HomeMy WebLinkAbout2411 F STREETUNIFIED PROGRAM CONSOLIDATED FORM
FACILITY INFORMATION
BUSINESS ACTIVITIES
Page 1 of _
I. FACILITY IDENTIFICATION
FACILITY ID # EPA ID # (Hazardous Waste Only) 2
Agency Use Only) CAD981663347
3
BUSINESS NAME (Same as Facility Name of DBA -Doing Business As):
Boys Store #0622Pep
BUSINESS SITE ADDRESS
2411 F Street 103
BUSINESS SITE CITY CA ZIP CODE
Bakersfield 104 93301 105
II. ACTIVITIES DECLARATION
NOTE: If you check YES to any part of this list,
please submit the Business Owner /Operator Identification page (OES Form 2730).
Does your facility... If YES, please com lete these pages of the UPCF....
A. F;'aZARDOUS MATERIALS
Have on site (for any purpose) hazardous materials at or above 55 BUSINESS OWNER/OPERATORgallonsforliquids, 500 pounds for solids, or 200 cubic feet for IDENTIFICATION
compressed gases (include liquids in ASTs and USTs); or the EYES NO 4
applicable Federal threshold quantity for an extremely hazardous HAZARDOUS MATERIALS INVENTORY —
substance specified in 40 CFR Part 355, Appendix A or B; or CHEMICAL DESCRIPTION
handle radiological materials in quantities for which an emergency
Ian is required pursuant to 10 CFR Parts 30, 40 or 70?
B. REGULATED SUBSTANCES
Have Regulated Substances stored onsite in quantities greater than YES ® NO 4a Coordinate with your local Agency
the threshold quantities established by the California Accidental responsible for CaIARP.
Release Prevention Program CalARP ?
YES ® NO 5
UST FACILITY
UST TANK (one per tank) C. UNDERGROUND STORAGE TANKS (USTs)
Own or operate underground storage tanks?
NO FORM REQUIRED CUPAsD. ABOVE GROUND PETROLEUM STORAGE
Store greater than 1,320 gallons of petroleum products (new or YES ® NO 8 May require SPCC plan. . used in aboveground tanks or containers.
E. HAZARDOUS WASTE YES NO g EPA ID NUMBER — provide at the top of
Generate hazardous waste? this page
YES ® NO 10 RECYCLABLE MATERIALS REPORT (oneRecyclemorethan100kg /month of excluded or exempted
recyclable materials (per HSC 25143.2)? perrecyder)
Treat hazardous waste on site? YES ® NO 11 ONSITE HAZARDOUS WASTE
TREATMENT — FACILITY
ONSITE HAZARDOUS WASTE
TREATMENT — UNIT (one page per unit)
Treatment subject to financial assurance requirements (for YES ED NO 12 CERTIFICATION OF FINANCIALPermitbyRuleandConditionalAuthorization)? ASSURANCE
Consolidate hazardous waste generated at a remote site? YES ® NO 13 REMOTE WASTE / CONSOLIDATION
SITE ANNUAL NOTIFICATION
Need to report the closure /removal of a tank that was YES ® NO 14 HAZARDOUS WASTE TANK CLOSURE
classified as hazardous waste and cleaned onsite? CERTIFICATION
Generate in any single calendar month 1,000 kilograms (kg) (2,200
pounds) or more of federal RCRA hazardous waste, or generate in Obtain federal EPA ID Number, file
any single calendar month, or accumulate at any time, 1 kg (2.2 YES ® NO 14a Biennial Report (EPA Form 8700- 13A/B),
pounds) of RCRA acute hazardous waste; or generate or and satisfy requirements for RCRA Large
accumulate at any time more than 100 kg (220 pounds) of spill Quantity Generator.
cleanup materials contaminated with RCRA acute hazardous
waste?
YES ® NO 14b See CUPA for required forms. Household Hazardous Waste (HHW) Collection site?
F. LOCAL REQUIREMENTS: Note: If you have answered "NO" to question "A" listed above, complete and submit the Statement 15
of Exemption page.
Revised (6/06)
OES FORM 2730
Revised (6/06)
UNIFIED PROGRAM CONSOLIDATED FORM
FACILITY INFORMATION
BUSINESS OWNER /OPERATOR IDENTIFICATION
Page _ of
I. IDENTIFICATION
FACILITY ID# 1 BEGINNING DATE 100 ENDING DATE 101
03 -01 -2011 03 -01 -2012
Ik..
BUSINESS NAME (Same as FACILITY NAME or DBA — Doing Business As) 3 BUSINESS PHONE 102
Pep Boys Store#0622 661 - 325 -9015
BUSINESS SITE ADDRESS 103 BUSINESS FAX 102a
2411 F Street
BUSINESS SITE CITY 104 ZIP CODE 105 COUNTY
Bakersfield CA 93301 Kern 108
DUN & BRADSTREET 106 PRIMARY SIC 107 PRIMARY NAICS 107a
60- 316-4666 5598 441310
BUSINESS MAILING ADDRESS 108 a
Pep Boys — Manny, Moe & Jack, Attn: Environmental Department, 3111 West Allegheny Avenue
BUSNI ESS MAILING CITY 108 b STATE ZIP CODE
Philadelphia PA 108 c 19132 108 d
BUSINESS OPERATOR NAME BUSINESS OPERATOR PHONE
Pep Boys — Manny, Moe & Jack 109 215 - 430 -9095 110
II. BUSINESS OWNER
OWNER NAME 111 OWNER PHONE 112
Pep Boys — Manny, Moe & Jack 215 - 430 -9095
OWNER MAILING ADDRESS 113
Pep Boys — Manny, Moe & Jack, Attn: Environmental Department, 3111 West Allegheny Avenue
OWNER MAILING CITY 114 STATE 115 ZIP CODE 116
Philadelphia PA 19132
III. ENVIRONMENTAL CONTACT
CONTACT NAME 117 CONTACT PHONE 118
Yolanda Gallardo 215 - 430 -9017
CONTACT MAILING ADDRESS 119 CONTACT EMAIL 119a
Pep Boys — Manny, Moe & Jack, Attn: Environmental Dept., 3111 West Allegheny Ave. Yolanda GallardoCcDPeaBovs.com
CONTACT MAILING CITY 120 STATE 121 ZIP CODE 122
Philadelphia PA 19132
PRIMARY- IV. EMERGENCY CONTACTS -SECONDARY -
NAME 123 NAME 128
Jose Jimenez Guadalupe Morales
TITLE 124 TITLE 129
Service Manager Store Manager
BUSINESS PHONE 125 BUSINESS PHONE 130
661 - 325 -9015 661 - 325 -9015
24 -HOUR PHONE 126 24 -HOUR PHONE 131
661- 619 -3655 661 - 549 -6810
PAGER # 127 PAGER # 132
ADDITIONAL LOCALLY COLLECTED INFORMATION: 133
Pep Boys — Manny, Moe & Jack, Attn: Environmental Dept., 3111 West Allegheny Avenue, Philadelphia, PA 19132
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 OWN R/OPERATO R DESIGNATED REPRESENTATIVE DATE 134 NAME OF DOCUMENT PREPARER 135
tt G''tltY 02 -28 2011 Yolanda Gallardo1
NAME OF SIGNER (print) 136 TITLE OF SIGNER 137
Yolanda Gallardo Environmental Coordinator
OES FORM 2730
Revised (6/06)
Unified Program (UP) Form
CONSOLIDATED CONTINGENCY PLAN
COVER PAGE
FACILITY IDENTIFICATION
BUSINESS NAME 3 FACILITY ID # 1
Pep Bo s#0622
Hazardous Waste Generator (HWG)
SITE ADDRESS 103 1 CITY 104 ZIP CODE 105
2411 F Street Bakersfield 93301
The Consolidated Contingency Plan provides businesses a format to comply with the emergency planning
requirements of the following three written hazardous materials emergency response plans required in California:
0 Hazardous Materials Business Plan (HSC Chapter 6.95 Section 25504 (b) and 19 CCR Sections 2729 - 2732),
W Hazardous Waste Generator Contingency Plan (22 CCR Section 66264.52), and,
Underground Storage Tank Emergency Response Plan and Monitoring Program (23 CCR Sections 2632
and 2641).
This format is designed to reduce duplication in the preparation and use of emergency response plans at the same facility,
and to improve the coordination between facility response personnel and local, state and federal emergency responders
during an emergency. Use the chart below to determine which sections of the Consolidated Contingency Plan need to be
completed for your facility. If you are unsure as to which programs your facility is subject to, refer to the Business
Activities Page.
PROGRAMS SECTION(S) TO BE COMPLETED
Hazardous Materials Business Plan (HMBP) Cover Page, Section I, and Site Map(s)
Hazardous Waste Generator (HWG) Cover Page, Section I, and Site Map(s)
Underground Storage Tank (UST) Cover Page, Sections I and II, and Site Map(s)
HMBP, HWG, UST Cover Page, Sections I and II, and Site Map(s)
A copy of the plan shall be submitted to your local CUPA and at least one copy of the plan shall be maintained at
the facility for use in the event of an emergency and for inspection by the local agency. Describe below where a
copy of your Contingency Plan, including the hazardous material inventories and Site Map(s), is located at your business:
PLAN CERTIFICATION
I certify under penalty of law that I have personally examined and I am familiar with the information provided by this plan
and to the best of my knowledge the information is accurate, complete, and true.
Printed Name of Owner/ Operator
Yolanda Gallardo
Title of Owner /Operator
Environmental Coordinator
Signature of Owner/ Operator JO(4"IQ— /
Date
02 -28 -2011
We appreciate the effort of local businesses in completing these plans and will assist in every possible way. If
you have any questions, please contact your local CUPA or PA.
OFFICIAL USE ONLY DATE RECEIVED REVIEWED BY
DIV I BN STA OTHER DISTRICT I CUPA PA
UP FORM (01/2000 Version) 1 UPF_LAC4 : 03_FI_CP
THE CUPAs OF LOS ANGELES COUNTY
Unified Program (UP) Form
CONSOLIDATED CONTINGENCY PLAN
SECTION I: BUSINESS PLAN AND CONTINGENCY PLAN
I. FACILITY IDENTIFICATION
BUSINESS NAME 3 FACILITY ID # 1
Pep Boys #0622
REVIEWED BY
SITE ADDRESS 103 1 CITY 104 ZIP CODE 105
2411 F Street Bakersfield 93301
II. EMERGENCY CONTACTS
PRIMARY SECONDARY
NAME 123 NAME 128
Jose Jimenez Guadalupe Morales
TITLE 124 TITLE 129
Service Manager Retail Manager
BUSINESS PHONE 125 BUSINESS PHONE 130
641- 325 -9015 661- 325 -9015
24 -HOUR PHONE 126 24 -HOUR PHONE 131
661- 619 -3655 661- 549 -6810
PAGER # 127 PAGER # 132
III. EMERGENCY RESPONSE PLANS AND PROCEDURES
A. Notifications
Your business is required by State Law to provide an immediate verbal report of any release or threatened release of a
hazardous material to local fire emergency response personnel, this Unified Program Agency (CUPA or PA), and the
Office of Emergency Services. If you have a release or threatened release of hazardous materials, immediately call:
FIRE /PARAMEDICS /POLICE /SHERIFF
PHONE: 911
AFTER the local emergency response personnel are notified, you shall then notify this Unified Program Agency and the
Office of Emergency Services.
Local Unified Program Agency: ( ) -
State Office of Emergency Service: (800) 852 -7550 or (916) 262 -1621
National Response Center: (800) 424 -8802
Information to be provided during Notification:
M Your Name and the Telephone Number from where you are calling.
W Exact address of the release or threatened release.
0 Date, time, cause, and type of incident (e.g. fire, air release, spill etc.)
M Material and quantity of the release, to the extent known.
W Current condition of the facility.
M Extent of injuries, if any.
w Possible hazards to public health and/ or the environment outside of the facility.
B. Emergency Medical Facility
List the local emergency medical facility that will be used by your business in the event of an accident or injury
caused by a release or threatened release of hazardous material
HOSPITAL /CLINIC: PHONE NO:
Mercy Hospital 661- 632 -5000
ADDRESS:
2215 Truxtun Avenue
CITY: ZIP CODE:
Bakersfield 93301
OFFICIAL USE ONLY DATE RECEIVED REVIEWED BY
DIV I BN STA OTHER DISTRICT I CUPA PA
UP FORM (01/2000 Version) 3 UPF_LAC4 : 03_FI_CP
THE CUPAs OF LOS ANGELES COUNTY
Unified Program (UP) Form
CONSOLIDATED CONTINGENCY PLAN
SECTION I: BUSINESS PLAN AND CONTINGENCY PLAN
C. Private Emergency Response
DOES YOUR BUSINESS HAVE A PRIVATE ON -SITE EMERGENCY RESPONSE TEAM? Yes ® No
If yes, provide an attachment that describes what policies and procedures your business will follow to notify your
on -site emergency response team in the event of a release or threatened release of hazardous materials.
CLEANUP /DISPOSAL CONTRACTOR
List the contractor that will provide cleanup services in the event of a release.
NAME OF CONTRACTOR: PHONE NO:
Environmental Management, Inc. 405 - 282 -8510
ADDRESS:
P.O. Box 700
CITY: ZIP CODE:
GRUthrie, OK 73044
D. Arrangements With Emergency Responders
If you have made special (i.e. contractual) arrangements with any police department, fire department, hospital, contractor,
or State or local emergency response team to coordinate emergency services, describe those arrangements on the lines
below:
On Site emergency response activities are managed by Environmental Management, Inc. of Guthrie, OK.
E. Evacuation Plan
1. The following alarm signal(s) will be used to begin evacuation of the facility (check all which apply):
Verbal ® Telephone (including cellular) ® Alarm System ® Public Address System Intercom
Pagers Portable Radio Other (specify):
2. Evacuation map is prominently displayed throughout the facility.
3. ® Individual(s) responsible for coordinating evacuation including spreading the alarm and confirming the business has
been evacuated:
F. Earthquake Vulnerability
Identify areas of the facility where releases could occur or would require immediate inspection or isolation because of the
vulnerability to earthquake related ground motion.
Hazardous Waste/ Hazardous Materials Storage Areas Production Floor Process Lines
Bench/ Lab Waste Treatment ® Other:
Identify mechanical systems where releases could occur or would require immediate inspection or isolation because of
the vulnerability to earthquake related ground motion.
Utilities ® Sprinkler Systems Cabinets ® Shelves
Racks ® Pressure Vessels Gas Cylinders ® Tanks
Process Piping ® Shutoff Valves Other:
UP FORM (01/2000 Version) 4 UPF_LAC4 : 03_FI_CP
THE CUPAs OF LOS ANGELES COUNTY
Unified Program (UP) Form
CONSOLIDATED CONTINGENCY PLAN
SECTION I: BUSINESS PLAN AND CONTINGENCY PLAN
G. Emergency Procedures
Briefly describe your business standard operating procedures in the event of a release or threatened release of
hazardous materials:
1. PREVENTION (prevent the hazard) - Describe the kinds of hazards associated with the hazardous materials
present at your facility. What actions would your business take to prevent these hazards from occurring? You may
include a discussion of safety and storage procedures.
The primary hazards are fire, ground and surfacewater contamination. All on -site containers of hazardous materials have
been reduced both to th smallest size & minimum quantity as is practical. All containers are properly labeled. All
aboveground storage is inside the building & on concrete. Pressurized cylinders, used for welding, are securely stored
one portable cart.
2. MITIGATION (reduce the hazard) - Describe what is done to lessen the harm or the damage to person(s),
property, or the environment, and prevent what has occurred from getting worse or spreading. What is your immediate
response to a leak, spill, fire, explosion, or airborne release at your business?
Should there be a liquid spill or threatened release, the emergency coordinator would (a) diverge the spill by using
dikes, (b) minimize exposure by covering the exposed materials with an absorbent, and (c) shovel the contaminated
absorbent into a labeled drum. If there is a release of compressed gas the emergency coordinator would (a) isolate a
1/4 mile in all directions (b) stay upwind and ventilate closed spaces before entering (c) shut off ignition sources.
For large spill, the 24 hour Emergency Contractor is immediately contacted by Pep Boys Corporate Environmental
Department.
3. ABATEMENT (remove the hazard) - Describe what you would do to stop and remove the hazard. How do you
handle the complete process of stopping a release, cleaning up, and disposing of released materials at your facility?
Should there be a spill or release of hazardous material, the Emergency Coordinator (Store Manager) will cover the
exposed material and divert any spill runoff away from storm drains and surface water bodies. Spill kits are available
for small spills. Pep Boys will dispatch appropriate vendors to dispose of any spent/contaminated materials. Approved
Emergency Contractors handle larger spills.
UP FORM (01/2000 Version) 5 UPF_LAC4 : 03_FI_CP
THE CUPAs OF LOS ANGELES COUNTY
Unified Program (UP) Form
CONSOLIDATED CONTINGENCY PLAN
SECTION I: BUSINESS PLAN AND CONTINGENCY PLAN
IV. Emergency Equipment
22 CCR, Section 66265.52(e) [as referenced by Section 66262.34(a)(3)] requires that emergency equipment at
the facility be listed. Completion of the following Emergency Equipment Inventory Table meets this requirement.
EMERGENCY EQUIPMENT INVENTORY TABLE
I.
Equipment
Category
2.
Equipment
Type
3.
Location *
4.
Description "
Personal Cartridge Respirators
Protective, Chemical Monitoring Equipment describe
Equipment, Chemical Protective Aprons /Coats
Safety Chemical Protective Boots
Equipment, Chemical Protective Gloves Srvc Bys Found in the spill kit
aid Chemical Protective Suits (describe)
First Aid E] Face Shields
Equipment First Aid Kits /Stations describe Srvc Bys Service Bay area
Hard Hats
Plumbed Eye Wash Stations
Portable Eye Wash Kits (i.e. bottle type) Srvc Bys Eye wash station
Respirator Cartridges (describe)
Safety Glasses /Splash Goggles Srvc Bys Located in the service desk
Safety Showers
Self- Contained Breathing Apparatuses (SCBA
Other (describe)
Fire Automatic Fire Sptinkler Systems Multi Loc. Through out the Retail and Service area
Extinguishing Fire Alarm Boxes /Stations Multi Loc.
Systems Fire Extinguisher Systems (describe) Multi Loc.
Other describe
Spill Absorbents (describe) Multi Loc. In the spill kit and in the Retail store
Control Berms /Dikes (describe) Multi Loc. Booms inside the spill kit
Equipment Decontamination Equipment (describe)
and Emergency Tanks (describe)
Decontamination Exhaust Hoods
Equipment Gas Cylinders Leak Repair Kits describe
Neutralizers (describe) Multi Loc. Baking soda inside the spill kit
Overpack Drums
Sumps (describe)
Other (describe)
Communications
and
Chemical Alarms (describe)
Intercoms/ PA Systems Multi Loc.
Alarm Portable Radios
Systems Telephones Multi Loc.
Underground Tank Leak Detection Monitors
Other (describe)
Additional
Equipment
Use Additional
Pages if
Needed.)
Use the Location Codes (LC) from the Site Map(s) prepared for your Contingency Plan.
Describe the equipment and its capabilities. If applicable, specify any testing /maintenance procedureslntervals. Attach additional pages,
numberedappropriately, if needed.
UP FORM (01/2000 Version) 6 UPF_LAC4 : 03_FI_CP
THE CUPAs OF LOS ANGELES COUNTY
Unified Program (UP) Form
CONSOLIDATED CONTINGENCY PLAN
SECTION 1: BUSINESS PLAN AND CONTINGENCY PLAN
V. EMPLOYEE TRAINING
All facilities which handle hazardous materials must have a written employee training plan. A blank plan
has been provided below for you to complete and submit. The items listed below are required per Health
and Safety Code Section 25504 (c) and Title 19 Section 2732.
Facility personnel are trained as follows:
0 Familiarity with all plans and procedures specified in the Contingency Plan.
ur Methods for Safe Handling of Hazardous Materials.
M Safety procedures in the event of a release or threatened release of a hazardous material.
0 Use of Emergency Response equipment and supplies under the control of the business.
0 Procedures for Coordination with local Emergency Response Organizations.
Training shall be provided:
M Initially for all new employees.
0 Annually, including refresher courses, for all employees.
Note: These training programs may take into consideration the position of each employee.
Additional training should include:
r Internal alarm /notification procedures.
uz Evacuation /re -entry procedures and assembly point locations.
M Material Safety Data Sheet (MSDS) training including specific hazard(s) of each chemical
to which employees may be exposed, including routes of exposure (i.e. inhalation, ingestion, absorption).
VI. HAZARDOUS WASTE GENERATOR TRAINING
If your business is a hazardous waste generator, you are required to provide training in hazardous
waste management for all workers who handle hazardous waste at your site (22 CCR §66265.16).
You are also required to document training. The items below are required.
EMPLOYEE TRAINING
M Facility personnel will successfully complete training within six months after the date of their employment
or assignment to a facility or to a new position at a facility.
r Employees will not handle hazardous wastes without supervision until trained.
TRAINING DOCUMENTATION
The owner or operator must maintain the following documents and records at the facility:
W Job title for each position at the facility that is related to hazardous waste management, and the names
of the employee(s) filling the position(s).
W Description for each position listed above (must include required skill, education, or other qualifications
as well as duties of employees assigned to the position.
Qi Description of type and amount of both introductory and continuing training given to each employee.
GT Records that document that the requirements for training or job experience have been met.
M Current employees' training records to be retained until closure of the facility).
M Former employees' training records to be retained at least three years after termination of employment).
UP FORM (01/2000 Version) 7 UPF_LAC4 : 03_FI_CP
THE CUPAs OF LOS ANGELES COUNTY
Unified Program (UP) Form
CONSOLIDATED CONTINGENCY PLAN
SITE MAP
A site plan and storage map must be included with your Contingency Plan. For relatively small facilities, these documents
may be combined into one drawing. Since these drawings are intended for use in emergency response situations, larger
facilities (generally those with complex and /or multiple buildings) should provide an overall site plan and a separate
storage map for each building /storage area. A blank Facility Site Map has been provided on the reverse side of this page.
You may complete that page or attach any other drawing(s) which contain(s) the information required below.
Site Plan: This drawing shall contain, at a minimum, the following information:
a. Site Orientation (north, south, etc.);
b. Approximate scale (e.g. "1 inch = 10 feet ".);
c. Date the map was drawn;
d. Locations of all buildings and other structures;
e. Parking lots and internal roads;
f. Hazardous materials loading /unloading areas;
g. Outside hazardous materials storage or use areas;
h. Storm drain and sanitary sewer drain inlets;
i. Wells for monitoring of underground tank systems;
j. Primary and alternate evacuation routes, emergency exits, and primary and alternate staging areas;
k. Adjacent property use;
I. Locations and names of adjacent streets and alleys;
m. Access and egress points and roads.
2. Storage Map(s): The map(s) shall contain, at a minimum, the following information:
a. General purpose of each section /area within each building (e.g. "Office Area ", "Manufacturing Area ", etc.);
b. Location of each hazardous material /waste storage, dispensing, use, or handling area (e.g. individual
underground tanks, aboveground tanks, storage rooms, paint booths, etc.). Each area shall be identified by a
unique location code number, letter, or name (e.g. "1", "2", "3'; "A ", "B ", "C; etc.);
c. Entrances to and exits from each building and hazardous material /waste room /area;
d. Location of each utility emergency shut -off point (i.e. gas, water, electric.);
e. Location of each monitoring system control panel (e.g. underground tank monitoring, toxic gas monitoring, etc.).
3. Map Legend
Item and /or Description Location Code LC
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UP FORM (01/2000 Version) 11 UPF_LAC4 : 03_FI_CP
THE CUPAs OF LOS ANGELES COUNTY
Unified Program (UP) Form
CONSOLIDATED CONTINGENCY PLAN
SITE MAP
BUSINESS NAME 3
Pep Bo s#0622
SITE ADDRESS 103 CITY 104 1 ZIP CODE 105
2411 F Street Bakersfield 93301
DATE MAP DRAWN MAP # FACILITY ID # 1 "
02 -01 -2011
1
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4
5
6
7
8
9
10
11
12
A B C D E F G H 1 J For Site Map
Scale of Map
Loading Areas
Parking Lots
Internal Roads
Storm and Sewer
Drains
Adjacent Property Use
Locations and Names
of Adjacent Streets and
Alleys
Access and Egress
Points and Roads
Primary and Alternate
Evacuation Routes
For Sub -Site Map
Scale of Map
Location of Each
Storage Area
Location of Each
Hazardous Material
Handling Area
Location of Emergency
Response Equipment
Scale:
1. = Ft.
INorth
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OFFICIAL USE ONLY DATE RECEIVED REVIEWED BY
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I BN STA I DISTRICT I CUPA PA
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Locations and Names
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Access and Egress
Points and Roads
Primary and Alternate
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For Sub -Site Map
Scale of Map
Location of Each
Storage Area
Location of Each
Hazardous Material
Handling Area
Location of Emergency
Response Equipment
Scale:
1. = Ft.
INorth
Y X
OFFICIAL USE ONLY DATE RECEIVED REVIEWED BY
DIV I BN STA I DISTRICT I CUPA PA
UP FORM (01/2000 Version) 12 UPF_LAC4 : 03_FI -CP
THE CUPAs OF LOS ANGELES COUNTY
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UNIFIED PROGRAM (UP) FORM
HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION
one page per materialper buildin or area
ADD DELETE ®REVISE REPORTING YEAR 2011 200 1 Page of
I. FACILITY INFORMATION
BUSINESS NAME (Same as FACILITY NAME or DBA — Doing Business As) 3
Pep Boys Store #0622
CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL 202
Service Bays EPCRA) YES ONO
1 MAP# (optional) 203 GRID# (optional) 204
FACILITY ID # v. 's:
II. CHEMICAL INFORMATION
CHEMICAL NAME 205 TRADE SECRET Yes ONO 206
Used Petroleum Hydrocarbon IfSubject to EPCRA, referto instructions
COMMON NAME Used Motor Oil 207 EHS* Yes Z No 208 1 RS* Yes No 246a
CAS# Mixture 209 IfEHS or RS is "Yes ", all amounts below must be in lbs.
FIRE CODE HAZARD CLASSES (Complete ifrequired by CUPA) Combustible Liquid 210
HAZARDOUS MATERIAL
TYPE!Check one item only) a. PURE b. MIXTURE ® c. WASTE 21l RADIOACTIVE Yes ®No 212
213
CURIES n/a
PHYSICAL STATE
Check one item only) [I a. SOLID ®b. LIQUID c. GAS 214
215
LARGEST CONTAINER 250 gallons
FED HAZARD CATEGORIES 216
Check all that apply) ® a. FIRE b. REACTIVE Cl c. PRESSURE RELEASE ® d. ACUTE HEALTH ® e. CHRONIC HEALTH
AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220
15 1 25 1 9125 1 221
221 DAYS ON SITE: 222
UNITS* Za. GALLONS b. CUBIC FEET c. POUNDS d. TONS 365Checkoneitemonly) * IfEHS, amount must be in pounds.
STORAGE
CONTAINER ® a. ABOVE GROUND TANK e. PLASTIC/NONMETALLIC DRUM i. FIBER DRUM Elm. GLASS BOTTLE q. RAILCAR
b. UNDERGROUND TANK f. CAN j. BAG Cl n. PLASTIC BOTTLE r. OTHER
c. TANK INSIDE BUILDING g. CARBOY k. BOX o. TOTE BIN
d. STEEL DRUM h. SILO 1. CYLINDER p. TANK WAGON 223
STORAGE PRESSURE ® a. AMBIENT b. ABOVE AMBIENT c. BELOW AMBIENT 224
STORAGE TEMPERATURE ® a. AMBIENT b. ABOVE AMBIENT c. BELOW AMBIENT d. CRYOGENIC 225
WT HAZARDOUS COMPONENT (For mixture or waste only) EHS RS 246b CAS #
183 -93 226 Aliphatic Petroleum Distillates 227 Yes 228 Dyes 64742 -65 -0 229
2 6 -16 230 Detergent/Dispersant Engine Oil Package 231 Yes 232 Yes 233
3 1.0 234 Zinc Compounds 235 Yes 236 ZYes 68649 -42 -3 237
4 238 239 Yes 240 Yes 241
5 242 243 Yes 244 E] Yes 245
Ifmore hazardous components are present at greaterthan I % by weight ifnon - carcinogenic, or 0.1 % by weight if carcinogenic, attach additional sheets of paper capturing the required information.
ADDITIONAL LOCALLY COLLECTED INFORMATION 246
IfEPCRA, Please Sign Here
Facilities reporting Chemicals subject to EPCRA reporting thresholds must sign each Chemical Description pagefor each EPCRA reported chemical.)
OFFICIAL USE ONLY IDATERECEIVED REVIEWED BY
DIV BN STA OTHER DISTRICT CUPA PA
UPFORM LAC4:UPFORMS3
THE CUPAs OF LOS ANGELES COUNTY
E
UNIFIED PROGRAM (UP) FORM
HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION
one a e material building or area
ADD DELETE ®REVISE REPORTING YEAR 2011 200 Page of
I. FACILITY INFORMATION
BUSINESS NAME (Same as FACILITY NAME or DBA — Doing Business As) 3
Pep Boys Store #0622
CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL 202
Service Bays EPCRA) YES Z NO
t MAP# (optional) 203 GRID# (optional) 204
FACILITY ID #
II. CHEMICAL INFORMATION
CHEMICAL NAME 205 TRADE SECRET Yes Z No 206
Used Petroleum Hydrocarbon/Filter IfSubject to EPCRA, referto instructions
COMMON NAME Used Motor Oil Filters 207 EHS* Yes ONO 208 1 RS* []Yes No 246a
CAS# Mixture 209 If EHS or RS is "Yes ", all amounts below must be in tbs.
FIRE CODE HAZARD CLASSES (Complete ifrequired by CUPA) Combustible Liquid 210
HAZARDOUS MATERIAL
TYPE!Check one item only) El a. PURE b. MIXTURE M c. WASTE 2i I RADIOACTIVE Yes ®No 21Z
213
CURIES n/a
PHYSICAL STATE 214
Check one item only) ® a. SOLID b. LIQUID c. GAS
215
LARGEST CONTAINER 55 gallon drum
FED HAZARD CATEGORIES 216
Check all that apply) ® a. FIRE b. REACTIVE c. PRESSURE RELEASE d. ACUTE HEALTH ® e. CHRONIC HEALTH
AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220
10 units 1 20 units 1 7300 1
221 DAYS ON SITE: 222
UNITS* a. GALLONS b. CUBIC FEET c. POUNDS d. TONS 365Checkoneitemonly)* IfEHS, amount must be in pounds.
STORAGE
CONTAINER [Ia. ABOVE GROUND TANK e. PLASTICINONMETALLIC DRUM i . FIBER DRUM m. GLASS BOTTLE q. RAILCAR
b. UNDERGROUND TANK f. CAN j. BAG n. PLASTIC BOTTLE r. OTHER
c. TANK INSIDE BUILDING g. CARBOY k. BOX o. TOTE BIN
M d. STEEL DRUM h. SILO 1. CYLINDER p. TANK WAGON 223
STORAGE PRESSURE ® a. AMBIENT b. ABOVE AMBIENT c. BELOW AMBIENT 224
STORAGE TEMPERATURE ® a. AMBIENT b. ABOVE AMBIENT c. BELOW AMBIENT d. CRYOGENIC 225
WT HAZARDOUS COMPONENT (For mixture or waste only) EHS RS 246b CAS #
1 83 -93 226 Aliphatic Petroleum Distillates 227 yes 228 yes 229
64742 -65 -0
2 6 -16 230 Detergent/Dispersant Engine Oil Package 231 Yes 232 Yes 233
3 1.0 234 Zinc Compounds 235 Yes 236 Yes 68649 -42 -3 237
4 238 239 Yes 240 Yes 241
5 242 243 Yes 244 Yes 245
Ifmore hazardous components are present at greater than 1% by weight ifnon - carcinogenic, or0.1 % by weight ifcarcinogenic, attach additional sheets ofpaper capturing therequired information.
ADDITIONAL LOCALLY COLLECTED INFORMATION 246
IfEPCRA, Please Sign Here
Facilities reporting Chemicals subject to EPCRA reporting thresholds must sign each Chemical Description pagefor each EPCRA reported chemical.)
OFFICIAL USE ONLY DATE RECEIVED I REVIEWED BY
DIV BN STA OTHER DISTRICT CUPA PA
UPFORM LAC4:UPFORMS3
THE CUPAS OF LOS ANGELES COUNTY
UNIFIED PROGRAM (UP) FORM
HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION
one a material buildin or area
ADD DELETE ®REVISE REPORTING YEAR 2011 200 1 Page of
I. FACILITY INFORMATION
BUSINESS NAME (Same as FACILITY NAME or DBA — Doing Business As) 3
Pep Boys Store #0622
CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL 202
Service Bays EPCRA) YES ® NO1
MAP# (optional) 203 GRID# (optional) 204
FACILITY ID # 1
II. CHEMICAL INFORMATION
CHEMICAL NAME 205 TRADE SECRET Yes ® No 206
Waste Inhibited Ethylene Glycol IfSubject to EPCRA, refer to instructions
COMMON NAME Waste Antifreeze /Coolant 207 EHS* Yes ® No 208 1 RS* []Yes No 246a
CAS# Mixture 209 If EHS or RS is "Yes ", all amounts below must be in lbs.
FIRE CODE HAZARD CLASSES (Complete ifrequired by CUPA) Combustible Liquid, Toxic 210
HAZARDOUS MATERIAL
TYPE (Check one item only) a. PURE b. MIXTURE ® c. WASTE
211 RADIOACTIVE Yes ®No 212
213
CURIES n/a
PHYSICAL STATE 214
Check one item only) a. SOLID ®b. LIQUID c. GAS
215
LARGEST CONTAINER 280 gallons
FED HAZARD CATEGORIES 216
Check all that apply) ® a. FIRE b. REACTIVE c. PRESSURE RELEASE ® d. ACUTE HEALTH ® e. CHRONIC HEALTH
AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220
10 1 15 1 5475 1 342
221 DAYS ON SITE: 222
UNITS* ®a. GALLONS b. CUBIC FEET c. POUNDS d. TONS 3651Checkoneitemonly) * IfEHS, amount must be in pounds.
STORAGE
CONTAINER ® a. ABOVE GROUND TANK e. PLASTIC/NONMETALLIC DRUM i . FIBER DRUM m. GLASS BOTTLE q. RAILCAR
b. UNDERGROUND TANK f. CAN j. BAG n. PLASTIC BOTTLE r. OTHER
c. TANK INSIDE BUILDING g. CARBOY k. BOX o. TOTE BIN
d. STEEL DRUM h. SILO 1. CYLINDER p. TANK WAGON 223
STORAGE PRESSURE ® a. AMBIENT b. ABOVE AMBIENT c. BELOW AMBIENT 224
STORAGE TEMPERATURE ® a. AMBIENT b. ABOVEAMBIENT c. BELOW AMBIENT d. CRYOGENIC 225
WT HAZARDOUS COMPONENT (For mixture or waste only) EHS RS 246b CAS #
1 80 -95 226 Ethylene Glycol 227 Yes 228 Yes 107 -21 -1 229
2 0 -8 230 Diethylene Glycol 231 Yes 232 Yes 111 -46 -6 233
3 234 235 YeS 236 Yes 237
4 238 239 Yes 240 YeS 241
5 242 243 Yes 244 Yes 245
Ifmore hazardous components arepresent at greater than 1% by weight if non - carcinogenic, or 0.1 % by weight ifcarcinogenic, attach additional sheets ofpapercapturing the required information.
ADDITIONAL LOCALLY COLLECTED INFORMATION 246
If EPCRA, Please Sign Here
Facilities reporting Chemicals subject to EPCRA reporting thresholds must sign each Chemical Description pagefor each EPCR,4 reported chemical.)
OFFICIAL USE ONLY IDATERECEIVED REVIEWED BY
DIV BN STA OTHER DISTRICT CUPA PA
UP FORM LAC4 : UPFORMS3
THE CUPAs OF LOS ANGELES COUNTY
It
UNIFIED PROGRAM (UP) FORM
HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION
one a material buildingorarea)
ADD DELETE ®REVISE REPORTING YEAR 2011 200 Page of
I. FACILITY INFORMATION
BUSINESS NAME (Same as FACILITY NAME or DBA — Doing Business As) 3
Pep Boys Store #0622
CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL 202
Service Bays EPCRA) YES ® NO
1 MAP# (optional) 203 GRID# (optional) 204
FACILITY ID #
11. CHEMICAL INFORMATION
CHEMICAL NAME 205 TRADE SECRET Yes ® No 206
Waste Water IfSubject to EPCRA, refer to instructions
COMMON NAME Waste Water 207 EHS* Yes ONO 208 1 RS* Yes No 246a
CAS# Mixture of oily water 209 If EHS or RS is "Yes ", all amounts below must be in lbs.
FIRE CODE HAZARD CLASSES (Complete ifrequired by CUPA) 210
HAZARDOUS MATERIAL
TYPETCheck one item only) a. PURE b. MIXTURE ® c. WASTE 211 RADIOACTIVE Yes ®No 212
213
CURIES n/a
PHYSICAL STATE 214
Check one item only) a. SOLID ®b. LIQUID c. GAS
215
LARGEST CONTAINER 280 gallons
FED HAZARD CATEGORIES 216
Check all that apply) ® a. FIRE b. REACTIVE c. PRESSURE RELEASE ® d. ACUTE HEALTH e. CHRONIC HEALTH
AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220
5 1 15 1 5475 1
zzi DAYS ON SITE: 222
UNITS* ®a. GALLONS b. CUBIC FEET c. POUNDS d. TONS 365Checkoneitemonly) * If EHS, amount mustbe in pounds.
STORAGE
CONTAINER ® a. ABOVE GROUND TANK e. PLASTIC/NONMETALLIC DRUM i . FIBER DRUM m. GLASS BOTTLE q. RAILCAR
b. UNDERGROUND TANK f. CAN j. BAG n. PLASTIC BOTTLE r. OTHER
c. TANK INSIDE BUILDING g. CARBOY k. BOX o. TOTE BIN
d. STEEL DRUM h. SILO I. CYLINDER p. TANK WAGON 223
STORAGE PRESSURE ® a. AMBIENT b. ABOVE AMBIENT c. BELOW AMBIENT 224
STORAGE TEMPERATURE ® a. AMBIENT b. ABOVEAMBIENT c. BELOW AMBIENT d. CRYOGENIC 225
WT HAZARDOUS COMPONENT (For mixture or waste only) EHS RS 246b CAS #
1 226 Water 227 Yes 228 Yes 7732 -18 -5 229
2 230 Aliphatic Petroleum Distillates 231 Yes 232 Yes 64742 -65 -0 233
3 234 DetergenvDispersant Engine Oil Package 235 Yes 236 Yes 237
4 238 Zinc Compounds 239 Yes 240 Yes 68649 -42 -3 241
5 242 243 Yes 244 Yes 245
Ifmore hazardous components are present at greater than 1% by weight ifnon- careinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information.
ADDITIONAL LOCALLY COLLECTED INFORMATION 246
IfEPCRA, Please Sign Here
Facilities reporting Chemicals subject to EPCRA reporting thresholds must sign each Chemical Description pagefor each EPCRA reported chemical.)
OFFICIAL USE ONLY IDATERECEIVED REVIEWED BY
DIV BN _T STA OTHER DISTRICT CUPA PA
UPFORM LAC4:UPFORMS3
THE CUPAs OF LOS ANGELES COUNTY
w
UNIFIED PROGRAM (UP) FORM
HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION
one a material building orarea
ADD DELETE ®REVISE REPORTING YEAR 2011 200 Page of
I. FACILITY INFORMATION
BUSINESS NAME (Same as FACILITY NAME or DBA — Doing Business As) 3
Pep Boys Store #0622
CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL 202
Service Bays EPCRA) YES ® NO
1 MAP# (optioom) 203 GRID# (optional) 204
FACILITY ID #
II. CHEMICAL INFORMATION
CHEMICAL NAME 205 TRADE SECRET [:]Yes ® No 206
IfSubject to EPCRA, refer to instructions
COMMON NAME Waste Brake Fluid 207 EHS* Yes ® No 208 1 RS* Yes No 246a
CAS# Mixture 209 If EHS or RS is "Yes ", all amounts below must be in lbs.
FIRE CODE HAZARD CLASSES (Complete ifrequired by CUPA) IIIB 210
HAZARDOUS MATERIAL
TYPE' Check one item only) a. PURE ®b. MIXTURE c. WASTE 211 RADIOACTIVE Yes ®No 212
213
CURIES n/a
PHYSICAL STATE 214Checkoneitemonly) a. SOLID ®b. LIQUID Cl c. GAS LARGEST CONTAINER 64 oz.
215
FED HAZARD CATEGORIES 216
Check all that apply) [Ia. FIRE b. REACTIVE ® c. PRESSURE RELEASE ® d. ACUTE HEALTH e. CHRONIC HEALTH
AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220
8 1 16 1 n/a 1 343
221 DAYS ON SITE: 222
UNITS* ®a. GALLONS b. CUB]C FEET El c. POUNDS d. TONS 365Checkoneitemonly) • If EHS, amount must be in pounds.
STORAGE
CONTAINER a. ABOVE GROUND TANK e. PLASTIC/NONMETALLIC DRUM i . FIBER DRUM m. GLASS BOTTLE q. RAILCAR
b. UNDERGROUND TANK f. CAN j. BAG [In. PLASTIC BOTTLE r. OTHER
c. TANK INSIDE BUILDING g. CARBOY k. BOX o. TOTE BIN
d. STEEL DRUM h. SILO [11. CYLINDER p. TANK WAGON 223
STORAGE PRESSURE ® a. AMBIENT b. ABOVE AMBIENT c. BELOW AMBIENT 224
STORAGE TEMPERATURE ® a. AMBIENT b. ABOVE AMBIENT c. BELOW AMBIENT d. CRYOGENIC 225
WT HAZARDOUS COMPONENT (For mixture or waste only) EHS RS 246b CAS #
I >1 226 Ethexytriglicol 227 Yes 228 Yes 112 -50 -5 229
2 >1 230 Methozytriglycol 231 Yes 232 Yes 112 -35 -6 233
3 0 -8 234 Diethylene Glycol 235 Yes 236 Yes 111 -46 -6 237
4 238 Zinc Compounds 239 Yes 240 Yes 241
5 242 243 Yes 244 Yes 245
Ifmore hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1% by weight ifcarcinogenic, attach additional sheets ofpapercapturing the required information.
ADDITIONAL LOCALLY COLLECTED INFORMATION 246
If EPCRA, Please Sign Here
Facilities reporting Cliemicals subject to EPCRA reporting thresholds must sign each Chemical Description pagefor each EPCRA reported chemical.)
OFFICIAL USE ONLY IDATERECEIVED REVIEWED BY
DIV BN STA OTHER DISTRICT CUPA PA
UPFORM LAC4:UPFORMS3
THE CUPAs OF LOS ANGELES COUNTY
UNIFIED PROGRAM (UP).FORM
HAZARDOUS MATERIALS INVENTORY — CHEMICAL DESCRIPTION
one pageper material perbuilding or area
ADD DELETE ®REVISE REPORTING YEAR 2011 200 Page of
I. FACILITY INFORMATION,
BUSINESS NAME (Same as FACILITY NAME or DBA— Doing Business As) 3
Pep Boys Store #0622
CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL 202
EPCRA) YES ® NO1ServiceBays
MAP# (options]) 203 GRID# (option I) 204
FACILITY ID #
II. CHEMICAL INFORMATION
CHEMICAL NAME 205 TRADE SECRET Yes ®No 206
Liquid Content-Spent Sulfuric Acid IfSubject to EPCRA, refer to instructions
COMMON NAME 207 EHS* ® Yes [:]No 208 1 RS* Yes No 246a
CAS# Mixture, Electrolyte Solution 209 If EHS or RS is "Yes ", all amounts below must be in lbs.
FIRE CODE HAZARD CLASSES (Complete ifrequired by CUPA) 210
HAZARDOUS MATERIAL
TYPE heck one item only) a. PURE ®b. MIXTURE c. WASTE 211 RADIOACTIVE []Yes ®No 212
213
CURIES n/a
PHYSICAL STATE 214
Check one item only) a. SOLID ®b. LIQUID c. GAS
215
LARGEST CONTAINER 1.77 Ibs sulfuric acid per car battery
FED HAZARD CATEGORIES 216
Check all that apply) a. FIRE ® b. REACTIVE ® c. PRESSURE RELEASE ® d. ACUTE HEALTH e. CHRONIC HEALTH
AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220
5 1 15 1 5475 N/a
221 DAYS ON SITE: 222
UNITS* [3a. GALLONS b. CUBIC FEET ® c. POUNDS d. TONS 365Checkoneitemonly) * IfEHS, amount must be in pounds.
STORAGE
CONTAINER [Ia. ABOVE GROUND TANK e. PLASTIC/NONMETALLIC DRUM i . FIBER DRUM m. GLASS BOTTLE q. RAILCAR
b. UNDERGROUND TANK f. CAN j. BAG n. PLASTIC BOTTLE ® r. OTHER
c. TANK INSIDE BUILDING g. CARBOY k. BOX o. TOTE BIN
d. STEEL DRUM h. SILO [11. CYLINDER p. TANK WAGON 223
STORAGE PRESSURE ® a. AMBIENT b. ABOVE AMBIENT c. BELOW AMBIENT 224
STORAGE TEMPERATURE ® a. AMBIENT b. ABOVEAMBIENT c. BELOW AMBIENT d. CRYOGENIC 225
WT HAZARDOUS COMPONENT (For mixture or waste only) EHS RS 246b CAS #
1 20 -40 226 Sulfuric Acid 227 Yes 228 Yes 229
7664 -93 -9
2 230 231 Yes 232 Yes 233
3 234 235 Yes 236 Yes 237
4 238 239 Yes 240 Yes 241
5 242 243 Yes 244 Yes 245
If more hazardous components are present at greater than I % by weight Ifnon - carcinogenic, or 0.1 % by weight Ifcarcinogenic, attach additional sheets of paper capturing the required information.
ADDITIONAL LOCALLY COLLECTED INFORMATION 246
If EPCRA, Please Sign Here
Facilities reporting Chemicals subject to EPCRA reporting thresholds must sign each Chemical Description pagefor each EPCRA reported chemical.)
OFFICIAL USE ONLY IDATERECEIVED REVIEWED BY
DIV BN STA OTHER DISTRICT CUPA PA
UPFORM LAC4:UPFORMS3
THE CUPAs OF LOS ANGELES COUNTY
UNIFIED PROGRAM (UP) FORM
HAZARDOUS MATERIALS INVENTORY — CHEMICAL DESCRIPTION
one page per materta perbut mg or area
ADD []DELETE ®REVISE REPORTING YEAR 2011 200 1 Page of
I. FACILITY INFORMATION
BUSINESS NAME (Same as FACILITY NAME or DBA — Doing Business As) 3
Pep Boys Store #0622
CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL 202
Service Bays EPCRA) YES ONOI
1 MAP# (optional) 20T optional) 204
FACILITY ID #
71D#
II. CHEMICAL INFORMATION
CHEMICAL NAME 205 TRADE SECRET Yes ® No 206
Petroleum Hydrocarbon IfSubjectto EPCRA, refer to instructions
COMMON NAME Motor Oil (Bulk Oil for oil change at Service Bays - Ecobox) 207 EHS* Yes ® No 208 1 RS* Yes No 246a
CAS# Mixture 209 If EHS or RS is "Yes ", all amounts below must be in lbs.
FIRE CODE HAZARD CLASSES (Complete ifrequired by CUPA) Combustible Liquid, TOXIC 210
HAZARDOUS MATERIAL
TYPEFCheck one item only) El a. PURE ®b. MIXTURE c. WASTE 211 RADIOACTIVE Yes ®No 212
213
CURIES n/a
PHYSICAL STATE
Check one item only) C] a. SOLID ®b. LIQUID c. GAS 214
215
LARGEST CONTAINER 7 gallons
FED HAZARD CATEGORIES 216
Check all that apply) ® a. FIRE b. REACTIVE c. PRESSURE RELEASE ® d. ACUTE HEALTH ® e. CHRONIC HEALTH
AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220
42 1 84 1 n/a 1 n/a
DAYS ON SITE: 222
d. TONSUNITS* ®a. GALLONS b. CUBIC FEET c. POUNDS El d. 365Checkoneitemonly) * If EHS, amount mustbe in pounds.
STORAGE
CONTAINER ® a. ABOVE GROUND TANK e. PLASTICINONMETALLIC DRUM i . FIBER DRUM m. GLASS BOTTLE q. RAILCAR
b. UNDERGROUND TANK f. CAN j. BAG ® n. PLASTIC BOTTLE r. OTHER
c. TANK INSIDE BUILDING g. CARBOY k. BOX o. TOTE BIN
d. STEEL DRUM h. SILO 1. CYLINDER p. TANK WAGON 223
STORAGE PRESSURE ® a. AMBIENT b. ABOVE AMBIENT c. BELOW AMBIENT 224
STORAGE TEMPERATURE ® a. AMBIENT b. ABOVE AMBIENT c. BELOW AMBIENT d. CRYOGENIC 225
WT HAZARDOUS COMPONENT (For mixture or waste only) EHS RS 246b CAS #
1 83 -93 226 Aliphatic Petroleum Distillates 227 Yes 228 Yes 64742 -65 -0 229
2 6 -16 230 Detergent%Dispersant Engine Oil Package 231 Yes 232 Yes 233
3 1.0 234 Zinc Compounds 235 Yes 236 Yes 68649 -42 -3 237
4 238 239 Yes 240 Yes 241
5 242 243 E] Yes 244 Yes 245
Ifmore hazardouscomponents are present at greater than 1 % by weight ifnon - carcinogenic, or 0.1 % by weight ifcarcinogenic, attach additional sheets of paper capturing the required Information.
ADDITIONAL LOCALLY COLLECTED INFORMATION 246
If EPCRA, Please Sign Here
Facilities reporting Chemicals subject to EPCRA reporting thresholds must sign each Chemical Description pagefor each EPCRA reported chemical.)
OFFICIAL USE ONLY IDATERECEIVED REVIEWED BY
DIV BN STA OTHER DISTRICT CUPA PA
UPFORM LAC4:UPFORMS3
THE CUPAs OF LOS ANGELES COUNTY
UNIFIED PROGRAM (UP) FORM
HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION
one page per material per building or area
ADD DELETE ®REVISE REPORTING YEAR2011 200 1 Page of
I. FACILITY INFORMATION
BUSINESS NAME (Same as FACILITY NAME or DBA — Doing Business As) 3
Pep Boys Store #0622
CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL 202
Service Bays EPCRA) YES ® NO
FACILITY ID #
x 1 MAP# (optional) 203
1 GRID# ( optionai) 204
II. CHEMICAL INFORMATION
CHEMICAL NAME 205 TRADE SECRET Yes ® No 206
Oxygen IfSubjectto EPCRA, refer to instructions
COMMON NAME Oxygen 207 EHS* Yes ® No 208 1 RS* Yes No 246a
CAS# 7782 -44 -7 209 If EHS or RS is "Yes ", all amounts below must be in Ibs.
FIRE CODE HAZARD CLASSES (Complete ifrequired by CUPA) 210
HAZARDOUS MATERIAL
TYPE t,heck one item only) ® a. PURE b. MIXTURE c. WASTE 211 RADIOACTIVE [--]Yes ®No 212
213
CURIES n/a
PHYSICAL STATE 214Checkoneitemonly) a. SOLID b. LIQUID ® c. GAS LARGEST CONTAINER 122
215
FED HAZARD CATEGORIES 216
Check all that apply) ® a. FIRE b. REACTIVE ® c. PRESSURE RELEASE d. ACUTE HEALTH e. CHRONIC HEALTH
AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220
122 1 244 N/a 1 N/a
221 DAYS ON SITE: 222
UNITS" Oa. GALLONS ®b. CUBIC FEET c. POUNDS d. TONS 3651Checkoneitemonly) * IfEHS, amount must be in pounds.
STORAGE
CONTAINER [Ia. ABOVE GROUND TANK e. PLASTICINONMETALLIC DRUM i . FIBER DRUM m. GLASS BOTTLE q. RAILCAR
b. UNDERGROUND TANK f. CAN j. BAG n. PLASTIC BOTTLE r. OTHER
c. TANK INSIDE BUILDING g. CARBOY k. BOX o. TOTE BIN
d. STEEL DRUM h. SILO ® I. CYLINDER p. TANK WAGON 223
STORAGE PRESSURE [Ia. AMBIENT ® b. ABOVE AMBIENT c. BELOW AMBIENT 224
STORAGE TEMPERATURE ® a. AMBIENT b. ABOVE AMBIENT c. BELOW AMBIENT d. CRYOGENIC 225
WT HAZARDOUS COMPONENT (For mixture or waste only) EHS RS 246b CAS #
l
226 227 E] Yes 228 Yes 229
2 230 231 Yes 232 Yes 233
3 234 235 Yes 236 Yes 237
4 238 239 Yes 240 Yes 241
5 242 243 Yes 244 Yes 245
If more hazardous components are present at greaterthan 1 % by weight ifnon - carcinogenic, or 0.1% by weight ifcarcinogenic, attach additional sheets of paper capturing the required information.
ADDITIONAL LOCALLY COLLECTED INFORMATION 246
IfEPCRA, Please Sign Here
Facilities reporting Chemicals subject to EPCRA reporting thresholds must sign each Chemical Descriptionpagefor each EPCRA reported chemical.)
OFFICIAL USE ONLY IDATERECEIVED REVIEWED BY
DIV BN STA OTHER DISTRICT CUPA PA
UPFORM LAC4:UPFORMS3
THE CUPAS OF LOS ANGELES COUNTY
UNIFIED PROGRAM. (UP) FORM
HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION
one page per material per building or area
ADD DELETE ®REVISE REPORTING YEAR 2011 200 1 Page of
I. FACILITY INFORMATION
BUSINESS NAME (Same as FACILITY NAME or DBA — Doing Business As) 3
Pep Boys Store #0622
14CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL 202
Service Bays EPCRA) YES ENO
yy
1 MAP# (optional) 20T optional) 204
AGILITY ID #
7D#
II. CHEMICAL INFORMATION
CHEMICAL NAME 205 TRADE SECRET Yes ® No 206
Acetylene IfSubjectto EPCRA, refer to instructions
COMMON NAME Acetylene 207 EHS* Yes ® No 208 1 RS* Yes [--]No 246a
CAS# 74 -86 -2 209 If EHS or RS is "Yes ", all amounts below must be in lbs.
FIRE CODE HAZARD CLASSES (Complete i£ required by CUPA) Flammable 210
HAZARDOUS MATERIAL
TYPE 'Check one item only) ® a. PURE b. MIXTURE C1 c. WASTE 211 RADIOACTIVE Yes ®No 2t2
213
CURIES n a
PHYSICAL STATE 214Checkoneitemonly) a. SOLID b. LIQUID ® c. GAS LARGEST CONTAINER 122
215
FED HAZARD CATEGORIES 216
Check all that apply) ® a. FIRE b. REACTIVE ® c. PRESSURE RELEASE ® d. ACUTE HEALTH ® e. CHRONIC HEALTH
AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220
122 1 244 1 N/a 1 N/a
221 YS ON SITE: 222DAYS
UNITS* n. GALLONS ®b. CUBIC FEET c. POUNDS d. TONS
Check one item only)* IfEHS, amount must be in pounds.
STORAGE
CONTAINER a. ABOVE GROUND TANK e. PLASTIC/NONMETALLIC DRUM i . FIBER DRUM m. GLASS BOTTLE q. RAILCAR
b. UNDERGROUND TANK f. CAN j. BAG n. PLASTIC BOTTLE r. OTHER
c. TANK INSIDE BUILDING g. CARBOY k. BOX o. TOTE BIN
d. STEEL DRUM h. SILO ® 1. CYLINDER p. TANK WAGON 223
STORAGE PRESSURE a. AMBIENT ® b. ABOVE AMBIENT c. BELOW AMBIENT 224
STORAGE TEMPERATURE ® a. AMBIENT b. ABOVEAMBIENT c. BELOW AMBIENT d. CRYOGENIC 225
WT HAZARDOUS COMPONENT (For mixture or waste only) EHS RS 246b CAS #
I
226 227 Yes 228 Yes 229
2 230 231 Yes 232 Yes 233
3 234 235 Yes 236 Yes 237
4 238 239 Yes 240 YeS 241
5 242 243 Yes 244 Yes 245
Ifmore hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1% by weight ifcarcinogenic, attach additionalsheets of papercapturing the required information.
ADDITIONAL LOCALLY COLLECTED INFORMATION 246
If EPCRA, Please Sign Here
Facilities reporting Chemicals subject to EPCRA reporting thresholds must sign each Chemical Description pagefor each EPCRA reported chemical.)
OFFICIAL USE ONLY IDATERECEIVED REVIEWED BY
DIV BN STA OTHER DISTRICT CUPA PA
UPFORM LAC4:UPFORMS3
THE CUPAs OF LOS ANGELES COUNTY