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HomeMy WebLinkAboutFIRE_HAZARDOUS_MATERIALSNEWPORT BEACH FIRE DEPARTMENT Life Safety Services Division (949) 644-3106 100 Civic Center Drive - P.O. Box 1768 Newport Beach, CA 92660-8915 HAZARDOUS MATERIALS BUSINESS EMERGENCY PLAN FIELD INSPECTION NOTICE OCCUPANT ID NO. INSPECTION DATE Inspector Steve Michael (949) 644-3108 G2 5 2 's Inspector Raymi Wun (949) 644-3110 BUSINESS NAME PHONE NO. 0o N or� Gca'A Z�-h JOSco BUSINESS ADDRESS (Newport Beach) 1525 Sv MAILING ADDRESS (Iff different from BusyAddress) CITY ZIP OWNER/MANAGER NAME (Print) ❑ Hazardous Materials Business Emergency Plan Meets The Requirements 0-'Hazardous Materials Business Emergency Plan Implementation (1ol000l) ❑ Hazardous Materials Business Emergency Plan Submittal (1o10002) ❑ Business Activities Page and/or Business Owner/Operator Identification Page (101003) ❑ Hazardous Material Inventory Forms (101004) ❑ Annotated Site Map (1010005) ❑ Hazardous Materials Inventory Forms Update (1ol0006) ❑ Business Plan Deficiencies (1010007) ❑ Hazardous Materials Inventory Re -Certification or Re -Submittal (1010008) ❑ Triennial Hazardous Materials Business Plan Review and Re -Certification (1o10009) ❑ Emergency Response Plan and Procedures Not Included or Not Adequate (1o10olo) ❑ Property Owner Notification (1oloo11) ❑ Property Owner Business Plan (1010012) ❑ Training Program Not Included or Is Not Adequate (1020001) ❑ Training Program Not Implemented (1020002) ❑ Release Reporting (1040001) Comments: ')�r% 50 C- T- of 02 Vl�'dl -f� t✓1 Sib Original White - Life Safety Services Division Yellow - OwnerfTenant Revised: April 2015 NEWPORT BEACH FIRE DEPARTMENT 100 Civic Center Drive P.O. Box 1768, Newport Beach, CA 92660-8915 Life Safety Services Division (949) 644-3106 i INSPECTION DA E 8 INSPECTOR NAME S G G c`G a eL BUSINESS! NAME /[J ,CL Clr oe) / l�cJ ov C PHONE NO BUSINESS ADDRESS j (� -700 ask CITY ZIP MAILING ADDRESS (If different) CITY ZIP OWNER/MANAGER (Print) TITLE' C>311� -. is Nexlth &.Safety: bde l�iv: 20`:r� at Ee� 6;$S-Aiftcl i SectiOtis 55�0=255 4T& Galifginia iC ide f [�egul tic!ns7ttle l9 #}(v..:A #icte �oii,272 ,: Hazardous materials Business Emergency Plan is correct and up to date. ❑ Hazardous materials Business Emergency Plan not available onsite for review. ❑ Business owner/operator page is missing, incomplete, or requires updating. ❑ Hazardous material chemical page(s) not available on site for review. ❑ Hazardous material chemical page(s) require updating or new chemical(s) onsite require=disclosure. ❑ Emergency plan is missing, incomplete, or requires updating. ❑ Facility map(s) is missing or requires updating. Other — explain: ❑ Failure to report a release or threatened release. The above marked item(s) is in violation of California law and requires immediate correction. Failure to correct the violation(s) will result in civil penalties and prosecution. Contact the _Life Safety Services Division regarding completing the necessary correction(s). I declare that l have examined and received a copy of this Field Inspection Notice. Date: Original White — Life Safety Services Division Yellow — Owner/Tenant Revised: 04-18.13 NEWPORT BEACH FIRE DEPARTMENT 100 Civic Center Drive P.O. Box 1768, Newport Beach, CA 92660-8915 Life Safety Services Division (949) 644-3106 FIELD INSPE ON NOTICE ICTION ATE 701 INSP CT R NAME /0"C �ae �— I q zfe BUdINESS AME / f PHONE NO pw v� a-0Cr BUSINESS AD RESS V ;III q ( .ew o- W /- A- CITY ZIP MAILING ADDRESS (If differe t) CITY ZIP OWNER/MANAGER (t) TITLE MaAa VfVd%�,�rI v CaIlnfo al#ii safety God+a Yv„ p=;Ctra�►ier:6:95 i riial :lvSeatlaiis -Noe., ; 2 5 t! ii ' Iola,Code.�f it ub ►�s�;i�e �9-:Ul�rr,2 Ark cae :S an: Ld Hazardous materials Business Emergency Plan is correct and up to date. ❑ Hazardous materials Business 'Emergency Pla`ri` riot available onsite'fior review. ❑ Business owner/operator page is missing, incomplete, or requires updating. ❑ Hazardous material chemical page(s) not available on site for review. ❑ Hazardous material chemical page(s) require updating or new chemical(s) onsite require disclosure. ❑ Emergency plan is missing, incomplete, or requires updating. ❑ Facility map(s) is missing or requires updating. Other — explain: Original White — Life Safety Services Division Yellow— Ownerf tenant Revised: 04.18.13 NEWPORT BEACH FIRE DEPARTMENT 100 Civic Center Drive P.O. Box 1768, Newport Beach, CA 92660-8915 Life Safety Services Division (949) 644-3106 FIELD INSPECTION NOOK INSPECTION ATE S a 6 15 INSPECTOR NAME Seve- ftchaeL BUS174ESS NAME o Wt L 16irAeK PHONE NO 171/7- G BUSINESS A DRESS Z5oo SQL 7 v;� �,CLS f2�• CITY o�� a�G, ZIP MAILING ADDRESS (If differ t) CITY ZIP OWNERIMANAGER (Print) TITLE Cati%riii` " ° at)i &Safi' Gole:Cbaer:9 liticfe`1"sciionsif5liiii,25q.:aiifrffia,oe af."iejuans`1iUe'1"-piv� 2-i�iiticie°?t:eeiotiair7 ❑ Hazardous materials Business Emergency Plan is 66rrect grid up to Mate. ❑ Hazardous materials Business Emergency`Plari"not available onsite for review: ❑ Business owner/operator page is missing, incomplete, or requires updating. ❑ Hazardous material chemical page(s) not available on site for review. XHazardous material chemical page(s) require updating or new chemical(s) onsite require disclosure. ❑ Emergency plan is missing, incomplete, or requires updating. ❑ Facility map(s) i missing or requires updating. n�J Other —explain: w 6% w tL anda-s a �'ee 2e D✓t iJ�S� S Ewr ej PLa1 AZp ❑ Failure to report a release or th The above marked item(s) is in violation of California law and.requires immediate correction. Failure to correct the violation(s) will result in civil penalties and prosecution. Contact the Life Safety Services Division regarding completing the necessary correction(s). I declare that I have examined and received a copy of this Field Inspection Notice. Original White — Life Safety Services Division Yellow— Owner[Tenant Revised: 0448.13 NEWPORT BEACH FIRE DEPARTMENT Life Safety Services Division (949) 644-3106 100 Civic Center Drive - P.O. Box 1768 Newport Beach, CA 92660-8915 HAZARDOUS MATERIALS BUSINESS EMERGENCY PLAN FIELD INSPECTION NOTICE OCCUPANT ID NO. INSPECTION DATE Ej Inspector Steve Michael (949) 644-3108 I Inspector Raymi Wun (949) 644-3110 BUSINESS NAME PHONE NO. rVlc'-/r C Cy -!1 q--70 6 - G30v ov� r J CA BUSINESS ADDRESS (Newport Beach) Coy L/ 2A k-1-- 12d MAILING ADDRESS (If ifferent from usiness Address) CITY, ZIP 1V OWNPMA AGER NAME (Print) �/ et, (✓I A Noi U Hazardous Materials Business Emergency Plan Meets The Requirements ❑ Hazardous Materials Business Emergency Plan Implementation (1ol000l) ❑ Hazardous Materials Business Emergency Plan Submittal (1010002) ❑ Business Activities Page and/or Business Owner/Operator Identification Page (101003) ❑ Hazardous Material Inventory Forms (101004) ❑ Annotated Site Map (1010005) ❑ Hazardous Materials Inventory Forms Update (1oloow) ❑ Business Plan Deficiencies (1010007) ❑ Hazardous Materials Inventory Re -Certification or Re -Submittal (1010008) ❑ Triennial Hazardous Materials Business Plan Review and Re -Certification (1omoos) ❑ Emergency Response Plan and Procedures Not Included or Not Adequate (1oloolo) ❑ Property Owner Notification (1oloo11) ❑ Property Owner Business Plan (1010012) ❑ Training Program Not Included or Is Not Adequate (1020001) ❑ Training Program Not Implemented (1020002) ❑ Release Reporting (1040001) Comments: Original White - Life Safety Services Division Yellow - Owner/Tenant Revised: April 2015 �e0RT e� PROPERTY RELE ►E AFTER EMERGENCY I N 1(0o 3:7--73 For the safety and welfare of the community, the Newport Beach Fire Department assumed control of the property at The necessity for assuming control of the property ias because of Pursuant to this document, as of (Time) � (Date) subject property is to be under the ontrol and responsibility of the property owner and/or a responsible representative of the owner. Listed below are some of the recommendations and precautions to alert you to the steps necessary to provide a reasonable degree of fire and/or life safety: 1-. A rekindle or second fire from a hot spot is possible. A fire watch should be posted with a means to extinguish hot spots for at least 24 hours. /2/ This str ure may have been weakened by the incident. Until a structural 7a�ry rcan be made, it is advisable to keep all unnecessary people out of and romthe building. So or all of the utilities may have been shut off. It is advisable to contact the propriate utility company before turning the service on. uild ing and/or repairing the damage will require a permit from the City yuilding Department. Xt may be necessary to provide a security guard, barricades, fences or other means of boarding up to keep people out of the involved property: ,P/"Remove and/or provide security of valuables from theft and vandalism. Provide protection of further damage from the weather. 8. Other precautions (describe). -ko j-rio, elS� This list is not necessarily all inclusi e. It is intended as a guidelin pursuant to the fire depart Ue ercise of di cretin _'n providing emergency assistance advice. Signe Date: - (- Time: Owner/Owner's Repr0�1: e Signed: Date: Fire Officer in harge White-M Owner/Tenant-Yellow NEWPORT BEACH FIRE DEPARTMENT FIRE PREVENTION DIVISION P.O. Box 1768, Newport Beach, CA 92658-8915 (949) 644-3106 ........................................................................................................................................ Notice of Referral to the Fire Prevention Division ...................................................................................................................................... Date A member of the Newport Beach Fire Department conducted a fire and life safety inspection at the following location/business on i 1 t i Business Name: qF�A�ZTp�l�J Business Address: I S 42 t-t(ot_�"lJi A fV At that time, a violation notice was issued indicating the corrections required to gain compliance with the applicable codes, regulations, and ordinances pursuant to the 1998 California Fire Code, Section 103.2.1. A second inspection was conducted on IN b 1 (. in an attempt to verify compliance with the written Notice of Reinspection and Non -Compliance. During this inspection, it was found that some or all of the violations had not been corrected. This notice is to inform you that your business is being referred to a member of the Newport Beach Fire Department's Fire Prevention Division. They will perform a reinspection of the above business at the prevailing fee schedule set forth by City Council. If the necessary corrections have not been completed, the Fire Prevention Division will deliver to you a Final Notice and Notice of Intent to Prosecute. Your prompt attention in this matter is appreciated. Responsible Party: G F o (LG F N1 ' two S r--_Y Inspector's Name: T`.�1-U O� Phone Number: 01q q (aq�j 3 _;�67 -,7— Left with Responsible Party ❑ Fax Number Original - Owner/Responsible Party Yellow - Fire Company/FPD NEWPORT BEACH FIRE DEPARTMENT FIRE PREVENTION DIVISION P.O. Box 1768, Newport Beach, CA 92658-8915 (949) 644-3106 Notice of Reinspection and Non -Compliance Date 01 A member of the Newport Beach Fire Department conducted a fire and life safety inspection at the following location/business on 1 Business Name: O Eu.( P oczT A v_= 2 o aA J T t c_,* C_ Sri L-f-:-S Business Address: 1 S+Z 1`<1(9r4IzoV1 A A JE- At that time, a violation notice was issued indicating the corrections required to gain compliance with the applicable codes, regulations, and ordinances pursuant to the 1998 California Fire Code, Section 103.2.1. This notice is to inform you that your business is entitled to one more fire company reinspection, which will occur on or after k 1i ed I (© . If all violations are not corrected at that time, your business will be referred to the Fire Prevention Division. The Fire Prevention Division will perform a subsequent reinspection of your business at the prevailing fee schedule set forth by City Council. Your prompt attention in this matter is appreciated. Responsible Party: � � o�� M . IoSE Inspector's Name: �`� Lum Or_- Phone Number: 9 4ef - (44 — ?�-22 ❑ Left with Responsible Party C,a�� V--- M A i (_. Original - Owner/Responsible Party Yellow-- Fire Company/FPD NEWPORT BEACH FIRE DEPARTMENT 100 Civic Center Drive P.O. Box 1769, Newport Beach, CA 92660-8915 Office (949) 644-3106 — Fax (949) 644-3120 VIOLATION NOTICE Inspector Name: Captain Ty Lunde Unit: NT62 Inspection Date:11 /11 /2015 Business/Building Name: Newport Aeronautical Sales Business Address:1542 Monrovia Avenue, Newport Beach, CA 92663 Business Phone: 949-574-4100 Business Email: george@newportaero.com Violation Codes See Reverse Side for Violation Code Descriptions Date Cleared (office use only) BH Provide annual fire alarm inspection, testing, and maintenance report. AC Service and tag each extinguisher annually. SELF -CLEARING: only a fire extinguisher violation may be self -cleared. If one was noted above, it may be self - cleared by certifying below that it has been serviced or replaced and tagged appropriately. Please return this notice to the above address within 14 days of the Inspection Date. I hereby certify that the fire extinguisher violation has been corrected on (Date) Print Name: Signature: ORDER TO COMPLY: You are hereby required to correct the above condition(s) immediately upon receipt. Non- compliance with the foregoing order before the date of re -inspection may render you liable to the penalties provided by law for such violation(s). A re -inspection date is noted on the bottom of this notice. George M. Posey Via Email Print - Responsible Party george@newportaero.com Email Signature — Responsible Party 01 /04/15 Re -inspection Date Revised: 10-15-14 INSPECTION AND TESTING. FORM Date: 391f � SERVICE ORGAr1T17,,� oc SSi,� S Name: r Address: '''�_�•� a Representative: ,c J i of to t License No.: �h Telephone:"to v - 3`� (. q 3 MONITORING ENTITY Contact: Telephone: Monitoring Account Ref. No.: TYPE TRANSMISSION ❑ McCulloh ❑ Multiplex ❑ Digital ❑ Reverse Priority ❑ RF ❑ Other (Specify) Control Unit Manufacturer: Time„ A) PROPERTY NAME (USER) Name: Prod"Ctioy ft etc, �QrT►7trs Address;l$`) mohrvvtA It•e Owner Contact: 7 ac. 6 Fe L Ai jt S Telephone: I I - q 3 3" 13oa APPROVINGAGENCY Contact: 5 1 e ve Pk,*c 6. C N 0 F D Telephone: q� �� q- 310 V SERVICE ❑ Weekly 1] Monthly Q Quarterly ❑ Semiannually 2aAnnually • Ofhei (Specify) Model No.: Circuit Styles: Number of 'Circuits: Software Rev.: Last Date System Had Any Service Performed: Last Date That Any Software or Configuration Was Revised'. ALARM -INITIATING DEVICES AND CIRCUIT INFORMATION Quantity of Quantity of Devices Installed Circuit Style, Devices Tested ManuatFire Alarm Boxes Ion Detectors Photo Detectors Duct Dete'cttirs Heat Detectors j� Waterflow'Switches ✓ Supelvlsory Switches Other (Specify)-, Alarm verification feature is i0sabled ❑ enabled isll -1A 72, >"r�ure 10,6.2 3 (p. i Copyright ©2009 National Fire Protedtion Association This fonn may be cbpied for individual use other than for resele..lhmay riot be.copiedrfor commercial sale or distr (b)'Secondary (Standby): f g Stora a Battery: Am -Hr Rating Y P Amp-Hrs to operate for Jiours Calculated capacity in+1 Engine -driven generator dedicated to.fire alarm system: Location of fuel storage: TYPE BATTERY ❑ Dry Cell ❑ Lead -Acid ❑ Nickel -Cadmium ❑ Other (Specify): oJft,Sealed Lead Acid (c) Emergency or standby system used as a backup'to primary power supply, instead of using.a. secondary power supply, Emergency system described in NFPA 70", Article 700 Legally required standby described in NFPA 70, Article 701 Optional standby system described in NFPA 701, Article 702, which also meets; the performance requirements of Article 700 or 701 PRIOR TO ANY TESTING NOTIFICATIONS ARE MADE Yes No Who Monitoring Entity `' ❑ Building Occupants ❑ Building Management 6T, ❑ Other (Specify) ❑ ❑ ABJ Notified of Any Impairments ❑ ❑ SYSTEM TESTS AND INSPECTIONS TYPE Visual Functional Comments Control Unit Interface Equipment Lamps/LEDs 471 '❑ Fuses ❑ Primary Power Supply Trouble Signals Disconnect Switches ❑ ❑ Ground -Fault Monitoring ❑ ❑ fTime; to Vv-,\� N,';PA 72, Figure 10-6-2.3 (p. 3 Of 6) Copyright © 2009 National Fire Protection Association. This form maybe copied for individual use other than for resale. It may not:be copied fdr."coininercial'sale at distribution. ALARM NOTIFICATION APPLIANCES AND CIRCUIT IN' QRMATION Quantity of Quantity of Appliances Installed Circuit Style Appliances Tested l ( 1 Bells Horns Chimes Strobes Speakers Other'(Specif'y): No, of alarm notification appliance circuits: Are circuits monitored for integrity? �es El No SUPERVISORY SIGNAL -INITIATING DEVICES AND CIRCUIT INPORMATION Quantity of Quantity of Devices Installed Circuit Style Devices Tested BuildingTemp. Site Water Temp. Site Water Level Fire Pump Power Fire Pump, Running Fire Pump Auto Position Fire Pump .bf Pump Controller Trouble Fire Pump Running 0eneraior inAuto Position Generator or ControilerTiouble Syvitch Transfer Generator Engine Running. Other (Specify: SIGNALING LINE CIRCUITS Quantity and style of signaling line circuits connected to system (see NFPA '72", Table 6.6.1): Quantity I Style(s) SYSTEM POWER SUPPLIES (a) Primary (Main): Nominal Voltage ( -7`0j � ( j AC, Amps 1f Overcurrent Protection: Type !� Amps Location (of Primary Supply Panelboard): Disconnecting Means Location: �l i PP.A ! 2, ,F£Cgtlf*; 10.6.2.3 Ip, t t , G) Copyright ©2009 National Fire Protection Association. This form maybe copied'for individual use otherthan for resale. It moy "not be copied for.cbmmereialsale of distritigtiori. SECONDARY POWER TYPE Visual Functional Battery Condition wzff Load Voltage` Discharge Test Charger Test Specific Gravity ❑ TRANSIENT SUPPRESSORS ❑ .REMOTE ANNUNCIATORS ❑ ❑ NOTIFICATION APPLIANCES Comments Audible ❑ Visible ❑ ❑ Speakers ❑ ❑ Voice Clarity ❑ Loc. & SIN Comments: INITIATING AND SUPERVISORY DEVICE TESTS AND INSPECTIONS Device Visual Functional Measured Type Check Test Factory Setting Setting ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ EMERGENCY COMMUNICATIONS EQUIPMENT Visual Functional Phone SetLP Phone Jacks —A "F Off-FIook Indicator °T- Amplifiers) ❑ ❑ Tone Generator(s) ❑ ❑ Call -in Signal[ System Performance 1VFF1, 72", Flt-' Frt� 70,6.2.3 (p, 4 of 6} Copyright © 2009 National Fire Protection Association, This form may be copied for individual use,other than for resale. It may,'not be copied for eommercial.sele,or distribu[ibn. COMBINATION SYSTEMS Fire Extinguisher Monitoringbevice/System Carbon Monoxide Detector/System (Specify) INTERFACE EQUIPMENT (Specify) (Specify) (Specify) SPECIAL HAZARD SYSTEMS (Specify) (Specify) (Specify) Special Procedures: Comments: SUPERVISING STATION MONITORING Alarm Signal Alarm Restoration Trouble Signal Trouble Signal Restoration Supervisory Signal Supervisory Restoration NOTIFICATIONS THAT TESTING IS COMPLETE Building Management Monitoring Agency Building Occupants Other (Specify) The following did not operate correctly: System restored to normal operation: �-O Visual bdvice,Uper'ation ,Simulated Operation ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0 ❑ ❑ ❑ ❑ Yes No 1 ❑ Yes No Time Who Comments Time Date: lf� 'Time:, AIFPA 72, Figure I t . -23 (p� 6 of 6) Copyngbt 92009 National Fire Protection Association. This form maybe copied far individual use other than for resale. It may nol be copied fbrcommeroiai ssleror distribution. 'THIS TESTING WAS PERFORMED IN ACCORDANCE WITH APPLICABLE NFPA STANDARDS Naive bf inspectori . Signature: Name of Owner or Representative: Signature: Date! Time: , FP,,, r2, Figure 'IO' 231(0. 0 of ) Copyright 02009 National Fire Protection Association. This form maybe copied for individual use otherthan'for resale..lt mad not be copied.for commercial sale or distribution. 'BOYD& ASSOCIATES Meant ToW,Semlity FIRE ALARM INSPECTION &, TESTING ChOTIFICA TE I I A100':i25 bamtractort Lic. 7827-94- e s Name t - rccount Number , Water Flow % 1.0 K- Door Holders AJI Pull Stations A' Pre -Action r I I 1A 714 SbOdAsqq,Tarnoery y Operatln§'Voltage .4 f Smoke Detectors Stand -By Batteries "Vr Addib-le-Dbvi —§ Cgrnmunication fe- s f I Horh/,Sfr6beg' pee't.bf-NQfhbdr- oiea -comments-Reg-ar,0 ing.fire.AlarrTI:Sysien NIS- 47 T#ctj� nature I �(066 Canary_ §t r P! k AP Ala. 'MO �'Cdhtfa ti ivii6 if btjd CALIFORNIA DEPARTMENT OF FORESTRY AND FIRE PROTECTION FFICE OF THE STATE FIRE MARSHAL FIRE ENGINEERING r FIREWORKS PROGRAM P.O. Box 944246, Sacramento, California 94244-2460 I (916) 445-8373 Fax (916) 445-8458 PYROTECHNIC OPERATOR POST DISPLAY REPORT Pursuant to California Code of Regulations, Title 19, Section 1005(a) within ten (10) working days following any public display, the licensed pyrotechnic operator in charge of the display shall submit a complete, accurate and factual written report directly to the State Fire Marshal Failure to comply with these requirements may result in suspension or revocation of your license. j Mike Tockstein (310) 344-3432 , CSFM license number 2562-02 , Pyrotechnic Operator (Name and Phone Number) supervising the discharge of fireworks for this display, submit the following report per Title 19, Section 1005: 1. FIREWORKS COMPANY NAME AND PHONE NUMBER GPD# 672 Pyro Spectaculars, Inc. 909-355-8120 2. FIREWORKS COMPANY ADDRESS 3. CITY 3196 N. Locust Avenue Rialto, CA 4. DATE OF DISPLAY 5. TIME OF DISPLAY 1 %d- 2/20/2016 FROM & G 6 S may, to 6. EXACT LOCATION OF DISPLAY The Resort at Pelican Hill ; 22701 S. Pelican Hill Rd. ,Newport Coast Ica 7. DEFECTIVE SHELLS LIST MANUFACTURER'S NAME, SIZE OF SHELL, AND MALFUNCTION. (Refer to list below for definitions to be used.) 8. INJURY TO PERSON FROM FIREWORKS. PROVIDE INJURED PERSON's NAME AND ADDRESS Verbal notification is required within 24 hours to the State Fire Marshal in Injury or Death. ❑ Yes R No 9. VIOLATIONS OF HEALTH AND SAFETY CODE OR REGULATIONS RELATING TO PUBLIC DISPLAY OF FIREWORKS. ❑Yes RNo 10. FIRES CAUSED BY FIREWORKS. INCLUDE OWNER'S NAME, ADDRESS AND A BRIEF SUMMARY OF INCIDENT. Verbal notification is required within 24 hours to the State Fire Marshal if emergency action or response was required due to the fire. ❑ Yes RNo 11. RECOMMENDATIONS OR COMMENTS 12. LIST NAMES OF PYROTEECCHNIC ASSISTANTS AND STATE FIRE MARSHAL PYROTECHNIC LICENSE NUMBER IF APPLICABLE. A. T 1 pl� �/ ✓t �O C �/ S _ C1 B. "Q a vt Sec( C. ca. 01 D. / vC C <D G 7 E. F. 13. SIGNATURE OF PYROT H PERATOR IN CHARGE 14. DATE 2/20/16 Attfch additional phes if r�dceda'ry. "Defective Shell" definitions: TERM DEFINITION Detonation The entire shell and lifting charge explode at the bottom of the mortar. Detonation should not be confused with a "Flower Pot" or "Mine" for the following reasons: (1) There is no shower of stars and burning materials; (2) The entire shell and lifting charge are consumed in one instantaneous explosion. Dud A pyrotechnic item that leaves the mortar and returns to earth Without producing the intended burst or effect. Flower Pot A shell (not a lifting charge) that explodes at or near the bottom of a mortar blowing a shower of stars and burning materials into the air. Low Break The shell explodes below the prescribed height. Low Burst The shell explodes below the prescribed height. Misfire A pyrotechnic item that fails to function as designed after initiation. Muzzle Burst The process of ail aerial shell breaking or bursting just as it leaves the mortar, scattering stars and burning material. .j Additional Crew: Rafael Rangle Anthony Meyers Hannah Tran Eric Arganosa Colby Nordberg ' Nathan Mayfield Michelle Ayers , Justin Lopez Tony Odonnel Veronica Rico Monette Bunyapanasarn Talyor Harrison Corey Drake Ruben Guzman Chandra Barnett NEWPORT BEACH FIRE DEPARTMENT Life Safety Services Division (949) 644-3106 100 Civic Center Drive - P.O. Box 1768 Newport Beach, CA 92660-8915 HAZARDOUS MATERIALS BUSINESS EMERGENCY PLAN FIELD INSPECTION NOTICE OCCUPANT ID NO. INSPECTION DATE '3 3 33 '? / J11 d / / 14 gnspector Steve Michael (949) 644-3108 Inspector Raymi Wun (949) 644-3110 / BUSINESS NAME PHONE NO. ` I Q�W Orf�' GOus0' SvY Cr C en ►' 1C(qCj--11'g-3900 BUSINESS ADDRESS (Newport Beach) tggt 60cado Nvc 4a 103 MAILING ADDRESS (If different from Business Address) CITY ZIP OWNER/MANAGER NAME (Print) Hazardous Materials Business Emergency Plan Meets The Requirements ❑ Hazardous Materials Business Emergency Plan Implementation (1ol000l) ❑ Hazardous Materials Business Emergency Plan Submittal (1010002) ❑ Business Activities Page and/or Business Owner/Operator Identification Page (101003) ❑ Hazardous Material Inventory Forms (101004) ❑ Annotated Site Map (1010005) ❑ Hazardous Materials Inventory Forms Update (1010006) ❑ Business Plan Deficiencies (1010007) ❑ Hazardous Materials Inventory Re -Certification or Re -Submittal (1010008) ❑ Triennial Hazardous Materials Business Plan Review and Re -Certification (1010009) ❑ Emergency Response Plan and Procedures Not Included or Not Adequate (1oloom) ❑ Property Owner Notification (1oloo11) ❑ Property Owner Business Plan (1010012) ❑ Training Program Not Included or Is Not Adequate (1020001) ❑ Training Program Not Implemented (1020002) ❑ Release Reporting (1040001) Comments: Original White - Life Safety Services Division Yellow - Owner/Tenant Revised: April 2015 NEWPORT BEACH FIRE DEPARTMENT Life Safety Services Division (949) 644-3106 100 Civic Center Drive - P.O. Box 1768 Newport Beach, CA 92660-8915 HAZARDOUS MATERIALS BUSINESS EMERGENCY PLAN FIELD INSPECTION NOTICE OCCUPANT ID NO. INSPECTION DATE Inspector Steve Michael (949) 644-3108 -3 4 -% `I 3/3 / 16 I] Inspector Raymi Wun (949) 644-3110 BUSINESS NAME PHONE NO. o,rov1ct, l L Ma._ -7 6 BUSINESS ADDRESS (Newport Beach) 1E. /oaSd pw vi,O1 C, MAILING ADDRESS (If different from Business Address) CITY ZIP OWNER/MANAGER NAME (Print) ate,` vlr California Health & Safety Code Chapter 6.95 Section 25508 and California Code of Regulations Title 19 Sections 2729.4 & 2729.5 O'Hazardous materials Business - •- The Requirements ❑ Hazardous Materials Business Emergency Plan Implementation (1ol000l-) ❑ Hazardous Materials Business Emergency Plan Submittal (1010002) ❑ Business Activities Page and/or Business Owner/Operator Identification Page (1010003) ❑ Hazardous Material Inventory Forms (1010004) ❑ Annotated Site Map (1010005) ❑ Hazardous Materials Inventory Forms Update (1010006) ❑ Business Plan Deficiencies (1010007) ❑ Hazardous Materials Inventory Re -Certification or Re -Submittal (1010008) ❑ Triennial Hazardous Materials Business Plan Review and Re -Certification (lol000s) ❑ Emergency Response Plan and Procedures Not Included or Not Adequate (1oloolo) ❑ Property Owner Notification (1oloo11) ❑ Property Owner Business Plan (1010012) ❑ Training Program Not Included or Is Not Adequate (1020001) ❑ Training Program Not Implemented (1020002) ❑ Release Reporting (1040001) Comments: Original White — Life Safety Services Division Yellow— Owner/Tenant Revised: April 2015 NEWPORT BEACH FIRE DEPARTMENT Life Safety Services Division (949) 644-3106 100 Civic Center Drive - P.O. Box 1768 Newport Beach, CA 92660-8915 HAZARDOUS MATERIALS BUSINESS EMERGENCY PLAN FIELD INSPECTION NOTICE OCCUPANT ID NO. INSPECTION DATE Inspector Steve Michael (949) 644-3108 V g q 1 3 3116 ❑ Inspector Raymi Wun (949) 644-3110 BUSINESS NAME PHONE NO. �I � 1S -7o/ f , c,J BUSIN SS AIDDRESS (Newport Beach) a 6GJo ��j' th kkotoieL, MAILING ADDRESS (If different frQfn Business Address) CITY ZIP OWNERIMAN/AGER NAME (Print) vl'o� a�✓I Hazardous Materials Business Emergency Plan Meets The Requirements ❑ Hazardous Materials Business Emergency Plan Implementation (1ol000l) ❑ Hazardous Materials Business Emergency Plan Submittal (1010002) ❑ Business Activities Page and/or Business Owner/Operator Identification Page (101003) ❑ Hazardous Material Inventory Forms (101004) ❑ Annotated Site Map (1o1oom) ❑ Hazardous Materials Inventory Forms Update (1010006) ❑ Business Plan Deficiencies (1010007) ❑ Hazardous Materials Inventory Re -Certification or Re -Submittal (1oloom) ❑ Triennial Hazardous Materials Business Plan Review and Re -Certification (1o10009) ❑ Emergency Response Plan and Procedures Not Included or Not Adequate (1oloolo) ❑ Property Owner Notification (1oloo11) ❑ Property Owner Business Plan (1010012) ❑ Training Program Not Included or Is Not Adequate (1020001) ❑ Training Program Not Implemented (1020002) ❑ Release Reporting (1040001) Comments: Original White - Life Safety Services Division Yellow - Owner/Tenant Revised: April 2015 NEWPORT BEACH FIRE DEPARTMENT Life Safety Services Division (949) 644-3106 100 Civic Center Drive - P.O. Box 1768 Newport Beach, CA 92660-8915 HAZARDOUS MATERIALS BUSINESS EMERGENCY PLAN FIELD INSPECTION NOTICE OCCUPANT ID NO. INSPECTION DATE Inspector Steve Michael (949) 644-3108 3 I I I 3/3'�6 Inspector Raymi Wun (949) 644-3110 BUSINESS NAME PHONE NO. K&v, o, � < < 0 0 5 1G Ce� BUSINES ADDRESS (New rt Beach) 1 cosAVOCO)CIO MAILING ADDRESS (If different from Business Address) CITY ZIP OWNER/MANAGER NAME (Print) Hazardous Materials Business Emergency Plan Meets The Requirements ❑ Hazardous Materials Business Emergency Plan Implementation (1o1000l) ❑ Hazardous Materials Business Emergency Plan Submittal (1010002) ❑ Business Activities Page and/or Business Owner/Operator Identification Page (101003) ❑ Hazardous Material Inventory Forms (101004) ❑ Annotated Site Map (1010005) ❑ Hazardous Materials Inventory Forms Update (loloom) ❑ Business Plan Deficiencies (1010007) ❑ Hazardous Materials Inventory Re -Certification or Re -Submittal (1010008) ❑ Triennial Hazardous Materials Business Plan Review and Re -Certification (1ol0009) ❑ Emergency Response Plan and Procedures Not Included or Not Adequate (101001o) ❑ Property Owner Notification (1oloo11) ❑ Property Owner Business Plan (1010012) ❑ Training Program Not Included or Is Not Adequate (1020001) ❑ Training Program Not Implemented (1020002) ❑ Release Reporting (1040001) Comments: Original White - Life Safety Services Division Yellow - Owner/Tenant Revised: April 2015 NEWPORT BEACH FIRE DEPARTMENT. Life Safety Services Division (949) 644-3106 100 Civic Center Drive - P.O. Box 1768 Newport Beach, CA 92660-8915 HAZARDOUS MATERIALS BUSINESS EMERGENCY PLAN FIELD INSPECTION NOTICE OCCUPANT ID NO. INSPECTION DATE Inspector Steve Michael (949)644-3108 & —] a g 3' I 6 Inspector Raymi Wun (949) 644-3110 BUSINESS NAME PHONE NO. f3i'Can GL�L onC0,4 BUSINESS ADDRES (NlIewport Beach) I q 5 0 Tambore-p- 9, . MAILING ADDRESS (if different from Business Address) CITY ZIP OWNER/MANAGER NAME (Print) 7e FF V3eard s to Hazardous Materials Business Emergency Plan Meets The Requirements ❑ Hazardous Materials Business Emergency Plan Implementation (1ol000l) ❑ Hazardous Materials Business Emergency Plan Submittal (1010002) ❑ Business Activities Page and/or Business Owner/Operator Identification Page (101003) ❑ Hazardous Material Inventory Forms (101004) ❑ Annotated Site Map (1010005) ❑ Hazardous Materials Inventory Forms Update (1010006) ❑ Business Plan Deficiencies (1010007) ❑ Hazardous Materials Inventory Re -Certification or Re -Submittal (loloom) ❑ Triennial Hazardous Materials Business Plan Review and Re-Certification'(1o10009) ❑ Emergency Response Plan and Procedures Not Included or Not Adequate (1oloolo) ❑ Property Owner Notification (101oo11) ❑ Property Owner Business Plan (1010012) ❑ Training Program Not Included or Is Not Adequate (1020001) ❑ Training Program Not Implemented (1020002) ❑ Release Reporting (1040001) Comments: Original White - Life Safety Services Division Yellow - Owner/Tenant Revised: April 2015 NEWPORT BEACH FIRE DEPARTMENT Life Safety Services Division (949) 644-3106 100 Civic Center Drive - P.O. Box 1768 Newport Beach, CA 92660-8915 HAZARDOUS MATERIALS BUSINESS EMERGENCY PLAN FIELD INSPECTION NOTICE OCCUPANT ID NO. INSPECTION DATE Cl"I'nspector Steve Michael (949) 644-3108 -30 0 -% 1 3 (� ��6 Inspector Raymi Wun (949) 644-3110 BUSINESS NAME PHONE NO. S Kin Cancer d- Pe todv iv4- .SVY-er CeJer BUSINESS ADDRESS (Newport B ch) O N el- Cc -,I (.ma,Itev- D Y. MAILING ADDRESS (indifferent from Business Address) CITY ZIP OWNERIMANAGER NAME (Print) Hazardous Materials Business Emergency Plan Meets The Requirements ❑ Hazardous Materials Business Emergency Plan Implementation (1ol000l) ❑ Hazardous Materials Business Emergency Plan Submittal (1010002) ❑ Business Activities Page and/or Business Owner/Operator Identification Page (1o1003) ❑ Hazardous Material Inventory Forms (101004) ❑ Annotated Site Map (1010005) ❑ Hazardous Materials Inventory Forms Update (lol0006) ❑ Business Plan Deficiencies (1010007) ❑ Hazardous Materials Inventory Re -Certification or Re -Submittal (1010008) ❑ Triennial Hazardous Materials Business Plan Review and Re -Certification (1ol0009) ❑ Emergency Response Plan and Procedures Not Included or Not Adequate (1oloolo) ❑ Property Owner Notification (1010o11) ❑ Property Owner Business Plan (1010012) ❑ Training Program Not Included or Is Not Adequate (1020001) ❑ Training Program Not Implemented (1020002) ❑ Release Reporting (1040001) 1 . idTTiitM', Original White - Life Safety Services Division Yellow - Ownerfrenant Revised: April 2015 NEWPORT BEACH FIRE DEPARTMENT Life Safety Services Division (949) 644-3106 100 Civic Center Drive - P.O. Box 1768 Newport Beach, CA 92660-8915 HAZARDOUS MATERIALS BUSINESS EMERGENCY PLAN FIELD INSPECTION NOTICE OCCUPANT ID NO. INSPECTION DATE Inspector Steve Michael (949) 644-3108 -3 3 5 t 3 /1 /1' p Inspector Raymi Wun (949) 644-3110 BUSINESS NAME PHONE NO. I' Oa N.ew 0V4 !'vr 1Ca1re. BUSINESS ADDRESS (Newport Beach) 14 g t AVOGaoio Ave. #- 10 D MAILING ADDRESS (If different from Business Address) CITY ZIP OWNER/MANAGER NAME (Print) Hazardous Materials Business Emergency Plan Meets The Requirements ❑ Hazardous Materials Business Emergency Plan Implementation (1o1000l) ❑ Hazardous Materials Business Emergency Plan Submittal (1010002) ❑ Business Activities Page and/or Business Owner/Operator Identification Page (1o1003) ❑ Hazardous Material Inventory Forms (101004) ❑ Annotated Site Map (1010005) ❑ Hazardous Materials Inventory Forms Update (1010006) ❑ Business Plan Deficiencies (1010007) ❑ Hazardous Materials Inventory Re -Certification or Re -Submittal (1ol0008) ❑ Triennial Hazardous Materials Business Plan Review and Re -Certification (1ol0009) ❑ Emergency Response Plan and Procedures Not Included or Not Adequate (1oloolo) ❑ Property Owner Notification (1o1oo11) ❑ Property Owner Business Plan (1010012) ❑ Training Program Not Included or Is Not Adequate (1020001) ❑ Training Program Not Implemented (1020002) ❑ Release Reporting (1040001) Comments: Original White - Life Safety Services Division Yellow - Owner/Tenant Revised: April 2015 NEWPORT BEACH FIRE DEPARTMENT Life Safety Services Division (949) 644-3106 100 Civic Center Drive - P.O. Box 1768 Newport Beach, CA 92660-8915 HAZARDOUS MATERIALS BUSINESS EMERGENCY PLAN FIELD INSPECTION NOTICE OCCUPANT ID NO. 5 v 6 INSPECTION DATE 3 I (1) 6 Inspector Steve Michael (949) 644-3108 Inspector Raymi Wun (949) 644-3110 BUSINESS NAME VGA' CCG� Ct If5 V L UGL PHONE NO. BUSINESS ADDRESS (Newport Beach) g53-7 W, 00-4 w MAILING ADDRESS (If different from Business dress) CITY ZIP OWNER/MANAGER NAME (Print) Hazardous Materials Business Emergency Plan Meets The Requirements ❑ Hazardous Materials Business Emergency Plan Implementation (1ol000l) ❑ Hazardous Materials Business Emergency Plan Submittal (1010002) ❑ Business Activities Page and/or Business Owner/Operator Identification Page (1o1003) ❑ Hazardous Material Inventory Forms (101004) ❑ Annotated Site Map (1010005) ❑ Hazardous Materials Inventory Forms Update (1010006) ❑ Business Plan Deficiencies (1010007) ❑ Hazardous Materials Inventory Re -Certification or Re -Submittal (1010008) ❑ Triennial Hazardous Materials Business Plan Review and Re -Certification (1ol0009) ❑ Emergency Response Plan and Procedures Not Included or Not Adequate (1oloolo) ❑ Property Owner Notification (1oloo11) ❑ Property Owner Business Plan (1010012) ❑ Training Program Not Included or Is Not Adequate (1020001) ❑ Training Program Not Implemented (1020002) ❑ Release Reporting (1040001) Comments: Original White - Life Safety Services Division Yellow - Owner/Tenant Revised: April 2015 NEWPORT BEACH FIRE DEPARTMENT Life Safety Services Division (949) 644-3106 100 Civic Center Drive - P.O. Box 1768 Newport Beach, CA 92660-8915 HAZARDOUS MATERIALS BUSINESS EMERGENCY PLAN FIELD INSPECTION NOTICE OCCUPANT ID NO. INSPECTION DATE Inspector Steve Michael (949) 644-3108 r [ 2— 311116 Inspector Raymi Wun (949) 644-3110 BUSINESS NAME PHONE NO. V 01^s Ar-o400z tA 3 dd S BUSINESS ADDRESS (Newport Beach) 3100 (baLbo. W MAILING ADDRESS (If different from Business Address) CITY ZIP- OWNER/MANAGER NAME (Print) L,,s Hazardous Materials Business Emergency Plan Meets The Requirements ❑ Hazardous Materials Business Emergency Plan Implementation (1ol000l) ❑ Hazardous Materials Business Emergency Plan Submittal (1010002) ❑ Business Activities Page and/or Business Owner/Operator Identification Page (101003) ❑ Hazardous Material Inventory Forms (101004) ❑ Annotated Site Map (1010005) ❑ Hazardous Materials Inventory Forms Update (1o1oom) ❑ Business Plan Deficiencies (1010007) ❑ Hazardous Materials Inventory Re -Certification or Re -Submittal (lol0008) ❑ Triennial Hazardous Materials Business Plan Review and Re -Certification (1010009) ❑ Emergency Response Plan and Procedures Not Included or Not Adequate (1oloolo) ❑ Property Owner Notification (1oloo11) ❑ Property Owner Business Plan (1010012) ❑ Training Program Not Included or Is Not Adequate (1020001) ❑ Training Program Not Implemented (1020002) ❑ Release Reporting (1040001) Comments: Original White - Life Safety Services Division Yellow - OwnerfTenant Revised: April 2015 NEWPORT BEACH FIRE DEPARTMENT Life Safety Services Division (949) 644-3106 100 Civic Center Drive - P.O. Box 1768 Newport Beach, CA 92660-8915 HAZARDOUS MATERIALS BUSINESS EMERGENCY PLAN FIELD INSPECTION NOTICE OCCUPANT ID NO. INSPECTION DATE l Inspector Steve Michael (949) 644-3108 o� 5 G l� 3 r j 1' 6 Inspector Raymi Wun (949) 644-3110 BUSINESS NAME PHONE NO. I'rG Le K a 5"� 0.2 BUSINESS ADDRESS (Newport Beach) g555 VV. ©asd fiv,- MAILING ADDRESS (If different from Busineso Address) CITY ZIP OWNER/MANAGER NAME (Print) r7(,:d Hazardous Materials Business Emergency Plan Meets The Requirements ❑ Hazardous Materials Business Emergency Plan Implementation (1o1000l) ❑ Hazardous Materials Business Emergency Plan Submittal (1010002) ❑ Business Activities Page and/or Business Owner/Operator Identification Page (101003) ❑ Hazardous Material Inventory Forms (101004) ❑ Annotated Site Map (1ol000m) ❑ Hazardous Materials Inventory Forms Update (lol0006) ❑ Business Plan Deficiencies (1010007) ❑ Hazardous Materials Inventory Re -Certification or Re -Submittal (lol000a) ❑ Triennial Hazardous Materials Business Plan Review and Re -Certification (1ol0009) ❑ Emergency Response Plan and Procedures Not Included or Not Adequate (1oloolo) ❑ Property Owner Notification (1o10o11) ❑ Property Owner Business Plan (1010012) ❑ Training Program Not Included or Is Not Adequate (1020001) ❑ Training Program Not Implemented (1020002) ❑ Release Reporting (1040001) Comments: Original White - Life Safety Services Division Yellow - Owner/Tenant Revised: April2015 NEWPORT BEACH FIRE DEPARTMENT Life Safety Services Division (949) 644-3106 100 Civic Center Drive - P.O. Box 1768 Newport Beach, CA 92660-8915 HAZARDOUS MATERIALS BUSINESS EMERGENCY PLAN FIELD INSPECTION NOTICE OCCUPANT ID NO. INSPECTION DATE Inspector Steve Michael (949) 644-3108 10 Ll Z' 2 0(� � 6 ❑ Inspector Raymi Wun (949) 644-3110 BUSINESS NAME PHONE NO. Ngw 04 &ea ck Svr er �� ►' BUSINESS ADDRESS (Newport BeaA ) 3 110S �ct L MAILING ADDRESS QIf different from Business Address) CITY ZIP OWNER/MANAGER NAME (Print) M4 S ea - Hazardous Materials Business Emergency Plan Meets The Requirements ❑ Hazardous Materials Business Emergency Plan Implementation (1ol000l) ❑ Hazardous Materials Business Emergency Plan Submittal (1010002) ❑ Business Activities Page and/or Business Owner/Operator Identification Page (101003) ❑ Hazardous Material Inventory Forms (101004) ❑ Annotated Site Map (loloom) ❑ Hazardous Materials Inventory Forms Update (1010006) ❑ Business Plan Deficiencies (1010007) ❑ Hazardous Materials Inventory Re -Certification or Re -Submittal (1010008) ❑ Triennial Hazardous Materials Business Plan Review and Re -Certification (1o10009) ❑ Emergency Response Plan and Procedures Not Included or Not Adequate (1oloolo) ❑ Property Owner Notification (1o10011) ❑ Property Owner Business Plan (1010012) ❑ Training Program Not Included or Is Not Adequate (1020001) ❑ Training Program Not Implemented (1020002) ❑ Release Reporting (1040001) Comments: Original White - Life Safety Services Division Yellow - Owner/Tenant Revised: April 2015 NEWPORT BEACH FIRE DEPARTMENT Life Safety Services Division (949) 644-3106 100 Civic Center Drive - P.O. Box 1768 Newport Beach, CA 92660-8915 HAZARDOUS MATERIALS BUSINESS EMERGENCY PLAN FIELD INSPECTION NOTICE OCCUPANT ID NO. INSPECTION DATE �spectorSteve Michael (949) 644-3108 `�I/ ��// & 7 i 2- 2LV lb p Inspector Raymi Wun (949) 644-3110 BUSINESS NAME PHONE NO. RaL l s atk@4 # -7 4 BUSINESS ADDRESS (Newport Beach) a- 5 5 5 EadbL v 4 MAILING ADDRESS (If different from Business Address) CITY ZIP OWNER/MANAGER NAME (Print) Hazardous Materials Business Emergency Plan Meets The Requirements ❑ Hazardous Materials Business Emergency Plan Implementation (1ol000l) ❑ Hazardous Materials Business Emergency Plan Submittal (1010002) ❑ Business Activities Page and/or Business Owner/Operator Identification Page (101003) ❑ Hazardous Material Inventory Forms (101004) ❑ Annotated Site Map (1010005) ❑ Hazardous Materials Inventory Forms Update (1010006) ❑ Business Plan Deficiencies (1010007) ❑ Hazardous Materials Inventory Re -Certification or Re -Submittal (1010008) ❑ Triennial Hazardous Materials Business Plan Review and Re -Certification (lol000s) ❑ Emergency Response Plan and Procedures Not Included or Not Adequate (1oloolo) ❑ Property Owner Notification (1o10011) ❑ Property Owner Business Plan (1010012) ❑ Training Program Not Included or Is Not Adequate (1020001) ❑ Training Program Not Implemented (1020002) ❑ Release Reporting (1040001) Comments: Original White - Life Safety Services Division Yellow - Owner/Tenant Revised: April 2015 Poke t P 5 f !C Nile NEWPORT BEACH FIRE DEPARTMENT Life Safety Services Division (949) 644-3106 VA C/G1 100 Civic Center Drive - P.O. Box 1768 Newport Beach, CA 92660-8915 HAZARDOUS MATERIALS BUSINESS EMERGENCY PLAN FIELD INSPECTION NOTICE OCCUPANT ID NO. 1 o g l INSPECTION DATE / 112SI1 6 Inspector Steve Michael (949) 644-3108 Inspector Raymi Wun (949) 644-3110 BUSINESS NAME PHONE NO. 4oaA (Mew► vrta` 14 I'- d- 04 a I'eej Svv er BUSINESS ADDRESS (Newpo Beach) 3 5 l 110 MAILING ADDRESS (If different from Business Address) CITY ZIP OWNER/MANAGER NAME (Print) Hazardous Materials Business Emergency Plan Meets The Requirements ❑ Hazardous Materials Business Emergency Plan Implementation (101oo01) ❑ Hazardous Materials Business Emergency Plan Submittal (1010002) ❑ Business Activities Page and/or Business Owner/Operator Identification Page '(101003) ❑ Hazardous Material Inventory Forms (101004) ❑ Annotated Site Map (1010005) ❑ Hazardous Materials Inventory Forms Update (1010006) ❑ Business Plan Deficiencies (1010007) ❑ Hazardous Materials Inventory Re -Certification or Re -Submittal (1o10008) ❑ Triennial Hazardous Materials Business Plan Review and Re -Certification (1010009) ❑ Emergency Response Plan and Procedures Not Included or Not Adequate (101oolo) ❑ Property Owner Notification (1oloo11) ❑ Property Owner Business Plan (1010012) ❑ Training Program Not Included or Is Not Adequate (1020001) ❑ Training Program Not Implemented (1020002) ❑ Release Reporting (1040001) Comments: Original White - Life Safety Services Division Yellow - OwnedTenant Revised: April2015 D NEWPORT BEACH FIRE DEPARTMENT Life Safety Services Division (949) 644-3106 100 Civic Center Drive - P.O. Box 1768 Newport Beach, CA 92660-8915 HAZARDOUS MATERIALS BUSINESS EMERGENCY PLAN FIELD INSPECTION NOTICE OCCUPANT ID NO. INSPECTION DATE Inspector Steve Michael (949) 644-3108 5 3 ff W i /� S�� b p Inspector Raymi Wun (949) 644-3110 BUSINESS NAME ''nnnn PHONE NO. �k-w ao4 t' do IVI4cc L CenLr' BUSINESS ADDRESS (Newport Beach) 3 6 1 14o,S i &L iZ A. MAILING ADDRESS (it different from Business Address) CITY ZIP OWNER/MANAGER NAME (Print) Hazardous Materials Business Emergency Plan Meets The Requirements ❑ Hazardous Materials Business Emergency Plan Implementation (1ol000l) ❑ Hazardous Materials Business Emergency Plan Submittal (1010002) ❑ Business Activities Page and/or Business Owner/Operator Identification Page (1olop ❑ Hazardous Material Inventory Forms (101004) ❑ Annotated Site Map (1610005) ❑ Hazardous Materials Inventory Forms Update (1oloo06) ❑ Business Plan Deficiencies (1010007) ❑ Hazardous Materials Inventory Re -Certification or Re -Submittal (1010008) ❑ Triennial Hazardous Materials Business Plan Review and Re -Certification (1ol0009) ❑ Emergency Response Plan and Procedures Not Included or Not Adequate (1oloolo) ❑ Property Owner Notification (1oloo11) ❑ Property Owner Business Plan (1010012) ❑ Training Program Not Included or Is Not Adequate (1020001) ❑ Training Program Not Implemented (1020002) ❑ Release Reporting (1040001) Comments: Original White - Life Safety Services Division Yellow - Owner/Tenant Revised: April 2015 NEWPORT BEACH FIRE DEPARTMENT Life Safety Services Division (949) 644-3106 100 Civic Center Drive - P.O. Box 1768 Newport Beach, CA 92660-8915 HAZARDOUS MATERIALS BUSINESS EMERGENCY PLAN FIELD INSPECTION NOTICE OCCUPANT ID NO. INSPECTION DATE [nspector Steve Michael (949) 644-3108 5 1 bo S 6 p Inspector Raymi Wun (949) 644-3110 BUSINESS NAME PHONE NO. C©as� GLea. erS BUSINESS ADDRESS (Newport Beach) 3.200 E - CoaS1 w MAILING ADDRESS (If different from Business Address) CITY ZIP OWNERIMANAGER NAME (Print) Hazardous Materials Business Emergency Plan Meets The Requirements ❑ Hazardous Materials Business Emergency Plan Implementation (1o1000l) ❑ Hazardous Materials Business Emergency Plan Submittal (1010002) ❑ Business Activities Page and/or Business Owner/Operator Identification Page (1o1003) ❑ Hazardous Material Inventory Forms (101004) ❑ Annotated Site Map (1010005) ❑ Hazardous Materials Inventory Forms Update (loloom) ❑ Business Plan Deficiencies (1010007) ❑ Hazardous Materials Inventory Re -Certification or Re -Submittal (lol0008) ❑ Triennial Hazardous Materials Business Plan Review and Re -Certification (lol000s) ❑ Emergency Response Plan and Procedures Not Included or Not Adequate (1oloolo) ❑ Property Owner Notification (1oloo11) ❑ Property Owner Business Plan (1010012) ❑ Training Program Not Included or Is Not Adequate (1020001) ❑ Training Program Not Implemented (1020002) ❑ Release Reporting (1040001) Comments: Original White - Life Safety Services Division Yellow - Ownerfrenant Revised: April 2015 D',_ 11241t NEWPORT BEACH FIRE DEPARTMENT Life Safety Services Division (949) 644-3106 100 Civic Center Drive - P.O. Box 1768 Newport Beach, CA 92660-8915 HAZARDOUS MATERIALS BUSINESS EMERGENCY PLAN FIELD INSPECTION NOTICE OCCUPANT ID NO. INSPECTION DATE Inspector Steve Michael (949) 644-3108 51-7 C �" r 6 p Inspector Raymi Wun (949) 644-3110 BUSINESS NAME PHONE NO. Una e'd ©.L Co A 3 2 BUSINESS ADDRESS (Newport Beach) 3 goo E. Coa � w MAILING ADDRESS (If different from BLIsiness Address) CITY ZIP OWNERIMANAGER NAME (Print) Hazardous Materials Business Emergency Plan Meets The Requirements ❑ Hazardous Materials Business Emergency Plan Implementation (1ol000l) ❑ Hazardous Materials Business Emergency Plan Submittal (1010002) ❑ Business Activities Page and/or Business Owner/Operator Identification Page (101003) ❑ Hazardous Material Inventory Forms (101004) ❑ Annotated Site Map (1010005) ❑ Hazardous Materials Inventory Forms Update (1010006) ❑ Business Plan Deficiencies (1010007) ❑ Hazardous Materials Inventory Re -Certification or Re -Submittal (lol000s) ❑ Triennial Hazardous Materials Business Plan Review and Re -Certification (1ol0009) ❑ Emergency Response Plan and Procedures Not Included or Not Adequate (1oloolo) ❑ Property Owner Notification (1oloo11) ❑ Property Owner Business Plan (1010012) ❑ Training Program Not Included or Is Not Adequate (1020001) ❑ Training Program Not Implemented (1020002) ❑ Release Reporting (1040001) Comments: Original White - Life Safety Services Division Yellow - OwnerlTenant Revised: April 2015 NEWPORT BEACH FIRE DEPARTMENT /2 Life Safety Services Division (949) 644-3106 100 Civic Center Drive - P.O. Box 1768 Newport Beach, CA 92660-8915 HAZARDOUS MATERIALS BUSINESS EMERGENCY PLAN FIELD INSPECTION NOTICE OCCUPANT ID NO. INSPECTION DATE Inspector Steve Michael (949) 644-3108 5 1-72-I[ a S /6 Inspector Raymi Wun (949) 644-3110 BUSINESS NAME PHONE NO. ra Le_ c_Lea ►Prs BUSINESS ADDRESS (Newport Beach) 2 3o 1 F. MAILING ADDRESS (if different from Business Address) CITY ZIP OWNAERIMANAGER NAME (Print) V\d re6k U]a'Sh /ir Hazardous Materials Business Emergency Plan Meets The Requirements ❑ Hazardous Materials Business Emergency Plan Implementation (1o10oo1) ❑ Hazardous Materials Business Emergency Plan Submittal (1010002) ❑ Business Activities Page and/or Business Owner/Operator Identification Page (101003) ❑ Hazardous Material Inventory Forms (101004) ❑ Annotated Site Map (1010005) ❑ Hazardous Materials Inventory Forms Update (1010006) ❑ Business Plan Deficiencies (1010007) ❑ Hazardous Materials Inventory Re -Certification or Re -Submittal (1010008) ❑ Triennial Hazardous Materials Business Plan Review and Re -Certification (1ol000g) ❑ Emergency Response Plan and Procedures Not Included or Not Adequate (1oloolo) ❑ Property Owner Notification (1oloo11) ❑ Property Owner Business Plan (1010012) ❑ Training Program Not Included or Is Not Adequate (1020001) ❑ Training Program Not Implemented (1020002) ❑ Release Reporting (1040001) Comments: Original White - Life Safety Services Division Yellow - Owner/Tenant Revised: April 2015 NEWPORT BEACH FIRE DEPARTMENT Life Safety Services Division (949) 644-3106 100 Civic Center Drive - P.O. Box 1768 Newport Beach, CA 92660-8915 HAZARDOUS MATERIALS BUSINESS EMERGENCY PLAN FIELD INSPECTION NOTICE OCCUPANT ID NO. INSPECTION DATE Inspector Steve Michael (949) 644-3108 5 0 8 8 J ' !15 / G / ❑ Inspector Raymi Wun (949) 644-3110 BUSINESS NAME PHONE NO. Malik P041-erSopi =AC. BUSINESS ADDRESS (Newport Beach) 3 4 ,�- 5 E. CoaSI ld w MAILING ADDRESS (if different from Busine s Address) CITY ZIP OWNERIMANAGER NAME (Print) Hazardous Materials Business Emergency Plan Meets The Requirements ❑ Hazardous Materials Business Emergency Plan Implementation (1ol000l) ❑ Hazardous Materials Business Emergency Plan Submittal (1010002) ❑ Business Activities Page and/or Business Owner/Operator Identification Page (101003) ❑ Hazardous Material Inventory Forms (101004) ❑ Annotated Site Map (1010005) ❑ Hazardous Materials Inventory Forms Update (1010006) ❑ Business Plan Deficiencies (1010007) ❑ Hazardous Materials Inventory Re -Certification or Re -Submittal (lol0008) ❑ Triennial Hazardous Materials Business Plan Review and Re -Certification (lol000s) ❑ Emergency Response Plan and Procedures Not Included or Not Adequate (1o1oo1o) ❑ Property Owner Notification (1oloo11) ❑ Property Owner Business Plan (1010012) ❑ Training Program Not Included or Is Not Adequate (1020001) ❑ Training Program Not Implemented (1020002) ❑ Release Reporting (1040001) Comments: Original White - Life Safety Services Division Yellow - Ownerrrenant Revised: April 2015 South Coast AIR QUALITY MANAGEMENT DISTRICT 21865 E. Copley Drive, Diamond Bar, CA 91765-4182 (909) 396-2000 NOVEMBER 16, 1995 ID - 000197 NEWPORT BEACH CITY, FIRE DEPT 3300 NEWPORT BLVD NEWPORT BEACH CA 92663-3884 OFFICIAL DOCUMENT ACKNOWLEDGMENT OF ANNUAL OPERATING PERMIT FEE PAYMENT Dear Permit Holder: This letter is official acknowledgment of your annual operating permit fee payment for the Permit(s) to Operate listed on the enclosed attachment. A Facility Permit shall serve as a comprehensive Permit to Operate for all equipment at a Regional Clean Air Incentives Market (RECLAIM) facility. For the holder of a Permit to Operate, pursuant to District Rule 20-3(b), equipment shall not be operated contrary to the conditions specified in the permit to operate. A Facility Permit,holder shall, pursuant to Air Quality Management District (AQMD) Rule 2004(f), at all times comply with all applicable District rules and shall comply with all permit conditions as specified in the Facility Permit. You may consider the Permit(s) to Operate listed on the enclosed attachment renewed; the permit expiration date is stated oft the attachment. Pursuant to AQMD Rule 206, a person granted a permit under Rule 202 or 203 shall not operate or use any equipment unless the entire permit to operate or a legible facsimile of the entire permit is affixed upon the equipment in such manner that the permit number, equipment description, and the specified operating conditions are clearly visible and accessible. In the event that the equipment iz so constructed or operated that the permit to operate or a legible facsimile cannot be so placed, the entire permit to operate or the legible facsimile of the entire permit shall be mounted so as to be clearly visible in an accessible place within 8 meters (26 feet) of the equipment, or as otherwise approved in writing by AQMD's Executive Officer. If you have any questions about this payment,ackhowledgment letter or if you need a cop of your Permit to Operate, please call Customer Service at T909} 396-2900. PAGE 1 South Coast AIR QUALITY MANAGEMENT DISTRICT 21865 E. Copley Drive, Diamond Bar, CA 91765-4182 (909) 396-2000 NOVEMBER 16, 1995 ID — 000197 NEWPORT BEACH CITY, FIRE DEPT 868 SANTA BARBARA DR NEWPORT BEACH CA 92662 PERMIT RENEWALS PERMIT APPLIC EXPIRATION NUMBER DESCRIPTION NUMBER DATE" ---------------------------------------------- -------------- D49097 I C E (50-500 HP) EM ELEC GEN—DIESEL 185859 1.2/01/96 PAGE 2 �- South coast Air Quality Management District -� 21865 E. Copley Drive, Diamond Bar, CA 91765-4182 Q [S! (909) 396-2000 • http://www.agmd.gov DATE: 11-04-96 EQUIPMENT LOCATED AT: 868 SANTA BARBARA DR NEWPORT BEACH, CA 92662 LEGAL OWNER CO. ID: 197 OR OPERATOR NEWPORT BEACH CITY, FIRE DEPT 3300 NEWPORT BLVD• NEWPORT BEACH KC� 2, 43� -3#L84' PERMIT RENEWALS -------------------------------------------------------------------------- PERMIT/ EQUIPMENT DESCRIPTION EXPIRE APPL NBR DATE ------------------------------------ ------------------------------------ D49097 I C E (50-500 HP) EM ELEC GEN-DIESEL 12-01-97 ---------------------------- ------------------------------------------- w a� South Coast Air Quality � uali Management District QCaIU 21865 E. Copley Drive, Diamond Bar, CA 91765-4182 (909) 396-2000 - http://www.agmd.gov ACKNOWLEDGMENT OF ANNUAL OPERATING PERMIT FEE PAYMENT Dear Permit Holder: This letter acknowledges your recent annual operating permit fee payment for the permits to operate or applications listed on the enclosed attachment. Each permit or application expiration date is stated on the attachment. For those facilities that have been issued a Facility Permit, the Facility Permit serves as a comprehensive permit to operate for all equipment at that location. This payment acknowledgment letter does NOT replace your original permit or permits to operate, and you should NOT discard the original permits. You are required by AQMD Rule 206 to affix the original permit to operate or a legible facsimile of the permit upon the equipment -so that the permit -number, equipment description, and the operating conditions are clearly visible. If you have any questions about this payment acknowledgment letter or if you need- a. copy of your permit to operate please call Customer Service at (909) 396-2900. �--- - -� South Coast ' Q 'Air Quality Management District �- -- 21865 E. Copley Drive, Diamond Bar, CA 91765-4182 (909) 396-2000 - http://www.agmd.gov - DATE: 11-17-97 EQUIPMENT LOCATED AT: 868 SANTA BARBARA DR NEWPORT BEACH, CA 92662 LEGAL OWNER CO. ID: 197 OR OPERATOR NEWPORT BEACH CITY, FIRE DEPT 3300 NEWPORT BLVD NEWPORT BEACH, CA 92663- 3884 PERMIT RENEWALS ----------------------------------- PERMIT/ EQUIPMENT DESCRIPTION EXPIRE APPL NBR DATE - - D49097 I C E�(50-500 HP) EM ELEC GEN-DIESEL 1-2-01--98 j South Coast Air Quality Management District Q a y-u 21865 E. Copley Drive, Diamond Bar, CA 91765-4182 (909) 396-2000 • http://www.agmd.gov ACKNOWLEDGMENT OF ANNUAL OPERATING PERMIT FEE PAYMENT Dear Permit Holder: This letter acknowledges your recent annual operating permit fee payment for the permits to operate or applications listed on the enclosed attachment. Each permit or application expiration date is stated on the attachment. For those facilities that have been issued a Facility Permit, the Facility Permit serves as a comprehensive permit to operate for all equipment -at that- location-. This payment acknowledgment letter does NOT replace your original permit or permits to operate, and you should NOT discard the original permit You are required by AQMD Rule 206 to affix the origdnai pernut to operate or a legible facsimile of the permit upon the equipment so that the permit number, equipment description, and the operating conditions are clearly visible. if you' have any questions about this payment acknowledgment letter or if you need a copy of your permit to operate please call Customer Service at (909) 396-2900. 19470 199714� %YEARS OF PROGRESS TOWARD CLEAN AIR u ACOPY QF THIS PLAN MUST BE KEPT ON SITE AT ALL TIMES BUSINESS EMERGENCY PLAN Newport Beach Fire Department This BUSINESS EMERGENCY PLAN will be used as a working.document for the Fire Department. This document satisfies the requirements as set forth in the California Health & Safety Code, Section 25504. Please limit yourself to this format. Utilize these forms and attach additional sheets as necessary. COVER SHEET - PRELIMINARY INFORMATION Business Name (DBA) y/,eO 77674) Business Addres Mailing Address Business phone ,0 Lid - 3303 Primary Contact (full name) SS'C &-rr .4LL Title f�A-??'�tL1'Qa.) Date Type of Business Operation P::::fZr— _<,-T74_-7_706j Number of Employees Hours of Operation Z4 900'(ZSS wy Property Owner (name) Cj -'yam' OF A)&ujQo2Z Address 33©0__JE&&2p0Pa- ZcO D Emergency Contact Information (after business o s The EmergencyCoordinator shall have full access to the facility, site familiarity and authority to make decisions for the business. Emergency Coordinator (name)�"'7.',4L,lJ(r- r�- Telephone (area):, I4 (home phone) &c� - 33(a Emergency Coordinator ( alternate) QQ ��D U 7-y ��-1 ,,Z Telephone (area) 4 (home phone) &,444 - :337.3- Additional Information A copy of this plan shall be kept on site at all times BEP#4.FRM PAGE 2 2j91 0 BUSINESS EMERGENCY PLAN Newport Beach Fire Department PART I EMERGENCY NOTIFICATIONS A handler of hazardous materials is required to immediately report any release or,threatened release of a hazardous material to the NEWPORT BEACH FIRE DEPARTMENT and to the California Office of Emergency Services. Failure to do so will result in criminal and/or civil,prosecution (Health and Safety Code, Section 25515). A. AGENCY NOTIFICATIONS Organization Phone Number 1. Fire Department 911 2. Police Department 911 3. Paramedics 911 4. Office of Emergency Services (800) 852-7550 INFORMATION REQUIRED * Name of person and business. * Business street address. * Location of the incident. * Type incident (spill, gas release, etc.). * Nature and volume of materials involved. * Extent of 'injuries . * Possible hazards to human health and/or the environment. * Emergency call -'back telephone (7l,4 ) 644 - A B. MISCELLANEOUS CONTACT INFORMATION Phone Number 1. Hazardous Waste Contractor name: ( ) - 2. Insurance Company name: e (ZV 0E- WPs22Q � s�As: (m) &664- 3. Poison Control Center (UCI) (714) 634-5988 (Los .Angeles) (213) 484-5151 A copy of this plan'shall be kept on site at all times BEP,#4.FRM PAGE 2 2/91 2`E£77§ §/ R! ; kk 2;§2§ ) | | E(£22 0 }} (/)31 k OX i�|\dGei �in k��� z /«§ER 2`/ ` M /2 § kk () � �E /2 � / P k(§§(( '\ S 8§ k°§ 2 k k K� k k f w§ 2 R! k§ E § E/ § § E « m « m M §.0 «(§ & a c a } § \ ) ) i 2 A m / / BUSINESS EMERGENCY PLAN Newport Beach Fire Department PART II BUSINESS PERSONNEL EMERGENCY NOTIFICATIONS AND RESPONSIBILITIES A. EMPLOYEE EVACUATION 1. List the type of alarm signals that will be used to initiate an evacuation at the facility:: L,nw ,.... - n r-..�,.....A, /J i A. , n . � . ,� •/1 � !1 /�.,nA f �n L C.%^YG �/! 2. Describe the evacuation routes, emergency exits.; and staging areas for employees at the facility: a. Work area: jre& Maws ZOOM Evacuation route: 6Z Emergency exits: CAejar� ®2 S� 40A p Staging area: or STId. b. Work -V 0 Staging c. Work area: jP: ram- c25 ��r✓t Evacuation route: 'RREDOLF ' Emergency exits:APPAQ47US &ovK DeoPS Staging area: &49 9P T"1Bo•l UTILIZE ADDITIONAL COPIES AS NEEDED EVACUATION DRILLS SHALL BE CONDUCTED ANNUALLY OR MORE FREQUENTLY AS REQUIRED Records of drills shall be maintained for a period .of three years and shall be available for review.by fire department personnel. The record shall include the facilitators name, title, facility location, date of drill, and the signature of the facilitator. ' A copy of this plan shall be kept on site at all times BEP#4.FRM PAGE 3 2_/91 BUSINESS EMERGENCY PLAN Newport Beach Fire Department B. "EMERGENCY COORDINATOR,TASK COMPLETION SHEET" MAINTAIN COPIES OF THIS FORM READILY AVAILABLE FOR USE Date and time the incident was reported: Date Time: Identify the nature.and extent of the incident. Activate internal facility alarms or communication systems. r Notify the Fire Department. Designate an employee to direct emergency response units to `- the incident scene and to the location of the emergency, coordinator. Initiate.pre-arranged mitigation and evacuation plans. Secure all emergency shut off valves (as required). Initiate internal company notification. Account for all evacuated personnel. Have resource material available for use by responding '— agencies (maps, drawings, Material Data Safety Sheets (MSDS), etc.) Identify the location of, or the need for, emergency equipment (e.g. spill control measures, fire extinguishers, etc.) . Identify actions taken by the business to control the incident. Secure the incident; scene to include treatment., storage or disposal of hazardous materials or waste involved.. Contact the State Office of Emergency Services (5-16). 427-4341 or (800) 852-7550.: Others: (specify) THIS FORM SHALL BE GIVEN TO THE EMERGENCY RESPONDERS UPON THEIR ARRIVAL AT THE FACILITY A copy of this plan 'shall be kept on site at all times BEP#4.FRM ! PAGE 4 2/91 BUSINESS EMERGENCY PLAN Newport Beach Fire Department C. EMPLOYEE RESPONSIBILITIES: Identify who will be responsible for the following: * Emergency notification (as listed in PART. I) * Mitigation Actions and/or cleanup j!!�*-rrAjj0E&j * Evacuation of personnel C;tjTy Ai -citlS * Shut off essential valves t� IDENTIFY RESPONSIBILITIES OF KEY EMPLOYEES: - JOB TITLE: ��}-�',4L6(+Fr2L�lrrJ� Coa 2 Dc.yg-TBirL} EMERGENCY FUNCTIONS) a. ('-oru7`gaCr Q r wcLQjgn3-t- b. N�7,r— C.Aj'2g:,-) er � Q c= tma r�tT d. %1)ftM r-(R'S A - U PZ aL� JOB TITLE: 1VA-P7?gY- . &IA�,411,,—, O�IN� EMERGENCY FUNCTIONS) a. r i b. ll ''uu t I • 1. O ``, I i ... dr/F9a JOB TITLE: EMERGENCY FUNCTION(S) r.�.' c► 1 !mot _� � ./ ��. � ../1 ,_�✓L .� •�r•:►.►rj � UTILIZE ADDITIONAL COPIES AS REQUIRED A copy of this plan shall be kept on site at all times BEP,#4.FRM PAGE 5 2/9l BUSINESS EMERGENCY PLAN Newoort Beach Fire Department PART III TRAINING : OUTLINE THE STEPS YOUR BUSINESS' SHALL TAKE TO MEET THE TRAINING REQUIREMENTS NOTED IN THIS SECTION Evacuation drills shall be conducted annually at a minimum. Records of drills shall be kept on site for at least three years. A. METHODS FOR SAFE HANDLING OF HAZARDOUS MATERIALS: (For example, location of MSDS, protective clothing, equipment, etc.) C©(1lR.D ',DuR,A)4 TkA-rA)irj,4 3 rl-sD5 t'i eac-'s 0 FPc Cam. B. PROCEDURES FOR NOTIFICATION OF AND COORDINATION WITH EMERGENCY AGENCIES: (For example, who is responsible for notifying the agencies listed in Part I ?) C. USE OF EMERGENCY RESPONSE EQUIPMENT AND SUPPLIES UNDER THE CONTROL OF THE HANDLER: (For example, location of fire extinguishers and spill control equipment.) Pt ttj--- ay-rcf U cs 0-ee5 A2r &W AGL `bLP� . U sv i r,.,5 1 CAV 5'J`-4-•rzotv�' D. EMERGENCY MITIGATION PROCEDURES IN RESPONSE TO A RELEASE OR THREATENED RELEASE OF.A HAZARDOUS MATERIAL: (Include procedures for shutting down process and machinery, and for cleaning up spills. Who is responsible for mitigation procedures?)! -6777}-TWAJ 64f--' AJ t/``�k lr--S i''tAa.,� 1.1 kvi P m r 7-1 d*--7ZnaJ (�Q.�S, �— s�S '�2o�c-r •rEf-a-�v� N GC.�r�rU—u� E. PROCEDURES FOR ASSURANCE OF TRAINING AND MAINTENANCE OF TRAINING RECORDS: (Who maintains training records? Where are records kept? Frequency of training?) -WE. 5-T7t-iZo^�) CPr-o+t •%dS oh 0�-Drn14 ar-T71 -cnu i-,J4, 77�- T24rA.)i•v4 I5 ' W rk OUAY2.,T�y SEE ATTACHED SAMPLE "CHEMICAL TRAINING RECORD" A copy of this plan shall be kept on site at all times BEP#4.FRM PAGE 6 2/91 BUSINESS EMERGENCY PLAN Newport Beach Fire Department PART III TRAINING : OUTLINE THE STEPS YOUR BUSINESS SHALL TAKE TO MEET THE TRAINING REQUIREMENTS NOTED IN THIS SECTION A. METHODS FOR SAFE HANDLING OF HAZARDOUS MATERIALS: Material Safety Data Sheets are available for all employees using or handling hazardous materials. Protective clothing and equipment is available on site. B. PROCEDURES FOR NOTIFICATION OF AND COORDINATION WITH EMERGENCY AGENCIES: All personnel have reviewed PART I, page 2 of this BEP and are familiar with emergency notification procedures. C. USE OF EMERGENCY RESPONSE EQUIPMENT AND SUPPLIES UNDER THE CONTROL OF THE HANDLER: All personnel have been trained on the location and use of fire extinguishers. All personnel have been trained on the location and use of spill control equipment. D. EMERGENCY MITIGATION PROCEDURES IN RESPONSE TO A RELEASE OR THREATENED RELEASE OF A HAZARDOUS MATERIAL: E. Employees have been trained in containment and cleanup activities for small spills of hazardous materials, as well as emergency equipment shut-off procedures. PROCEDURES FOR ASSURANCE OF TRAINING AND MAINTENANCE OF TRAINING RECORDS: Personnel records indicate most recent date of traininc include the minimum requirements for hazardous material training. Training records are kept on site for 3 yeaz Employee training is provided within 30 days of employe and refresher training is conducted annually. OUR BUSINESS HAS IMPLEMENTED THE ABOVE TRAINING PROGRAM. OWNERS NAME DATE SIGNATURE j,26j: &� A copy of this plan shall be kept on site at all timef BEP#4.FRM PAGE 7 2� BUSINESS EMERGENCY PLAN Newport Beach Fire Department CHEMICAL TRAINING RECORD 1. INSTRUCTOR �jj0 2. TRAINING DATE III CHEMICAL SUBSTANCE 4. CHEMICAL USE T-5U 6). 5. DATE OF LAST EVACUATION DRILL S1/ZP> 6. EMPLOYEE TRAINING PROVIDED ON: F—tR.F-- ('nNIT'YLQ'l(_ / W,LC. %`Vjr.,, A. EMPLOYEE RESPONSIBILITY TO REPORT ANY RELEASE OR THREATENED RELEASE OF A HAZARDOUS MATERIAL TO: / �f YES NEWPORT BEACH FIRE DEPARTMENT (911), AND OYES STATE OFFICE OF EMERGENCY SERVICES (800-852-7550) B. NAME OF PERSONS WITHIN FACILITY WHO ARE RESPONSIBLE TO RESPOND TO AN INCIDENT: YES NAMEI PHONE NAMED P (7{ � PHONE /, YES C. INFORMATION CONTAINED IN MATERIAL SAFETY DATA SHEETS (Attach MSDS to training records) ZYES D. WARNING LABELS ZYES E. SAFE WORKING PRACTICES YES F. PROCEDURES TO 'FOLLOW DURING A RELEASE OR THREATENED RELEASE (DISCUSS POSSIBLE RELEASE SCENARIO, WHERE TO MEET FIRE DEPARTMENT, POSSIBLE EVACUATION OF BUILDING). _,ZYES G. USE OF EMERGENCY EQUIPMENT AND SUPPLIES ZYES H. USE AND LOCATION OF PERSONAL PROTECTIVE EQUIPMENT 7. EMPLOYEES TRAINED: F. i1 _i ' ? i. 1 A copy of this plan ;shall be kept on site at'all times BEP#4.FRM PAGE 8 2/91 BUSINESS EMERGENCY PLAN Newport Beach Fire Department PART IV PREVENTION: LIST ACTIONS WHICH HAVE BEEN ACCOMPLISHED TO ABATE HAZARDS RELATING TO THE USE, HANDLING OR STORAGE OF HAZARDOUS MATERIALS Utilize additional copies of this page as needed, or attach additional sheets as necessary. HAZARDOUS MATERIALS PREVENTIVE MEASURES STORAGE LOCATION 1.1l t_h�Vyl,) i A) S% aR6� 10 A-P-PfenASI) f-4�b 2. ���?I�SS<�2 ?� a�ss�arzi,z � 492 s ? DQFcPGy' 70Z? It 3.Z2/1ESf4- L rL�fl/Y%� 4. Comments relating to the listed storage areas: A copy of this plan shall be kept on site at all times BEP,#4.FRM PAGE 9 2/91 BUSINESS EMERGENCY PLAN. Newport Beach Fire Department A BUSINESS IS REQUIRED BY LAW TO NOTIFY THE NEWPORT BEACH TIRE DEPARTMENT, IN WRITING, WITHIN THIRTY DAYS OF ANY OF THE FOLLOWING EVENTS: 1. Change in business address. 2. Change of business ownership 3. Change of business name. 4. Cessation of business operation. 5. Use or handling of a previously undisclosed hazardous material. 6. A 100% increase in the quantity of a previously disclosed hazardous material. A COPY OF THE BUSINESS EMERGENCY ELAN HALL BE RETAINED AT YOUR BUSINESS AND SHALL BE AVAILABLE FOR REVIEW $Y FIRE DEPARTMENT PERSONNEL I (OWNER OR AUTHORIZED'REPRESENTATIVE) CERTIFY, UNDER PENALTY OF PERJURY, THAT THE ENCLOSED INFORMATION IS TRUE AND CORRECT TO BEST OF MY KNOWLEDGE. SIGNATURE I, 6L, 1/2. NAME (print) (DAV IOd Q 10�ou_)M z TITLE �LI 6�J� f6\) EXECUTED AT ( CITY) ON (DATE) A COPY OF THIS PLAN MUST BE KEPT ON SITE AT ALL TIMES I BEP,#4 . FRM .'` F E B 5 1990 &4,c2c,u-c a K- BUSINEsS EMERGENCY PLAN l%l r7 a� 7 A 5140 Newport Beach Fire Department This BUSINESS EMERGENCY PLAN will be used as a working document for the Fire Department. This document satisfies the requirements as set forth in the California Health & Safety Code, Section 25504. Please limit yourself to this format. Utilize these forms and attach additional sheets as necessary. M COVER SHEET - PRELIMINARY INFORMATION Business Name (DBA) /I/�'�i���% �,AGff lC/�� d� # Business Address 8,�g8 SApyr,* Mailing Address Business phone _���f--�,---3 Primary Contact (full name) ,SC©TT ,�LLEN Title 2134T7;;9z-low Date Type of Business Operation Number of Employees /2 Hours of Operation 2-j-' hood. /6),4� Property Owner (name) Address 33e:2e /l/-jr ,49v ZT /3LYd Emergency Contact Information after business hours The Emergency Coordinator shall have full access to the facility, site familiarity and authority to make decisions.for the business. Emergency Coordinator (name) Telephone (area)671 (home phone) Emergency Coordinator • (alternate). IG� la.G Zflcc/�.Pa Telephone (area)�(/f/J .(home phone)-. 3 Additional Information A copy of this plan shall be kept on site at all times BEP.FRM PAGE 1 1/88 BUSINESS EMERGENCY PLAN Newport Beach Fire Department PART I EMERGENCY NOTIFICATIONS A handler of hazardous materials is required to immediately w report any release or threatened release of a hazardous material to the NEWPORT BEACH FIRE DEPARTMENT and to the California Office of EmergencyServices. Failure to do so will result in criminal and/or civil prosecution (Health and Safety Code, Section 25515). A. AGENCY NOTIFICATIONS Organization Phone Number 1. Fire Department 911 2. Ponce Department 911 3. Paramedics 911 4. Office of Emergency Services (800) 852-7550 INFORMATION REQUIRED * Name of person and business. * Business street address. * Location of the incident. * Type incident (spill, gas release, etc.). * Nature and volume of materials involved. * Extent of injuries. * Possible hazards to human health and/orthe environment. * Emergency call-back telephone ( 77t4) B. MISCELLANEOUS CONTACT INFORMATION Phone Number 1. Hazardous Waste Contractor name: G 6 s;C'%e � Vi r. �YIa h�Sc . ( ) 13 6S- 2. Insurance Company name : �t,�_�, 7 3. Poison Con e 714 ) 634-5988 (Los )geles) „(213) 484-515,1 A copy of this plan shall'be kept on site at all times BEP.FRM PAGE 2 1/88 ti 3 $USINESS EMERGENCY PLAN �� r. of Newport Beach Fire Department �� �� B. EMERGENCY COORDINATOR TASK COMPLETION SHEET" MAINTAIN COPIES OF THIS FORM READILY AVAI BLE FOR Date and time the incident was reported: Date Time: _ Identify the nature and extent of the incident. Activate internal facility alarms or communication systems. Notify the Fire Department. Designate an employee to direct emergency response units to the incident scene and 'to the location -of the emergency coordinator. _ Initiate pre -arranged mitigation and evacuation plans. _ Secure all emergency shut off valves (as required). _ Initiate internal company notification. — Account for all evacuated personnel. Have resource material available for use by responding agencies (maps, drawings, Material Data Safety Sheets (MSDS), etc.). Identify the location of, or the need for, emergency equipment (e.g. spill control measures, fire extinguishers, etc.). Identify actions taken by the business to control the incident. Secure the incident scene to include treatment, storage or _ disposal of hazardous materials or waste involved. _ Contact the State Office of Emergency Services (916) 427-4341 or (800) 852-7550. Others: (specify) THIS FORM SHALL BE GIVEN TO THE EMERGENCY RESPONDERS UPON THEIR ARRIVAL AT THE FACILITY A copy of this plan shall be kept on site at all times BEP.FRM PAGE 4 1/88 BUSINESS EMERGENCY PLAN Newport Beach Fire Department PART III TRAINING : OUTLINE THE STEPS YOUR BUSINESS SHALL TAKE TO MEET THE TRAINING REQUIREMENTS NOTED IN THIS SECTION -A. METHODS FOR SAFE HANDLING OF HAZARDOUS MATERIALS: (For example, location of MSDS, protective clothing, equipment, etc.) 1,iW9oP1Are... / //�� 7�i�.I''j�"�I�/•//!'�' %�'� S, l) S /S /ft/ /, �`", `+ !»"ram•• B. PROCEDURES FOR NOTIFICATION OF AND COORDINATION WITH EMERGENCY AGENCIES: (For example, who is responsible for notifying the agencies listed in Part I ?) �i�r-r-ri" c-%ate► C#f �, j 4P r' �7-A�- ucle �.p • 7V ,SC ;rum IKI-J 7-. • 4- — r t f; C. USE OF EMERGENCY RESPONSE EQUIPMENT AND SUPPLIES UNDER THE CONTROL OF THE HANDLER: (For example, location of fire extinguishers and spill control equipment.) �••,%7 D. EMERGENCY MITIGATION PROCEDURES IN RESPONSE TO A RELEASE OR THREATENED RELEASE OF A HAZARDOUS MATERIAL: (Include procedures for shutting down process and machinery, and for cleaning up spills. Who is responsible for mitigation procedures?) 1:-;•-4-776" CC"�-W tart fit .'��t- Gr1Uri D��ti /•'T�:� % �f . / rnpL t"rrEd at~A.t47-+, ®�.. r"L: vE n,► rYi Nti"'�` w! 1 T/ lr�� i"7 u-z l Q C, , ? '�`�` T�`` /TS G� S'S•�~a� /�/ '; E. PROCEDURES FOR ASSURANCE OF TRAINING AND MAINTENANCE OF TRAINING RECORDS: (Who maintains training records? Where are records kept? Frequency of training?) �'1,q--//�•�:/ rti'/t-��' a� �'7?•�3 iT�•/�'I � /�•���'�''f1� • ram' /�7Z'��c'�r�-' A-/t/D �'!l•�'�j"J���'''•,'a'`••� y lZ�-•�-.'i�.'F`�r'�.G � i.� f' y' �'VC'fL•.'f' ,tad- / .�'csf� ��:"./,� //;: /.,•r;„�M.,.. SEE ATTACHED SAMPLE "CHEMICAL TRAINING RECORD" A copy of this plan shall be kept on site at all times BEP.FRM PAGE 6 - A 1/88 BUSINESS EMERGENCY PLAN Newport Beach Fire Department CHEMICAL TRAINING RECORD 1. INSTRUCTOR ,rC'T�" ",W0Le_,0 2. TRAINING DATE_/- /--9D ,3 . CHEMICAL SUBSTANCE 1D/4_-5 AT t 4. ATTACH MATERIAL SAFETY DATA SHEETS -TO TRAINING RECORD. 5. CHEMICAL USE 6. EMPLOYEE TRAINING PROVIDED ON: rpf.4C YH' A. EMPLOYEE RESPONSIBILITY TO REPORT ANY RELEASE OR, THREATENED RELEASE OF A HAZARDOUS MATERIAL TO: AYES NEWPORT BEACH FIRE DEPARTMENT (911), AND ,...--_YES STATE OFFICE OF EMERGENCY SERVICES (800-852-7550) B. NAME OF PERSONS WITHIN FACILITY WHO ARE RESPONSIBLE TO RESPOND TO AN INCIDENT: �- YES NAME Sco`7'"T` 4_-L7v.!L8,C) PHONE NAME PHONE AYES C. INFORMATION CONTAINED IN MATERIAL SAFETY DATA SHEETS --YES D. WARNING LABELS -''YES E. SAFE WORKING PRACTICES ✓YES F. PROCEDURES TO FOLLOW DURING A RELEASE OR THREATENED RELEASE (DISCUSS POSSIBLE RELEASE SCENARIO, WHERE TO MEET FIRE DEPARTMENT, POSSIBLE EVACUATION OF BUILDING). 1--ES G. USE OF EMERGENCY EQUIPMENT AND SUPPLIES .-YES H. USE AND LOCATION OF PERSONAL PROTECTIVE EQUIPMENT 7. EMPLOYEES TRAINED: SIGNATURE WORK AREA A copy of this plan shall be kept on site at all times BEP.FRM PAGE 7 1/88 7 BUSINESS EMERGENCY PLAN Newport Beach Fire Department A BUSINESS IS REQUIRED BY LAW TO NOTIFY THE NEWPORT BEACH FIRE DEPARTMENT, IN WRITING, WITHIN THIRTY DAYS OF ANY OF THE FOLLOWING EVENTS: 1. Change in business address. 0. 2. Change of business ownership 3. Change of business name. 4. Cessation of business operation. 5. Use or handling of a previously undisclosed hazardous material. 6. A 100% increase in the quantity of a previously disclosed hazardous material. 0'-'A COPY OF THE BUSINESS EMERGENCY PLAN SHALL BE RETAINED AT YOUR BUSINESS AND SHALL BE AVAILABLE FOR REVIEW BY FIRE DEPARTMENT PERSONNEL I (OWNER OR VE) CERTIFY, UNDER PENALTY OF PERJURY, THAT'THE ENCLOSED INFORMATION IS TRUE AND CORRECT TO BEST OF MY KNOWLEDGE./ /% � SIGNATURE V NAME (print) Rc—?a� TITLE jr9 ,fur/ Al DATE A copy of this plan shall be kept on site at all times BEP.FRM PAGE 11. 1/88 CITY OF NEWPORT BEACH HAZARDOUS MATERIALS DISCLOSURE PROGRAM ANNUAL FEE AND REPORTING REQUIREMENTS January 19,1998 Owner: City of Newport Beach Address: 868 Santa Barbara Dr, Newport Beach, CA 92660 Facility: CNB - Fire and Marine Dept., 868 Santa Barbara Dr, Newport Beach, CA 92660 Your business has been identified as a location where hazardous materials are stored and/or used in the City of Newport Beach. California Law and City Ordinance requires that this information be annually updated to assure accuracy. Section 1: If the chemical information contained in your previously submitted inventory form(s) is complete, accurate, and up to date, use the enclosed fee worksheet to calculate your 1998 disclosure fee. Please note that new fees have been adopted since last year's reporting. Complete the "Total Amount Due" section below and sign. Return this form, the hazardous materials fee worksheet, and your payment by February 23,1998. Please use the enclosed mailing label when returning these documents. **If new chemicals have been added or any chemicals have been discontinued, skip to Section 2 below.** Calendar Year 1998---------- ---- AMOUNT DUE: * A late fee of 25% will be assessed if * LATE FEE: payment is not received by February 23,1998. TOTAL AMOUNT DUE: $ I certify that all disclosure information previously filed with the City of Newport'Beach is complete, accurate, and up to date. My payment for annual review is enclosed. �PrintName 114'— ` v r A COL." Signatur5��- Date -3— 2 e-- f%'e (Telephone Number ( ) Fax Number ( ) Section 2: Complete the following one if any changes have occurred. If your chemical inventory and/or emergency plan information has changed, check the box(s) below advising which forms you need mailed to your office for completion. Return this form to our office using the enclosed label within 30 days. IJHazardous Materials Inventory Chemical inventory has changed, please send new Hazardous Materials Inventory forms. Business Emergency Plan IWJ Business Emergency Plan has changed, please send new Business Emergency Plan forms. NOTE: Please do not submit a Business Emergency Plan or Chemical Inventory on forms of your own design. For further assistance or questions, contact the Fire Prevention Division at (714) 644-3106. CITY OF NEWPORT BEACH 11 HAZARDOUS MATERIALS DISCLOSURE PROGRAM ANNUAL FEE AND REPORTING REQUIREMENTS January 17,1997 Owner: Address: Facility: Your business has been identified as a location where hazardous materials gaze stored and/or used in the City of Newport Beach, California Law and City Ordinance requires that this information be annually updated to assure accuracy. Below is an assessment for calendar year 1997, based on the number of chemicals which have been disclosed at your facility. Section 1: If the chemicals are still in use and no new chemicals have been added, use the enclosed fee to calculate your 1997 disclosure fee. Please complete the "Total Amount Due" section below, sign this form, the calculation worksheet, and your payment using the label enclosed. If new chemicals have been added or any chemicals have been discontinued see Section 2 below h Calendar Year 1997-------------------- AMOUNT DUE: * A late fee of 25% will be assessed if * LATE FEE: payment is not received within 30 days. TOTAL AMOUNT DUE: $ I certify that all disclosure information previously filed with the City of Newport Beach is accurate. My pay annual review is enclosed. F Print Telephone Number (71q ) IOYLf' 3I i7� Section 2: Complete the following if any changes have occured. Review the following options if any changes have occurred since last year's reporting. Please us the enclosed fee calculation sheet to calculate your revised fee. (—Z Hazardous Materials Inventory ��•1 Chemical Inventory has changed, please send new Inventory forms. Business Emergency Plan Business Emergency Plan has changed, please send new Business Emergency Plan form NOTE: Please do not submit a Business Emergency Plan or Chemical Inventory on forms of your own design. I certify that our previously filed Business Emergency Plan is accurate, please find enclosed an updated Hazardous Materials Inventory. l--{, I certify that our previously filed Hazardous Materials Inventory is accurate, please f nd enclosed an updated Business Emergency Plan. Print Name Signature Date Number L� Note: Should you require a copy of the last Business Emergency Plan and/or Inventory that yoi have filed, please come to our office located at Fire Administration, 3300 Newport Blvd., Newpc Beach, and a copy will be made for a nominal fee. For further assistance or questions about this form, contact the program manager at (714) 644- ` CITY OF NEWPORT BEACH 11 11 HAZARDOUS MATERIALS DISCLOSURE PROGRAM ANNUAL FEE AND REPORTING REQUIREMENTS March 28,1996 Owner: ICity of Newport Beach Address: 1868 Santa Barbara Dr. Newport Beach, CA. 92660 Facility: -Fire Dept, 868, Santa Barbara Dr, Newport Beach, CA In 1995, your business was identified as a location where Hazardous M+ used in the City of Newport Beach. California Law and City Ordinance be annually updated to assure accuracy. Below is an assessment for cab number of chemicals which have been disclosed at your facility. red 'and/or based on the Section 1: If the chemicals are still in use and no new chemicals have been added, an annual fee of $0.00 is now due. Please complete the "Total Amount Due" section below, sign and return this form with your payment. If new chemicals have been added or any chemicals have been discontinued see Section 2 below for details. Calendar Year 1996 AMOUNT DUE: $0.00 * A late fee of 25% will be assessed if * LATE FEE:1da t" vavment is not received within 30 days. TOTAL AMOUNT DUE: $Lo, 00_ 11 I certify that all disclosure information previously filed with the City of Newport Beach.is accurate. My payment for annual review is enclosed. /� _ , Print Name_ LA V Telephone Number (:&4) /oct,+—.33% Section 2: Complete the following if any changes have occured. Review the following options if any changes have occurred since last year's reporting. Please use the enclosed fee calculation sheet to calculate your revised fee. Hazardous Materials Inventory: Chemical Jpventory has changed, please send new Inventory forms. (� Business Emergency Plan: Business Emergency Plan has changed, ` please send new Business Emergency Plan forms. NOTE: Please do not submit a Business Updated Business Emergency Plan Included. Emergency Plan or Chemical Inventory on forms of your own Updated Hazardous Materials Inventory Included. design. CERTIFICATION ZkI certify that our previously filed Business Emergency Plan is accurate, please find enclosed an updated Hazardous Materials Inventory. I certify that our previously filed Hazardous Materials Inventory is accurate, please find enclosed an updated Business Emergency Plan. Print Telephone Number ( ote: Should you require a copy of the last Business Emergency Plan and/or Inventory that you ive filed, please come to our office located at Fire Administration, 3300 Newport Blvd., Newport ?ach, and a copy will be made for a nominal fee. a 2/02/94 N E W P 0 R T BEACH FIRE DEPARTMENT Hazardous Materials Disclosure Report PART I: CRITERIA FOR DISCLOSURE - PART I -A (CHECK ONE) No chemicals are used in any way (complete Parts II and IV). [ j Chemicals are used in our company but do not meet the requirements for disclosure (complete parts II and IV). [ ] Chemicals are used in our business (complete all parts). PURPOSE OF DISCLOSURE - PART I-B (CHECK ONE) [ ] Annual disclosure report (due prior to MARCH 1 annually) [ ] Change in business name, address or ownership'(CIRCLE ONE) [ ] Change in quantity of previously disclosed hazardous material. f ] Addition of previously undisclosed hazardous material. PART II: GENERAL INFORMATION If the following information is incorrect please lineout and update. Fill in any blank spaces. BUSINESS NAME: CNB - Fire Dept BUSINESS ADDRESS: 868 SANTA BARBARA DR SUITE CITY: Newport Beach MAILING ADDRESS: Station 3 Inter-dept. mail CONTACT NAME #1: Scott Allan TELEPHONE: 644-3363 CONTACT NAME 02: TELEPHONE: OWNER'S NAME: City of Newport Beach TELEPHONE: 644-3106 OWNER'S ADDRESS: 3300 Newport Blvd, Newport Beach EMERGENCY NAME #l: Battalion Chief TELEPHONE: 644-3363 EMERGENCY NAME #2: Dispatch TELEPHONE: 911 DESCRIPTION OF BUSINESS OPERATION: Fire Station I certify that the ab a in/f/orm tion is correct: W Signature: /�/ ��---� Date: a�C OFFICE USE ONLY: NO. OF HM: BLDG ID: 2485 INV FORM SENT: 1 25/93 OCCUP ID: 2485 INV FORM RECD: 4-/01/93-- a / DISC: Y SENT BACK FOR CORR: CAUTION STMT: low COPY SENT TO: FIXED PROPERTY USE: 888 COPY SENT (DATE): NOTES: NEWPORT BEACH FIRE DEPARTMENT 3300 NEWPORT BOULEVARD NEWPORT BEACH, CA 92663 (714) 644-3106 HAZARDOUS MATERIALS BUSINESS EMERGENCY PLAN CERTIFICATION Business Name r Fore- "O" jDate Business Address ate- o- I Suite Please check the statement below which applies to your business: l� I certify that I have reviewed the Business Emergency Plan and Chemical Inventor list in accordance with California Health & Safety Code section 25505. I certify that the business plan and chemical inventory, which is on file with the Newport Beach Fire Department, is current and all information is up to date. Revisions are not required for 1994. Signature of owner or opera or:�--�- LJ Our business has made modifications to our Business Emergency Plan. Please send us new forms to update the information. ❑ Our business has made changes to our Hazardous Material Inventory. Please send us new inventory forms to update this information. I certify that I will update the business plan and inventory information within 30 days. Signature of owner or operator: Date: Keep a copy of this certification and your 1993 hazardous materials disclosure forms on Me and matte these available during fire department inspections. Mail original certification form to the Fire Department by March 1, 1994. -r T OUNTY OF C:)Fk^r*J43M 5 `t 3 HEALTH CARE AGENCY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1725 W.17TH STREET SANTA ANA, CALIFORNIA 92706 September, 20 1988 (714) 834.8356 Donald Simpson, Public Works Newport Beach City Hall 3300 Newport Blvd. Newport Beach, CalifoJria 92658 SEP 2 9 M,o TOM URAM DIRECTOR L. REX EHUNG, M.D. HEALTH OFFICER ENVIRONMENTAL HEALTH DIVISION ROBERT E MERRYMAN, R. 8. MPH DEPUTY -DIRECTOR MAILING ADDRESS: P.O. BOX-355 SANTA ANA, Ck92702 Subject: Soil and Groundwater Contamination Located At 870'Santa Barbara, Newport Beach, California 92660 Dear, Mr,. Simpson Based on inspections and field tests conducted on August 31, 1988 it has been determined that gasoline contaminated soil and groundwater, are pres- ent at the subject location. This Agency is authorized to enforce the State Hazardous Waste and Under- ground Storage Tank Laws and Regulations and, under, contract with the State Water; Resources Control Board, is responsible for oversight of cleanup of soil and ground water contamination resulting from unauthorized releases from underground storage tanks. By this letter, you are directed to conduct an investigation to assess the extent and significance of contamination at the site specified in the subject above. The Objective of this site investigation is to provide sufficient informa- tion to evaluate 1) the sensitivity of the site, 2) the potential threat of exposure to humans, 3) remedial actions and/or alternative mitigation strategies. At a minimum this investigation should include: 1. A clear delineation of the nature and extent of soil and ground water: contamination. 2. A hydrogeological characterization'including depth to ground water, and, if ground water, is contaminated, site specific determination of ground water, gradient. 3. The proximity to wells and surrounding land uses; and future use of the site itself. 4. The potential impacts of contamination to public health and the environment. Donald Simpson Page 2 The California Code of Regulations, Title 23, Subchapter, 16, Section 2652 requires that the following information be reported to the local agency every three (3) months until cleanup is complete: 1. The results of all investigations completed at that time to determine the extent of soil or, ground water or: surface water; contamination due to the release. 2. Method of cleanup implemented to date, proposed cleanup actions, and approximate cost of actions taken to date. 3. Method and location of disposal of the released hazardous substance and any contaminated soils or ground water, or surface water (indicate whether a hazardous waste manifest(s) is utilized). Violation of these requirements are subject to a civil penalty of up to Five Thousand Dollars ($5,000.00) per, day. Guidelines providing further,, information relating to site assessment and the site investigation objectives are available upon request. Although not required, an initial wor,kplan or, study design may be submitted to this Agency for review and comment. If you have any questions, please contact me at (714) 834-7844. Ver: tr,ul yours, isa Casner, Hazardous Waste Specialist Waste Management Section Environmental Health LC:dsw cc: Newport Beach Fire Department Santa Ana Regional Water Quality Control Board COUNTY OF ORANGE HEALTH CARE AGENCY PUBLIC HEALTH DIVISION OF ENVIRONMENTAL HEALTH December 2, 1998 Dennis Danner, Interim City Manager -CARRY M. LEAMAN INTERIM DIRECTOR HUGH F. sTALLWORTH, M.D, MPH DIRECTOR OF PUBLIC HEALTW HEALTH OFFICER JACK MILLER, REHS DEPUTY DIRECTOR MAILING ADDRESS: 2W9 EAST EDINGER AVENUE SANTA ANA, CA 92705.4720 TELEPHONE (714) 667-3600 FAX (714) 972-0749 CERTIFIED LETTER OCHCA Case #98TI137 City of Newport Beach P.O. Box 1768 - - 3300 Newport Blvd. ! ! Newport Beach, CA 92658-8915 j ' DEC — Subject: Underground Storage Tanks^ Fire Station #3- 868 Santa Barbara Dr., Newport Beach, CA Dear Mr. Danner: THIS IS A NOTICE TO COMPLY According to our records, the underground storage tanks located at the facility listed above do not meet the State and Federal upgrade requirements. Therefore, the Environmental Health Division has not issued an Upgrade Compliance Certificate for the petroleum underground storage tank system(s) at the facility identified above. State and Federal law requires all underground storage tank systems to be properly protected against corrosion, spills and overfills by December 22, 1998 (H&SC, Chapter 6.7, Sections 25291 and 25292 and 40 CFR, Section 280). In addition, State law requires that all underground storage tank systems that store petroleum must meet the December 22, 1998, upgrade requirements or the facility will be prohibited from receiving fuel deliveries after January 1, 1999 (H&SC, Chapter 6.7, Sections 25284, 25292.3 and 25299.50). In order to comply with the December 22, 1998 upgrade requirements, and to obtain an Upgrade Compliance Certificate for petroleum underground storage tank systems, the following documentation must be submitted to the Environmental Health Division within 15 (fifteen) days of receipt of this Notice: 1. REGULATIONS (one of the following December 22, 1998, upgrade requirement options must be met for each petroleum product. and/or used oil underground storg e tank system) , Dennis Danner December 2,1998 Page 2 (A) Striker Plate I hereby certify that a proper striker plate has been installed below all tank openings that can be used for manual dip -sticking in the following petroleum product and/or used oil underground storage tank(s): HCA Tank ID #/ or Tank Volume Tank Date Tank and Contents I Manufacturer Manufactured (Please list the petroleum product and/or used oil storage tank(s) that have proper striker plate(s) installed. Include the HCA tank identification number(s) or the tank volume(s) and tank contents, the tank manufacturer(s) and the date(s) that the tanks were manufactured. Attach any available documentation to support your claim.) Authorized Signature Print Name (B) Drop Tube Mounted Catch Basket Title Date I hereby certify that a proper drop tube mounted catch basket has been installed in the following petroleum product and/or used oil underground storage tank(s): HCA Tank ID # or Tank Volume and Contents Date Installed (Please list the petroleum product and/or used oil unaergrouna storage uuucks) mitt navc a proper drop tube mounted catch basket installed. Include the HCA tank identification number(s) or the tank volume(s) and tank contents, and the date(s) that the catch basket(s) were installed. Attach any available documentation to support your claim.) Authorized Signature Print Name Title Date Dennis Danner December 2, 1998 Page 3 2. INSTAL_LATION OF SPILL CONTAINER AS REQUIRED BY SECTION 2665, ARTICLE 6. TITLE 23, CALIFORNIA CODE OF REGULATIONS -(the following December 22, 1998, upgrade requirement must be met for each petroleum product and/or used oil underground storage tank system) 0 I hereby certify that a proper spill container (with an exterior wall that is protected from galvanic corrosion, with a minimum five gallon capacity, and which either has a drain valve to allow drainage of the collected spill into the primary container or provides a means to keep the spill container empty) has been installed on the following petroleum product and/or used oil underground storage tank(s): or (Please list the petroleum product and/or used oil underground storage tank(s) that have a proper spill container installed. Include the HCA tank identification number(s) or the tank volume(s) and tank contents, and the date(s) that the spill container(s) were installed. Attach any available documentation to support your claim.) Authorized Signature Title Print Name Date (one of the following December 22,1998, upgrade requirement options must be met for each petroleum product underground storage tank) (A) Equipment that shall alert the transfer operator when a petroleum. product underground storage tank is filled to 90 percent of tank capacity by restricting the flow into the tank I hereby certify that proper ball float "vent -valve" overfill prevention equipment, which shall not be manually over -ridden, has been installed in the following petroleum product underground storage tank(s) to alert the transfer operator by restricting flow into the tank when the tank is filled to 90 percent of tank capacity: Dennis Danner December 2,1998 Page 4 HCA Tank ID # .or Tank Volume and Contents Date Installed (Please list the petroleum product underground storage tank(s) that have proper ball float valve equipment installed. Include the HCA tank identification number(s) or, the rani voiume(s) ana tanx contents, and the date(s) that the ball float valve(s) were installed. Attach any available documentation to support your claim.) Authorized Signature Title Print Name --- Date (B) Equipment that shall alert the transfer operator when a petroleum product underground storage tank is filled to 90 percent of tank capacityby activating an audible and visual alarm I hereby certify that proper audible and visual "high-level" alarm overfill prevention equipment, which shall not be manually over -ridden, has-been installed on the following petroleum product underground storage tank(s) to alert the transfer operator by activating the alarm when the tank is filled to 90 percent of tank capacity or Tank Contents I (Please list the petroleum product Alarm Model' Installed - storage tank(s)' that have proper audible' and visual alarm equipment installed. Include the HCA tank identification number(s) or the tank volumes) and tank contents, the alarm manufacturer(s), the alarm model(s) and the date(s) that the alarm(s) were, installed. Attach any available documentation to support your claim.) Authorized Signature Print Name Title Date Dennis Danner December 2,1998 Page 5 (C) Equipment to restrict flow into a petroleum product underground storage tank at least 30 minutes before the tank overfills (provided that the restriction occurs before the tank is filled to 95 percent of tank capacity) and to activate an audible alarm at least five minutes before the tank overfills I hereby certify that proper overfill prevention equipment, that shall not be manually over -ridden, has been installed on the following petroleum product underground storage tank(s) to restrict flow into the tank at least 30 minutes before the tank overfills (provided that the restriction occurs before the tank is filled to 95 percent of tank capacity) and to activate an audible alarm at least five minutes before the tank overfills: HCA Tank ID # or Tank Volume and Contents Equipment Manufacturer Model Date Installed (Please list the petroleum product underground storage tank(s) that have proper overflow prevention equipment meeting this option installed. Include the HCA tank identification number(s) or the tank volume(s) and tank contents, the overfill prevention equipment manufacturer(s), the model(s) and the date(s) that the overfill prevention equipment was installed. Attach any available documentation to support your claim.) (Please describe the overfill prevention equipment qualifying for this option; use additional pages if necessary) Authorized Signature Print Name Title Date (D) Eauipment to provide positive shut-off of flow into a petroleum product underground storage tank when the tank is filled to no more than 95 percent of tank capacity I hereby certify that proper "flapper valve" overfill prevention equipment, which shall not be manually over -ridden, has been installed in a drop tube in the following petroleum product underground storage tank(s) to provide positive shut-off of flow when the tank is filled to no more than 95 percent of tank capacity: Dennis Danner December 2, 1998 Page 6 and Please list the petroleum product underground storage tank(s) that have proper "flapper valve" equipment installed. Include the HCA tank identification number(s) or the tank volume(s) and tank contents, and the date(s) that the flapper valve(s) were installed. Attach any available documentation to support your claim.) Authorized Signature Print Name Title Date (E) Equipment to provide positive shut-off of flow into a petroleum product underground storage tank so that none of the fittings located on the top of the tank .are exposed to product due to overfilling I hereby certify that overfill prevention equipment, which shall not be manually over- ridden, has been installed on the following petroleum product underground storage tank(s) to provide positive shut-off of flow into the tank so that none of the fittings located on the top of the tank are exposed to overfilling: HCA Tank ID # or Tank Volume and Contents Equipment Manufacturer Model Date Installed (Please list the petroleum product underground storage tank(s) that have a proper overtlow prevention equipment meeting this option installed. Include the HCA tank identification number(s) or the tank volume(s) and tank contents, the overfill prevention equipment manufacturer(s), the model(s) and the date(s) that the overfill prevention equipment was installed. Attach any available documentation to support your claim.) (Please describe the overfill prevention system qualifying for this option; use additional pages if necessary) Dennis Danner December 2, 1998 Page 7 4. Authorized Signature Print Name Title Date WALL UNDERGROUND STORAGE TANK SYSTEMS) CONTAINING WASTE OIL AS REQUIRED BY SECTION 2666, ARTICLE 6, TITLE 23, CALIFORNIA CODE OF REGULATIONS -(one of the following December 22, 1998, upgrade reuuirement options must be met by each used oil underground storage tank system) (A) Euuil2ment that shall alert the transfer operator when a used oil underground storage tank is filled to 90 percent of tank capacity by activating an audible and visual alarm I hereby certify that proper audible and visual "high-level" alarm overfill prevention equipment, which shall not be manually over -ridden, has been installed on the following used oil underground storage tank(s) to alert the transfer operator by activating the alarm when the tank is filled to 90 percent of tank capacity; I am aware that this option allows for the tank vent line and riser, any tank fill riser and any remote fill lines and risers to remain as "unregulated" piping: HCA Tank ID # or Tank Volume and Contents Alarm Manufacturer Model Date Installed (Please list the used oil underground storage tank(s) that have proper audible and visual alarm equipment installed. Include the HCA tank identification number(s) or the tank volubie(s) and tank contents, the alarm manufacturer(s), the alarm model(s) and the date(s) that the alarm(s) were installed. Attach any available documentation to support your claim.) Authorized Signature Title Print Name Date (B) Eauinment that shall alert the transfer operator when a used oil underground storage tank is filled to 90 percent of tank capacily by restricting the flow into the tank I hereby certify that proper ball float "vent -valve" overfill prevention equipment, which shall not be manually over -ridden, has been installed in the following used oil underground storage tank(s) to alert the transfer operator by restricting flow into the tank when the tank is filled to 90 percent of tank capacity; I also certify that while this Dennis Danner December 2,1998 Page 8 option allows for the tank vent line and riser to remain "unregulated", both the tank fill riser and any remote fill lines and risers must be secondarily contained and continuously, electronically monitored as "regulated" piping: HCA Tank ID # .or Tank Volume and Contents Date Installed (Please list the used oil underground storage tank(s) that have proper ball float valve equipment installed. Include the HCA tank identification number(s) or the tank volume(s) and tank contents, and the date(s) that the ball float valve(s) were installed. Attach any available documentation to support your claim.) Authorized Signature Title Print Name Date (C) Claim of "local agency overfill prevention equipment waiver" as provided by Section 2635(b)(3) Article 3 Title 23 California Code of Regulations4for double walled, used oil underground storage_tank systems, including vent line) I hereby certify that the following used oil underground storage tank system(s) qualify for the "local agency overfill prevention equipment waiver" because the tank inlet exists in an observable area, the spill container is adequate to collect any overfill, and the tank system is filled by transfers of no more than 25 gallons at one time; I also certify that this option requires that the tank fill riser, any remote fill lines and risers and the vent line and riser must be secondarily 'contained and continuously, electronically monitored as "regulated" piping. HCA Tank ID # .or Tank Volume and Contents Date Claimed ,(Please list the used oil underground storage tank(s) to be claimed for the "local agency overfill prevention equipment waiver". Include the HCA tank identification number(s) or the tank volume(s) and tank contents, and the date(s) when the tank(s) first qualified for the waiver. Attach any available documentation to support your claim) Dennis Danner December 2, 1998 Page 9 5. Authorized Signature Title Print Name systems) Date ' I hereby certify that all metal pipeline fittings (i.e., elbows, tees, couplings, reducers, adapters, swing joints, flex -lines, etc.) under product dispenser(s), along piping runs, ,at tank sumps or at risers, for the following petroleum product and/or used oil underground storage tank system(s), have corrosion protection (i.e., cathodic protection, isolation, etc.) installed: Q HCA Tank ID # or Tank Volume and Contents Method.. Date Installed (Please list the petroleum product and/or used oil underground storage. tanks) that have corrosion protection for pipeline fittings (i.e., deep dispenser pans, flex boots, etc.) installed. Include the HCA tank identification number(s) or the tank volume(s) and contents, the method(s) of corrosion protection utilized and the date(s) that the corrosion protection devices(s) were installed. Attach any available documentation to support your claim.) Authorized Signature Print Name Title Date ARTICLE 7, TITLE 23, CALIFORNIA CODE OF REGULATIONS (A) , Temporary Closure Underground storage tank system(s) that cannot meet tank upgrade requirements by December 22, 1998, but are to be returned to service in the, future after being upgraded, may be "temporarily closed" for a period of up to twelve (12) months. Plans for temporary closure must be approved by the Environmental Health Division prior to Dennis Danner December 2, 1998 Page 10 implementation and the contents of the tank emptied by December- 22, 1998. Contact the Environmental Health Division if you plan to implement this option. (B). Permanent Closure Underground storage tank system(s) that are not planned to be upgraded must be "permanently closed" (i.e., abandonment -in -place or removal). Plans for permanent closure must be approved by the Environmental Health Division prior to implementation and the contents of the tank emptied by December 22, 1998. Contact the Environmental Health Division if you plan to implement this option. Upon receipt of this completed certification document, and the requested information, the facility identified above will be inspected by the Environmental Health Division to verify the information received. If the inspection verifies that the information received is satisfactory and the facility is found to be in compliance with all the provisions of the law and regulations, an Upgrade Compliance Certificate for the petroleum underground storage tank system(s) will be issued to the facility. If, after December 22, 1998, the required information has not been received by the Environmental Health Division, or an inspection reveals that the facility is not in compliance, the facility identified above will be in violation of the upgrade requirements, will not receive an Upgrade Compliance Certificate, and the Environmental Health Division may initiate legal action against the owner and/or operator of the underground storage tanks. If convicted, the owner and/or operator can be subject to civil penalties of up to five thousand dollars ($5,000) for each day of violation. All information requested, including this document, should be returned to: County of Orange Health Care Agency Environmental Health Division Hazardous Materials Management Section 2009 E. Edinger Ave Santa Ana, CA 92705 If you have any questions regarding this matter, please contact Brenda Puepke at (714) 667-3787. rry L. 'er, HS Supervising Hazardous Waste Specialist Hazardous Waste Management Section Environmental Health Division TLC:dap cc: Jan Sturla, District Attorney's Office ' Michael Pisani, Facility Operator 1/22/93 NEWPORT BEACH FIRE DEPT. - HAZARDOUS MATERIALS DISCLOSURE REPORT PART I: CRITERIA FOR DISCLOSURE - PART I -A (CHECK ONE) [ ] No chemicals are used in any way (complete Parts II and IV). [ ] Chemicals are used in our company but do not meet the requirements for disclosure (complete parts II and IV). [ ] Chemicals are used in our business (complete all parts). PURPOSE OF DISCLOSURE - PART I-B (CHECK ONE) [ ] Annual disclosure report (due prior to MARCH 1 annually) Change in business name, address or ownership (CIRCLE ONE) [ ] Change in quantity of previously disclosed hazardous material. [ ] Addition of previously undisclosed hazardous material. PART II: GENERAL INFORMATION If the following information is incorrect please lineout and update. Fill in any blank spaces. BUSINESS NAME: CNB - Fire Dept BUSINESS ADDRESS: 868 SANTA BARBARA DR CITY: Newport Beach MAILING ADDRESS: 868 Santa Barbara Dr Newport Beach, CA 92660 CONTACT NAME 01: Scott Allan TELEPHONE: 644-3363 CONTACT NAME 12: TELEPHONE: OWNER'S NAME: City of Newport Beach TELEPHONE: 644-3106 OWNER'S ADDRESS: 3300 Newport Blvd, Newport Beach EMERGENCY NAME #1: Battalion Chief TELEPHONE: 644-3363 EMERGENCY NAME #2: TELEPHONE: 911 (DESCRIPTION OF BUSINESS OPERATION: Fire -Station OFFICE USE ONLY: NO. OF HM: BLDG ID: 2485 LJ INV FORM SENT: -21-034,22 OCCUP ID: 2485 INV FORM RECD: 272'42 V-1 DISC: Y SENT BACK FOR CORR: CAUTION STMT: low COPY SENT TO: FIXED PROPERTY USE: 888 COPY SENT (DATE): NOTES: �j { PLEASE FILL OUT LIST OF CHEMICALS ON PART III, NEXT PAGE PLEASE COMPLETE ALL SECTIONS OF PART III PAGE THIS IS FOR 1993 ANNUAL- UPDATE ONLY. PRINT OR TYPE - ILLEGIBLE FORMS WILL BE RETURNED TO YOU! PART III HAZARDOUS MATERIALS DISCLOSURE I E ORY ORM BUSINESS NAME /V ®4 �-'YS `* Lis .Trade Secret - chemicals on separate BUSINESS LOCATION Cyst G d page-,*, (1) TN = TRADE OR COMMON NAME CN = CHEMICAL NAME OR MIXTURE COMPONENTS CONSULT MATERIAL SAFETY DATA SHEETS (2) HAZARD CLASS TABLE #1 (3) DUT ID` See- List (4) MAX. AMT. ON SITE (5)- HOW STORED TABLE , #2 - aN -s�-7,te d��'3 c ( S LOCATION OF MATERIAL IN FACILITY: 2 TN CN LOCATION OF MATERIAL IN FACILITY: 3 TN CN LOCATION OF MATERIAL IN FACILITY: 24 TN 1/ Yp3 S d �5 CN LOCATION OF MATERIAL IN FACILITY: 5 TN S I CN LOCATION OF MATERIAL IN FACILITY: CHECK HERE IF THIS PAGE CONTAINS TRADE SECRET CHEMICALS (See instructions for definition of Trade Secret) WHEN COMPLETING THIS FORM, USE INSTRUCTION SHEET AS GUIDANCE. (9 3-HMD . PKT) PAGE PRINT OR TYPE - ILLEGIBLE FORMS WILL BE RETURNED TO YOU! PART III HAZARDOUS MATERIALS DISCLOSURE IN_V/ Y FORM BUSINESS NAME /��°c� �/ `/ a a�� a.st Trade Secret chemicals on separate BUSINESS LOCATION q&Tpage * (1) (2) (3) (4) HOW TN = TRADE OR COMMON NAME HAZARD'DOT MAX. CN = CHEMICAL NAME OR MIXTURE COMPONENTS CLASS ID # ANT. STORED CONSULT MATERIAL SAFETY DATA SHEETS TABLE See ON TABLE #1 List SITE f2 6 TN CN LOCATION OF MATERIAL IN FACILITY: 7 TN ear p /a CN LOCATION OF MATERIAL IN FACILITY: 8 TN � ' °� /oC CN LOCATION OF MATERIAL IN FACILITY: 9 TN Ye � I � /0a ((`j®� �� (l CN LOCATION OF MATERIAL IN FACILITY: 10 TN 114 0- � U$ u. } CN LOCATION OF MATERIAL IN FACILITY: CHECK HERE IF THIS PAGE CONTAINS TRADE SECRET CHEMICALS (See instructions for definition of Trade Secret) WHEN COMPLETING THIS FORM, USE INSTRUCTION SHEET AS GUIDANCE. (93HMD.PKT) Within 30 days of the following events, any business shall contact the Newport Beach Fire Department, Hazardous Materials Section (644-3113) for an updated disclosure form. 1) Change of business address 2) Change of business ownership 3) Change of business name 4) Cessation of business operations 5) Use or handling of previously undisclosed materials 6) A significant change in the use, quantity or handling of a hazardous material for which disclosure has been previously made. PART V: SIGNATURE I certify, under penalty of perjury, that the above information is true anA gorrgct tp the best of my knowledge. KEEP A COPY OF INVENTORY DISCLOSURE FORM FOR YOUR RECORDS RETURN ORIGINAL FORM TO: Newport Beach Fire Department Hazardous Materials Section 3300 Newport Blvd. P.O. Box 1768 Newport Beach, CA 92658-8915 (9 3HMD . PKT) _ 4ITY OF NEWPORT BEACH FIRE DEPARTMENT BUSINESS EMERGENCY PLAN CERTIFICATION CNB - Fire Dept 868 SANTA BARBARA DR Newport Beach CA IN ACCORDANCE WITH HEALTH AND SAFETY CODE SECTION 25505(0), A HAZARDOUS „ MATERIALS HANDLER MUST REVIEW THE BUSINESS EMERGENCY PLAN AT LEAST ONCE EVERY TWO YEARS TO DETERMINE IF A REVISION IS NEEDED AND SHALL CERTIFY TO THE ADMINISTERING AGENCY THAT THE REVIEW WAS MADE AND SHALL SUBMIT ANY NECESSARY CHANGES TO THE PLAN. REVIEWING THE PLAN SHALL INCLUDE THE FOLLOWING: THE CONTACT NAMES AND TELEPHONE NUMBERS ARE CURRENT. TRAINING ELEMENTS ARE IN PLACE AND UP TO DATE. HAZARDOUS MATERIALS MANAGEMENT, STORAGE AND HANDLING HAS BEEN REVIEWED. SITE MAPS SUBMITTED ARE CURRENT. REVISIONS TO THE CURRENT BUSINESS EMERGENCY PLAN ARE NOT REQUIRED. I (WE) CERTIFY THAT I (WE) HAVE REVIEWED THE BUSINESS EMERGENCY PLAN IN ACCORDANCE WITH THE HEALTH AND SAFETY CODE SECTION'25505(c), AND THAT REVISIONS TO THE PLAN ARE NOT REQUIRED. NAME: (PRINT) SIGNATURE: TITLE: DATE: IF THE ABOVE IS NOT TRUE AND CORRECT, CONTACT THE FIRE DEPARTMENT FOR BLANK COPIES OF THE BUSINESS EMERGENCY PLAN FORMS.(714) 644-3113. C. So1-vC/vr BUSINESS EMERGENCY PLAN Newport Beach Fire Department .T T PAiy7" J7 fJi�P� Co/ylPR6SS r., �SG PS-/1,1.4 T'/G -7 11 B. G.95!oll vE' H• ,4GyT -N6 4 4j-%"oe P T A/R, Co/�IPRESSE,D E. 0/L 1/31/92 NEWPORT BEACH FIRE DEPT. - HAZARDOUS MATERIALS DISCLOSURE REPORT PART I: CRITERIA FOR DISCLOSURE - PART I -A (CHECK ONE) [ ] No chemicals are used in any way (complete Parts II and IV). [ ] Chemicals are used in our company but do not meet the requirements for disclosure (complete parts II and IV). [ ] Chemicals are used in our business (complete all parts). PURPOSE OF DISCLOSURE - PART I-D (CHECK ONE) ({{'] Annual disclosure report (cue prior to MARCH 1 annually)- [ ] Change in business name, address or ownership (CIRCLE ONE,) [ ] Change in quantity of previously disclosed hazardous material. [ ] Addition of previously undisclosed hazardous material. PART II: GENERAL INFORMATION If the following information is incorrect please lineout and update. Fill in any blank spaces. BUSINESS NAME: CNB - Fire Dept BUSINESS ADDRESS: 868 SANTA BARBARA DR SU,TE CITY: Newport Beach MAILING ADDRESS: 868 Santa Barbara Dr Newport Beach, CA 92660 CONTACT NAME #1: B '3 a '-_ , : -�- r'` TELEPHONE: 644-3303 CONTACT NAME #2: TELEPHONE: OWNER'S NAME: City of Newport Beach TELEPHONE: 644-3106 OWNER'S ADDRESS: 3300 Newport Blvd, Newport Beach EMERGENCY NAME #1: Battalion Chief TELEPHONE: 644-3363 EMERGENCY NAME #2: Dep. Bat. Chief TELEPHONE: 911 DESCRIPTION OF BUSINESS OPERATION: OFFICE USE ONLY: NO. OF HM: BLDG ID: 2485 OCCUP ID: 2485 DISC: Y CAUTION STMT: low FIXED PROPERTY USE: 888 NOTES: INV FORM SENT: INV FORM RECD : SENT BACK FOR CORK: COPY SENT TO: COPY SENT (DATE): PLEASE FILL OUT LIST OF CHEMICALS ON PART III, NEXT PAGE 2/01/91 FEB 2 4 1992 ip PLEASE COMPLETE ALL SECTIONS OF PART III PAGE PRINT OR TYPE - ILLEGABLE FORMS WILL BE RETURNED TO YOU! PART III HAZARDOUS MATERIALS DISCLOSURE IENTORY FORM BUSINESS NAME t o��� J •�'i* List Trade Secret / chemicals on separate BUSINESS LOCATION 0(0 �/Ice page (1) TN = TRADE OR COMMON NAME CN = CHEMICAL NAME OR MIXTURE COMPONENTS CONSULT MATERIAL SAFETY DATA SHEETS (2) HAZARD CLASS TABLE #1 (3) DOT ID # See List (4) MAX. AMT. ON SITE (5) HOW STORED TABLE, #2 1 TN g e � / � / 3L� ( �,� �5 CN LOCATION OF MATERIAL IN FACILITY: 2 TN CN LOCATION OF MATERIAL IN FACILITY: 3 TN CN LOCATION OF MATERIAL IN FACILITY: 4 TN L4 e d : w oleo, 9 J CN LOCATION OF MATERIAL IN FACILITY: 5 TN d'G LA CN LOCATION OF MATERIAL IN FACILITY: CHECK HERE IF THIS PAGE CONTAINS TRADE SECRET CHEMICALS (See instructions for definition of Trade Secret) WHEN COMPLETING THIS FORM, USE INSTRUCTION SHEET AS GUIDANCE. (HMD92) PAGE PRINT OR TYPE - ILLEGABLE FORMS WILL BE RETURNED TO YOU! PART III HAZARDOUS MATERIALS DISCLOSURE INVgm ORY FORM BUSINESS NAME ldl� a� e i care-S �D� * List Trade- ,Secret g chemicals on separate: BUSINESS LOCATION �p� �c� LDl�. page (1) (2) (3) (.4) HOW TN = TRADE OR COMMON NAME HAZARD DOT MAX. CN = CHEMICAL NAME OR MIXTURE COMPONENTS CLASS ID # AMT. STORED CONSULT MATERIAL SAFETY DATA SHEETS TABLE See ON TABLE #1 Last SITE #2 6 TN EX 17 CN LOCATION OF MATERIAL IN FACILITY: 7 TN 4g te A p CN LOCATION OF MATERIAL IN FACILITY: 8 TN �'� % ° 20 eQ ®$ CN LOCATION OF MATERIAL IN FACILITY: 9 TN S CN LOCATION OF MATERIAL IN FACILITY: 10 5 CN8 LOCATION OF MATERIAL IN FACILITY: CHECK HERE IF THIS PAGE CONTAINS TRADE SECRET CHEMICALS (See instructions for definition of Trade Secret) WHEN COMPLETING THIS FORM, USE INSTRUCTION SHEET AS GUIDANCE. (HMD92) R Within 30 days of the following events, any business shall contact the Newport Beach Fire Department, Hazardous Materials Section (644-3113) for an updated disclosure form. 1) Change of business address 2) Change of business ownership 3) Change of business name 4) Cessation of business operations 5) Use or handling of previously undisclosed materials 6) A significant change in the use, quantity or handling of a hazardous material for which disclosure has-been previously made. PART IV: SIGNATURE I certify, under penalty of perjury, that the above information is true_.ANd,cogrect to__the best of my knowledge. 4_15,, _F��Us NAME (pipase type or prinL) TIT E X CUTE C TY ON (DATE) KEEP A COPY OF INVENTORY DISCLOSURE FORM FOR YOUR RECORDS RETURN ORIGINAL FORM TO: Newport Beach Fire Department Hazardous Materials Section 3300 Newport Blvd. P.O. Box 1768 Newport Beach, CA 92658-8915 (92HMD.PKT) r i;. CITY OF NEWPORT BEACH FIRE DEPARTMENT BUSINESS EMERGENCY PLAN CERTIFICATION CNB - Fire Dept 868 SANTA BARBARA DR Newport Beach CA IN ACCORDANCE WITH HEALTH AND SAFETY CODE SECTION 25505(G), A HAZARDOUS MATERIALS HANDLER MUST REVIEW THE BUSINESS EMERGENCY PLAN AT LEAST ONCE EVERY TWO YEARS TO DETERMINE IF A REVISION IS NEEDED AND SHALL CERTIFY TO THE ADMINISTERING AGENCY THAT THE REVIEW WAS MADE AND SHALL SUBMIT ANY NECESSARY CHANGES -TO THE PLAN. REVIEWING THE PLAN SHALL INCLUDE THE FOLLOWING: THE CONTACT NAMES AND TELEPHONE NUMBERS ARE CURRENT. TRAINING ELEMENTS ARE IN PLACE AND UP TO DATE. HAZARDOUS MATERIALS MANAGEMENT, STORAGE AND HANDLING HAS BEEN REVIEWED. SITE MAPS SUBMITTED ARE CURRENT. REVISIONS TO THE CURRENT BUSINESS EMERGENCY PLAN ARE NOT REQUIRED. I (WE) CERTIFY THAT I (WE) HAVE REVIEWED THE BUSINESS EMERGENCY PLAN IN ACCORDANCE WITH THE HEALTH AND SAFETY CODE SECTION 25505(C), AND THAT REVISIONS TO THE PLAN ARE NOT REQUIRED. NAME: (PRINT) SIGNATURE: TITLE: DATE: IF THE ABOVE IS NOT TRUE AND CORRECT, CONTACT THE FIRE DEPARTMENT FOR BLANK COPIES OF THE BUSINESS EMERGENCY PLAN FORMS (714) 644-3113. Q/ d J ...r- a rn n A la A e g. G/t_ ( // I /. / �p .Z: PAin�T' p' 7�i �►v eR J- AIR, COMPREssE,o E. G/L BUSINESS EMERGENCY PLAN Newport Beach Fire Department PART V-B BUSINESS SITE PLAN - FACILITY LAYOUT MAP C. Sol-veNT- .Z" P�irt? D' �7�i �� cT A/R� Ca/yIPRE'SSED BUSINESS EMERGENCY PLAN Newport Beach Fire Department eJ'- AiR, Co/y/PRESSEA m.bwy m tf 4. 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Fill V . �Im a m cl Y : n 0 C 31' G a t o a 3 CAp o m 21 < 0 rn S.h A IM m s• z O fn \4 0 0 3 D r h A Z t /\� '�z m ti LU I FEB 5 1990 File Plumber 002437 THIS PERMIT MUST BE POSTED IN A CONSPICUOUS LOCATION Page Number- 1 ORANGE COUNTY HEALTH CARE AGENCY PUBLIC HEALTH I ENVIRONMENTAL HEALTH PERMIT TO OPERATE UNDERGROUND STORAGE TANKS PERMIT NUMBER NUMBER OF TANKS OPERATED ISSUANCE EXPIRATION 7023-2 UNDER THIS PERMIT 4 DATE 12-17-96 DATE 12-16=2001 FACILITY OWNER OPERATOR CITY OF NEWPORT BEACH FIRE ST CITY OF NEWPORT BEACH 868 SANTA BARBARA DR 3300 NEWPORT BLVD NEWPORT BEACH, CA 92660 P 0 BOX 1766 NEWPORT BEACH, CA 92658-871 R E M E W A L The underground storage tanks (USTs) located at this facility are permitted to operate provided the following conditions are complied with: 1. Any changes to the information {provided in the UST permit application must be reported, within thirty (30) daysv to this Agency. 2. The replacements repair7 or upgrade of all or part of any UST or pipes connected thereto must be reported7 and approved by this Agency, prior to the commencement of work. 3. All unauthorized releases must be reported to this Agency within the time limits and according to the manner specified in Title 23, Sections 2650-55 of the California Code of Regulations (CCR). 4. Written records, as required by Section 2712(b)v of Title 23Y CCR: of all monitoring & maintenance performed shall be maintained on -site for a period of at least three (3) years from the date the monitoring was Performed. Written records of all monitoring and maintenance performed in the last -three (3) years shall be shown to representatives of this Agency upon request during any site inspection. 5. If ownership of the USTs is transferred* the new owner must submit a Transfer of Ownership application to this Agency within thirty (30) days of the change in ownership. 6. This permit is valid for a period of five (5) years from the date of issuance. An application for renewal must be made by the owner of the UST and received by this Agency prior to the expiration of this permit. 7. The USTs must be monitored in accordance with the approved method. This man-itoring method is identified below and can be found in Sections 2632 & 2640-48 of Title 23v CCR and Sections 25291 & 25292 of the Health and Safety Code (44&SC). 13. The USTs must be properly closed in accordance with the requirements of Sections 2670-72v of .Title 23a CCR and Section 25298 of the H&SC.- Section 25299 of the H&SC states that owners and operators of USTs are liable for civil penalties of not less than Five Hundred Dollars ($500.00) or more than Five Thousand Dollars (S5,000.00) per day for violating the conditions of the permit or any other provisions of the UST law or regulations. ANK * a MONITORING METHOD 0 -02S-001 33-NEW DBL WALL TANKS/CONTINUOUS LEAK DETECTORS/DOUBLE WALL PIPING L23-0f52 33-NEW DBL WALL TANKS/CONTINUOUS LEAFS DETECTORS/DOUBLE WALL PIPING �;23-003 33-NEW DBL WALL TANKS/CONTINUOUS LEAK DETECTORS/DOUBLE WALL 01,PINSS W.&d-005 33-NEW DBL FALL TANKS/CONTINUOUS LEAK DETECTORS/DOUBLE WALL PIPING UNDERGROUND STORAGE TANK PROGRAM OFFICE ADDRESS: 2009 E. EDINGER AVE, SANTA ANA, CA 92705 MAILING ADDRESS: P.O. BOX 355, SANTA ANA, CA 92702 TELEPHONE: (714) 667.3700 F0272-9.1528.2 2*: !"DF -V&,2\cumuiwnoj1a FENN mmommmm mvrr bibim .01-002 wnm ow my amommonom Fm DMEC1002WOMFE PTV VMG :31-05 n-vom PBF myrF wwwwwoAnum FEW wwwowwwmm MVFF blblWe 31-101 32-vEm ow mwrF immsomionow rEVK DELECA92nown mvFr bibive MK * e WOMIMMS MAC 0 1 w nsi ivu — wasymovie, (VAIUMM*00% bay qSA fOL A101WITUI YPS C3JqjjjDUQ Of jPS KIM VL SUA,M;PS6 WAYaQUa Of- 0:301se 0, 00; 1662 AM LIAS H"1:q6GQ DOITSIR 1*2614M) lb W064 ;PSU }:PAO 1ponaouq pmj79kE- 28L,7oj 52mZ. of fpF HWEV Ejw;S2 Zp9f OMUS6a allq CbeSSLUOZ Q nejO 06S IISPJS +00 QQ! , 3910-M Of ITTIS F34 CZB VU4 28CADU WAS S! 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BENCH MA OL WEMbOd! PEVCH S2-5 hy;* mnwp.l Q-MIRR MAY 1 '69 13:53 TRUSCO TANK FRESNO PAGE.01 },a. ►r.•, Mvst�:' nag: • ' iii.'444iL{►� TRUSCO TANK INC. T5LECOPrER COVER 1HE&I DATE 1.. 781 T XME. STARTED t PROJECT NOt 0 DELIVER THE FOLLOWING PAGES TO t NAMES COMPANY t.t: TEL.ECOP(/U I" ERPHONE NO t 91 TELECOPY FROM t NAME t WE ARE TRANSMITTING PAGES INCLUDING THIS COVER LETTER. IF TRANSMISSION IS INCOMPLETE* PLEASE CALL 209-264-4741. P.O, Box 11925, Fresno, CA 93775 (209) 264.4741 MAY I IE39 13:54 TRUSCO TANK FRESNO PAGE.02 TRUSCO TANK INC. T om It May Concern, This is to certify that the sUPL1tTANK(S) purchased by Luba Lift located at 16639 Valley.View, Cerritos, CA, for the City of Newport Beach projects to be installed at Corner of superior & Industrial Way and , $73 Santa Barbara Ave. and 810 Santa Barbara Ave. and 32cnd St. & rills Way, Newport beach, CA are methanol compatible. This certification is based upon the following performance and test criteria: 1) PRIMARY "DANK The primary tank is a UL58 steel tank. UL58 steel tanks are compatible with 85% and 100% Methanol. UL58 steel tanks are intended for -use with Oil Burning Equipment, NFPA-•30 and Flammable and Combustible Liquids Codes XFPA-30. Methyl Alcohol is listed as a flammable liquid in NFPA-30. UL58 steel tanks have a history in application of compatibility with Methanol. Our tanks are shipped with a UL58 label with serial number. The Trusco Tank Inc. 30 year warranty specifically addresses Methanol. 2) SECONDARY CONTAINMENT (TANK) The secondary containment of the 3VPE'aTANK is Fiberglass Reinforced Plastic which has an Isopthalic resin base. The primary and secondary containment vessels bnve been in a tasting program with Underwriters Laboratories since December of 1987. The fuel tests have been completed at this time. Tests indicate our FRP satisfactorily meets the requirements for compatibility as a secondary containment material. 3) CONTAINMENT RINGS AND RISERS The containment rings and risers are made of the same FRP as the Secondary Containment of the B.UPERTANK. Date: ^q Sales Order No(s).: 3220 and 3221 Tank Site(s): 2 - 12,000 91. UL No(s)•: 1 20,000 al. 1 - 6,000 gI. 1 675 al. 12m J497133 And J497136 20m ! J497134 Sn J497137 675 J497111 P.O. Pox 11925. Fresno. CA 93775 (209) 264.4ZIl _ _.. .._. ... .�