HomeMy WebLinkAboutBUS-ACTIVITIES 3/1/2012UNIFIED PROGRAM (UP) FORM
BUSINESS ACTIVITIES
I. FACILITY IDENTIFICATION
FACILITY ID # EPA ID # (Hazardous Waste Only) 2
F CAL000024620
BUSINESS NAME (Same as Facility Name ofDBA -Doing Business As): Pep Boys Store #0677 3
4605 Planz Road, Bakersfield, CA 93309
II. ACTIVITIES DECLARATION
NOTE: If you check YES to any part of this list,
lease submit the Business Owner/Operator Identification page.
Does your facility... IfYes, please com lete these pages of the UPCF....
A. HAZARDOUS MATERIALS
Have on site (for any purpose) hazardous materials at orabove 55 gallons for liquids, 4 HAZARDOUS MATERIALS INVENTORY500poundsforsolids, or 200 cubic feet for compressed gases (include liquids in ASTs CHEMICAL DESCRIPTIONandUSTs); or the applicable Federal threshold quantity for an extremely hazardous YES NO 4
substance specified in 40 CFR Part 355, Appendix A or B; or handle radiological 4 CONSOLIDATED CONTINGENCY PLAN
materials in quantities for which an emergency plan is required pursuant to 10 CFR Section I and Site Map(s))
Parts 30, 40 or 70? 4 TRAINING PLAN
B. UNDERGROUND STORAGE TANKS (USTs) OUST FACILITY
1. Own or operate underground storage tanks? YES ® NO 5 OUST TANK (one page pertank)
2. Intend to upgrade existing or install new USTs? YES ® NO 6 4UST FACILITY
4UST TANK (one pertank)
4UST INSTALLATION - CERTIFICATE OF
COMPLIANCE (one page per tank)
3. Need to report closing a UST? YES ® NO 7 4UST TANK closure portion -one page per tank)
C. ABOVE GROUND PETROLEUM STORAGE TANKS (APSTs)
Own or operate APSTs above this threshold:
the total capacity for the facility is greater than 1,320 gallons? YES ® NO 8 NO FORM REQUIRED TO CUPAs
D. HAZARDOUS WASTE
1. Generate hazardous waste? 4 EPA ID NUMBER— provide at the top ofthis
YES NO 9 page
4 As a generator, answer YES to Item E2b
and complete Waste Generator Form
2. Recycle more than 100 kg/month ofexcluded or exempted
recyclable materials (per HSC 25143.2)? YES ® NO 10 4 RECYCLABLE MATERIALS REPORT
3. Treat hazardous waste on site? YES ® NO 11 4 ONSITE HAZARDOUS WASTE
TREATMENT— FACILITY
4 ONSITE HAZARDOUS WASTE
TREATMENT — UNIT (one pageper unit)
4. Treatment subject to financial assurance requirements (for YES ® NO 12 4 CERTIFICATION OF FINANCIAL
Permit by Rule and Conditional Authorization)? ASSURANCE
5. Consolidate hazardous waste generated at a remote site? YES ® NO 13 4 REMOTE WASTE / CONSOLIDATION
SITE ANNUAL NOTIFICATION
6. Need to report the closure/removal ofa tank that was classified as YES N NO 14 4 HAZARDOUS WASTE TANK CLOSURE
hazardous waste and cleaned onsite? CERTIFICATION
E. LOCAL REQUIREMENTS 15
1. REGULATED SUBSTANCES
Have Regulated Substances (RS) including Extremely Hazardous Substances (EHS) 15a In addition to Hazardous Materials
stored on site at greater than the threshold planning quantities established by the YES NO requirements, complete:
California Accidental Release Program (Cal ARP) ? 4 Regulated Substance Registration
4 Risk Management Plan when required)
2. OTHER REQUIREMENTS
a. Have hazardous materials stored on site at orabove a threshold amount 15b 4 Consult local CUPA or PA for added
established by a CUPA's or PA's local ordinance? YES NO reporting requirements
b. Required by a CUPA or PA to provide other information? 15c
YES NO 4 Waste Generator Form LA Count
OFFICIAL USE ONLY UP FORM HW HM ARP AST UST TP CUPA PA
UNIFIED PROGRAM (UP) FORM
BUSINESS OWNER/OPERATOR IDENTIFICATION
NEW BUSINESS OUT OF BUSINESS ® REVISE/UPDATE (EFFECTIVE: 03 /01 /2011) PAGE OF
I. IDENTIFICATION
FACILITY ID#
f
1 BEGINNING DATE 100
03/01/2011
ENDING DATE 1 01
03/01/2012
BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3
Pep Boys Store #0677
BUSINESS PHONE 102
616- 834 -6858
BUSINESS SITE ADDRESS 103
4605 Planz Road
CITY Bakersfield 104 CA ZIP CODE 93309 105
DUN & BRADSTREET 04- 527 -8707 106 SIC CODE (4 digit #) 5531/7538 107
COUNTY LOS ANGELES 106 UNINCORPORATED Yes No 133a.
BUSINESS OPERATOR NAME 109
Pep Boys — Manny, Moe & Jack
BUSINESS OPERATOR PHONE 110
215- 430 -9095
II. BUSINESS OWNER
OV:'NER NAME 111
Pep Boys — Manny, Moe & Jack I OWNER PHONE 112
215- 430 -9095
OWNER MAILING ADDRESS 113
Pep Boys — Manny, Moe & Jack, Attn.: Environmental Department, 3111 West Allegheny Avenue
CITY Philadelphia 114 STATE PA 175 1 ZIP CODE 19132 116
III. ENVIRONMENTAL CONTACT
CONTACT NAME 117
Yolanda Gallardo
CONTACT PHONE 118
215 - 430 -9017
CONTACT MAILING ADDRESS 119
Pep Boys — Manny, Moe & Jack, Attn.: Environmental Department, 3111 West Allegheny Avenue
CITY Philadelphia 120 1 STATE PA 121 ZIP CODE 19132 122
IV. EMERGENCY CONTACTS
PRIMARY SECONDARY
NAME Scott Romano 123 NAME Benjamin Santoy 126
TITLE Service Manager 124 TITLE Retail Manager 129
BUSINESS PHONE 661 - 834 -6858 125 BUSINESS PHONE 661- 834 -6858 130
24 -HOUR PHONE 661- 496 -9746 126 24 -HOUR PHONE 661- 343 -2655 131
PAGER # 127 PAGER # 132
E -MAIL ADDRESS (if any) svcmngr0677@PepBoys.com 133b E -MAIL ADDRESS (if any) mngr0677@PepBoys.com 133b
V. ADDITIONAL LOCALLY COLLECTED INFORMATION 133
FEDERAL TAX IDENTIFICATION NUMBER FEIN #95 - 1099890
133c NO. OF EMPLOYEES 25 133dNAME, POSITION, AND DATE OF BIRTH
DRIVER'S LICENSE NUMBER AND STATE I BUSINESS CODE 01 133e
MAILING/ BILLING INFORMATION
ADDRESS Pep Boys — Manny, Moe & Jack 133f CITY 1338 STATE 133h ZIP CODE 133i
Attn.: Environmental Department, 3111 W Allegheny Ave Philadelphia PA 1 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 OWNER/OPERAT R OR DESIGNATED REPRESENTATIVE DATE 1702 -28 -2011
NAME OF DOCUMENT PREPARER 135
Yolanda Gallardo
NAME OF SIGNER (print) 136 TITLE
Yolanda Gallardo
OF SIGNER 137
Environmental Coordinator
OFFICIAL USE ONLY UP Form HW HM ARP APST UST TP CUPA PA
INSPECTOR DISTRICT DATE OF INSP. DIVISION BATTALION STATION
UP FORM (4/2006 Version) UPF_LAC4: 02_2730
THE CUPAs OF LOS ANGELES COUNTY
Unified Program (UP) Form
CONSOLIDATED CONTINGENCY PLAN
COVER PAGE
FACILITY IDENTIFICATION
BUSINESS NAME 3 FACILITY ID # 1
Pep Bo s #0677
Hazardous Waste Generator (HWG)
SITE ADDRESS 103 I CITY 104 ZIP CODE 105
4605 Planz Road Bakersfield 93309
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:
rs Hazardous Materials Business Plan (HSC Chapter 6.95 Section 25504 (b) and 19 CCR Sections 2729 - 2732),
0 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 Title of Owner /Operator
Yolanda Gallardo Environmental Coordinator
Signature of Owner/ Operator 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 I 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 Bo s#0677
SITE ADDRESS 103 CITY 104 ZIP CODE 105
4605 Planz Road 1 Bakersfield 93309
II. EMERGENCY CONTACTS
PRIMARY SECONDARY
NAME 123 NAME 128
Scott Romano Benjamin Santo
TITLE 124 TITLE 129
Service Manager Retail Manager
BUSINESS PHONE 125 BUSINESS PHONE 130
661- 834 -6858 661- 834 -6858
24 -HOUR PHONE 126 24 -HOUR PHONE 131
661 - 496 -9746 661- 343 -2655
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.
M Exact address of the release or threatened release.
M 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.
0 Current condition of the facility.
M Extent of injuries, if any.
M 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 793301
OFFICIAL USE ONLY DATE RECEIVED REVIEWED BY
DIV I BN STA I 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:
Guthrie, 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. Z 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
on-a 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 dosed 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
1.
Equipment
Category
2.
Equipment
Type
3.
Location
4.
Description"
Personal Cartridge Respirators
Protective, Chemical Monitoring Equipment describe
Equipment,
Safety
Chemical Protective Aprons /Coats
Chemical Protective Boots
Equipment, Chemical Protective Gloves Srvc Bys Found in the spill kit
avid Chemical Protective Suits (describe)
First Aid 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
Systems
Fire Alarm Boxes /Stations Multi Loc.
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
and
Decontamination Equipment (describe)
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 Chemical Alarms (describe)
and Intercoms/ PAS stems 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 foryour Contingency Plan.
Describe the equipment and its capabilities. Ifapplicable, specify any testing /maintenance proceduresMtervals. Attach additional pages,
numbered appropriately, if needed.
UP FORM (0112000 Version) 6 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
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:
M Familiarity with all plans and procedures specified in the Contingency Plan.
M 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:
0 Initially for all new employees.
W Annually, including refresher courses, for all employees.
Note: These training programs may take into consideration the position of each employee.
Additional training should include:
ua Internal alarm /notification procedures.
0 Evacuation /re -entry procedures and assembly point locations.
0 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
0 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.
M 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:
0 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).
0 Description for each position listed above (must include required skill, education, or other qualifications
as well as duties of employees assigned to the position.
a Description of type and amount of both introductory and continuing training given to each employee.
M 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).
0 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.
1. 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.).
Map Legend
and/oritem Description
ffl(! I (1
IMI-affa Am
I
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#0677
SITE ADDRESS 103 1 CITY 104 1 ZIP CODE 105
4605 Planz Road Bakersfield 93309
DATE MAP DRAWN MAP # FACILITY ID # 1
02 -01 -2011
I
3-
4
5
6
7
8
9
10
11
12
A B C D E F G H I J For Site Map
Scale of Map
Loading Areas
Parking Lots
Internal Roads
Storm and Sewer
I CUPA
WOMEN
Locations and Names
of Adjacent Streets and
Alleys
Access and Egress
I
Primary and Alternate
Evacuation Routes
0= = c c sas o.ca..coo a ac rt
Scale of Map
Location of Each
Storage Area
Location of Each
Hazardous Material
Handling Area
Location of Emergency
Response Equipment
Scale:
J" = Ft.
1 515-555-51
Y X
II
a —ssa o dc sa. I) i=_aa=_ 59i
1K i ICI
gym
ic;c —as I
ml
Scale of Map
Loading Areas
Parking Lots
Internal Roads
Storm and Sewer
I CUPA
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:
J" = Ft.
North I
Y X
OFFICIAL USE ONLY I DATE RECEIVED I REVIEWED BY
DIV I BN STA I OTHER DISTRICT I CUPA PA
UP FORM (01/2000 Version) 12 UPF_LAC4 : 03_FI_CP
THE CUPAs OF LOS ANGELES COUNTY
k
LGS i-F er.Af.o.C'c'VES 1. t3xau£S kSuYdu1c'.E
atx, Yylu, -r1l
ta it.- ,vn ' t' ac0L.E
a
ice. •
ti R•,
Air
oil
VON ` ~
a
10 ell
4. Vow-
4
L
1
i .
1
UNIFIED PROGRAM (UP) FORM
HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION
one page per material per buildm or area)
ADD DELETE ZREVISE REPORTING YEAR 2011 200 Page of
I. FACILITY INFORMATION
BUSINESS NAME (Same as FACILITY NAME or DBA — Doing Business As) 3
Pep Boys Store #0677
CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL 202
Service Bays EPCRA) YES Z NO1
I MAP# (optional) 203 GRID# (optional) 204
FACILITY ID #
II. CHEMICAL INFORMATION
CHEMICAL NAME 205 TRADE SECRET Yes 0 No 206
Used Petroleum Hydrocarbon IfSubjectto EPCRA, refer to instructions
COMMON NAME Used Motor Oil 207 EHS* Yes Z 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 210
HAZARDOUS MATERIAL
TYPE tCheck one item only) a. PURE b. MIXTURE Z c. WASTE 21 i RADIOACTIVE []Yes ®No 212
213
CURIES n/a
PHYSICAL STATE 214Checkoneitemonly) a. SOLID Zb. LIQUID c. GAS
215
LARGEST CONTAINER 500 gallons
FED HAZARD CATEGORIES 216
Check all that apply) ® a. FIRE b. REACTIVE c. PRESSURE RELEASE ® d. ACUTE HEALTH Z 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
DAYS ON SITE: 222
c. POUNDS d. TONSUNITS* ®a. GALLONS b. CUBIC FEET El c. 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 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 83 -93 226 Aliphatic Petroleum Distillates 227 Yes 228 Yes 64742 -65 -0 229
2 6 -16 230 DetergenVDispersant 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 Yes 245
Ifmore hazardous components arepresent at greater than I% by weight ifnon - carcinogenic, or0.1 % 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 EPCRA reported chemical.)
OFFICIAL USE ONLY IDATERECEIVED REVIEWED BY
DIV BN --TSTA OTHER DISTRICT CUPA PA
UPFORM LAC4:UPFORMS3
THE CUPAs OF LOS ANGELES COUNTY
UNIFIED '.PROGRAM (UP) FORM
HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION
one pageper matena per building or area
ADD DELETE ZREVISE 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 #0677
CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL 202
Service Bays EPCRA) YES [ONO
MAP# (optionaq 203 GRID# (optional) 204
FACILITY ID # 1
II. CHEMICAL INFORMATION
CHEMICAL NAME 205 TRADE SECRET Yes ONO 206
Used Petroleum Hydrocarbon/Filter IfSubject to EPCRA, refer to instructions
COMMON NAME Used Motor Oil Filters 207 EHS* Yes Z 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 210
HAZARDOUS MATERIAL
TYPE (Check one item only) a. PURE b. MIXTURE Z c. WASTE 211 RADIOACTIVE Yes ®No 212
213
CURIES n/a
PHYSICAL STATE 214
Check one item only) Z a. SOLID b. LIQUID c. GAS
215
LARGEST CONTAINER 55 gallon drum
FED HAZARD CATEGORIES 216
Check all thatapply) Z a. FIRE b. REACTIVE c. PRESSURE RELEASE d. ACUTE HEALTH Z 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
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. CLASS 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 229
64742 -65 -0
2 6 -16 230 DetergenvDispersant 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 E] Yes 241
5 242 243 Yes 244 Yes 245
If more hazardous components are present at greater than 1 % by weight ifnon - carcinogenic, or 0.1 % by weight if carcinogenic, attachadditional 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 DATE RECEIVED
r
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 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 #0677
CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL 202
Service Bays EPCRA) YES ONO
MAP# (optional) 203 GRID# (optional) 204
FACILITY ID #r`
II. CHEMICAL INFORMATION
CHEMICAL NAME 205 TRADE SECRET Yes ® No 206
Waste Inhibited Ethylene Glycol IfSubjectto EPCRA, refer to instructions
COMMON NAME Waste Antifreeze /Coolant 207 EHS* El Yes ® No 208 RS* Yes ONO 246a
CAS# Mixture 209 If EHS or RS is "Yes ", all amounts below must be in lbs.
FIRE CODE HAZARD CLASSES (complete ifrequired bycUPA) Combustible Liquid, Toxic 210
HAZARDOUS MATERIAL 211TYPEtCheckoneitemonly) a. PURE b. MIXTURE ® c. WASTE RADIOACTIVE []Yes ONO 212
213
CURIES n/a
PHYSICAL STATE 214Checkoneitemonly) 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 15 5475 1 342
221 DAYS ON SITE: 222
UNITS* ®a. 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 m. GLASS BOTTLE q. RAIL CAR
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 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 are present at greater than 1% by weight ifnon - carcinogenic, or 0.1% by weight ifcarcinogenic, attach additionalsheets of paper capturing therequired 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
UP FORM LAC4:UPFORMS3
THE CUPAs OF LOS ANGELES COUNTY
UNIFIED PROGRAM (UP) FORM
HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION
one page per material per building orarea
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 #0677
CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL 202
Service Bays EPCRA) YES S NO
1 MAP# (optional) 203 CRID# (optional) 204
FACILITY ID # N , f ,
i
II. CHEMICAL INFORMATION
CHEMICAL NAME 205 TRADE SECRET Yes ® No 206
Waste Water IfSubjectto EPCRA, refer to instructions
COMMON NAME Waste Water 207 EHS* Yes ONO 208 1 RS* Yes No 246a
CAS# Mixture ofoily 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 211TYPE (Check one item only) El a. PURE b. MIXTURE S c. WASTE RADIOACTIVE Yes No 212 CURIES n/a
213
PHYSICAL STATE 214Checkoneitemonly) a. SOLID Ob. LIQUID c. GAS
215
LARGEST CONTAINER 280 gallons
FED HAZARD CATEGORIES 216
Check all that apply) S a. FIRE b. REACTIVE c. PRESSURE RELEASE S 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
221 DAYS ON SITE: 222
UNITS* Sa. GALLONS b. CUBIC FEET C] c. POUNDS [I d. TONS 365Checkoneitemonly) • IfEHS, amount must be in pounds.
STORAGE.
CONTAINER S a. ABOVE GROUND TANK e. PLASTIC/NONMETALLIC DRUM i . FIBER DRUM m. GLASS BOTTLE q. RAILCAR
b. UNDERGROUNDTANK 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 S a. AMBIENT b. ABOVE AMBIENT c. BELOW AMBIENT 224
STORAGE TEMPERATURE S a. AMBIENT b. ABOVE AMBIENT 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 Oyes 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 hamrdous 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 Description pagefor each EPCRA reported chemical.)
OFFICIAL USE ONLY IDATERECEIVED REVIEWED BY
DIV BN __TSTA OTHER DISTRICT CUPA PA
UPFORM LAC4:UPFORMS3
THE CUPAs OF LOS ANGELES COUNTY
r,
UNIFIED PROGRAM (UP) FORM
HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION
onepageper material per bu I Ing 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 #0677
CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL 202
Service Bays EPCRA) YES ONO1
MAP# (optional) 20T GR (optionaq 204
FACILITY ID # r
a u
71D#
II. CHEMICAL INFORMATION
CHEMICAL NAME 205 TRADE SECRET Yes Z No 206
IfSubject to EPCRA, referto 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 byCUPA) 1111 210
HAZARDOUS MATERIAL 211TYPE (Check one item only) a. PURE Ob. MIXTURE c. WASTE RADIOACTIVE Yes ZNo 212 CURIES n/a
213
PHYSICAL STATE 214Checkoneitemonly) a. SOLID Zb. LIQUID c. GAS
215
LARGEST CONTAINER 64 oz.
FED HAZARD CATEGORIES 216
Check all that apply) a. FIRE b. REACTIVE Z c. PRESSURE RELEASE Z 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 n/a 1 343
221 DAYS ON SITE: 222
UNITS* Za. 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
Z d. STEEL DRUM h. SILO I. CYLINDER p. TANK WAGON 223
STORAGE PRESSURE Z a. AMBIENT b. ABOVE AMBIENT c. BELOW AMBIENT 224
STORAGE TEMPERATURE Z a. AMBIENT b. ABOVE AMBIENT c. BELOW AMBIENT d. CRYOGENIC 225
WT HAZARDOUS COMPONENT (For mixture or waste only) EHS RS 246b CAS #
1 >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 ifnon - carcinogenic, or0.1% by weight ifcarcinogenic, attach additional sheets of papercapturing 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 pageforeach 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 PROGRAW(UP). FORM
HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION
one pageper matena per buildin . 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 #0677
CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL 202
Service Bays EPCRA) YES ONO
1 MAP# (optional) 203 GRID# (optional) 204
FACILITY ID # 1
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 El c. WASTE 211 RADIOACTIVE Yes ®No 212
213
CURIES n/a
PHYSICAL STATE 214
Check one itemonly) a. SOLID ®b. LIQUID c. GAS
215
LARGESTCONTAINER 1.77 lbs 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 1 N/a
221 DAYS ON SITE: 222
a. GALLONS b. CUBIC FEET ® c. POUNDS d. TONSUNITS* [3a. 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 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 On. 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 2466 CAS #
l 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 E] 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
If EPCRA, Please Sign Here
Facilities reporting Chemicals subject to EPCRA reporting thresholds must sign each Chemical Descriptionpagefar each EPCRA 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
i
UNIFIED. PROGRAM (UP) FORM
HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION
onepaRe 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 #0677
CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL 202
Service Bays EPCRA) YES ONO1
1 MAP# (optional) 203 GRID# (optional) 204
FACILITY ID # 1
II. CHEMICAL INFORMATION
CHEMICAL NAME 205 TRADE SECRET Yes IZ No 206
Petroleum Hydrocarbon IfSubject to EPCRA, referto 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 IfEHS or RS is "Yes ", all amounts below must be in lbs.
FIRE CODE HAZARD CLASSES (Complete ifrequired byCUPA) Combustible Liquid, Toxic 210
HAZARDOUS MATERIAL 211TYPE (Check one item only) a. PURE ®b. MIXTURE c. WASTE RADIOACTIVE Yes ®No 212
213
CURIES n/a
PHYSICAL STATE 214Checkoneitemonly) a. SOLID ®b. LIQUID c. GAS
zls
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 n/a I n/a
DAYS ON SITE: 222DA
c. POUNDS d. TONSUN1TS41 ®a. GALLONS b. CUBIC FEET El c.
Check one item only)* 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 On. 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 #
183 -93 226 Aliphatic Petroleum Distillates 227 Yes 228 Yes 64742 -65 -0 229
2 6 -16 230 DetergentOispersant 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 if non - carcinogenic, or0.1 % by weight ifcarcinogenic, attach additional sheetsofpapercapturing 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
r;
UNIFIED PROGRAM (UP) FORM
HAZARDOUS MATERIALS INVENTORY — CHEMICAL DESCRIPTION
one page per material per 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 #0677
CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL 202
Retail Store Shelves EPCRA) YES ONO1
i MAP# (optional) 203 GRID# (optional) 204
FACILITY ID #.
Ii. CHEMICAL INFORMATION
CHEMICAL NAME 205 TRADE SECRET Yes Z No 206
Liquid Content — Sulfuric Acid IfSubject to EPCRA, refer to instructions
COMMON NAME Sulfuric Acid, Battery Electrolyte 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 211TYPE (Check one item only) a. PURE ®b. MIXTURE El c. WASTE RADIOACTIVE Yes ®No 212
213
CURIES n/a
PHYSICAL STATE 214Checkoneitemonly) 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) [Ia. FIRE ® b. REACTIVE ® c. PRESSURE RELEASE ® d. ACUTE HEALTH e. CHRONIC HEALTH
AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 216 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220
1000 1000 n/a 1 n/a
DAYS ON SITE: 222
d. TONSUNITS* a. GALLONS b. CUBIC FEET ® c. POUNDS El d. 365Checkoneitemonly) * If EHS, 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 1. CYLINDER p. TANKWAGON 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 20-40 226 Sulfuric Acid 227 ZYeS 228 Yes 7664 -93 -9 229
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 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
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
UP FORM LAC4:UPFORMS3
THE CUPAS OF LOS ANGELES COUNTY
b
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 #0677
CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL 202
Service Bays EPCRA) YES ® NO
optional) 203 GRID# (optional) 204
FACILITY ID #
7AP#
II. CHEMICAL INFORMATION
CHEMICAL NAME 205 TRADE SECRET Yes ®No 206
Oxygen IfSubject to EPCRA, referto instructions
COMMON NAME Oxygen 207 EHS* Yes ONO 208 1 RS* Yes []No 246a
CAS# 7782 -44 -7 209 IfEHS or RS is "Yes ", all amounts below must be in lbs.
FIRE CODE HAZARD CLASSES (Complete if required by CUPA) 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 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 N/a
221 DAYS ON SITE: 222
UNITS* a. GALLONS ®b. CUBIC FEET c. POUNDS d. TONS 3651Checkoneitemonly) * If EHS, 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 ® 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
226 227 Yes 228 E] 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 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
UNIFIED PROGRAM (UP) FORM
HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION
one page per material per buildin orarea
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 #0677
CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL 202
EPCRA) [:]YES ONO1ServiceBays
1 MAP# (optional) 203 GRID# (optional) 204
FACILITY ID #
@y
y
II. CHEMICAL INFORMATION
CHEMICAL NAME 205 TRADE SECRET Yes ® No 206
Acetylene IfSubject to EPCRA, refer toinstructions
COMMON NAME Acetylene 207 EHS* Yes ® No 208 I 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 ifrequired by CUPA) Flammable 210
HAZARDOUS MATERIAL
TYPE ¢Check one item only) ® a. PURE b. MIXTURE c. WASTE 211 RADIOACTIVE Yes ®No 2t2
213
CURIES n/a
PHYSICAL STATE
Check one item only) a. SOLID [:1b. LIQUID ® c. GAS 214
215
LARGEST CONTAINER 122
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 27ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220
122 1 244 N/a 1 N/a
221 YS ON SITE: 222DAYS
UNITS* n. GALLONS ®b. CUBIC FEET c. POUNDS d. TONS
Check one item only) * 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 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. ABOVEAMBIENT c. BELOW AMBIENT d. CRYOGENIC 225
WT HAZARDOUS COMPONENT (For mixture or waste only) EHS RS 246b CAS #
1
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 arepresent at greater than I % by weight if non - carcinogenic, or0.1 % 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 EPCRA 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