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UNIFIED PROGRAM CONSOLIDATED FORM CITY OF ANAHEIM FIRE DEPARTMENT ENVIRONMENTAL PROTECTION SECTION 201 S. ANAHEIM BOULEVARD, SUITE 300, ANAHEIM, CA 92805 PHONE: (714) 765-4050 FAX: (714) 765-4608 SPECIAL WASTE GENERATOR CONTINGENCY PLAN A. General Information This form is to be completed and returned to the City of Anaheim Fire Department (CUPA) if your facility has hazardous waste and none of the individual hazardous waste quantities equals or exceeds 55 gallons for liquids, 500 pounds for solids, or 200 kilograms. If, at any time, any of your individual hazardous waste quantities equals or exceeds the above amounts, a Hazardous Materials Business Plan (HMBP) may be required (pursuant to Chapter 6.95 of the California Health & Safety Code). If you must submit a HMBP, this special generator form is not required. B. Facility Information Business Name: Type of Business: Site Address: City: ANAHEIM Zip Code: Mailing/Billing Address: (if different from site address) City: Zip Code: Business Owner/Contact Person: Phone Number: Property Owner: Phone Number: EPA ID Number: SIC Code: C. Hazardous Waste Inventory Information Complete the table below for all waste inventories. Use additional pages if needed. State/EPA Waste Code Name of Hazardous Waste Treatment/Disposal Method(s) (Definitions provided on bottom of page) Max. Qty. (At any one time) Annual Qty. Generated Location(s) Refer to Site Map Recycled on-site. Treated on-site. Shipped off-site for recycling/treatment/disposal Kg. Gal. Lbs. Kg. Gal. Lbs. Recycled on-site. Treated on-site. Shipped off-site for recycling/treatment/disposal Kg. Gal. Lbs. Kg. Gal. Lbs. Recycled on-site. Treated on-site. Shipped off-site for recycling/treatment/disposal Kg. Gal. Lbs. Kg. Gal. Lbs. Check if N/A NOTE : APPLIES ONLY TO PHOTOGRAPHIC WASTE GENERATOR 541 Fixer and or developer liquid waste containing silver Recycle (fixer shipped off-site for recycling) Treated, then sewer (sludge sent off for further reclamation) Kg. Gal. Lbs. Kg. Gal. Lbs. 171 Sludge containing silver generated from the treatment of fixer solution Recycle (fixer shipped off-site for recycling) Treated, then sewer (sludge sent off for further reclamation) Kg. Gal. Lbs. Kg. Gal. Lbs. Certification: Based on my inquiry of those individuals responsible for obtaining the information, I certify under penalty of law that I have personally examined and am familiar with the information submitted and believe the information is true, accurate, and complete. SIGNATURE OF OWNER/OPERATOR OR DESIGNATED REPRESENTATIVE DATE 134 NAME OF DOCUMENT PREPARER NAME OF SIGNER (print) 136 TITLE OF SIGNER UP FORM (04/2004 Version) OFFICE USE ONLY CITY OF ANAHEIM FIRE DEPARTMENT CUPA REVIEWED BY:_________REVIEWED ---PAGE BREAK--- EMERGENCY RESPONSE PROCEDURES 1. EVACUATION PROCEDURES: Notify employees to evacuate by shouting or fire alarm. Employees will exit through nearest exit door. Refer to evacuation map. Emergency Coordinator will be available to assist emergency responders. 2. NOTIFICATION PROCEDURES: In an event of a release or threatened release of a hazardous material the following agencies are to be notified. a. Local Emergency Response Agencies 911 b. Anaheim Fire Department (714) 765-4050 c. State Office of Emergency Services (800) 852-7550 or (916) 845-8911 3. EMERGENCY PROCEDURES: Main concerns: FIRE AND CHEMICAL SPILL If there is a fire or medical attention is needed, call 911. Fire – Employees will notify local Fire Department. If safe, mechanics will shut off power and attempt to control fire using fire extinguishers. If a volatile, flammable material is spilled, immediately warn everyone, control sources of ignition and ventilate the area. Notify your Supervisor and Management of the accident as soon as possible. Small Spill – Apply absorbent material to the affected areas and allow it to absorb the chemical. Employees will use proper protective clothing and safety equipment. Waste will be placed in a labeled waste drum. Large Spill – Employers will notify the Fire Department. Trained employees will use proper safety equipment and attempt to prevent spill from entering storm drain or running off site. If safe, a cleanup contractor will be called to remove spill as necessary. 4. EMPLOYEE TRAINING: Training will be done annually and shall include topics in regards to: a. Procedures for handling hazardous materials, including hazardous wastes - hazardous waste storage, handling, and labeling. Review proper methods for all hazardous waste disposal and record keeping requirements, review MSDS and safety procedures for materials handling. b. Coordination with Emergency Response Agencies - review of emergency response plan and emergency notification procedures to ensure coordination with the local Fire Department, paramedics and clean up contractor. c. Use of emergency response equipment and materials under the business’ control- annual inspection and maintenance of safety equipment such as fire extinguishers, eyewash stations, and review of procedures for proper use of safety and spill control equipment. d. Emergency Response Plan-review emergency response plan, evacuation procedures, location of emergency shut-off switches and specific responsibilities of all employees. Remind employees of the location of the emergency response contingency plan. 5. EMERGENCY EQUIPMENT: Describe Materials (Check only that applies) Location or Area PERSONAL PROTECTIVE & SAFETY EQUIPMENT Safety Glasses Cartridge Respirators Gloves SCBA (Self-Contained Breathing Apparatus) Coats Exhaust Hoods Chemical Suits First Aid Stations Boots Chemical Antidote Hard Hats Other: First Aid Kits EMERGENCY RESPONSE EQUIPMENT “Ultrasorb” absorbent material Fire Extinguishers (Type A, B, C, D) Metal Scoop or Dust Pan Fire Hose Broom or Brush Chemical Monitoring Equipment Chemical Waste Bags Chemical Alarm /Bells Eye Wash, Safety Showers Other: COMMUNICATIONS EQUIPMENT Alarms Verbal Phone / cell / Portable Radio Other: Intercom STRUCTURAL EQUIPMENT Berms and Dikes Tanks (Emergency) Containment (secondary) Other: UP FORM (04/2004 Version) OFFICE USE ONLY CITY OF ANAHEIM FIRE DEPARTMENT CUPA REVIEWED BY:_________REVIEWED ---PAGE BREAK--- EMERGENCY PROCEDURES Post near telephones and as appropriate In case of a fire, spill, or other emergency involving hazardous chemicals or wastes, do the following: Major Emergency ⇒ Evacuate the affected areas per the facility Evacuation Plan ⇒ Call 911 and report the emergency ⇒ Report the emergency to the facility Emergency Coordinator Minor Emergency ⇒ Try to control the emergency if you are trained to do so and can do it safely ⇒ Report the emergency to the facility Emergency Coordinator Facility Emergency Coordinators (EC) Name Work Phone 24 Hour Phone Primary EC: Alternate EC: Emergency Agencies Agency Phone No. Fire Department, Ambulance, Police 911 Governor’s Office of Emergency Services (800) 852-7550 Anaheim Fire Department (Local CUPA Agency) (714) 765-4050 Emergency Equipment Locations of fire extinguishers, fire alarms (if any), and equipment for controlling chemical spills are shown on the facility site plan posted with this notice. This document is only a summary of emergency procedures. Refer to this facility’s written emergency response plan for detailed procedures. UP FORM (04/2004 Version) OFFICE USE ONLY CITY OF ANAHEIM FIRE DEPARTMENT CUPA REVIEWED BY:_________REVIEWED ---PAGE BREAK--- UNIFIED PROGRAM CONSOLIDATED FORM CITY OF ANAHEIM FIRE DEPARTMENT ENVIRONMENTAL PROTECTION SECTION 201 S. ANAHEIM BOULEVARD, SUITE 300, ANAHEIM, CA 92805 PHONE: (714) 765-4050 FAX: (714) 765-4608 SPECIAL WASTE GENERATOR CONTINGENCY PLAN SYMBOLS Fire Control Room Tank Monitoring Water Main Gas Main Electrical Sewer Manhole Storm Drain Knox Box Hazardous Materials Safe Refuge Area Elevator Stairs Door Aboveground Tank Underground Tank Hydrant Sprinkler Connection Standpipe Railroad Fences North Arrow UP FORM (04/2004 Version) OFFICE USE ONLY CITY OF ANAHEIM FIRE DEPARTMENT CUPA REVIEWED BY:_________REVIEWED ---PAGE BREAK--- UNIFIED PROGRAM CONSOLIDATED FORM CITY OF ANAHEIM FIRE DEPARTMENT ENVIRONMENTAL PROTECTION SECTION 201 S. ANAHEIM BOULEVARD, SUITE 300, ANAHEIM, CA 92805 PHONE: (714) 765-4050 FAX: (714) 765-4608 SPECIAL WASTE GENERATOR CONTINGENCY PLAN SITE MAP BUSINESS NAME: SITE ADDRESS: CITY: ANAHEIM ZIP CODE: DATE MAP DRAWN - - MAP # FACILITY ID A B C D E F G H I J K L 1 2 3 4 5 6 7 8 9 10 11 12 UP FORM (04/2004 Version) OFFICE USE ONLY CITY OF ANAHEIM FIRE DEPARTMENT CUPA REVIEWED BY:_________REVIEWED