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� lowr <br /> ,'y �, - "fir Yn►.�. _.. <br /> 10590 Armstrong Avenue•Suite A•Mather,CF 9565/ 5 ems e 8 am-tY.net 9161875.8550•FAX:9161875-8513 <br /> On the web: <br /> CESQG/SQG Emergency Response Procedures Certification Form <br /> Eligibility A generator of less than 270 gallons of hazardous waste per month and who is not subject to <br /> Hazardous Materials Business Plan requirements is exempt from written Contingency Plan <br /> requirements. <br /> Consult the back page of this document titled Contingency Plan Exemption for CESQGs/SQGs to <br /> determine whether you are eligible for the Contingency Plan Exemption. <br /> Alternate A CESQG or an SQG is not required to prepare a full written Contingency Plan. However, a <br /> ingency Plan requirements must still implement specific <br /> requirements CESQG or SQG exempt from Cont <br /> emergency response procedures described in Section II below. <br /> What you must 1. Complete the Emergency Coordinator and Equipment Information(Section 1)of this <br /> do document and return to the Environmental Compliance Division(ECD). <br /> 2. Post a copy of this form by your facility telephone(s). <br /> , e <br /> j FACILIIYNAME: 1005 E- P'_sC er A. � 117FACILITYdD#: ` <br /> FACILITY ADDRESS: CITY&ZIP: $,.L^�w�0 ?j 0Y <br /> EMERGENCY I Name: Phone#: Always On-Site ❑ <br /> COORDINATOR IS: Q770On-Call <br /> LOCAL FIRE DEPT PHONE'NUMBER: <br /> Equipment Locations <br /> Fire Extinguishers Spill Control Materials Fire Alarm(if any) <br /> 'Z 1 n tk lcwcPon, ( u L)19 Doc <br /> Name of document preparer: Signature of document Preparer: Phone#: <br /> ------ ----------- Qlfo Z 7cl <br /> ------------ t------ 9 3 7I3 <br /> ---- - - ------------' <br /> ' POST COPY BY THE TELEPHONE(S). <br /> If a>re occus; Call the Fire Department,and, if safe,attempt to extinguish the fire using fire extinguishers. <br /> if a spill occurs: P 9 9 g I ` <br /> Contain the flow of hazardous.waste to the extent possible. Clean up the hazardous wast s <br /> --and any-contaminated soil or materials as soon as <br /> resultant hazardous waste. pessit •"Properly dispose of <br /> /f fire,explosion or If human health Or the environment beyond the facility is threatened <br /> release threatens <br /> surface water, call the National Response Center at 1-800 424-8802 (24 houror if a lnumber) and <br /> human health or provide the following information: <br /> environment outside <br /> facility: 1. Facility name&address <br /> 2. Facility EPA ID# 5. Time of accident <br /> 6. Specify injuries,if any <br /> i 3. Amount of hazardous waste involved quantity p <br /> ---------__-_-_-_- 4. Accid*t date Estimate uantit &disposition of recovered materials,if any ; <br /> ' MW:B�6118/d9 Vi4lDalaIFORMSARCHIVEIHMWMPIHMPICESDGSQG EMERG RESP -------------- <br /> ---------- <br /> M* <br /> ' <br /> CERT FpRM.doc <br /> y Page 1 <br />