTOR: KERRY BOYLEFACILITY REP: Wade Brown
FAGtLtTy NAME: KEN'S BODY r--)P ADDRESS: f-''30 HORIZON LN #D\ -AN LUrs oBrsPo, cA 93401HAZARDOUS WASTE GENERATORvtol. #YES NO N/AtrtrtrEPA ID NO/PERMITSGenerator has an EPA lD number to treat, store, dispose, transport or transfer hazardous waste (22 CCR66262.12) lf not, Call (800) 618-6942 to obtain your CAL EPA lD numberHAZARDOUS WASTE DETERMINATIONHazardous waste determination conducted (22 CCR 66262.11)trown knowledge tranalysis trotherHazardous waste analysis/test records are kept for at least 3 years(22 GCR 66262.a0.(c))D IS P OSA UTRA N S P O RTATIO NHazardous wastes disposed of at an authorized location (HSC 25189.5, 22 CCR 66262.121Facility utilizes a registered hazardous waste transporter, and hazardous wastes shipped with a manifest (HSGHazardous waste "satellite" collection is managed properly (complete labeling[accumulation time/5S-gal or 1-qtlimit) (22 CCR 66262.3a(e))lgnitable or reactive wastes are located 15 m (50 feet) from facility's property line (22 GGR 66262.34(aXl),66265.176)Containers of hazardous waste are properly labeled (includes appropriate date,"HAZARDOUS WASTE," wastecompositiory'physical state, hazardous properties, name/address of generator) (22 CCR 66262.31, 66262.34(f))Containers/tanks containing hazardous wastes are in good conditiodhandled to minimize the release or reaction(22 CCR 66262.34;22 CCR 66265.171-.179, 66265.177(c))Containers/tanks/liners are compatible with waste stored or transferred (22 CCR 66262.34,66265.172)Containers storing hazardous wastes are closed/sealed (22 CGR 66262.34,66265.173)Weekly inspection of areas where hazardous waste containers are stored is conducted (22 CCR 66262.34,66265.174)Daily inspection of all tank systems is conducted and documented (22 CCR 66262.34,66265.195)Empty containers or inner liners > 5 gal has date when emptied and are properly managed within one year ofdate emptied (22 CCR 66261.7(fl)RECYCLABLE WASTEUsed oil is managed as hazardous waste until recycled (includes proper labeling, storage, etc) (HSC 25250.41Used oil filters for recycling are managed properly (drained of free flowing liquid, stored in closed rainproofcontainer, labeled "drained used oil filters," and transferred for metal reclamation) (Title22 CCRS 66266.130)Spent leacl-acid batteries are being properly stored and transferred offisite under manifest or bill of lading forrecycling, reuse, or reclamation (22 CCR 66266.81)Solvents/other recyclable materials are managed as hazardous wastes until recycled (22 CCR 66266.2)SOURCE REDUCTION:For facilities generating >12,000 kg./yr. of hazardous waste on site.Generator is subject to SB14 and has prepared and retained current source reduction documents or is able maktthem available to the inspector within (5) days. (HSC 25244.19/.21l,.22;22 CCR 67100.7/8)Source Reduction Evaluation and Plan contains the following five elements:certification, amounts of wastesgenerated, process description, block diagrams, and implementationschedule of selected source reductionmeasures. (HSC 25244.191 .21 , 22 CCR 67100.7/.8)Haa raste Contingency Plan prepared, current, submitted to the CUPA, maintained onsite. (22CCR 66262.34(a)(4),66265.51-.54)Employees trained upon hire, annually; training records maintained at facility as required (22 CCR 66262.34(aX4)66265.16)Facility is operated and maintained to prevenUminimize/mitigate fire, explosion, or release of hazardousmaterials/waste constituents to the environment. Maintains all required or appropriate equipment including analarm and communications system (22 CCR 66265.31-.37)trtrtrtrtrtratrGTOlGTO3GTO4GTO5GTO6GTO9GT{OGT11GT12GT13GT14GT15GT16GT17GT18GT19GT2OGT21GT22GT23GT24GT25ERO225160, 25163(a); 22 CCR 66262.20,66263.41)trmilkrun trotherAtrtrGToTManifestsand/or receipts areproperly completed/retained by generator for 3 years (22 CCR 66262.23,EtrtrGTO866262.40(a))STORAGE AND MANAGEMENT OF CONTAINERS/TANKSHazardous wastes are accumulated on site as follows: ( HSC 25123.3 (hXl)(bX1); 22 CCR 66262.34)tr90 days if waste generated per month is greater than or equal to 100 kg. (220 lbs.)D180 days if waste generated per month is less than 100 kg (see note)tr270 days if waste generated per month is less than 100 kg and transported more than 200 miles (see note)Note: Applies only if hazardous waste accumulated on site never exceeds 6000k9(13,200 lbs) and noacutely/extremely hazardous waste over 'lkg(2.2|bs.) is held on site for over 90 days.trtrtrtrtrtrtrtrtrtrtrtrtrtrBtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtr
SUMMT .IY OF OBSERVATION9VIOT/ TIONSE No violations of underground storage tank, hazardous materials, or hazardous waste laws/regulations werediscovered. SLO CUPA greatly appreciates your efforts to comply with all the laws and regulations applicable to yourfacility.tr Violations were observed/discovered as listed below. All violations must be corrected by implementing thecorrective action listed by each violation. lf you disagree with any of the violations or corrective actions required,please inform the CUPA in writingALL VIOLATIONS MUST BE CORRECTED WITHIN 30 DAYS OR AS SPECIFIED CUPA must be informed in writing witha certification that compliance has been achieved. A false statement that compliance has been achieved is a violationof the law and punishable by a fine of not less than $2,000 or more than $25,000 for each violation. Your facility maybe reinspected any time during normal business hours.You may request a meeting with the Program Manager to discuss the inspection findings and/or the proposedcorrective actions. The issuance of this Summary of Violations does not preclude the CUPA from takingadministrative, civil, or criminal action.FACILITY NAME: KEN'S BODY SHOPADDRESS: 4130 HORIZON LN #DSAN LUIS OBISPO, CA 93401VIOLATIONSVIOL. NO CORRECTIVE ACTION REOUIREDUWO2 IMMEDIATELY BEGIN TAKING ALL NECESSARY MEASURES TO PROPERLY RECYCLE/D/SPOSE OFUNIVERSALWASTE AND MAINTAIN ALL RECORDS AS REQUIRED.INSPECTION COMMENTS:Good record keeping for hazardous waste disposal. Shop in good orderNote: Do not dispose of florescent light tubes in dumpster. lnformation on Universal Waste was given to thebusiness owner. Tubes were recovered and were taken to a recycler or ewaste recyling facility. Violationcorrected same day.INSPECTED BY: KERRY BOYLEDATE: 12o5t2018NAME OF FACILITY REP: Wade BrownSIGNATURE OF FACILITY REP:STATEMENT OF COMPLIANCE: I certify under penalty of perjury that this facility has complied with the corrective actions listed onis inspection form.ignature of Owner/OpeTitle:- Date
Gounty of San Luis ObispoEnvironmental Healfh Services(805) 781.5544P.O. Box 14892156 Sierra WaySan Luis Obispo, CA 93406{cttvoLsan lrils oBtspoFire Department (805) 781-73802160 Santa Barbara AvenueSan Luis Obispo CA 93401-5240CERTIFIED UNIFIED PROGRAM AGENCY (CUPA)HAZARDOUS MATERIALS INSPECTION FORMEFW dataentry by:iifr;$l$'ftittlfPERMISSION TO INSPECT: tnspections may involve obtaining photographs, reviewing and copying records, anddetermininq compliance with-adopted codes. GRANTED BY(NAME/TITLE)tFr* Generatorn Business Plan,{no n YESREINSPECTION REQUIRED:!cnmnnn ecrE usrE Business PlanPROGRAMS INSPECTED:ncnmnp[] ncrn usrHW Generator--avPHONE:ADDRESS:FACILITY NAMEAGENCY! EHSl-l ec DEPT:.14 CITY FIREr-IN32 37 33 3170 80 90n ComplaintutineResult Code:Action Code:ReinspectionOtherYES NO COStru n!u nnn nn!nnnnN/ABUSINESS PLANBusiness plan is complete, current, & available during inspection (HSC 25503.5, Title 19 CCR2729)Inventory of hazardous materials is complete (HSC 25504' Title 19 CCR2729)Site layout/facility maps are accurate (HSC 25504, Title 19 CCR2729)TRAINING PLANFacility has appropriate training program (Title 19 CCR2732 & 22 CCR 66265,16)Training documentation is maintained on site for current personnel (Title 19 CCR2732 & 22 CCR6626s.16)EMERGENCY RESPONSE PLANContingency plan is complete, updatedo and maintained on site (HSC 25504, Title 19 CCx-273I &22ccR $ 6626s.s3ts4)Facility is operated and maintained to prevent/minimize/mitigate fire, explosiono or release ofhazardous materials/waste constituents to the environment. Maintains all required or appropriateequipment including an alarm and communications system (Title 19 CCR 2731 & 22 CCR66265.31-.43)ABOVEGROUND PETROLEUM STORAGE TANK ACTSPCC Plan is reviewed and certified by a registered engineer within last 5 yrs. (40 CFR 112.5(b)SPCC Plan is maintained on site or nearest field office. (HSC 25270)BPOlBPO2BPO3nnTROlTRO2DROlERO2ATOlAT02Go toCOMMENTStoforms to-BP03, TR01 andINSPECTOR:FACILITY REP:
l(Environmental Health Services(805) 7815544P.O.Box 14892156 Sierra Way Ste. BSan Luis Obisoo. CA 93406l'cffiyblsAnlursoBrspoFire Deoartment (805) 78173802160 Santa Barbara AvenueSan Luis Obispo CA 934015240Dale:1210812016cERTtFtED UNTFTED PROGRAM AGENCY (CUPA)HMARDOUS MATERIAL INSPECTION FORMTime:PERMISSION TO INSPEGT: lnspections may involve obtaining photographs, reviewing and copying records, anddetermining compliance with adopted codes.GRANTED BY (NAME/TITLE): Name: Wade BrownTitle: Owner4tutrTPEtrCalARPtrAGTtrUSTtrHWGeneratorEHazmatREINSPECTION REQUIRED:trTPEtrCalARPtrAGTtrUSTBHW GeneratorEHazmatPROGRAMS INSPEGTED:Facility Name: KEN'S BODY SHOPAgency lnspection TypetrEHS trRoutinetrClTY FIRE trReinspectiontrChargeable ReinspectiontrChange of OwnershiptrComplainttrSecondary Containment TestingtrChargeable Secondary Containment TestinlSite Address:4130 HORIZON LN #DSAN LUIS OBISPO, CA 93401Phone: (805)543-5450Facility lD: FA0007202Serial Number: DAOSDF9JOYES NO N/A BUSINESS PLANtr tr E BP01 Business plan is complete, current, available during inspection (HSC 25503.5, Title 19 CCR 2729)tr tr B BP02 tnventory of hazardous materials is complete (HSC 25504, Title 19 CCR 2729)tr tr tr BP03 Site layouUf;acility maps are accurate (HSC 25504, Title 19 CCR 2729)TRAINING PLANE tr tr TR01 Facility has appropriate training program (Title 19 ccR2732 & 22 ccR 66265.16)tr tr tr TR02 Trainingdocumentationismaintainedonsiteforcurrentpersonnel (Title19CCR2732&22ccR) 66265.16E tII,E BEEN, $Y,,8'F 9P q,N Ptr tr B ER01 Emergency response/contingency plan is complete, updated, and maintained on slte (HSG25504, Title 19 CCR 2731 & 22 CCR S 66265.53/54)tr tr tr ER02 Facility is operated and maintained to prevenUminimize/mitigate fire, explosion, or release ofhazardous materials/waste constituents to the environment. Maintains all required orappropriate equipment including an alarm and communications system (Title 19 CCR2731&22ccR 66265.31-37, 66267.34 (dX2),40CFR 1 265.31)B tr tr ER03 Secondary containment is installed and sufficiently impervious to discharges.ICHSC 25270.4.5; 40 CFR 1 1 2.8(cX2)lGENERAL EH VIOLATIONStr tr tr FEot Environmental Health fees paid. [cBPc 17200, Local Ordinance]GPS Goordinates: Latitude: 35.2413200000 ,- GPS Coordinates: Longtitude: 120.6656500000INSPECTOR: KERRY BOYLE FACILITY REP: WAdE BTOWN
/FAGTLITY NAME: KEN'S E Y SHOP ADDIHAZARDOUS WASTE GENERATOR5: 4130 HORIZON LN #DSAN LUIS OBISPO, CA 93401EPA ]D CAD008252405NUMBER:Total generated/month:Lbs or gals (average)Waste Oil:Solvents:Antifreeze: Others:-YES NO N/AtrtrtrVIOL- # EPA ID NO/PERMITSGT01 Generator has an EPA lD number to treat, store, dispose, transport or transfer hazardouswaste (Title 22CCRS66262.12) lf not, Call (800) 618-6942 to obtain your CAL EPA lD numberBtrtrtrtr GTO3tr cro4tr GTOstr GTO6trtrtrGT07trtrtrcT08trtrtrnHAZARDOUS WASTE DETERM INATIONHazardous waste determination conducted (Title 22 CCR 566262.11)Eown knowledge tranalysis trotherHazardous waste analysis/test records are kept for at least 3 yearc(Title 22 CCR $66262.40.(c))DISPOSAUT RANS PO RTAT I O NHazardous wastes disposed of at an authorized location (HSC 525189.5 , Title 22 CCR 566262.12)Facility utilizes a registered hazardous waste transporter, and hazardous wastesshipoed with a manifest (Title 22 CCR S66262.20. HSC Q25160/25163(a))ned by generatorfor 3 yearcllitle 22 CCR $66263.4A 66262.23,66262.40 (a))STORAGE AN D MANAG EITII ENT OF CONTAINERS/TAN KSHazardous wastes are accumulated on site as follows (Title 22 CCR S66262.34)tr90 days if waste generated per month is greater than or equal to 100 kg. (220 lbs.)tr180 days if waste generated per month is less than 100 kg (see note)tr270 days if waste generated per month is less than 100 kg and transported more than 200miles (see note)Hazardous waste "satellite" collection is managed properly (completelabelingraccumulation time/55-gal or 1-qt limit) (Title 22 CGR $66262.34(c))lgnitable or reactive wastes are located 15 m (50 feet) from facility's property line (Title22 CCR 566265.176)Containers of hazardous waste are properly labeled (includes appropriate daIe,"HAZARDOUSWASTE," waste composition/physical state, hazardous properties, name/address ofgenerator) (litle 22 CCR 566262.31, 66262.34)Containers/tanks containing hazardous wastes are in good conditiodhandled tominimize the release or reaction (Title 22 CCR 566262.34 (dX2),Containers/tanks/liners are compatible with waste stored or transferred (Title 22 CCRSs66262.34 (dX2), 66265.1 72)Containers storing hazardous wastes are closed/sealed (Title 22CCR 5566262.34 (dX2), 66265.1Weekly inspection of areas where hazardous waste containers are stored is conducted (Title22 CCRSS66262.34 (dll2l, 66265.1 74)Daily inspection of all tank systems is conducted and documented (Title 22 CCR 5566262.34 (dX2),66265.195)Empty containerc or inner Iiners greater than 5 gal has date when emptied and are managedproperly within one year of date emptied (Title 22 CCR 566261.7 (f))RECYCLABLE WASTEUsed oil is managed as hazardous waste until recycled (includes proper labeling, storage, etc)(Title 22 CCRS 66266.13, HSC 525250.4)Used oil filters for recycling are managed properly (drained of free flowing liquid, stored inclosed rainproof container, labeled !'drained used oil filterc," and transferred for metalreclamation) (Title 22 CCRS 66266.r3)Spent lea&acid batteries are being properly stored and transferred offsite under manifest orbill of lading for recycling, reuse, or reclamation (Title 22 CCR 566266.81)Solvents/other recyclable materials are managed as hazardous wastes until recycled (Title 22ccR $66266.3)SOURCE REDUCTION:For facilities generating >12,000 kg./yr. of hazardous waste on site.Generator is subject to SB14 and has prepared and retained current source reductiondocuments or is able make them available to the inspector within (5) days. (67100.7, 67100.8, HSCSource Reduction Evaluation and Plan contains the following five elements:certification, amountsof wastes generated, process description, block diagrams, and implementationschedule ofselected source reduction measures. (67100.7. 67100.8. HSC Q252/t4.19)Hazwaste Contingency Plan prepared, current, submitted to the CUPA, maintained onsite. (Title22 CCR S66265.51-.54)trEtrtrtrtrtrtrEtrEtrEIDtrtrDtrtrtrtrtrtrtrtrtrtr GTO9tr GTIOtr GT1Itr GTI2tr GT13tr GT14tr GT15tr GTI6tl cr17tr GTIstr GTI9tr GT2Otr GT21trtrtrGT2ztrtrtrcr23trtrtrGr24
/- -' t'-'SUMNJ," ..tY OF OBSERVATIONS/VIC|*-TTIONStr No violations of underground storage tank, hazardous materials, or hazardous waste laws/regulations werediscovered. SLO CUPA greatly appreciates your efforts to comply with all the laws and regulations applicable to yotfacility.tr Violations were observed/discovered as listed below. All violations must be corrected by implementing thecorrective action listed by each violation. lf you disagree with any of the violations or corrective actions required,olease inform the CUPA in writinq.ALL VIOLATIONS MUST BE CORRECTED WITHIN 30 DAYS OR AS SPECIFIED. CUPA must be informed in writing wcertification that compliance has been achieved. A false statement that compliance has been achieved is a violatiorof the law and punishable by a fine of not less than $2,000 or more than $25,000 for each violation. Your facility maybe reinspected any time during normal business hours.You may request a meeting with the Program Manager to discuss the inspection findings and/or the proposedcorrective actions. The issuance of this Summary of Violations does not preclude the CUPA from takingadministrative, civil, or criminal action.FACILITY NAME: KEN'S BODY SHOPADDRESS: 4130 HORIZON LN #DSAN LUIS OBISPO, CA 93401VIOLATIONSVIOL. NO CORRECTIVE ACTION REOUIREDGT11 IMMEDIATELY BEGIN TO PROPERLY LABEL ALL CONTA'TVERS OF HAZARDOUS WASTE. IMPLEMENT APROCEDURE IO ENSURE THAT ALL CONTAINERS OF HAZARDOUS WASTE ARE PROPERLY LABELED.THE FINE FOR IHIS VIOLATION IS N{ INITIAL PENALTY OF UP TO $25,000, AND THEN AN ADDITIONALTWOPERCENT OF THE INITIAL PENALW PER DAY THEREAFTER.Waste container missing label - a label was provided, filled out, and placed on container.Violation corrected same day.INSPECTION COMMENTS:Hazardous waste containers were not properly labeled. A hazwaste label was provided and violationcorrected same day. Facility uses Cold Canyon "Small Business HazWaste Facility" to dispose ofsolvenUwaste paint. Owner to send waste disposal records for calendar year 2016 to SLO City Fire at thefollowing email address: kboyle@slocity.orgAll else ok.INSPECTED BY: KERRY BOYLEDATE: 12J08t2016NAME OF FACILITY REP: WAdE BrOWNSIGNATURE OF FACILITY REP:4tuSTATEMENT OF COMPLIANCECertification: I certify under penalty of periury that this facility has complied with the corrective actions listed onis inspection formSignature of Owner/Operator:-Title: Date:_
Environmf ,l Health ServicesfAOSVeluc++P.O.Box 14892156 Sierra WaySan Luis Obispo. CA 93406cITY.CsrnlursoBrst)0Fire Depa'rlment (805) 78173802160 Santa Barbara AvenueSan Luis Obispo CA 9340tr5240Date: 06/1012015GERT|FTED UNIFIED PROGRAM AGENCY (CUPA)HAZARDOUS MATERIAL INSPECTION FORMTime:PERMISSION TO INSPECT: lnspections may involve obtaining photographs, reviewing andcopying records, and determining compliance with adopted codes.GRANTED BY (NAME/TITLE): Name: Mike Beverly Title: OwnertrTPEtrCalARPtrAGTtrUSTtrHW GeneratortrHazmatREINSPECTION REQUIRED:trTPEtrCalARPtrAGTtrUSTtrHW GeneratortrHazmatPROGRAMS INSPEGTED:Facility Name: KEN'S BODY SHOPAgencvtrEHStrCITY FIRElnsnection TvpetrRoutinetrReinspectiontrChargeable ReinspectiontrChange of OwnershiptrComplainttrSecondary Containment TestingtrChargeable Secondary Containment TestingSite Address: 4130 HORIZON LN #DSAN LUIS OBISPO, CA 93401Phone: (805)543-5450Facility lD: FA0007202Serial Number: DAQPTXC9ZtrtrtrtrtrNOtrtrtrtrtrYEStrtrtrtruN/ABUSINESS PLANBusiness plan is complete, current, available during inspection (HSC 25503.5, Title 19 CCR 2729)lnventory of hazardous materials is complete (HSC 25504, Title 19 CCR 2729)Site layouUfacility maps are accurate (HSC 25504, Title 19 CCR 2729)TRAINING PLANFacility has appropriate training program (Title 19 CCR2732 & 22 CCR 66265.16)Training documentation is maintained on site for current personnel (Title 19 CCR2732 & 22 CCR)66265.1 6EMERGENCY RESPONSE PLANEmergency response/contingency plan is complete, updated, and maintained on site (HSC 25504,Title 19 ccR 2731 & 22 CCR S 66265.53/s4)Facility is operated and maintained to prevent/minimize/mitigate fire, explosion, or release ofhazardous materials/waste constituents to the environment. Maintains all required or appropriateequipment including an alarm and communications system (Title 19 CCR 2731& 22 CCR 66265.31'.37,66267.34 (dX2),40CFR 1 265.31)BPOlBPO2BPO3TROlTRO2EROlERO2trtrtrtr tr tr ER03 Secondary containment is installed and sufficiently impervious to discharges. ICHSC2527 0.4.5; 40 CFR 1 1 2.8(cX2)IGENERAL EH VIOLATIONStr tr tr FE01 Environmental Health fees paid. ICBPC 17200, Local Ordinance]GPS Coordinates: Latitude: 35.2413200000 GPS Coordinates: Longtitude: 120.6656500000INSPECTOR: KERRY BOYLEFACILITY REP: Mike Beverly
?SUM MTNY OF OBSERVATIONSruIOT^.TIONStr No violations of undergrol,...r storage tank, hazardous materials, or hazd' *.rus waste laws/regulations werediscovered. SLO CUPA greatly appreciates your efforts to comply with all the laws and regulations applicable toyour facility.tr Violations were observed/discovered as listed below. All violations must be corrected by implementing thecorrective action listed by each violation. lf you disagree with any of the violations or corrective actions required,please inform the CUPA in writing,ALL VTOLATIONS MUST BE CORRECTED WITHIN 30 DAYS OR AS SPECIFIED. CUPA must be informed in writingwith a certification that compliance has been achieved. A false statement that compliance has been achieved is aviolation of the law and punishable by a fine of not less than $2,000 or more than $25,000 for each violation. Yourfacility may be reinspected any time during normal business hours.You may request a meeting with the Program Manager to discuss the inspection findings andor the proposedcorrective actions. The issuance of this Summary of Violations does not preclude the CUPA from takingadministrative, civil, or criminal action.FACILITY NAME: KEN'S BODY SHOPADDRESS: 4130 HORIZON LN #DSAN LUIS OBISPO, CA 93401VIOLATIONSVIOL. NO CORRECTIVE ACTION REOUIREDINSPECTION COMMENTS:Facility well maintained and in good order. Facillity will be removed from Hazardous Materials Business Planprogram as they no longer store hazardous waste or hazardous materials above threshold quantities. Noviolations noted during facility inspections. Good record keeping and employee training program.INSPECTED BY: KERRY BOYLEDATE:0611012015NAME OF FACILITY REP: Mike BeverlySIGNATURE OF FACILITY REP:STATEMENT OF COMPLIANCErtification: I certify under penalty of perjury that this facility has complied with theinspection form.ignature of Owner/Operatocorrective actions listed onDate:
t'(Environn,-,,tal Health Services(80$ 7815544P.O.Box 14892156 Sierra WaySan Luis Obispo. CA 93406clwLsari lrirsOHSDOFire Deoaft ment (805L78 173802160 Santa Barbara AvenueSan Luis Obispo CA 934015240Date: 1112512013CERTTFTED UNIFIED PROGRAM AGENCY (CUPA)HAZARDOUS MATERIAL INSPECTION FORMTime: 9:30 amREINSPECTION REQUIRED: lonazmattrCalARPtrAGTtrUSTtrHWGeneratorPROGRAMS INSPECTED: lBHazmattrCa|ARPtrAGTNUSTEHWGeneratorFacility Name: KEN'S BODY SHOPlnsoection TypeSite Address: 4130NLN#DtrEHS trRoutinetrClTY FIRE trReinspectiontrChargeable ReinspectiontrChange of OwnershiptrComplainttrSecondary Containment TestingtrChargeable Secondary Containment TestingSAN LUIS OBISPO, CA 93401Phone: (805)543-5450Serial Number: DAASSRTULtrTPET]TPEPERMISSION TO INSPECT: lnspections may involve obtaining photographs, reviewing andcopying records, and determining compliance with adopted codes.BUSINESS PLANBp01 Business plan is complete, current, available during inspection (HSG 25503.5, Title 19 CCR 2729)BP02 lnventory of hazardoue materials is complete (HSC 25504' Title 19 CCR 2729)BP03 Site layouUfacility maps are accurate (HSC 25504, Title 19 CCR 2729)TRAINING PLANtr tr tr TRgl Facility has appropriate training program (Title 19 CCR 2732 & 22 CCR 66265.16)tr tr tr TRO2 Training documentation is maintained on site for current pensonnel (Title 19 CCR 2732 & 22 CCR)66265.16EMERGENGY RESPONSE PLANtrtrtrERglGontingencyplaniscomplete,updated,andmaintainedonsite(HSC25504,Title19CCR273'l&22ccR s 66265.53t54)E tr tr ER02 Facility is operated and maintained to prevenUminimizer'mitigate fire, explosion, or release ofhazardous materials/waste constituents to the environment. Maintains all required or appropriateequipment including an alarm and communications system (Title 19 CCR 2731& 22 CCR 66265'3t-.37,66267.34 (dX2),40CFR I 265.31)tr tr tr ER03 Secondary containment is installed and sufficiently impervious to discharges. ICHSC2527 0.4.5 ; 40 C F R 1 1 2.8(cl(2llGENERAL EH VIOLATIONStr tr B FE01 Environmental Heaiih fees paid. ICBPC 17200, Local Oidinance]GPS Coordinates: Latitude: 35.2413200000 GPS Coordinates: Longtitude: 120.6656500000YES NO N/AtrtrtrBtrtrtrtrtrINSPECTOR: KERRY BOYLEFAGILITY REP:
FAC|LTTY NAiUiE: KEN'S Br- -'SHOP ADDRaHMARDOUS WASTE GENERATOR4130 HORIZON LN #DSAN LUIS OBISPO, CA 93401aEPA IDNUMBER:CAD008ZSZ4O5 Total generatedlmonth: Lbs or gals (average)Waste Oit - Solvents:Antifreeze: Others:-YES NO N/AtrtrnVIOL. # EPA ID NO'PERMITSGTof Generator has an EPA lD number to treat, store, dispose, transport ortransfer hazardouswaste (Tiile 22CCRS66262.12) lf not, Gall (800) 618-6942 to obtain your CAL EPA lD numbertrtrtrtrtrBtrEn GT03tr GTO4E GTOStr GTO6trtrtrGT07tr tr EI GTOsHAZARDOUS WASTE DETERMINATIONHazardous wasie deternrinaiion condueied (Tiiie 22 CCR S66262.11)Eown knowledge tranalysis trotherHazardous waste analysis/test records are kept for at Ieast 3 years(Title 22 CCR S66262'40.(c))DISPOSAUTRANSPORTATIONHazardous wastes disposed of at an authorized location (HSC S25t89.5,Title 22 CCR 566262.12)Faciliry utllizes a registered hazardous waste transporter, and hazardous wastes shipped witha manifest (Title 22 CCR 566262.20, HSC 525160/25163(a))Bmilkrun trothermJi:+='"'mtetedreteCCR 566263.421 66262.23, 66262.40 (a))STORAGE AND MANAGEMENT OF CONTAINERS/TANKSHazardous waates are accumulated on site as follows (Title 22 CCR 566262.34)tr90 days if waste generated per month is greater than or equal to 100 kg (220 lbs')E18O days if waste generated per month is less than 100 kg (see note)tr270 days if waste generated per month is less than 100 kg and transported more than 200 miles (seenote)Note: Applies only if hazardous waste accumulated on site never exceeds 6000k9(13,200 lbs) and noHazardous waste "satellite' collection is managed properly (complete labelinglaccumulationtime/S$gal or 1 -qt I imit) Fitle 22 CCR S66262.34(c))lgnitable or reactive wastes are located 15 m (50 feet) from facility's property line (Title 22 CCRs66265.176)Containers of hazardous waste are properly labeled (includes appropriate date"'HAZARDOUSWASTE," waste compositiodphysical state, hazardous properties, name/address of generator) (Title22 CGR 566262.31, 6G202.34)Containers/tanks containing hazardous wastes are in good conditiory'handled to minimize theretease or reaction (Title 22 GGR $66262.34 (dX2), 66265'171-.191'66265.1771c11Containers/tanks/liners are compatible wlth waste stored or transferred (Title 22 CCRSs66262.34 (dX2), 66265.172)Containers storing hazardous wastes arc closed/sealed (Title 22 CCR 5$66262.34 (dX2)' 66265.t73)Weekly inspection of areas where hazardous waste containes are stored is conducted (Title 22 CCR$s66262.34 (d)(2i, 66265.174)Daily inspection of all tank systems is conducted and documented (Title 22 CCR 5566262.34 (dX2),66265.195)Empty containers or inner liners greater than 5 gal has date when emptied and are managed properlywithin one year of date emptied (litle 22 CCR S6626f .7 (f))RECYCLABLE WASTEUied oil is managed as hazardous waste until recycled (includes proper labeling, storage, etc) (Iitle22 CCRS 66266.13, HSC 525250.4)Used oil filters for recycling are managed properly (drained of free flowing liquid, stored in closedrainproof container, labeled "drained used oil filtel€," and transferred for metal rcclamataon) (litle 22ccRs 66266.13)Spent lea&acid bafteries are being properly stored and transferred offsite under manifest or bill oflading for recycling, neuse, or reclamation (Title22 CCR 566266'81)Solvenbtother recyclable materials are managed as hazardous wastes until recycled (Title 22 CCRs66266.3)SOURCE REDUGTION:For facilities generating >{2,000 kg./yr. of hazardous waste onGenerator is subject to SB14 and has prepared and retained currcnt source rcduction documenF or isabte make them a*.,ai!abte to the inspector within (5) days. (67100.7, 67!00.8, !{SC S25244.19,25244.211Source Reduction Evaluation and Plan contains the followlng five elements:certification, amounts ofwastes generated, procesa description, block diagrams, and implementationschedule of selected sourcereduction measures. 167 1 00.7, 671 00'8, HSC 525244.1 9)trtrtrtrtrtrtrutrtrtrtrtrtrtrEEtrtrtrtrEtr GTOgu GT10tr GT1Itr GT12tr GT13tr GT14tr GT15tr GTl6E GTITtr GTiStr GTtgtrutrGT20EtrtrGT21trtrEGT22trtrBGT23
;/uo( floNStr No violations of underground storage tank, hazardous materials, or hazardous waste lawslregulations werediscovered. SLO CUPA greatly appreciates your effofts to comply with all the laws and regulations applicable toyour facility.tr Violations were observedldiscovered as listed below. All violations must be corrected by implementing thecorrective action listed by each violation. lf you disagree with any of the violations or corrective actions required,please inform the CUPA in writing.ALL VTOLATTONS MUST BE CORRECTED WTHIN 30 DAYS OR AS SPECIFIED. CUPA must be informed in writingwith a ceriification that compliance has been achieved. A false statement that compliance has been achie'ued is aviolation of the law and punishable by a fine of not less than $2,000 or more than $25'000 for each violation. Yourfacility may be reinspected any time during normal business houts.you may reqi.iest a meeiing with the Program ftilanager- to discuss the inspection findings andlor the proposedcorrective actions. The issuance of this Summary of Violations does not preclude the CUPA from takingadministrative, civil, or criminal action.FACILITY NAME: KEN'S BODY SHOPADDRESS: 4130 HORIZON LN #DSAN LUIS OBISPO, CA 93401VIOLATIONSVIOL. NO CO-RRECTVEAE'TLOI REQUIREJtINSPECTION COMMENTS:FACILITY USES DISPOSAL SITE AT COLD CANYON CESQG. GOOD RECORD KEEPING FOR HAZWASTE DISPOSAL AND EMPLOYEE TRAINING.INSPECTED BY: KERRY BOYLEDATE: 1'tt25t2013NAME OF FAGILITY REP:SIGNATURE OF FACILITY REPSTATEMENT OF COMPLIANCE: I certify under penalty of perjury that this facility has complied with the corrective actions listed oninspection form.re of OwnTitle:- Date
(-Gounty of San Luis ObispoEnvironmental Health Services(80s) 781-5544P.O. Box 14892156 Sierra WaySan Luis Obispo, CA 93406Fire Department (805) 781-73802160 Santa Barbara AvenueSan Luis Obispo CA 93401-5240wffiKil5clwptsalr lussryoCERTIFIED UNIFIED PROGRAM AGENCY (CUPA)HAZARDOUS MATERIALS INSPECTION FORM. ,l A t-,.' j.trut"./'it'#Qri'5EFW dataentry by:INSPEGT: Inspections may involve obtaining photogcopying records, andERMISSIONcodes. GRANTED BYwithREINSPECTION REQUIRED:ffiwnrrBusiness PlanC*o n YESncnmnpn nern usrdr* Generator/ iu"in"J" er"nPROGRAMS INSPECTED:!cnlnnen acrn usrPfidfuE;,,"I- ,lf /. f]''"- !/- /ADDRESS:FAcrLFYKrifuit'= K {/AA }Action Gode: _32 _37 _33 -31fEHSDEPTFIRERoutineGomplaintResult Code: _70Time:N/AYES NO COStrn nnn nnn ntrn n!tr tru!trntr!nnBPOIBPO2BPO3TROlTRO2EROlERO2ATOlATO2BUSINESS PLAI\Business plan is complete, current, & available during inspection (HSC 25503.5, Title 19 CCR2729\Inventory of hazardous materials is complete (HSC 25504, Title 19 CCR2729)Site layout/facility maps are accurate (HSC 25504' Title 19 CCR2729)TRAININGPLAI{Facility has appropriate training program (Title 19 CCR2732 & 22 CCR 66265.16)Training documentation is maintained on site for current personnel (Title 19 CCR2732 & 22 CCR6626s.16)EMERGENCY RESPONSE PLAIIContingency plan is complete, updated, and maintained on site (HSC 25504, Title 19 CCR273I & 22ccR $ 6626s.s31s4)Facility is operated and maintained to prevent/minimize/mitigate fire, explosion, or release ofhazardous materials/waste constituents to the environment. Maintains all required or appropriateequipment including an alarm and commuhications system (Titte 19 CCR 2731 & 22 CCR 66265.31-.43)ABOVEGROUND PETROLEUM STORAGE TANK ACTSPCC Plan is reviewed and certified by a registered engineer within last 5 yrs. (40 CFR 112.5(b))SPCC Plan is maintained on site or nearest field office. (HSC 25270)coMMENTSTGotto obtaintocomply with BP01-8P03,and EROINSPECTOR:decimal minFACILITY REP:GPS Coordinates: Latitude: degLongitude:_deg -min-decimal min
FACILITY NAME.EPA IDNIJMBER:ADDWASTE GENERAf #,,i {tl,'if"},q"d lrrt'lLbs or gals(average)Tieredpermit: ncusw ' EiErsdT "' 'nca' " [rnnTreatment Equipment:Total generated/monthWaste oil:Antifreeze:Solvents:Others:YESF1,fl,8vil{aofl,i.I*"'E",-ni,'Ibiatni.a;n,Ei"EffijrE,tr,EnnN/AtrntruncosE-nxnntrNOEntruDtrvIoL. #GTOlGTO3GTO4GTO5GTO6GTOTGTOsGT09GTlOGTl1GTl2GT13GTI4GTl5GTl6GT17GTl8GTT9GT2OGT2TGT22GT23EPA ID NO/PERMITSGenerator has an EPA ID number to treat, store, dispose, transport or transfer hazardous waste(Title 22CCR 966262.12) If Not, Call (800) 618-6942 to obtain your CAL EPA ID number.IIAZARDOUS WASTE DETERMINATIONIlazardous waste determination-'conducted (Title 22 CCR S66262.11)[own knowledge lanalysis EotherHazardous waste analysis/test records are kept for at least 3 years (Title 22 CCR $66262.a0.(c))DISPOSAL/TRANSPORTATIONHazardous waster were transported and/or disposed to a facility wtth an EPA ID NO, and permitor authorization from DTSC (HSC $25189.5, Title22 CCR $66262.f2)flmrutrun EotherHazardous wastes are shipped with manifest (Title 22 CCR $66262.20)Manifests end/or receipts are properly completed/retained by generetor for 3 years (fitle 22 CCR966263.42t 66262.23)STORAGE AND MANAGEMENT OF CONTAINERS/TANKSHazardous wastes are accumulated on site as follows (litle22 CCR 56626234)E gO Oays if waste generated per month is greater than or equal to 100 kg (220 lbs.)irfl ttO days if weste generated per month is less then 100 kg (see note)[ 270 days itwaste generated per month is less than 100 kg and transported more than 200 miles(see note)Note: Applies only if hazardous waste accumulated on site never exceeds 6000 kg(13,200lbs.)and no acutely/extremely hazardous waste over t kC Q.2lbs.) is held on site for over 90days.Hazardous waste "satellite" collection is managed properly (complete labeling/accumulationtime/S5-gal or l-qt limit) (Title 22 CCR $662684(c))Ignitable or reactive wastes are located l5 m (50 feet) from facility's property line (Title 22 CCR$6626s.176)Containers of hazardous waste are properly labeled (includes appropriate date,66HAZARDOUSWASTE,' waste composition/physical stateo hazardous properties, name/address of generator)(Title 22 CCR $66262.31,66262.34)Conteiners/tanks containing hazardous wastes sre in good condition/handled to minimize releaseor reaction (T itle 22 CCR $662 65. I 7 I I .l I l, 66265.17 7 (cl)Containers/tanks/liners are compatible with waste stored or transferred (Title 22 CCRS66265.U2)Containers storing hazardous \ryasles are closed/sealed (Title 22 CCR $66265.173)lVeekly inspection ofareas where hazardous waste containers are stored is conducted(Title 22 CcR$6626s.174)Daily inspection of all tank systems is conducted gnd documented (Title 22 CCR S66265.195)E-pty containers or inner liners grealer lhan 5 gal has date when emptied and are managedproperly within one year of date emplied (Title 22 CCR $66261.7 (f))RECYCLABLE WASTEUsed oil is managed as hazardous wasle until recycled (includes properlabeling, storage, etc) (HSC$2s2s0.4)Used oil filters for recycling are managed properly (drained offree flowing liquid, stored in closedrainproof container, labeled "drained used oil liltersr" and transferred for metal reclamation)(Title 22 cCR$ 66266.130)Spent lead-acid batteries are being properly stored and transferred offsite under manifest or bill oflading for recycling, reuse, or reclamation (Title 22 CCR S66266.81)Solvents/other recyclable materials are managed as hazardous wastes until recycled (Title 22 CCRs66266.3)SOURCE REDUCTION: For facilities generating >12,000 kg./yr. of hazardous waste on site.Generator is subject to SBl4 and has prepared and retained current source reduction documentsor is able make them available to the inspector within (5) days. (HSC $25244.19,25244.2\,Source Reduction Evaluetion and Plan contains the following five elements:certification, amgunts of wastes generated, process description, block diagrams, andimplementation schedule ofselected source reduction measures. (IISC 525244.19)nInnxnnnnntrnniln"/nkfiLI;ntrTnnnnnntrtrntrnnnntruuntrnnnnuntruN#,r-M
Gounty of San Luis ObispootlursoBtsp,octwsanEnvironmental Health Services(805) 781 -s544P.O. Box 14892156 Sierra WaySan Luis Obispo, CA 93406Fire Department (805) 781-73802'160 Santa Barbara AvenueSan Luis Obispo CA 93401-5240CERTIFIED UNIFIED PROGRAM AGENCY (CUPA)HAZARDOUS MATERIALS INSPECTION FORM.1d',EFW dataentry by:PERMISSION TO INSPECT: tnspections may involve obtaining photographs, reviewing and copying records, anddetermining compliance with adopted codes. GRANTED BY (NAME/TITLE):,F,r.io ! YESREINSPECTION REQUIRED:Icnmnen acrn usrFffV,sJII.+J,n Business PlanPROGRAMS INSPECTED:flcnlane! rern usrGeneratorn Business PlanPilBfuE '(' 't* 'i f. : -!. {\,1f l f}"*u Ij' {'ADDRESSIFACIReinspection ^other '18/W4;,B0 90Result Code: _70Action Code: 32N37 33 31RoutineComplaintAGENCYE EHSn ec DEPTfl" crv rlneffi,A*t ilrnYES NO COSnn nntr nntr nBUSINESS PLANBusiness plan is complete, current, & available during inspection (HSC 25503.5, Title l9 CCI{2729)Inventory of hazardous materials is complete (HSC 25504, Title 19 CCR2729)Site layout/facility maps are accurate (HSC 25504, Title 19 CCR2729)TRATNING PLANFacility has appropriate training program (Title 19 CCR2732 & 22 CCR 66265.16)Training documentation is maintained on site for current personnel (Title 19 CCx-2732 & 22 CCR66265.16')EMERGENCY RESPONSE PLANContingency plan is complete, updated, and maintained on site (HSC 25504, Title 19 CCR273l &22ccR $ 6626s.s3/s4)Facility is operated and maintained to prevent/minimize/mitigate fire, explosion, or release ofhazardous materials/waste constituents to the environment. Maintains all required or appropriateequipment including an alarm and communications system (Title 19 CCR 273f & 22 CCR 66265.31-.43)ABOVEGROUND PETROLEUM STORAGE TANK ACTSPCC Plan is reviewed and certified by a registered engineer within last 5 yrs. (40 CFR 112.5(b))SPCC Plan is maintained on site or nearest field office. (HSC 25270)materials.htm, to obtainwith BPOI -BP03, TR01 and EROI_deg__min_decimal minN/nnnnntrntrnnBPOIBPO2BPO3TROlTRO2EROIERO2ATOIATO2Go toGPSINSPECTOR:Latitude: deg -min-decimal minFACILITY REP:
FACILITY NAMEADDRESS'A nu,l i'ijjYirt -i,,'f,',,x-7 '.tt'l\'.. IUS WASTE GENERATORIEPAIDNUMBER:Tiered Permit:Treatment EquipmentLbs or gals(average)Total generated/month:Wapte oil:Antifreeze:Solvents:Others:YESFld,p,pNOE-trTNTTTvIoL. #GTOIGTO3GTO4GTO5GTO6GTOTGTOSGTO9GTIOGTl1GT12GT13GTT4GT15GTl6GT17GTISGTI9GT2OGT21GT22GT23COS N/AE-'E-trEPA ID NO/PERMITSGenerator has an EPA ID number to treat, store, dispose, transport or transfer hazardous waste(Titte 22CCR 566262.12) If Not, Call (800) 618-6942 to obtain your cAL EPA ID number.HAZARDOUS WASTE DETERMINATIONHazardous waste determination conducted (Title 22 CCR $66262'11)nown knowledge [analysis notherHazardous waste analysis/test records are kept for at least 3 years (Title 22 CCR $66262.40'(c))DISPOSAL/TRANSPORTATIONHazardous wastes were transported and/or disposed to a facility with an EPA ID NO. and permitccR s66262.12)or authorization from DTSC (HSC $25189.5' Title22El'ntitt run f]otherfHuru.dour rnurt., @t (Tiue 22nITTf,TnTTtrInnTnnnTntrTtrtrnTTTTn,p-Fr,flpn#,vdF,B'TxpTTtr,D,wt7t{frFccR $66262.20)Manifests andior receipts are properly completed/retained by generator for 3 years (Title 22 CCRs66263.421 66262.23)STORAGE AND MANAGEMENT OF CONTAINERS/TANKSHazardous wastes are accumulated on site as follows (Title 22 CCR $66262.34)! 90 days ifwaste generated per month is greater than or equal to 100 kg (220 tbs.),-fftilOdays if waste generated per month is less than 100 kg (see note)F_- flZIO days if waste generated per month is less than 100 kg and transported more than 200 miles(see note)Note: Applies only ifhazardous waste accumulated on site never exceeds 6000 kg(13'200lbs.)and no acutely/extremely hazardous waste over I kg (2.2|bs.) is held on site for over 90days.Hazardous waste "satellite" collection is managed properly (complete labelingiaccumulationtime/55-gal or l-qt limit) (Title 22 CCR $66262.34(c))Ignitable or reactive wastes are located f5 m (50 feet) from facility's property line (Title 22 CCR$6626s.r76)Containers of hazardous waste are properly labeled (includes appropriate date,"HAZARDOUSWASTE," waste composition/physical state, hazardous properties, name/address of generator)(Title 22 CCR $66262.31, 66262.34)Containers/tanks containing hazardous wastes are in good condition/handled to minimize releaseor reaction (T itle 22 CCR $66265: 17 I I .19 l, 66265.17 7 (c)'lContainers/tanks/liners are compatible with waste stored or transferred (TiUe 22 CCRS66265.172)Containers storing hazardous wastes are closedisealed (Title22 CCR $66265.173)Weekly inspection of areas where hazardous waste containers are stored is conducted(T itte 22 CCR$66265. I 74)Daily inspection of all tank systems is conducted and documented (Title 22 CCIR $66265.195)Empty containers or inner liners greater than 5 gal has date when emptied and are managedproperly within one year of date emptied ('title 22 CCR 566261.7 (f))RECYCLABLE WASTEUsed oil is managed as hazardous waste until recycled (includes proper labeling, storage, etc) (HSCs2s2s0.4)Used oil filters for recycling are managed properly (drained offree flowing liquido stored in closedrainproof container, labeled "drained used oil filters,o' and transferred for metal reclamation)(T itle 22 CCR$ 66266.1 30)Spent lead-acid batteries are being properly stored and transferred offsite under manifest or bill oflading for recycling, reuse, or reclamation (Title22 CCR $66266.8I)Solvents/other recyclable materials are managed as hazardous wastes until recycled (Title 22 CCR$66266.3)SOURCE REDUCTION: For facilities generating >12,000 kg.lyr. of hazardous waste on site.Generator is subject to SB14 and has prepared and retained current source reduction documentsor is able make them available to the inspector within (5) days. (HSC 525244 .19,25244.21)Source Reduction Evaluation and Plan contains the following five elements:certification, amounts of wastes generated, process description, block diagrams' andimplementation schedule ofselected source reduction measures. (HSC S25244.19)T
t- -''GountY of S'an Luis ObisPoEnvironmental Health Services(805) 781-55/t4P.O. Box 14892156 Sierra WaYSan Luis ObisPo, CA 93406f;wL;safi lrils ouspo&ttFire Department (805) 781-73802160 Santa Barbara AvenueSan Luis Obispo CA 93401-5240CERTIFIED UNIFIED PROGRAM AGENCY (CUPA)iaznnoous MATERIALS INsPEcrloN FoRMEFW dataentry by:!.i,i ,.', , ,Date: lr ' 't , 'Time:YES NO COSEEHlTntrABUSINESS PLANBusiness plan is completeo current, & available during inspection (Hsc 25503.5' Title l9 cCR2729)Inventory of hazardous materials is complete (HSC 25504, Title 19 CCR2729)Site layout/facility maps are accurate (HSC 25504' Title 19 CCR2729)TRAINING PLANF;itty has appropriate training program (Title 19 CCR2732 & 22 CCR 66265'16)Training documentation is maintained on site for current personnel (Title 19 ccR2732 & 22 ccR6626s.16)EMERGENCY RESPONSE PLANContingency plan is complete, updated, and maintained on site (HSC 25504, Title 19 CCR273L & 22ccR s 66265.53ts4',)i".iif& f- "p"rated and maintained to prevent/minimize/mitigate fire, explosion, or release ofrrnr"idou, materials/waste constituents to the environment. Maintains all required or appropriate"qrip*.r, including an alarm and communications system (Title l9 ccR 2731 & 22 ccR 6626s.31-.43)ABOVEGROUND PETROLEUM STORAGE TANK ACTSpCC ptan is reviewed and certified by a registered engineer within last 5 yrs' (40 CFR 112.5(b))SPCC Plan is maintained on site or nearest field office' (HSC 25270)toforms to comply with BPOl,1R01 and ER0lnBPOlBPO2BPO3TROlTRO2EROIERO2ATOlATO2trTGo to httP://wwwwithcodesBYGRANTEDmaylnspectionsTnnvolveingobtaianaphotograreviewingphsdrecords,ndcopyingTO INSPERMISSIONADDRESS:NAME:FACILITY!cnmnpfl xw Generator[] ecrfl usrflcnunpHW Generatorn norn usrRoutineREINSPECTION REQUIREDPROGRAMS INSPECTEDn Business PlanE Business PlanEHSAG DEPTCITY FIREReinspectionOtherComplaint nNO tr YESResult Gode: _70 _80 -90Action Code: _32 _37 -33 -31INSPECTOR:Latitude:mlnFACILITY REP:min decimal minGPS Coordinates:deg'a...t'
Environmental Health Services(805) 78r-5s{4P.O. Box 1'1892156 Sierrr WaySrn Luis Obispo, CA 934116.'{iGwo[safi lrils,'l '-' :'oBtspo -!FItl Oepsftm.nt (805, 781 -73802160 Santa Barbara AwnucSan Luls Oblrpo CA 93.[01-52'fOCERTIFIED TJNIFIED PROGRAM AGENCY (CUPA)HAZARDOUS MATERIALS INSPECTION FORMIDate:EFW dataentry by:Time:YES NON/AnnntrItrnaGl-unnu@:.@:,@'VJE'BUSINESS PLANBnsiness plan is complete, current, & available during inspection (HSC 25503.5, Tltle 19 CCR2729,InventorX of hazardous matcrials is complete (HSC 25504' Title 19 CCR2729)Site layout/facility mapa are accuratc (HSC 25504, Title 19 CCRn2glTRAINING PLANFacility hos approprlate training program (Title 19 CCR 2732 & 22 CCR 6626.f6)Training documentation is maintained on site for current pcrsonnel (Tltle 19 CCR2732 & 22 CCRffii265.t51EMERGENCY RESPIONSE PLANContingency plan is comple3e, updated, and maintained on slte (HSC 2551)4' Title 19 CCR 2731 & 22ccR $ 66265.s3/s4)Facility is operated and maintained to prevenUminimize/mitigate fire' explmion, or release ofhrzirdors matcrials/waste constifirents to the environmenL Maintalns all rcquired or appropriateequipment inclnding an alsrm ard communications system (TiOe 19 CCR 2731 & 22 CCR 6626531-.43)ABOVEGROTJIYD PETROLEUM STORAGE TANK ACTSPCC Plan is reviewed and certified by a registered engineer within last 5 yrs. (4ll CFR f f2.5(b))SPCC Plan is malntained on site or nearest field office. (IIfiC 25270)4{i'ffi w',BmlBm2BPOSTROTTRO2ER.OlERO2ATOI'- LTO?REINSPECTION REOUIRED:Ecmnnp[f rcrElusrE nwccnorutorIfl Eurinecr PlanF"o trYEsflrcrE usr"ffi"* GencratoriBudne$ Plan\f,A '1A0^ PRocRAMS INSPECTED:!cnunePnbdE: '"'Yn'1... \r '\/-- ." ,, -*,r' I'FACILITf NAME: ,fil,l/,{ l<RoutlneReinspectlon[-l Comolaint r,n on"i,l{,,!l t,,{,*,fu|rll6D rllS \trICITY FIREAGENCYE ensGo to http://www.slopublichealth.org/environnrentalhealtMrazardous-materials,htm, to obtain forms to comply with BPOI-BP03, TROI and ERO|!iGPS Coordinates:degmin Longitude: deg-min--:decimol minFACILIIY REP:INSPECTOR:ME-frth1 \Temp\c. lotus. notes. data\1Form Page 1'.doc 24-Jan-06
, FACILITYEPAIDNT]MBER:fiercdPemit:TrcafuentF.quipment:WASTE GEI\ERATORfLbs or gds(average)Total generatedrhonth: /Waste oik Sol"""t* ,r/'Andfreeze: Otherr:4&s!,( ll,,'i=N/AE]nnnn{trnutrtrtrnnwwV@/'WnunI]trtrnnnD!Iuntrtrtr:trnYFS NOwEidtrBt'da"dnwwdwiw^www,niwni,trItrtrvIoI,.#GTOlGTO3GIO4GTOSGTII6GTI}7GTOSGT'OIDGTlOGT11GTl2GT13GT14GT15GT16GT17GTlEGT19GT2OGT21GT22GT23authdrizadond-ilkt""EPA IDNOIPERMITSC"i"""t""t*"" npl b number to trcaf store, dispme, fironsporlortransferhazardous wastc (fiOe?:2CCR9ffi262.12) If Not, Call (en) 61&6%2 to obtain your CAL EPA ID number.HAZARDOUS WASTE DETERMINATIONIlnzardous waste detemination conducted (I\tlet2 CCR $66252.11)do*ohowledge Eanarvss Eotherfutzardous waste anatysidtest records are kept for at least 3 years (Titlet2 CCR $66262.t10.(cDDISPIOSAUTRANSPORTATIONHazardous wastes were tranqlorted and/or dlspmed to a facili8 with an EPA ID NO. and pcrmit orfrom DTSC (HSC $251t9.5,T1fle22 CCR $65262.12)EotherHazardous wastes are shippd with manifest (litleZ2 CCR $66262.2,0)Manifests and/or receipts are properly completed/retained by generator for 3 yeas (Title 22 CCR*6f,263.4U ffiZel?s|STORAGE AND MANAGEMENT OF CONTAINERS/TANKSHazgrdous wostes are accumulated on site as follows (tllleZ2 CCR $6625234)dc1 dsys if waste generated per month is greater than or equal to 100 kg (220 lb*)E fm days if waste generated per month is less than llXl kg (sce note)I ZZO aays if waste ger:erated per month is less than lfil kg antf hansported more than 2lXl miles (seenote)Note AppHes only lf hazardous waste accumulatcd on slte never exceeds 6000 kg(13'200 lbsJand noacutely/extremely hazardous waste over 1 kg (22 lb$) is held on site for over 90 days.Hqzsrdorrs saste .tatsllite" collecdon is managed properly (complete labeling/accumuladon 6md55'gstor l-qt limit) (lftle t2 CCR $6526fi4(c))Ignitable or reactive wastes are located 15 m (50 feet) from facility's property line (Tttle ZU CCRg6f'?,f,s.t76)Containers of hazardous waste are propcrly labcled (includes appropriate dst€' "IIAZARDOUS\[ASTE," was3e composition/physicat statc, hazardous properfes, name/address of generator) (TldeZ2ccR $6626231,62G2.91Containerdtanks containing hazardous wastes are in good condition/handled to minimizc release orreaction(TltleU2CCR$56255.1711.191,6ff,65.177(e)lContainerdtankdliners are conpafible wlth waste stored or transferred (TiOe 22 CCRS66255.U2)Containers storing hazqrdous tf,ast€s are closcd/sealed (Iftle2i2 CCR $66265.173)lVeekly inspecfion ofareas where hazardous waste containers are storcd is conducted(fiOe 22 CCR$66265.174)Daily inspoction of all tqnk systems is conducted and docrmentcd (Tttle 22 CCR $65265.195) ,Empty containers or inner liners greater than 5 gal has date when emptied and are managed properlywithin one year of ilate enrptied (fitle 2:2 C&' $66251.7 (f))RECYCLABLE WASTEUscd oil is managed as hazardous waste until recycled (includes proper labeling storage, etc) (HSC$2s2s0.4)Uscd oit fllters for recycllng are managed properly (drained of frce flowing liqui{ stored in clmedrainprmf container, labeled ttdrained used oil fllters,tt and transferred for metal reclamation) (fitleZ2ccR$ 66256.13{l)Spent lead-acid battcries are being properly stored and bansferrcd ofrsite under nanifest or bill oflading for rccycling, reuse, or reclauration (TineUz CCR $66266.E1)Solventdother recyctable materials tre managed as hazardous wastes unfil recycled (Tttle 22 CCR$662563)SOTIRCE REDUCTION: tr'or facillties generadng >12,0ffi kgJyr. of hazardous waste on site.Generator is subject to SB14 and has prepared and retained current murce reduction documents or isable make then available to the inspector within (5) days. (HSC 925244.19,2524421'Source Reducdon Evaluation and Plan contains the following frve elements:cerdftcation, amounts of wastes generated, process description, block diagriams' and implementationschedule ofselected source reduction measures" (HSC $2!t244-19)hrA1\Repro\LOCALS-1\Temp\c.lotus.notes.data\2-Hazardous Waste Generator.doc 20-Jul-04 20-Jul-04
"''-oIlulsoBtspocftysanIEnvironmental Health Services(805) 781-5544P.O. Bor 14892156 Sierra VYaySan Luis Obispo, CA 93406rgFlre Department (805) 781-73802160 Santa Barbara AvenueSan Luls Oblspo CA 93'O1-5240CERTIFIED UNIFIED PROGRAM AGENCY (CUPA)HAZARDOUS MATERIALS INSPECTION FORMEFW dataentry by:EcaunpE rcr1b r"F "*cenerat(Businees Plan! NO trYESREINSPECTION REQUIRED:flcnunnefl rarE usrX "* GeneratorBusiness PlanIHPROGRAMS INSPECTED:PHONE:ADDRESS:RoutlneReinspectionTYPE! ottrerfl Complaint{ orv nnecA/_ffiKA&./{F$\QRPAGENCY! exsFACILITY NAME: KOIha ,rfd€trntrMfrtrn,trXN/Ann!BmlBm2BPO3TROTTR02EROIERO2ATOlAT02BUSINESS PLANBusiness plan is complete, current, & available during inspection (HSC 25503.5, Title 19 CCR2729)Inventory of hazardous materials is complete (HSC 25504, Title 19 CCR2729)Site layouUfacility maps are accurate (HSC 25504, Title 19 CCR2729\TRAINING PLANFacility has appropriate training program (Title 19 CCIi2732 & 22 CCR 66265.16)Training docurnentation is maintained on site for current personnel (Title 19 CCR2732 & 22 CCR66265.t6)EMERGENCY RESPONSE PLANContingency plan is complete, updated, and maintained on site (HSC 25504, Title f9 CCR 2l3l &22ccR $ 66265.s3/s4)Facility is operated and maintained to prevenUminimize/mitigate fire, explosion, or release ofhazardous materialVwaste constituents to the environment. Maintains all required or appropriateequipment including an alarm and communications system (Title 19 CCR 2731 & 22 CCR 66265.31-.431ABOVEGROUI\D PETROLEUM STORAGE TANK ACTSPCC Plan is reviewed and certilied by a registered engineer within last 5 yrs. (40 CFR U2.5(b))SPCC Plan is maintained on site or nearest field oflice. (HSC 25270)!trnnCOMMENTSGo to http://www.slopublichealth.org/environmentalhealth/hazardous_materials.htm, to obtain forms to comply with BP0l-8P03, TROl and EROlJGPS Coordinates:mtnFACILITY REP:INSPECTOR:E-1\Temp\c,lotus.1_lnspection Form1.doc 24-Jan-06I
FACILITY NAMEEPA ID ITIUMBER:Tiered Permit:TreatrnentEquipment:{US WASTE GENERATOR...,1 .r) .-..Total generated/month: ,""','*' tr" (.i')r;:u"{Lbs or gals(average)CAWaste oil:Antifreeze:Solvents:Others:YEStr-,4'HF"A,FE;N/AE'TnNOEtrntrnnfvIoL.#GTOlGTO3GT04GTOSGT06GTOTGTO8GTO9GTIOGTl1GT12GT13GT14GT15GT16GT17GT18GT19GT2OGT2IGT22GT23EPA ID NO/PERMITSGenerator has an EPA ID number to treat, store, dispose, transport or transfer hazardous waste (Title22CCR 866262.12) If Not, Call (8ffi) 618-6942 to obtain your CAL EPA ID number.HAZARDOUS WASTE DETERMINATIONHazardous waste determi4ation conducted (Title22 CCR S66262.11)Eown knowledge .flanalysis EotherHazardous waste analysi#test records are kept for at least 3 years (Title 22 CCR $66262.40.(c))DISPOSAL/TRANSPORTATIONHazardous wastes were transported and/or disposed to a facility with an EPA ID NO. and permit orauthorization from DTSC (HSC $25189.5, Title 22 CCRg66262.12\lmilkrun lotherHazardous wastes are shipped with manifest (TitleZ2 CCR $66262.20)Manifests and/or receipts are properly completed/retained by generator for 3 years (Title 22 CCRs66263.421 66262.23)STORAGE AND MANAGEMENT OF CONTAIIYERS/TANKSHazardous wastes are accumulated on site as follows (Title22 CCR $66262.34)il 90 aays if waste generated per month is greater than or equal to 100 kg (220 lbs.)E ffO days ifwaste generated per month is less than 100 kg (see note)IJ'|ZO a"y. if waste generated per month is less thcn 100 kg and transported more than 200 miles (see/hdt€)Note: Applies only if hazardous waste accumulated on site never exceeds 6fiX) kg(13,2fi] lbs.)and noacutely/extremely hazardous waste over lkgQ.2lbs.) is held on site for over 90 days.Hazardous waste "satellite" collection is managed properly (complete labeling/accumulation time/55-galor l-qt limit) (Title22 CCR $66262.34(c))Ignitable or reactive wastes are located 15 m (50 feet) from facility's property line (Title 22 CCx.[ltf;tt;ff'" hazardous waste are properly tabeled (includes appropriate date, "HAZARDousWASTE," waste composition/physical state, hazardo'rs properties, name/address of generator) (fitle 22ccR $66262. 3t, 66262.34)Containerdtanks containing hazardous wastes are in good condition/handled to minimize release or ,reaction(Title22CCR$66265.1711.191,66265.177(c))ContainerVtankMiners are compatible with waste stored or transferred (Title22 CCR$66265.172)Containers storing hazardous wastes are closed/sealed (Title 22 CCR $66265.173)Weekly inspection of areas where hazardous waste containers are stored is conducted(Title 22 C CR$ 66265. 1 74)Daily inspection of all tank systems is conducted and documented (Title ?2 CCR $66?65.195),Empty containers or inner liners greater than 5 gal has date when emptied and are managed properlywithin one year of date emptied (Title 22 CCR $66261.7 (f))RECYCLABLE WASTEUsed oil is managed as hazardous waste until recycled (includes proper labeling, storage, etc) (HSCs2s2s0.4)Used oil filters for recycling are managed properly (drained of free flowing liquid, stored in closedrainproof container, labeled "drained used oil filters," and transferred for metal reclamation) (Title22ccR$ 66266.130)Spent lead-acid batteries are being properly stored and transferred offsite under manifest or bill oflading for recycling, reuse, or reclamation (Title22 CCR $66266.81)SolventVother recyclable materials are managed as hazardous wastes until recycled (Title 22 CCRs66266.3)SOURCE REDUCTION: For facilities generating >12,000 kg./yr. of hazardous waste on site.Generator is subject to SB14 and has prepared and retained current source reduction documents or isable make them available to the inspector within (5) days. (HSC 82524/..19'2524.21)Source Reduction Evaluation and Plan contains the following five elements:certification, amounts of wastes generated, process description, block diagrams, and implementationschedule ofselected source reduction measures. (HSC $25244.19)nnntrEfl'dqnn@f"nnE,nH'' nENtrntrntrnii."'BX,qnutrnnH.nnnnnntr.j ,lr """' .' ','C:\DOCUME-1\Repro\LOCALS-1\Temp\c.lotus.notes.data\2,,Hazardous Waste Generator.doc 20-Jul-04 20-Jul-04
Date: 02/0112007ffi** cntY.ofFvbo^i*o' qAnil$O$l$p02156 Siena Wavsanluisobisoo.cAe34o6 }iffitrffi#-sunil-rc otirpo ca q3ao l-sz+oCERTIFIED UNIFIED PROGRAM AGENCY (CUPA)HAZARDOUS MATERIAL INSPECTION FORMTime:PERMISSION TO INSPECT: Inspections may involve obtaining photographs, reviewing and copyingrecords, and determining compliance with adopted codes.GRANTED BY (NAME/TITLE): Title: Name:trTPEtrCalARPtrAGTtrUSTEHW GeneratorEHazmatREINSPECTION REQUIRED:trTPEtrCalARPtrAGTtrUSTEHW GeneratorBHazmatPROGRAMS INSPECTEDFacility Name: KEN'S BODY SHOPAqencvtrEHStrCITY FIRElnspection TvpetrRoutinetrReinspectiontrComplaintSite Address: 4130 HORIZON LN #DSAN LUIS OBISPO, CA 93401Phone: (805)543-5450Facility lD: FA0007202YES NO N/A8trtr8trtrBtrECOMMENTS cotoGPS Coordinates: Latitude: 35.2413200000BUSINESS PLANBusiness ptan is complete, current, available during inspection (HSC 25503'5' Title f9 CCR 2729)Inventory of hazardous materials is complete (HSC 25504' Title 19 CCR2129)Site layouVfacility maps are accurate (HSC 25504' Title 19 CCR2729)TRAINING PLANFacility has appropriate training program (Title 19 CCR2732 & 22 CCR 66265.16)Training documentation is maintained on site for current personnel (Title 19 CCR 2732 & 22 CCR)66265.16EMERGENCY RESPONSE PLANContingency plan is complete, updated, and maintained on site (HSC 25504' Title 19 CCR273I & 22ccR s 6626s.s3/s4)Facility is operated and maintained to prevenVminimize/mitigate Iire, explosion, or release ofhazardous msterials/waste constituents to the environment, Maintains all required or appropriateequipment including an alarm and communications system (Title 19 CCR 2731& 22 CCRABOVE GROUND PETROLEUM STORAGE TANK ACTSPCC Plan is reviewed and certilied by a registered engineer within last 5 yrs' (40 CFR 1f2.5(b))SPCC Plan is maintained on site or nearest field office. (HSC 25270)to obtrin foms lo complywith BP01-8P03, TR01 .nd ERoltrtrBPOlBPO2BPO3TROlTRO2EROlERO2ATOIATO2trEtrtrGPS Coordinates: Longtituder 120.6656500000INSPEGTOR: PETER HAGUEFACILIW REP: RANDY JORDAN
a({ADDRESS: 4130 HORIZON LN #DsAN LU|S OBTSPO, CA 9340'lNOYESFAClLlry NAME: KEN'S BODY SHOPHAZARDOUS WASTE GENERATORN/A VIOL. # EPA ID NO/PERMITSSOURCE REDUCTION:For frcilities generating >12,000 kg./yr. of hazardous waste on site.E GT22 Generator is subject to SB14 and has prepared and retained current source reductiondocuments or is able make them available to the inspector within (5) days. (HSC $25244.19'B GT23 Source Reduction Evaluation and Plan contains the following five elements:certification,amounts ofwastes generrted, process description, block diagrams, and implementationscheduleofselected source reduction measures. (HSC 525244.19)trtrtrtrINSPECTED BYT PETER HAGUEDATEi 02101/2007
Date: 0111812006Environmental Health Services(805) 781-5544P.O.Box 14892156 Sierra WaySan Luis Obisoo. CA 93406BPOIBPO2BPO3TROlTRO2(cttvotsArilrirsousrcFire Department (805) 781-73802160 Santa Barbara AvenueSan Luis Obispo CA 93401-5240CERTIFIED UNIFIED PROGRAM AGENCY (CUPA)HAZARDOUS MATERIAL INSPECTION FORMTime:BUSINESS PLANBusiness plan is complete, current, available during inspection (HSC 25503.5, Title 19 CCR2729)Inventory of hazardous materials is complete (HSC 25504' Title 19 CCIi2729)Site layout/facility maps are accurate (HSC 25504' Title 19 CCx^2729)TRAINING PLANFacility has appropriate training program (Title 19 CCR2732 & 22 CCR66265.16)Training documentation is maintained on site for current personnel (Title 19 CCR2732 & 22 CCR)66265.16EMERGENCY RESPONSE PLANContingency plan is complete, updated, and maintained on site (HSC 25504, Title 19 CCR273t & 22ccR $ 6626s.s3/s4)Facility is operated and maintained to prevent/minimize/mitigate fire, explosion, or release ofhazardous materials/waste constituents to the environment, Maintains all required or appropriateequipment including an alarm and communications system (Title 19 CCR 2731& 22 CCRABOVE GROUND PETROLEUM STORAGE TANK ACTSPCC Plan is reviewed and certified by a registered engineer within last 5 yrs. (40 CFR 112.5(b)SPCC Plan is maintained on site or nearest field office. (HSC 25270)YES NO N/AtrtrtrtrtrtrutrutrtrtrtrtrtrEROIERO2ATOIATO2COM M ENTS co to htrp**.slopubliahoalth.org/onvironmsntalhoalth/hazardous-metorials.htm to obtain toms to comply with BPOl-BPo3, TRO I and ERo'lGPS Coordinates: Latituder 35.2413200000 GPS Coordinates: Longtitude: 120.66565000001lPERMISSION TO INSPECT: Inspections may involve obtaining photographs, reviewing and copyingrecords, and determining compliance with adopted codes.GRANTED BY (NAME/TITLE): Title: Name:trTPEtrCalARPtrAGTtrUSTtrHW GeneratortrHazmatREINSPECTION REQUIREDtrTPEOCaIARPtrAGTtrUSTtrHW GeneratortrHazmatPROGRAMS INSPECTEDFacility Name: KEN'S BODY SHOPAgencvtrEHStrCITY FIRElnspection TvpetrRoutinetrReinspectiontrComplaintSite Address: 4130 HORIZON LN #DSAN LUIS OBISPO, CA 93401Phone: (805)543-5450Facility lD: FA0007202INSPECTOR: AARON LA BARREFACILITY REP: Randy Jordan
trtrFACILITY NAME: KEN'S BOf' SHOPADDR('" r4130 HORIZON LN #DSAN LUIS OBISPO, CA 93401SUMMARY OF OBSERVATIONS/VIOLATIONSNo violations ofunderground storage tank, hazardous materials, or hazardous waste laws/regulations were discovered.SLO CUPA greatly appreciates your efforts to comply with all the laws and regulations applicable to your facility.Violations were observed/discovered as listed below. All violations must be corrected by implementing the corrective actionlisted by each violation. Ifyou disagree with any ofthe violations or corrective actions required, please inform the CUPAin writing.ALL VIOLATIONS MUST BE CORRECTED WITHIN 30 DAYS OR AS SPECIFIED. CUPA must be informed inwriting with a certification that compliance has been achieved. A false statement that compliance has been achieved is aviolation of the law and punishable by a fine of not less than $2,000 or more than $25,000 for each violation. Your facilitymay be reinspected any time during normal business hours.You may request a meeting with the Program Manager to discuss the inspection findings and/or the proposed correctiveactions. The issuance of this Summary of Violations does not preclude the CUPA from taking administrative, civil, orcriminal action.FACILITY NAME: KEN'S BODY SHOPADDRESS: 4130 HORIZON LN #DSAN LUIS OBISPO, CA 93401PE NO0726VIOLATIONSVIOL. NO VIOL. TYPEBPOlCORRECTIVE ACTION REQUIREDIMMEDIATELY TAKE NECESSARY ACTION TO ENSURE THAT THEBUSINESS PLAN IS COMPLETE AND AVAILABLE ON SITE.IMPLEMENT A PROCEDURE TO ENSURE THAT THE PLAN ISUPDATED AS REQUIRED BY HEALTH AND SAFETY CODESECTION 25503.5 AND TITLE 19 CALIFORNIA CODE OFREGULATIONS SECTION 2729.0726BPO2IMMEDIATELY COMPLETE THE INVENTORY OF HMARDOUSMATERIALS AND IMPLEMENT A PROCEDURE TO ENSURE THATTHE INVENTORY OF HAZARDOUS MATERIALS IS UPDATED (ASINVENTORY CHANGES) AS REQUIRED BY HEALTH AND SAFETYCODE SECTION 25504 AND TITLE 19 CALIFORNIA CODE OFREGULATIONS SECTION 2729.0726TRO2IMMEDIATELY PREPARE TRAINING DOCUMENTS ACCORDINGTO TITLE 19 CALIFORNIA CODE OF REGULATIONS SECTION2732 AND TITLE22 CALIFORNIA CODE OF REGULATIONSSECTION 66265.16 AND LOCATE TRAINING DOCUMENTATION ONSITE.0726BPO3IMMEDIATELY PREPARE S ITE LAYOUT/FACI LITY MAPSACCORDING TO HEALTH AND SAFETY CODE SECTION 25504AND TITLE 19 CALIFORNIA CODE OF REGULATIONS SECTION2729 OR CORRECT THE SITE LAYOUT/FACILITY MAPS FORACCURACY.0726EROlIMMEDIATELY COMPLETE, UPDATE AND MAINTAINCONTINGENCY PLAN ON SITE. IMPLEMENT A PROCEDURE TOENSURE THAT THE CONTINGENCY PLAN IS KEPT CURRENTAND ON SITE.0726TROlIMMEDIATELY DEVELOP AN APPROPRIATE TRAINING PROGRAMAND IMPLEMENT A PROCEDURE TO ENSURE THAT THETRAINING PROGRAM IS UPDATED TO INCLUDE ANY CHANGESIN OPERATIONS.INSPECTION COMMENTS:On site with Randy Jordan. He did not have the Business Plan completed. I asked him to provide it bv1-20-06. He said he would provide it bv then.INSPECTED BY: AARON LA BARRE DATE: OIIIsI2OO6
FACIL|TY NAME: KEN'S BODr\{OPADDREST\4130 HORTZON LN #DSAN LUIS OBISPO, CA 93401INSPECTED BY: AARON LA BARREDATE: out&/2006NAME OF FACILITY REP: Randy JordanSIGNATURE OF FACILITY REP:Certification: I certify under penalty of perjury that this facility has complied with the corrective actions listed on thisinspection form.Signature of Owner/Operator:Title:Date:
Environmental Health Services(805) 781-5544P.O. Box 1489'i156 Sierra waySan Luis Obispo, CL93406#ff"no*Fire Department (805) 781-73802160 Santa Barbara AvenueSan Luis Obispo CA 93401-5240CERTIFIED UNIFIED PROGRAM AGENCY (CUPA)HAZARDOUS MATERIALS INSPECTION FORMEFW dataentry by:Date: 1z-q-OETime:PERMISSION TO INSPECT: lnspections may idetermininq compliance with adopted codes. Gnvolve obtaining photographs, reviqyqing an{ gopyjng recopdso andRANTED BY (NAME/TITLE): Y(zIuT ZJC{ - \21Ifl.14REINSPECTION REQUIRED:!NOq"r.n acrE usrn |-lw Generator! Business Planncar-nnpPROGRAMS INSPECTED:n ncrn usrEfnw Generatorfi-Business PlanncamnpPHONE:San t+DADDRESS:/rFACILITY NAME:In nc DEPTE crY PlneAGENCYEMRoutineReinspectionComplaintn otnerYES NO N/AnilnnmntrqnVdnBPOlBPO2BP03TROlTRO2EROlERO2BUSINESS PLANBusiness plan is complete, current, & availabte during inspection (HSC 25503.5' Title 19 CCR2729)Inventory of hazardous materials is complete (HSC 25504' Title 19 CCR2729)Site layouUfacility maps are accurate (HSC 25504, Title 19 CCR2729)TRAINING PLANFacility has appropriate training program (Title t9 CCR2732 & 22 CCR 66265.16)Training documentation is maintained on site for current personnel (Title 19 CCR2732 &22 CCR6626s.16)EMERGENCY RESPONSE PLANContingency plan is complete, updated, and maintained on site (HSC 25504' Title 19 CCRn3l &22ccR s 6626s.531s4)Facility is operated and maintairied to prevenUminimize/mitigate fire, explosion, or release ofhazardous materials/waste constituents to the environment. Maintains all required or appropriateequipment including an alarm and communications system (Title 19 CCR 2731 & 22 CCR 66265.31-.43\Wn!ATOlATO2ABOVEGROUND PETROLEUM STORAGE TANK ACTSPCC Plan is reviewed and certified by a registered engineer within last 5 yrs. (40 CFR 112.5(b))SPCC Plan is maintained on site or nearest field office. (HSC 25270)COMMENTStoGPS Coordinates:.htm, toto comply with1-BP03, TR01 and ER01zo.min Longitude: , dee--min-decimalF'ACILITY REPINSPECTOR:C :\DOCU M F-l \Repro\LOCALS*1 \Temp\c. lolus. notes'data\1 *l nspectionrm Page 1.doc 13-Jun-05mIn
FACILITY NAMEADDRESSHAZARDOUS WASTE GENERATORsLoffiz_Total generated/month:Waste oil: Solvents:Lbs or gals(average)EPA ID NUMBER:Tiered Permit:TreatmentEquipment:YES NOWtrCESWCESQTAntifreeze:Others:EPA ID NO/PERMITSGenerator has an EPA ID number to treat, store, dispose, transport or transfer hazardous waste (Title22CCR566262.12) If Not, Call (800) 618-6942 to obtain your CAL EPA ID number.HAZARDOUS WASTE DETERMINATIONllaza;dous waste determination conducted (Title22 CCR $66262.11)Wwnknowledge lanalysis EotherHazardous waste analysis/test records are kept for at least 3 years (Title22 CCR $66262.40.(c)DISPOSAL/TRANSPORTATIONHazardous wastes were transported and/or disposed to a facility with an EPA ID NO. and permit or-l(N/AnnnvtoL.#GTOlGTO3GTO4GTO5GTO6GTOTGTOSGTO9GTlOGTl1GT12GT13GT14GT15GT16GTITGT18GT19GT2OGT2IGT22GT23WW4WWWwWWauthorization from DTSC (HSC $25189.5, Title 22 CCR 566262.12)pdirkrun P( -L lothernnnnnnITTTTTTITn{lWK{TTHazardous wastes are shipped with manifest (Title22 CCR 566262.20)Manifests and/or receipts are properly completed/retained by generator for 3 years (Title 22 CCRs66263.421 66262.23)STORAGB AND MANAGEMENT OF CONTAINBRSITANKSHazardous wastes are accuniulated on site as follows (Title22 CCR $66262.34)f] 90 days if waste generated per month is greater than or equal to 100 kg (220 tbs.)f] fgO days ifwaste generated per month is less than 100 kg (see note)ZZIO days if waste generated per month is less than 100 kg and transported more than 200 miles (seenote)Note: Applies only if hazardous waste accumulated on site never exceeds 6000 kg(13'200 lbs.)and noacutely/extremely hazardous waste over lkg(2.2Ibs.) is held on site for over 90 days.Hazardous waste "satellite" collection is managed properly (complete labeling/accumulation time/S5-galor l-qt limit) (Title 22 CCR *66262.34(c))Ignitable or reactive wastes are located 15 m (50 feet) from facility's property line (Title 22 CCR$6626s.176)Containers of hazardous waste are properly labeled (includes appropriate ilate, "HAZLRDOUSWASTET" waste composition/physical state, hazardous properties, name/address of generator) (Title22ccR $66262.3 l, 66262.34)Containers/tanks containing hazardous wastes are in good condition/handled to minimize release orreaction (T itle 22 C CR $ 66265. l7 I I .19 l, 66265.17 7 (c)\Containers/tanks/liners are compatible with waste stored or transferred (Title 22 CCR$66265.172)Containers storing hazardous wastes are closed/sealed (Title 22 CCR $66265.173)Weekly inspection of areas where hazardous waste containers are stored is conducted(T ifle i2 C CnS OOZOS. r Zl)Daily inspection of all tank systems is conducted and documented (Title 22 CCR S66265.195)Empty containers or inner Iiners greater than 5 gal has date when emptied and are managed properlywithin one year of date emptied (Title22 CCR $66261.7 (D)RECYCLABLE WASTEUsed oil is managed as hazardous waste until recycled (includes proper labeling, storage, etc) (HSC$2s250.4)Used oil lilters for recycling are managed properly (drained of free flowing liquid, stored in closedrainproof container, labeled "drained used oil filters," and transferred for metal reclamation) (Title 22ccR$ 66266.130)Spent lead-acid batteries are being properly stored and transferred offsite under manifest or bill oflading for recycling, reuse, or reclamation (Title 22 CCR $66266.81)Solvents/other recyclable materials are managed as hazardous wastes until recycled (Title 22 CCRs66266.3)SOURCE REDUCTION: For facilities generating >12,000 kg./yr. of hazardous waste on site.Generator is subject to SB14 and has prepared and retained current source reduction documents or isable make them available to the inspector within (5) days. (HSC 925244.19,25244.21)Source Reduction Evaluation and Plan contains the following five elements:certification, amounts of wastes generated, process description, block diagrams, and implementationschedule ofselected source reduction measures. (HSC $25244.19)trTITTNC:\DOCUMH-1\Repro\LOCALS-1\Temp\c.lolus"notes.data\2, Hazardous Waste Generator.doc 7-Mar-05 7-Mar-05
FACILITY NAADDRESS4SUMMARY OOBSERVATIONS/VIOLATIONSn No violations ofunderground storage tank, hazardous materials, or hazardous waste laws/regulations were discovered.H SLO CUpA greatly appreciates your efforts to comply with all the laws and regulations applicable to your facility.6Violations were observed/discovered as listed below. All violationsby each violation. Ifyou disagree with any oftheviolations oractions required, please inform the CUPA in writing.must be corrected by implementing the corrective action listedALL VIOLATIONS MUST BEAS SPECIFIED. CUPA must be informed in writing with acertification that compliance has beenthat compliance has been achieved is a violation of the law andpunishable by a fine of riot less than $2,000during normal business hours.$25,000 for each violation. Your facility may be reinspected any timeyou may request a meeting with the Program Manager to discuss the inspection findings and/or the proposed corrective actions.The issuance of this Summary of Violations does not preclude the CUPA from taking administrative, civil, or criminal action.y'aNUMBERVIOLATIONSMINOR MAJOR'2_CORR"ECTIVE ACTION REQUIRED#4-A false30COMMENTS:lnspected By:Date:Facility Rep Name:Signature:Signthe certification below and mail this form to the CUPA inspector after all corrective actions have beena copy for your records.Certification: I certify under penalty of perjury that this facility has complied with the corrective actions listed on thisinspection form.Signature of Owner/Operator:Title:Date:
Division of Environm' Lttealth(805) 781-5544P.O. Box 14892156 Sierra Way rSan Luis Obispo, CA 93406Department of Agriculture/MeasurementStandards (8os) 781-s9102156 Sierra Way Suite A rSan Luis Obispo' CA 93401.ity of San Luis ObisCERTIFIED UNIFIED PROGRAM AGENCY (CUPA)HMARDOUS MATERIALS INSPECTION FORMFire Department (805) 781-73802160 Santa Barbara AvenueSan Luis Obispo CA 93401-5240Utilities Department r (805) 781-7215879 Mono Street o San Luis Obispo, CA 93401IEFW dataentry by:Date:Time:it 1 7 1o-5J,5COMMENTS:!TNOKKtrtrKK!YESnTng!!EN/A!ITBPOlBPO2BPO3TROlTRO2EROlERO2BUSINESS PLANBusiness plan is complete, current, & available during inspection (HSC 25503.5' Title 19 CCR2729)Inventory of hazardous materials is complete (HSC 25504, Title 19 CCR2729)Site layouUfacility maps are accurate (HSC 25504, Title 19 CCR2729)TRAINING PLANFacility has appropriate training program (Title 19 CCR2732 & 22 CCR 66265.16)Training documentation is maintained on site for current personnel (Title 19 CCR2732 & 22ccR 66265.16)EMERGENCY RESPONSE PLANContingency plan is complete, updated, and maintained on site (HSC 25504' Title 19 CCR273t &22CCR $ 66265.53/54)Facility is operated and maintained to prevenUminimize/mitigate fire, explosion, or release ofhazardous waste to the environment. Maintains all required or appropriate equipmentincluding an alarm and communications system (Title 19 CCR 2731 &22 CCR66265.31'.43)PERMISSION TO INSPECT: Inspections may involve obtaining photographs, reviewing and copying records, and determining compliancewith adopted codes. GRANTED BY (NENONYESREINSPECTION REQUIRED:I usrn Hw Generatorn Business PlanE Tiered Permittingn EcrEl nw GeneratorX Business PlanPROGRAMS INSPECTED:! Tiered PermittingE ncrE usr5'/3-PHONE:qADDRESS:JOFACILITY NAMEsFACILITY ID NO:RoutineReinspectionn otn"tI ComplaintAGENCYffiEHn acDEPTn crrv rrnnn crrv UTTLITIESINSPECTOR:F'ACILITY REP:Repra 100"1 rcv.l0:\DOCUMFNT\,leifp\FQRM$\lnspection farms\CUPA inspeciion farms.doc 10-Sep-0 1
DATE:tLb{INSPECTORl"fttt^FACILITY NAME:EPA IDNUMBER:Tiered Permit:Treatment Equipment:LHAZARDOUS WASTE GENERATORO9aPBRTotal generated/month:Waste oil: SolventsAntifreeze: Others:Lbs or gals(average)WN/AEnKnTnYESEE!EBEKxnunnTnEu&6Entrnnn!n!ntrn!TnNO!TnvIoL. #GTOIGTO3GTO4GTO5GTO6GTOTGTOSGTO9GTIOGTl1GT12GTI3GTI4GTI5GTI6GTITGTISGT19GT2OGT2IEPA ID NO/PERMITSGenerator has an EPA ID number to treat, store, dispose, transport or transfer hazardous waste (Title22CCR66262.t2) If Not' Call (800) 618-6942HAZARDOUS WASTE DETERMINATIONHazardous waste determination conducted (Title 22 CCR 66262.11)flot"n knowledge lanalysis lotherHazardous waste analysis/test records are kept for at least 3 years (Title 22 CCR 66262.40.(c))DISPOSAL/TRANSPORTATIONHazardous wastes were transported and/or disposed toauthorization from DTSC ffiSC 25t89.5, Title 22 CCRfflnilLrun service Po.r#- Rrrn ,rn Ro"nothera facility with an EPA ID NO. and permit or66262.12)TtrtrEtraIxaTnTXreproHazardous wastes are shipped with manifest (T)tle22 CCR66262.20)Manifests and/or receipts are properly completed/retained by generator for 3 years (Title 22 CCR66263.421 66262.23)STORAGE AND MANAGEMENT OF CONTAINERS/TANKSHazardous wastes are accumulated on site as follows (Title 22 CCR 66262.34)! m aays if waste generated per month is greater than or equal to 100 kg (220 lbs.)@ ttO days ifwaste generated per month is less than 100 kg (see note)flZl0 days if waste generated per month is less than 100 kg and transported more than 200 miles (seenote)Note: Applies only if hazardous waste accumulated on site never exceeds 6000 kg(13200 lbs.)and noacutely/extremely hazardous waste over I kg (2.2|bs.) is held on site for over 90 days.Hazardous waste "satellite" collection is managed properly (complete labeling/accumulation time/55-galor l-qt limit) (Title 22 CCR6626234@\)Ignitable or reactive wastes are located 15 m (50 feet) from facility's property line (Title 22 CCR66265.176)Containers of hazardous waste are properly labeled (includes appropriate date, "HAZARDOUSWASTE," waste composition/physical state, hazardous properties, name/address of generator) (Title22ccR 66262.34)Containers/tanks containing hazardous wastes are in good condition/handled to minimize release orreaction (Title 22 CCR 66265.1711'l9l' 66265.177(c))Containers/tanks/liners are compatible with waste stored or transferred (Title 22 CCR 66265.172)Containers storing hazardous wastes are closed/sealed (Title 22 CCR 66265.173)Weekly inspection of areas where hazardous waste containers are stored is conducted(Title 22 CCR 66265. I 74)Daily inspection of all tank systems is conducted and documented (Title 22 CCR 66265.195)Empty containers or inner liners greater than 5 gal has date when emptied and are managed properlywithin one year of date emptied (Title 22 CCR 66261.7 (f))RECYCLABLE WASTEUsed oil is managed as hazardous waste until recycled (includes proper labeling, storage' etc) (HSC25250.A',)Used oil filters for recycling are managed properly (drained of free flowing liquid, stored in closedrainproofcontainer, labeled "drained used oil filters," and transferred for metal reclamation) (Title22ccR 66266.130)Spent lead-acid batteries are transferred offsite under manifest or bill oflading for recycling' reuse' orreclamation (Title 22 CCR 66266.8 I )Sotvents/other recyclable materials are managed as hazardous wastes until recycled (Title 22 CCR66266.3)I 183
Ear-SUMMARY OR OBSERVATIONSNIOLATIONSNo violations of underground tank, hazardous materials, inventory, and hazardous waste laws, regulations, and requirements werediscovered. SLO CUPA greatly appreciates your efforts to comply with all the laws and regulations appliceble to your facility.Violations were observed/discovered as listed below. All violations must be corrected by implementing the corrective action listed by eachviotation. If you disagree with any of the violations or proposed action, please inform us in writing.ALL VIOLATIONS MUST BE CORRECTED WTTHIN 30 DAYS OR AS SPECIFIED. CUPA must be informed in writing certifyingthat compliance has been achieved. A false statement that compliance has been achieved is e violation ofthe law and punishable by a fineof not less than $2,000 or more than $25,000 for each violation. Your facility may be reinspected any time during normal business hours.you may request a meeting with the Program Manager to discuss the inspection findings and/or proposed corrective actions. Theissuance of this Summary of Violations does not preclude CUPA from taking administrative, civil, or criminal action es e result of theviolations noted or that have not been corrected within the time specified.VIOLATIONSMINOR MAJORCORRECTIVE ACTION REQUIREIINUMBERbPor-asM-,TSzL--7-COMMENTS:Inspected By:Date:Facility Rep Name:/Signature:ropro ll27rev 1O:\DOCUMENT\Jeffp\FORMS\lnspection forrns\CUPA irrspection fortns.doc 10-Sep-01
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cwcr flnilndzrtlon witb tbe frcllit/s hrllrd conmunicetios progran and Erergecy Rerporrc llenlCoelingcney Plrn.
Srmmariu t1c taining for all enployees that worl with or come in conmct wi0r hoandous mqtdials/hsardous P"s!es. Desrribe how
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County of San Luis Obispo . Public Health Department
E nvironmental H e alth S ervic es
2I 56 Sierra Way . P.O. Box 1489
San Luis Obispo, Califurnia 93406
(805) 78r-s544 . FAX (805) 781-421 I
Gregory Thomas, M.D., M.P.H.
County Health Oficer
Public Health Director
VIA OVERNIGHT SERVICE, SIGNATURE REQUIRED Curtis A. Batson, R.Elt.S.,
Director5t24t2,g06
JORDAN, RANDY
KET{IS:BODY SHOP
A1ffi.hlORlZON LN #D
SAN,LUIS OBISPO, CA 93401
FAfr FAOOO72O2
FAGIU:IYADDRESS: 4130 HORIZON, SAN LUIS OBISPO
NOTICE OF VIOLATION
Our ,necsrds indicate that you have failed to correct the listed violations by the assigned
dearilline date. You must take appropriate action no later than 06/08/2006 to avoid further
enforcernent action. Enforcement action includes, but is not limited to, a chargeable
reingpection, administrative enforcement, and civil or criminal prosecution. Within 15 days of
the date.d this letter, initial each violation below that you have corrected, sign the statement
cer@ir.rg ,compliance, and return the signed copy to EHS with any required supporting
dos.rrnentation.
lf the listed violations have not been corrected, and you have not returned this form with any
reqr$r,ed supporting documentation by the deadline, you will be scheduled for an Otfice
Hearflng .at Environmental Health Services, 2156 Sierra Way, San Luis Obispo, CA on
nos_p at 1:30 PM to discuss required corrective actions, timetables for completion,
and potential penalties. lf you have corrected the listed violations and returned this letter,
please:catl me at (805) 781-5544 to cancel this hearing. lf you do not send in the certification
and you do not appear as scheduled, you may be assessed a fine or referred to the Office of
the District Attorney for prosecution.
Date of Violation: 1A9rc5 Violation Code: BP01 PE: 0726'. Original.Comply. By Date:: 1/9/06
Violation:Iext: BUSINESS PLAN WAS.NOT COMPLETE, CURRENI AND/ORAVAILABLE DURING'
INSPECTION
(HSC'25503.5, TITLE 19 CCR 2729),
Comments:.
ViOIAtiON GOTTECT|ON TEXt:: IMMEDIATELY TAKE NECESSARY ACTION TO ENSURE THAT TIM
BUSINESS.PLAN IS COMPLETE AND AVAILABLE ON SITE. IMPLEMENT A PROCEDURE TO ENSURE
T}IAT T.I{E PLAN IS UPDATED AS REQUIRED BY HEALTH AND SAFETY CODE SECTION 25503;5 AND
TITLE IS.CALIFORNIA CODE OF REGULATIONS SECTION 2729. FAILURE TO CORRECT THIS.
VIOI.AT{ON BY THE DATE SPECIFIED IN THIS'REPORT IVIAY RESULT IN CIVI AND/OR CRIMINAL
PENALTIES,OF UP TO $2,OOO PER DAY PERVIOI,ATION, AND/OR TT{E PENATTIES,DESCRIBED'IN TI{E
CA IIEi{t:r,H'& SAFETY CODE SECTION 25515'.
KEN'S BODY SHOP
NOTICE OF VIOLATION
FA#: FA0007202 5t24t2006
PAGE 2
Date of Violation: 1219105 Violation Code: BP02 PE: 0726 Original Comply By Date: 119106
Violation Text: INVENTORY OF HAZARDOUS MATERIALS WAS NOT COMPLETE (HSC 25s04,
TITLE t9 CCR2729)
Comments:
Violation CoTTection Text: IMMEDIATELY COMPLETE TIIE INVENTORY OF HAZARDOUS MATERIALS
AND IMPLEMENT A PROCEDURE TO ENSURE THAT THE INVENTORY OF HAZARDOUS MATERIALS IS
UPDATED (AS INVENTORY CHANGES) AS REQUIRED BY I{EALTH AND SAFETY CODE SECTION 25504
AND TITLE 19 CALIFORNIA CODE OF REGULATIONS SECTION 2729. FAILURE TO CORRECT THIS
VIOLATION BY THE DATE SPECIFIED IN THIS REPORT MAY RESULT IN CIVI AND/OR CRIMINAL
PENALTIES OF UP TO $2,OOO PER DAY PER VIOLATION, AND/OR THE PENALTIES DESCRIBED IN THE
CA HEALTH & SAFETY CODE SECTION 25515.
Date of Violation: 1219105 Violation Code: BP03 PE: 0726 Original Gomply By Date: 119106
Violation Text: SITE LAYOUTiFACILITY MAPS ARE NOT ACCURATE
2729)
(HSC 25504, TITLE 19 CCR
Gomments:
Violation Correction Text: IMMEDIATELY PREPARE SITE LAYOUT/FACILITY MAPS ACCORDING TO
IIEALTH AND SAFETY CODE SECTION 25504 AND TITLE 19 CALIFORNIA CODE OF REGULATIONS
SECTION 2729 OR CORRECT THE SITE LAYOUT/FACILITY MAPS FOR ACCURACY. FAILURE TO
CORRECT THIS VIOLATION BY TI{E DATE SPECIFIED IN THIS REPORT MAY RESULT IN CIVIL
AND/OR CRIMINAL PENALTIES OF UP TO $2,OOO PERDAY PERVIOLATION, AND/ORTHE PENALTIES
DESCRIBED IN THE CA HEALTH & SAFETY CODE SECTION 25515.
Date of Violation:1219105 Violation Code: ER01 PE: 0726 OriginalComply By Date: 119106
Violation Text: CONTINGENCY PLAN IS NOT COMPLETE, KEPT UPDATED, OR MAINTAINED ON
SITE (HSC 25504, TITLE 19 CCR 273t,TlTLE 22 CCR6625.53154)
Comments:
Violation Correction Text: IMMEDIATELY COMPLETE, UPDATE AND MAINTAIN CONTINGENCY
PLAN ON SITE. IMPLEMENT A PROCEDURE TO ENSURE THAT TIIE CONTINGENCY PLAN IS KEPT
CURRENT AND ON SITE. FAILIIRE TO CORRECT THIS VIOLATION BY THE DATE SPECIFIED IN THIS
REPORT MAY RESULT IN CIVIL ANDiOR CRIMINAL PENALTIES OF UP TO $2,OOO PERDAY PER
VIOLATION, AND/ORTIIE PENALTIES DESCRIBED IN TIIE CA.IIEALTH & SAFETY CODE SECTION.
25515..
KEN'S BODY SHOP
NOTICE OF VIOLATION
FA#: FA0007202
Date of Violation: 1219105 Violation Code: TR01 PE: 0726 Original Comply By Date: 1/9/06
Viofation Text: FACILITY LACKS APPROPRIATE TRAINING PROGRAM (TITLE 19 CCR 2732,TITLE
22 CCR 66265.16)
Comments:
VioIAtiOn COTTection Text: IMMEDIATELY DEVELOP AN APPROPRI.ATE TRAiNING PROGRAM AND
IMPLEMENT A PROCEDURE TO ENSURE THAT TI{E TRAINING PROGRAM IS UPDATED TO INCLUDE
ANY CHANGES IN OPERATIONS. FAILURE TO CORRECT THIS VIOLATION BY THE DATE SPECIFIED
IN THIS REPORT MAY RESULT IN CIVL AND/OR CRIMINAL PENALTIES OF UP TO $2,OOO PER DAY
PER VIOLATION, AND/OR THE PENALTIES DESCRIBED IN THE CA HEALTH & SAFETY CODE SECTION
25515.
Date of Violation:1/18/06 Violation Code: BP01 PE: 0726 OriginalGomply By Date: 1120106
Violation Text: BUSINESS PLAN WAS NOT COMPLETE, CURRENT AND/OR AVAILABLE DURING
INSPECTION
(HSC 25503.5, TITLE 19 CCR2729)
Comments:
Violation CoTTection Text: IMMEDIATELY TAKE NECESSARY ACTION TO ENSURE THAT TItr
BUSINESS PLAN IS COMPLETE AND AVAILABLE ON SITE. IMPLEMENT A PROCEDURE TO ENSURE
THAT THE PLAN IS UPDATED AS REQUIRED BY FIEALTH AND SAFETY CODE SECTION 25503.5 AND
TITLE 19 CALIFORNIA CODE OF REGULATIONS SECTION2729, FAILURE TO CORRECT THIS
VIOLATION BY THE DATE SPECIFIED IN THIS REPORT MAY RESULT IN CIVL ANDiOR CRIMINAL
PENALTIES OF UP TO $2,OOO PER DAY PER VIOLATION, AND/OR THE PENALTIES DESCRIBED IN THE
CA HEALTH & SAFETY CODE SECTION 25515.
Date of Violation: 1118106 Violation Code: BP02 PE: 0726 Original Comply By Date: 1120106
Violation Text: INVENTORY OF HAZARDOUS MATERTALS WAS NOT COMPLETE (HSC 25504,
TrTLE t9 CCR2729)
Gomments:
Violation CoTTection Text: IMMEDIATELY COMPLETE TI{E INVENTORY OF HAZARDOUS MATERTALS
AND IMPLEMENT A PROCEDURE TO ENSURE THAT TI{E INVENTORY OF HAZARDOUS MATERIALS IS
UPDATED (AS INVENTORY CHANGES) AS REQUIRED BY HEALTH AND SAFETY CODE SECTION 25504
AND TITLE 19 CALIFORNIA CODE OF REGULATIONS SECTION 2729. FAII-URE TO CORRECT THIS
VIOLATION BY T}IE DATE SPECIFiED IN THIS REPORT MAY RESUTT IN CIVL AND/OR CRIMINAL
PENALTIES OF UP TO $2,OOO PER.DAY PERVIOLATION, AND/ORTHE PENALTIES,DESCRIBED IN T}IE
CA IIEALTH & SAFETY CODE SECTION 25575,
5t24t2006
PAGE 3
KEN'S BODY SHOP
NOTICE OF VIOLATION
FA#: FA0007202
Date of Violation: 1118106 Violation Code: TR02 PE: 0726 Original Comply By Date: 1120106
Violation Text: TRAINING DOCIIMENTATION FOR CURRENT PERSONNEL IS NOT MAINTAINED ON
srTE. (TITLE 19 CCR 2732,TLTLE22CCR66265.16)
Comments:
Violation Correction Text: IMMEDIATELY PREPARE TRAINING DOCUMENTS ACCORDING TO TITLE
19 CALIFORNIA CODE OF REGULATIONS SECTION 2732 AND TITLE 22 CALIFORNIA CODE OF
REGULATIONS SECTION 66265.16 AND LOCATE TRAINING DOCUMENTATION ON SITE. FAILURE TO
CORRECT THIS VIOLATION BY TIIE DATE SPECIFIED IN THIS REPORT MAY RESULT IN CIVIL
AND/OR CRIMINAL PENALTIES OF UP TO $2,OOO PER DAY PER VIOLATION, AND/OR THE PENALTIES
DESCRIBED IN THE CA FIEALTH & SAFETY CODE SECTION 25515.
Date of Violation: 1118106 Violation Code: BP03 PE: 0726 Original Comply By Date: 1120106
Violation Text: SITE LAYOUT/TACILITY MAPS ARE NOT ACCURATE
272e)
(HSC 25504, TITLE 19 CCR
Comments:
Violation Correction Text: IMMEDIATELY PREPARE SITE LAYOUT/FACILITY MAPS ACCORDING TO
HEALTH AND SAFETY CODE SECTION 25504 AND TITLE 19 CALIFORNIA CODE OF REGULATIONS
SECTION 2729 OR CORRECT THE SITE LAYOUT/FACILITY MAPS FOR ACCURACY. FAILURE TO
CORRECT THIS VIOLATION BY THE DATE SPECIFIED IN THIS REPORT MAY RESULT IN CIVIL
AND/OR CRIMINAL PENALTIES OF UP TO $2,OOO PER DAY PER VIOLATION, AND/OR THE PENALTIES
DESCRIBED IN TI.{E CA I{EALTH & SAFETY CODE SECTION 25515.
Date of Violation: 1118106 Violation Gode: ER01 PE= 0726 Original Comply By Date: 1120106
Violation Text: CONTINGENCY PLAN IS NOT COMPLETE, KEPT UPDATED, OR MAINTAINED ON
SITE (HSC 25504, TITLE 19 CCR 273t,TtrLE 22 CCR 6625.53/54)
Gomments:
Violation Correction Text: IMMEDLATELY COMPLETE, UPDATE AND MAINTAIN CONTINGENCY
PLAN ON SITE. IMPLEMENT A PROCEDURE TO ENSURE THAT THE CONTINGENCY PLAN IS KEPT
CURRENT AND ON SITE. FAILURE TO CORRECT THIS VIOLATION BY THE DATE SPECIFIED IN THIS
REPORT MAY RESULT IN CIVI AND/OR CRIMINAL PENALTIES OF UP TO $2,OOO PER DAY PER
VIOLATION, AND/OR THE PENALTIES DESCRIBED IN THE CA IMALTH & SAFETY CODE SECTION
25515.
Date of'Violation:1'118106 Violation Code: TR01 PE: 0726 Original'Comply By Date:' 1/20i06
Violation Text: FACILITY L,ACKS APPROPRTATE TRAINING PROGRAM
22 CCR6626s.r6)
(TTTLE 19 CCR2732, TITLE
Comments:.
Violation Correction Text: IMMEDIATELY DEVELOP AN APPROPRIATE TRAINING PROGRAM AND
IMPLEMENT A PROCEDURE TO ENSURE THAT TI{E TRAINING PROGRAM IS UPDATED TO iNCLUDE
ANY CHANGES IN OPERATIONS. FAILURE TO CORRECT THIS VIOLATION BY THE DATE SPECIFIED
IN THIS REPORT MAY RESULT IN CIVL AND/OR CRIMINAL PENALTIES OF UP TO $2,OOO PER DAY
PER VIOLATION, AND/OR TI{E PENALTIES DESCRIBED IN TI{E CA HEALTH & SAFETY CODE SECTION
25s15.
5124t2006
PAGE 4
KEN'S BODY SHOP
NOTICE OF VIOLATION
FA#: FA0007202
lf you have questions regarding this notice, please contact me at (805) 781-5544.
AARON LA BARRE
Environmental Health Specialist
Program: HAZARDoUS MATERIALS HANDLER l-4
I hereby certify, under penalty of law, that the initialed violations, listed above, have been corrected. I
understand that a chargeable reinspection may be conducted to verify compliance.
Signature Title Date
5t2412006
PAGE 5
Report 9600
FdASTER Fit-E r{ECgRD (MFH) INPUTru.DDATE FORM
ii
i1
I]
I1
T1
T1
ii
i1
ii
iI
ii
T]
iI
CHEATE Ngl/ MFR RECORD !App. aracned)
CHANGE CURHENT MFR RECORD
RELEASFFLAN CK TO PBlldlT (App aactecl
CIiANGE OF OWNE"ESHIP tApp. aaaci:ec')
II.IACTIVATE MFR
CLOSE {DELETE MFR .
COMP. # a7oL t,//f /
FRoGRAutt * /ttSo/'' gi-gfl ;!7z4uzS
SUP. DIST. +'
ASSIGN FEE CODE + _
cH.qNGE Ei-Blt # _
CH.ANGE R1SK CATEGORYJB EI,ITEREN
CT|ANGE CUBRENT MFT1 IIUFORIIIIATION TO:
(4
0a't<,rl ''luA A../FIAZARDOUS UL{TERIALS SPECIFIC:
Number of Materials I
Number of Wa^ste Su'eams /
Number of Tanks
LABB-$ro, [. ]-New
Color Code
[ 1 Corrected
Comp. #
Site Aditress:
'Site Nam*,
(
6 4'*
q,/., 1)
Reviewed by trniuatt:
Supe:rvisor ' I I
Requested by:
DatE:
Inprrf Eflcred br
Data: "/z-2/- 0f
3"e3*Copy ic:
-1?CCCff!C:-;'.C:,161iCln\ti6EQCi.,ii=rE;-r"FCF3iSi€1E=:'iiF=ni-lC€ ?-lc;='€
December 22,2003
Countl -rf San Luis Obispo . Pur rc Health Department
Env ironmental H e alth S erv i c e s
2156 Sietra WoY ' PO. Box 1489
San Luis Obispo, California 93406
(805) 781-5544 . FAX (805) 781-4211
Gre gory Thomas, M.D., M.PH.
County Health OfJicer
Public Health Director
Curtis A. Batson, R.E.H.S.
Director
Ken's Body Shop
Vince Pellegrini
4l3}Hoizon Lane
San Luis Obispo, CA 93401
NOTICE OF VIOLATION
Re: Hazardous Materials Business Plan
Califomia Health and Safety Code $25503.5 requires facilities handling hazardous materials at
or above the reportable quantities of 55 gallons of a liquid, 500 pounds of a solid, 200 cubic feet
of a compressed gas, or any amount of hazardous waste, to submit a Business Plan and Inventory
Forms to this offlrce. Hazardous materials include, but are not limited to, gasoline, diesel,
propane, compressed gasses, etc. Hazardous wastes include, but are not limited to, waste oil,
antifreeze, solvents, paint, etc.
I conducted an inspection of your facility on Novemb er 7,2003,at which time you were
instructed to prepare and provide a business plan to this office. As of this date, our office has not
received your Business Plan or Inventory Forms. Pursuant to HSC $25514 (a), any business
which fails to provide the required Business Plan and lnventory Forms is civilly liable for as
much as two thousand dollars ($2,000) for each day of the violation.
This office must receive the enclosed Business Plan and Inventory Forms within the next thirty
days or an administrative enforcement order may be issued to your facility which will impose the
above referenced civil penalties of as much as two thousand dollars ($2,000) for each day of the
violation.
If you have questions, please contact me at (805) 781-5557.
Sincerely,
Arf?,rL
Scott Milner
Environmental Health Specialist III
Hazardous Materials Section