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Home My WebLink AboutBUSINESS PLAN 3/30/2001 MISCELLANEOUS RECEIVABLES ADJUSTMENT DATE ,~-,~(-'x)-~) . NEW ACCOUNT ADDRESS CHANGE CLOSE ACCT ' FINANCE CHARGE' OTHER.ADJ CUSTOMER NAME ~)c~ce_'~ac~ ~~cI(xi~ SITE ADDRESS X%~ ~%~ .~ P~CEL NUMBER (IF APPUC~ ADJUSTMENT CHG DATE CHARGE CODE /~,DJUSTMENT AMOUNT /-/'5--??' ~'~( ,.~,/0 -- ' ' / -/~-?? kl~i~ .m--" _... 1 -. CITY OF BAKERSFIELD FIRE DEPARTMENT..~ ": OFFICE OF ENVIRONMENTAL SERVICES/~/'" £1tlb'll:lOlit., UNIFIED PROGRAM INSPECTION CHEC~IsT 1715 Chester Ave., 3~a Floor, Bakersfield~ 93301 FACILITY NAME ~ ~4~ ~~~ ~SPEC TE ADD'SS /,~ffO ~ ~. PHONE~O. FACILITY CONTACT BUS'ESS ID NO. I~- ~SPECTION TIME NUMBER OF EMPLOYEES Section 1: Business Plan and Inventory Program ~ Routine ~ Combined ~ Joint Agency ~ Multi-Agency ~ Complaint ~ Re-inspection OPE~TION C V COMMENTS Appropriate pe~it on hand Business plan contact info~ation accurate Visible address Co~ect occupancy Verification of inventow materials Verification of quantities Verification of location Proper se~egation of material Verification of MSDS availabiliW Verification of Haz Mat training Verification of abatement supplies and procedures Emergency procedures adequate Containers properly labeled Housekeeping Fire Protection . Site Diagram Adequate & On Hand C=Compliance V=Violation Any hazardous waste on site?: ~ Yes ~ No Explain: Questions regarding this inspection? Please call us at (805) 326-3979 Business Site Resppnsible Pa~y CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 FACILITY NAME gj}-C~- ,~41'~ ~'/0~Cl,~'(l'l~3'- INSPECTION DATE ~ ADDRESS I ~ => ~ :z ~ 7"~ ~ -'r · PHONE NO. FACILITY CONTACT BUSINESS ID NO. 15-210- INSPECTION TIME ~ r~ ~/ NUMBER OF EMPLOYEES Section 1: Business Plan and Inventory Program ~ Routine [] Combined [] Joint Agency [] Multi-Agency [] Complaint [] Re-inspection OPERATION C V COMMENTS Appropriate permit on hand Business plan contact information accurate Visible address Correct occupancy Verification of inventory materials Verification of quantities Verification of location Proper segregation of material Verification of MSDS availability Verification of Haz Mat training Yerification of abatement supplies and procedures Emergency procedures adequate Containers properly labeled Housekeeping Fire Protection Site Diagram Adequate & On Hand · C=Compliance V=Violation ~.~-~.~/ Any hazardous waste on site?: [] Yes [] No Explain: Questions regarding this inspection? Please call us at (805) 326-3979 Business Site Responsible Party White - Env. Svcs. Yellow - Station copy Pink - Business Copy Inspector: MISCELLANEOUS RECEIVABLES ADJUSTMENT ADDRESS CHANGE CLOSE ACCT · FINANCE CHARGE l. / I · OTHER ADJ CUSTOMER NAME ~---~c~-__.'--[-~-'C~C~-- ~.D~__[ c~'[ -~ C.,~ I ~A~UN~ADDRESS ¢. ¢. ~~ Dt~ [ " C'~ ~~~C~¢ ~[a STATE ~ ZIP CODE~~ SITE ADDRESS ~ ~~ ~~ PARCEL NUMBER (IF APPUCABt--~ ADJUSTMENT I ! CHG DATE CHARGE CODE ADJUSTMENT AMOUNT I t ! . REMARKS: / APPROVED'BY CITY OF BAKERSFIELD 'OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., Bakersfield, CA (805) 326-3979 INSTRUCTIONS: )b~ ~ (qC~ 1. To avoid ~hcr a~io~ r¢~ tMs fo~ ~tMn 30 days of receipt. 2. T~E~~ ~S~S ~ ENGLISH. 3. ~swcr ~o qu~ons b~low for ~ busM~ss ~ a whole. 4. Be ~ brief ~d ~ncise ~ possible. ~ ~ ~ ~ ~- SECTION l' BUS.SS ~E~WICATION DATA BUSINESS NAME: LOCATION: / MAIl.lNG ADDRESS: CITY: STATE: __ ZIP: __ PHONE: DUN & BRADSTRBET NUMBER: SIC CODE:__ PRIMARY ACTMTY: OWNER: MAILING ADDRESS: SECTION 2: EMERGENCY NOTIFICATION CONTACT TITLE BUS. PHONE 24 HR. PHONE 2. ~ HAZARDOUS MATERIALS MANAGEMENT PLAN ' SECTION 3: TRAINING NUMBER. OF EMPLOYEES: MATERIAL SAFETY DATA SHEETS ON FILE: BRIEF SUMMARY OF TRAINING PROGRAM: SECTION 4: EXEMPTION REQUEST I CERTIFY UNDER PENALTY OF PERJURY THAT MY BUSINESS IS EXEMPT FROM THE REPORTING REQUIREMENTS OF CHAPTER 6.95 OF THE "CALIFORNIA HEALTH' & SAFETY CODE" FOR THE FOLLOWING REASONS: WE DO NOT HANDLE HAZARDOUS MATERIALS. WE DO HANDLE HAZARDOUS MATERIALS, BUT THE QUANTITIES AT NO TIME EXCF. ED THE MINIMUM REPORTING QUANTITIES. · OTHER (SPECIFY REASON) SECTION 5: CERTIFICATION I, CERTIFY THAT THE ABOVE INFORMATION IS ACCURATE. I UNDERSTAND THAT THIS INFORMATION WILL BE USED TO FULFILL MY FIRM'S OBLIGATIONS UNDER THE "CALIFORNIA HEALTH AND SAFETY CODE" ON HAZARDOUS MATERIALS (DIV. 20 CHAPTER 6.95 SEC. 25500 ET AL.) AND THAT INACCURATE INFORMATION CONSTITUTES PERJUKY. SIGNATUKE TITLE DATE 2 HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 6: NOTIFICATION AND EVACUATION PROCEDURES A. AGENCY NOTIFICATION PROCEDURES: B. EMPLOYEE NOTIFICATION AND EVACUATION: C. PUBLIC EVACUATION: D. EMERGENCY MEDICAL PLAN: . HAZARDOUS MATERIALS MANAGEMENT PLAN ' SECTION 7: MITIGATION, PREVENTION AND ABATEMENT PLAN A. RELEASE PREVENTION STEPS: B. RELEASE CONTAINMENT AND/OR MINIMIZATION: C. CLEAN-UP PROCEDURES: sECTION 8: UTII.ITY SHUT-OFFS .(LOCATION OF SHUT-OFFS AT YOUR FACILITY) NATURAL GAS/PROPANE: ELECTRICAL: WATER: SPECIAL: LOCK BOX: YES/NO IF YES, LOCATION: SECTION 9: PRIVATE FIRE PROTECTION/WATER AVAILABILITY A. PRIVATE FIRE PROTECTION: B. WATER AVA, II.ABILITY (FIRE HYDRANT): 4 ZARDOI[JS MATERIALS INVEN~iY Page of Business Name Addre~ CHEMICAL DESCRIPTION 1) INVENTORY STATUS: New [ ] Addition [ ] Revision [ ] Deletion [ ] Check if chemical is a NON Trade Secret [ ] Trade Secret [ ] 2) Common Name: ']kJ ~'x{"/~ 3) DOT # (optional) Chemical Name: AI-IM [ ] CAS # 4) Physical & Health PHYSICAL HEALTH Hazard Categories Fire [ ] Reactive [ ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ ] Delayed Health (Chronic) [ ] 5) WASTE CLASSIFICATION O-digit code from DHS Form g022) USE CODE 6) PHYSICAL STATE Solid [ I Liquid [ ] Oas [ I Pure [ ] Mixture [ ] Waste [ ] Radioactive [ ] 7) AMOUNT AND TIME AT FACILIT~r~i' UNITS OF MEAS~ 8) STORAGE CODES Maximum Daily Amount ~, Lbs [ ] Gal [ ] fL3 [~ a) Container:. Average Daily Amount Curies [ ] b) Pressure: Anmml Amount c) Temperature Largest Size Container # Days on Site Circle Which Months: All Year, $, F, M, A, M, $, $, A, S, O, N, D 9) MIXTURE: List COIVlPO~ CAS# % w'r AHM the three most ha:,~rdous 1) [ ] chemical components or 2) [ ] any AHM components 3) [ ] 10)LOCATION 1) INVENTORY STATUS: New [ ]Addition[ ]Revision[ ]Deletion[ ] Check ifchemical is a NON Trade Secret [ ]TradeSecret[ ] Chemical Name: AHM [ ] CAS # 4) Physical & Health PHYSICAL HEALTH Hazard Categories Fire[ ]Reactive[ ]SuddonRelea~seofPressure[ ] hnmediateHealth(Acute)[ ] Delayed Health (Chronic) [ ] 5) WASTE CLASSIFICATION (3-digit code from DHS Form 8022) USE CODE 6)?HYSICALST^~ So,iai I Liquid[ I C-~[ I Puli ] Mixture[ ] Waste[ ] V,~lio~ave[ ] 7) AMOUNT AND TIME AT FACILITY UNT~ OF MEASURE 8) STORAGE CODES Maximum Daily Amount --'~'~ Lbs [ ] Gal [ ] fl3 [~.] a) Contain~ Average Daily Amount Curies [ ] b) Pressure: Annual Amount c) Temperature Largest Size Container # Days on Site Circle Which Months: All Year, $, F, M, A, M, $, $, A, S, O, N, D 9) MIXTURE: List ~ _ ~ COMPONENT CAS# % V~ AHM the three most l~mao~ 1) '~ 7 S" [ ] chemical components or 2) ~/afe_~ ~;;~tOT:~/3~' ~ [ ] any AHM components 3) [ ] ! 0 )LOCATION I certify under penalty of law, that I have personally examined and am familiar with the information on this and all attached documents. I believe the submitted information is true, accurate and complete. PRINT Name & Title of Authorized Company Representative Signature Date BAZ~RDOUS MATERIALS INVENTO~ · Page of Business Name Address CBEMICAL i)ES~ON I)INVENTORYSTATUS:New[ ]Addition[ ]Rcvision[ ]Deletion[ ] Ch~kifchemicalisaNONTrad~m'et[ ]TradeSecret[ ] 2) Common Name: 3) DOT # (optional) Chemical Name: AHM [ ] CAS # 4) Physical & Health PHYSICAL HEALTH Hazard Categories Fire[ ]Reactive[ ]SuddenReleaseof~[ ] ImmediateHealth(Aont~)[ ] Delayed Health (Chronic) [ ] 5) WASTE CLASSn~ICATION O-digit code flora DHS Form 8022) USE CODE 6) PHYsicAL STATE SoUd [ ] Liquid [ ] Cas [ ] Pure [ ] Mixture [ ] Waste [ ] P. saio~dve [ ] 7) AMOUNT AND TIME AT FACILrrY 'UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount Lbs[ ] C.,-sl [ ] ti3 [ ] a) Container. Average Daily Amount Curies [ ] b) Pressure: Annual Amount ¢) Temperature Ia~est Size Container # Days on Sim Circle Which Months: All Year, $, F, M, A, M, $, $, A, S, O, N, D 9) MIXTURE: List COMPONENT CAS# % WT AHM the three most hazardous 1) [ , ] chemical compononts or 2) [ ] any AI-IM components 3) [ ] 10)LOCATION I)INVENTORYSTATUS:New[ ]Addition[ ]Revision[ ]Deletion[ ] CheckifchemicalisaNONTrad~Secret[ ]Trad~Secr~t[ ] 2) Common Name: 3) DOT # (optional) Chemical Name: AHM [ ] CAS # 4) Physical & Health PHYSICAL HEALTH Hazard Categories Fire[ ]Reactive[ ]SuddenReleaseofPressure[ ] Immediate Health (Acute) [ ]DelayedHealth(Chrunic)[ ] 5) WASTE CLASSIFICATION (3-digit c. od~ .%~a DHS Form 8022) USE CODE 6) ?WeSiCAL STATE Solid [ .1 Liquid [ ] ' C-as [ ] Pu~ [ ] Mixtu~ [ ] W~st~ [ ] P,~tio~tive [ ] 7) AMOUNT AND TIME AT FACILITY UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount Lbs [ ] Gal [ ] ft3 [ ] a) Container'. Average Daily Amount Curies [ ] b) ~: Annual Amount ¢) T~mlx~ture Largest Siz~ Container # Days on Site Circle Which Months: All Year, $, F. M, A, M,. $, J, A, S. O, N, D 9) MIXTURE: List COMPONENT CAS# % WT AHM the ~ most hazardous 1) [ ] chc'mical componants or 2) [ ] any AHM components 3) [ ] 10)LOCATION ! ce,lO/under penally of law. that I have personally examiued ami am familiar with the information on this and all attached documents. I believe the submitted information is true, accurat~ and complete. PRINT Name & Title of Authorized Company Representative Signature Dam HAZARDOUS MATERIALS INVENTORY Page of .... Business Name Address CI~EMICAL DESCRIPTION 1 ) INVENTORY STATUS: New [ ] Addition [ ] Revision [ ] D~letion [ ] Ch~ck if chemical is a NON Trac~ S(x'r~t { ] Trac~ Socr~ [ ] 2) Common Name: '~'~ ~'? ~-~ 3) DOT # (optional) Chemical Name: AI-IM [ ] CAS # 4) Physical & Health PHYSICAL HEALTH Iqaz&,'dCategories Fire[ ]Reactive[ ]SuddenRelemeofPressure[ ] Immediate Health (Acute) [ ]DelayedHeaith(Chroni¢)[ 5) wASTE cr. ssImc^Tio O- it Dm S0 ) USE CODE 6) PHYSICAL STATE Solid [ ] Liquid [ ] Gas [ ] Pure [ ] Mixture [ ] Waste,[i~q, Rm:lioactive [ ] 7) AMOOWr AWO ma~ ^T F^cturrv _ tmrrs oF Mm~.S~ S) sTom~,aE CODES Maximum Daily Amount ~.7_.~.3 Lbs [ ] Gal [ ] 9.3 [ ] a) Container:. Average Daffy Amount Curies [ ] b) ~: Annual Amount ¢) Temporamm Largest Size Container # Days on Site Cimle Which Months: All Year, I, F, M, A, M, $, $, A, S, O, N, D 9) MIXTURE: List COMI~NENT CAS# % WT AHM the three most h~o,-dons l) [ ] chemical components or 2) [ ] any AHM components 3) [ ] 10 )LOCATION I)INVENTORYSTA~S:New[ ]Addition[ ]Revision[ ]Deletion[ ] Check if chemical is a NON Trade Secret [ ]TradeSec~[ ] 2) Common Name: 3) DOT # (optional) Chemical Name: AHM [ ] CAS # 4) Physical & Health PHYSICAL HEALTH I-IazardCategories Fire[ ]Reactive[ ] Sudden Release of Pressure [ ] lmmediateHealth(Acute)[ ] Delayed Health (Chronic) [ ] 5) WASTE CLASSIFICATION (3-digit code from DHS Form 8022) USE CODE 6) PHYSICAL STATE Solid[ I Liquid[ ] Gas[ ] Pure[ ] Mixture[ ] Waste[ ] Radioactive[ ] 7) AMOUNT AND TIME AT FACILITY UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount Lbs [ ] Gal [ ] fO [. ] a) Conmin~ Average Daily Amount Curie~ [ ] b) Pressure: Annual Amount ¢) Temporamm Largest Size Container # Days on Site Cimle Which Months: All Year, $, F, M, A, M, ~, $, A, S, O, N, D 9) MIXTURE: List COMPONENT CAS# % WT AHM the three most lmzardons I) [ ] chemical components or 2) [ ] any AHM components 3) [ ] 10 )LOCATION I certify under penalty oflaw, that I have personally ex, refined and am famih'ar with the information on this and all atte~hed documents. I believe the submitted information is ~xue, accurate and complete. PRINT Name & Title of Authorized Company Representative Signature Date OUS MATE~S INVENTO Page of Business Name Address CHEMICAL DESCRIFrlON I ) INVENTORY STATUS: New [ ] Addition [ ] Revision [ ] Deletion [ ] Check if chemical is a NON Trade Secret [ ] Trade Secret [ ] 2) Common Name: 3) DOT # (optional)' Chemical Name: ARM [ ] CAS # 4) Physical & Health PHYSICAL HEALTH Hazard Categories Fire[ ]Reactive[ ]Sudd_~ReleaseofPressure[ ] lmmediateHealth(Acute)[ ]DelayedHealth(Chroni¢)[ ] 5) WASTE CLASSn~ICATION (3.digit code from DHS Form 8022) USE CODE 6) PHYSICAL STATE Solidi ] Liquid[ ] Gas[ ] Pu~[ ] Mixture[ ] Waste[ ] Radioactive[ ] 7) AMOUNT AND TIME AT FACIIXI'Y UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount Lbs [ ] C-al [ ] fl3 [ ] a) Conts!-~ Average Daily Amount Curies [ ] b) Pressure: Annual Amount c) Temperature # Dnys on Site Circle Whi~ lVionths: All Year, $, ~, I~ A, ~ $, $, A, S, O, N. D 9) MU~URE: List COMPONENT CAS# % WT AH~ the t~ree most hazardous 1) [ ' ] chemical components or 2) [ ] an~ ~ components ~) [ ] 10)LOCATION I)INVENTORYSTATUS:New[ ]Addition[ ]Revision[ ]Deletion[ ] Check if chemical is a NON Trade Secret [ ]TradeSec~[ ] 2) Common Name: 3) DOT # (optional) Chemical Name: AHM [ ] CAS # 4) Physical & Health PHYSICAL HEALTH I-Ia~ardCategories Fire[ ]Reactive[ ]SuddenReleaseofPressure[ ] Immediate Health (Acute) [ ]DelayedHealth(Chwnic)[ ] 5) wASTE cLASsIFICATION (3-digit code from DHS Form 8022) USE CODE 6) PHYSICAL STATE Solidi ] Liquid[ ] Oas[ ] Pure[ ] Mixture[ ] Waste[ ] Radioactive[ ] 7) AMOUNT AND TIME AT FACILITY UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount Lbs [ ] Gal [ ] fl3 [ ] a) Container:. Average Daily AmoUnt' Curies [ ] b) Pressure: Annual Amount ¢) Temperature Largest Size Container # Days on Site Circle Which Months: All Year, $, F, ]vi, A, M, $, $, A, S, O, N, D 9) MIXTURE: List COMPONEKr CAS# % WI' AHM the three most {,-7-,~lous 1) [ ' ] chemical components or 2) [ ] any AHM components 3) [ ] ! 0 )LOCATION [ certify under penalty oflaw, that I have persoually examined and am familiar with the iuformation on this and all attached documents. I believe the submitted information is true, accurate and complete. PRINT Name & Title of Authoriz~ Company Representative Signature Date I~ZARDOUS MATERIALS INVENTORY Page of. Business Name Addt~s Clff, MICAL BESCRIIq'ION 1 ) [NVE~ORY STATUS: New [ I Addition [ ] Revision [ ] Deletion [ ] Check il'chemical is a NON Trade Secret [ ] Trade Secret [ ] 2) Common Name: 3) DOT # (optional) Chemical Name: AI-IM [ ] CAS # 4) Physic. al & Health PHYSICAL HEALTH Hazard Categories Fir~ [ ] Reactive [ ] Suddeu Rel~.s~ ofPressu~ [ ] r,,,m_~i,,t~ Health (Acute) [ ] Delayed H~aith (Chmui¢) [ ] 5)'WASTE CLASSIFICATION (3-digit ~ fium BI-IS Form 8022) . USE CODE 6) PHYSICAL STATE So{id[ ] Liquid[ ] Oas[ ] Pur~[ ] Mixture[ ] Waste[ ] Radioactive[ ] 7) AMOUNT AND TIME AT FACILITY UNITS OF MEASURE 8) STORAGE CODES Maximum Daffy Amount Lbs [ ] Gal [ ] it] [ ] a) Coutaine~. Average Daffy Amotmt Curies [ ] b) Pressure: Atmuai Amount ¢) T ~c'ml~ratur~ Largest Siz~ Coutaiuer # Days on Sit~ C~l~ Which Month~ All Year, L F, M, A, M, $, $, A, S, O, N, D 9) MIXTURE: List COMPONENT CAS# )6 WT AHIVi the three most hazardous 1) [ ] chemical compouents or 2) [ ] any AHlVi compon~,,ts 3) [ ] 10)LOCATION I)[NVENTORYSTATUS:N~v[ ]Additiou[ ]Revisiou[ ]Deletiou[ ] cl~'kifch~micalisaNONTrad~S~cr~[ ]Trad~Sec~t[ l 2) Common Name: 3) DOT # (optioual) Chemical Name: AHM [ ] CAS # 4) Physical a I-I~mlm PHYSICAL HEALTH F-,-~lCat~ories Fire[ ]Rea~ive[ ]SuddenRelea~ofPressure[ ] ImmediateHealth(A~ute)[ ]DelayedHealth(Chroni¢)[ ] ~) WAST~ C~SSn~C^T~O~ O-~isit ~ c.~ DHS ~or~ S022)USE CODE 6) PHYSICAL STATE ,Solid [ ] Liquid [ ] Cas [ ] Pu~ [ ] ~ [ ] Wast~ [ ] P,~lioa~iv¢ [ ] 7) AlVIOUNT AND TIIVlE AT FACILITY UNITS OF kffiASURE 8) STORAGE CODES Maximum Daily Amount Lbs [ ] Gal [ ] fi3 [ ] a) Contain~ Average Daily Amount Curie~ [ ] b) Pressure: Annual Amount c) Temperature Largest Siz~ Container # Days on Sit~ Circle Which Months: All Year, $, F, M~ A, M, $, $, A, S, O, N, D 9) MIXTURE: List COMPONENT CAS# % WT AHM thc three most hazardous l) [ ] chemical components or 2) [ any AHIvt componen~ ~) [ ] l 0 )LOCATION [ ceftin/under p~naity of law, that ! hav~ ix~sonally c~aunin~! and am familiar with tl~ information on this and all attached docmncats. I believe the submitted information is tru~ accurat~ and complete. PRINT Name & Title 0f Authorized Company Representative Sigualur~ Da~ KAZARDOUS MATERIALS INVENTORY Page of ~ Business Name Addr~s' CI~MICAL DESCRllVrlON ~ ) INVENTORY STAI'US: New [ ] Addition [ ] Revision [ ] Deletion [ ] Check ifchcmical is a NON Trade Secret [ ] Trade Secret 2) Common Name: 3) DOT # (optional) Chemical Name: AHM [ ] CAS # 4) Physical & Health PHYSICAL HEALTH t4aT:ard Categories Fire [ ] Reactive [ ] Sua__,~.n Release ofPresaure [ ] Immediate Health (,acute) [ ] Delayed Health (Chronic) 5) WASTE CLASSIFICATION (3-digit code from DHS Form 8022) USE CODE 6) PHYSICAL STATE Solidi ] Liquid[ ] C-as[ ] Pure[ ] Mixture[ ] Waste[ ] Radioactive[ ] 7) AMOUNT AND TIME .AT FACILITY UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount Lbs [ ] Gal [ ] fa [ ] a) Contaia~ ^vemg¢ Daily Amount Curies [ ] b) Pressure: Annual Amount ¢) T~-m?emtute Larsest Size Container # Days on Site Circle Which Munths: AIl Year, $, F, M, A, M, $, $, A, S, O, N, D 9) MIXTURE: List COlVlPO~ CAS# % WT AHM the three most hazardous 1) [ chemical components or 2) [ any AHM components 3) [ 10)LOCATION I)INVENTORYSTATUS:New[ ]Addition[ ]Revision[ ]Deletion[ ] CheckifchemicalisaNONTradeSecrct[ ]TradeSecret[ ] 2) Common Name: 3) DOT # (optional) Chexmcal Name: AHM [ ] CAS # 4 ) Physical & Health PHYSICAL HEALTH HazardCategofies Fire[ ]Renative[ ]SuddanReleaseofPressure[ ] lmmediateHealth(Aonte)[ ] Delayed Health (Chronic) [ ] 5) WASTE CLASSIFICATION , (3-digit cede from DHS Form 8022) USE CODE 6) PHYSICAL STATE Sol/dj ] Liquid[ ] Gas[ ] Pure[ ] Mixture[ ] Waste[ ] Radioactive[ ] 7) AMOUNT AND TIME AT FACILrrY UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount Lbs [ ] Gal [ ] fO [ ] a) Containec. Average Daily Amount Curies [ ] b) Prr'~: Annual Amount c) Temperature Largest Size Containgr # Days on Site Circle Which Months: AU Year, I, F, M, A, M, $, $, A, S, O, N, D 9) MIXTURE: List COMPONENT CAS# % WT AHM the three most b---nious I) [ ] chemical components or 2) [ ] any AHM components 3) [ ] 10 )LOCATION [ certify under penalty of law, that [ have pe~mally examined and am familiar with the information on this and all attached doomumts. I believe the submitted information is trug, accurate and complete. PRII~ Name & Title of Authorized Company Representative Signature Date SITE DIAGRAM [ ! FACILITY DIAGRAM Business Name: Business Address: