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aQ�� California Self-Inspection Form for Business Plans, Hazardous Waste and Hazardous Materials (HWIHM) kz Zip Lour Lecat California Self-Inspection Form for Business Plans, SEC Hazardous Waste and Hazardous Materials HWIHM Tws IJlOR TYPE OF CONTAINER: SECTION II: HAZARDOUS WASTE CONTAINER IDRUMS)iNs CCU -TIONB COMPLETE WEEKLY 4 ❑ 55 GALLON DRUM THIS SECTION TO BE COMPI-ETED BY ALL RYDER CALIFORNIA FMS FACILITIES ❑ OTHER; (1) (z) hi (4) (S) (e) (7) DA' STORAGE AREA USED -- FREE OF SPH-(S - ANTIFgEE2E{9 ANo LEAkS COMPLETEb CA CoNTAINGhs INGCNIPAV ILE wAeTE STORED ANTWIR ONLY IN MONTH (INCLUDINe CONTAWLIi3, HAZAndOU1,: CI.0403 WASTE- � 'WIThIIN: 30-GALLON SECONaARY PROPERLY WASTE tJ.LLEL9 WHEN NOT IN PROPERLY ALLOWED CONTAINER(s)OR INSPECTED BY: DAY CONTANIVENT LABELED VISIBLE USE 95P r%kTE6 TIMEFRAM@ W KoDL•KAgT PRINT NAME ❑Yes❑NO ❑Yes❑No ❑Yes❑No ❑Yes❑No ❑Yes❑No ❑Yes❑No ❑Yos❑Ne ❑Yes❑No ❑Yes❑No ❑Yes❑No ❑Yes❑No ❑Yes❑No ❑Yos❑No ❑Yes❑Na ❑Yes❑No ❑Yes❑No ❑Yes❑No ❑Yes❑No ❑Yes❑No ❑Yos❑No ❑'ras❑No ❑Yes❑No ❑Yes❑No ❑Yes❑No ❑Yes❑No ❑Yes❑No ❑Yes❑NO ❑Yes❑NO ❑Yes❑No 0 Yes❑No ❑Yes❑No ❑Yes❑No :]Yes❑No ❑Yes❑No ❑Yes❑No ❑Yes❑No ❑Vrs❑Na ❑Yes❑No ❑Ves[]Nr� ❑Yes❑No ❑Yes❑No ❑Yes❑No SECTION III: HAZARDOUS MATERIAL BUSINESS PLAN- MSP (COMPLETE MONTHLY) THIS SECTION TO BE COMPLETED BY ALL RYDER CALIFORNIA FMS FACILITIES, �t-K 1 iO• 1 CERS information is up-to-date and a copy of the HMBP Is riled In Green File Folder No.4,1. Yes ❑No 2 HMBP and/or Tank Permit is current and posted. T Yes No Note date of HMBP and/or Tank Permit expiration date date,month,year). . Note HMBP Permit Issue Date, , Z4 . Note Tank Permit Issue Date. (Note NIA if facility's HMBP and Tank Permit are the same document or if facility does not require a Tank Permit 3 Annual HMBP Employee Training(EV300)has been completed and a copy of the Training Log is filed in Green File dyes ❑No Folder No.24.7. Far[raining requirements,refer to EPC Procedure No.2.16, 4 Facility's HMBP Sitemap is current and posted in facility's common areas. es No 5 Have any significant changes occurred,as defined below? If yes,notify Ryder Fuel Services immediately. Yes C01 ND - Any newly acquired hazardous material. - A 100%or greater increase in the quantities of materials previously reported within location's inventory. - Any changes to the contact information listed within the HMBP emergency contact page? E .:New OMs.FOMs,TICS 6 Emer enc Res onse and/or Contingency Plans are available for inspection and are filed In Green File Folder No.5.1. 0Yes ❑No IMPORTANT—IF SUPPORT IS NEEDED TO RESOLVE ANY ISSUE(S)IN SECTION III ABOVE,EMAIL RYDER FUEL SERVICES(RFS) AT(COMPLIANCE@@ RYDr;RFs,COM)AND ATTACH A SCANNED COPY OF THIS COMPLETED FORM. NOTE YOUR REQUEST(S)IN THE COMMENTSICORRECTIVE ACTION SECTION BELOW. SECTION IV: CESIGNATED OPERATOR(DO)AssURANGE REVIEws (COMPLETE MONTHLY) THIS SECTION TO BE COMPLETED BY ALL RYDER CALIFDRNUt FMS FACILITIES WITH LISTS MONITORED BY A 3RD PARTY VENDOR EXAMPLES: TAIT ENVIRONMENTAL,BALCH&BINomm ENVIRONMENTAL'ETC. 1 GoOV of 3rd Party Vendor's(DO)Certification is current/valid and filed In Green File Folder No.30. ZRaIder2,y s ❑Nc Proof of UST Owner's Statement of Designated UST Operator expiration dates are current and filed in Green File s ❑Ns 2 No.30.Copies of DO's monthly inspections have been reviewed and signed within 72 hours. Alarm history report and an ❑N3 u items have been resolved and noted. Co ies are filed in Green File Folder No,35.4 Proof Of site em ID ee trainin is current and filed in Green File Folder No,30. s ❑N Copies of current year passing Annual Testing(i.e.Leak Detector test,ATG Certification,Shear Valve and Spill Bucket [ yes ❑f, 5 tests)are filed in Green File Folder No.36. Note dale,month, ear of Iasi passing test: Copy of current(within 3 years of current calendar year)passing SB989 Secondary Containment Testing is filed in Green [3'Yes ❑1 6 File Folder No.36. Note date,month, ear of last passing SB989 test: Copy of current year's(October of current calendar year)Financial Responsibility is filed In Green File Folder ND,32 or 5.1 Yes ❑ 7 CERS. a� COMMENTS I CORRECTIVE ACTIONS TAKEN: PLEASE READ BEFORE SIGNING:' - — • THE FACILITY MANAGfA(OM,50Mi OR FOM).MAY DELFaATP COMPLETION OF THE ES-47 TO OTHER SHOP EMPLOYEES SUCH AS SUPERVISORS,TICS,CSSS,AND TECHNICIANS,HOWL'VERj'CI, NtY THE FACILITY MANAGER I FIELD OPERATIONS MANAGER CAN SIGN THIS FORM, BY SIGNING BELOW,THE FAC1UTYMANAQER/FfELA OPERATIONS MANAGERS CONPIRMS REVIw)AIgD(CERTIFIES COMPLETION)OF THIS FOI ` TiT LE ^ SIGNATURE: lrJ' FOR ASSISTANCE,CONTAC/TRY,DER ENVIRONMENTAL SERYIC ENVIRONMENTAL_SERVICES�Ia RYDER.CDM) Retention Period: Inde LS-17(061207.1)-Page 2 of 2 File Indellnitely In the Quarterly Cafifornia HMBP Self Inspection Form Fat