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HomeMy WebLinkAboutBUSINESS PLAN Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS OFPERMIT ON REVERSE SIDE ...... : This _~ermit Is Issued ~r ~ follo~: ~ H~Mous M~e~als P~n ~ U~e~mund Storage of H~ffiOus Mat~flals Permit ID ~:: 0t5~00~01767 D RiskManage~tP~mm APRIA HEALTHCARE' ~ H~ou~ w.m o~s,.,~ · LOCATION: 1314 MTH STA OFFICE OF ENWIR ONMENTAL SER I/ICES' " "" 1715 Chester Ave., 3rd Floor Approved by: ., ..~, . ."(.. Ralpi~Huey, D~ .~ issue Date Bakersfield, CA 93301 .- Voice (661) 326-3979 ':-~ FAX (661) 326-0576 "~ExpiiationDate: 'JLIII~ 30.. 2005 -'. ~- , "-'5"~'-'' :" Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS OF PERMIT ON REVERSE SIDE Issu~ by:  B~er, field Fke Depa~ment Approv~ by: ~ ~ ' 1715 Chewer Ave., ~rd Floor ce of ~~ B~e~fiel~ CA 93301 Voice (805) 32~3979 F~ (g05) 32~576 Exp~ationDate: ~un~ ~O~ ~snuc~: sotrr~c^!~n=o~^ ;;BRANCH: BAKERSFIELD ADD.SS' 1314-A 34~ ST. ~ ' BA~F~LD,CA 93301 ~GION: WESTERN I I ~--~ ;:-"' Policy 109-025 P R r ^ H E ^ L 'r H c ,~ R E A~achment 1 OPERATIONS INSERVICE LOG Location: Date~ime: Course: - Instructor(s): Company Representative: Product: Equipment: Other: ATTENDEE DEPARTMENT POSITION Additional Information: Supervisor's Signature: ~.. ¢.: Original: Location - Inservice Log F~le Copy: District Human J:~esources, ts approl2riate Note: Attach copy of outline/handouts, etc. o4/~ 5/94 APRIA HEALTHCARE ~R~'(~'~'~;~-'-F~ SiteID: 215-000-001767 / JUL252000 BI ~ Manager : ROEHL CARAGAO sPho e: (805) 324-4887 Location: 1314 34TH ST A I.~Y:~~ ~P : 103 Com~az : Minimal City : B~ERSFIELD id: 19C FacUnits: 1 AOV: CommCode: B~ERSFIELD STATION 04 SIC Code:4925 EPA Nu~: DunnBrad:97-31229 Emergency Contact / ~t~~l$O~ Emergency Contact / Title SCOTT BRYAN ,.-:j/. ~L"B'KD'"~T SE~JJIC~ ROEHL CARAGAO ,~/ BRANCH MANAGER Business Phone~ ~ ~4~. ~ 324-4887x Business Phone: (~) 324-4887x 24-Hour Phone ~%~) ~ - ~Tx 24.-Hour Phone : (~1)5~q -~x Pager Phone : (~)'~- ~x Pager Phone : (~)~ -~ x Hazmat Hazards: Fire Press Im~lth DelHlth Contact : Phone: (805) 324-4887x MailAddr: 1314 34TH ST A State: CA City : B~ERSFIELD Zip : 93301 (~ qz7 -2~ O~er JERRY ~ JOI~ES ~l ~A~ Phone: ) ~x Address : 3560 ~D AVE State: CA City : COSTA MESA Zip : 92626 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No Emergency Directives: ~ Hazmat Inventory One Unified List [-- As Designated Order All Materials at Site Hazmat Common Name... ISpocHaz]EPA HazardsI Frm I DailyMax Unit MCP OXYGEN F IH DH G 11666.00 FT3 Low LIQUID OXYGEN F P IH G 160.00 GAL Low I,..~o¢~L £~f-a~ Do hereby certify that I have (Type or pdn~ name) reviewed the at~ached hazardous rnaterials manage- ment plan for...~A iW-w~(..~-~ and ~hat i~ along with (Nam~ of Business) any corrections constitute a complete and correc~ man- agemem plan for my facility. , APRIA HEALTHCARE SiteID: 215-000-001767 ~ Inventory Item 0001 Facility Unit: Fixed Containers at Site -- COMMON NAME / CHEMICAL NAME OXYGEN Days On Site 365 Location within this Facility Unit Map: Grid: CAS# 7782-44-7 Gas Pure Above Ambient Ambient PORT. PRESS. CYLINDER AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum I Daily Average ~-O ~-~. 00 FT3I ~5 ~ ~ ~ 00 . FT3 I ~ --3~e. 00 FT3 HAZARD ASSESSMENTS ITsecretl ~SIBioHaz Radioactive/Amount EPA Hazards NFPA I USDOT# I MCP No N No No/ Curies F IH DH / / / Low ---- Inventory Item 0002 Facility Unit: Fixed Containers at Site LIQUID OXYGEN Days On Site 365 Location within this Facility Unit Map: Grid: CAS# 7782-44-7 as Pure Above Ambient Ambient PORT. PRESS. CYLINDER AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum Daily Average 160.00 GALI 160.00 GAL 160.00 GAL %Wt. HAZARDOUS COMPONENTS RS CAS# HAZARD ASSESSMENTS TSecret, RS BioHazl Radioactive~Amount , EPA Hazards NFPA USDOT# MOP NoI ° I IN No No/ Curies F P IH / / / Low 2 06/21/2000 F APRIA HEALTHCARE SiteID: 215-000-001767 Fast Format ~ Notif./Evacuation/Medical Overall Site --Agency Notification 04/03/1997 CHEMTREC 800-424-9300 BAKERSFIELD HAZARDOUS PREVENTION BUREAU 861-2761 APRIAS RISK MANAGEMENT 1-714--7~-~5-~r~H~o~ DRIVER WILL IMMEDIATELY CALL THE BRANCH FOR ASSISTANCE. -- Employee Notif./Evacuation 04/03/1997 WE WILL FOLLOW THE STEPS DESCRIBED IN THE APRIAS EMERGENCY PREPARDNESS -- Public Notif./Evacuation 04/03/1997 NOT AVAILABLE. Emergency Medical Plan 04/03/1997 MEMORIAL HOSPITAL AND SAN JOAQUIN COMMUNITY HOSPITAL. 3 06/21/2000 APRIA HEALTHCARE SiteID: 215-000-001767 Fast Format ~Mitigation/Prevent/Abatemt Overall Site ~ Release Prevention 04/03/1997 WE USE GLOVES, SHIELD, EAR PROTECTION WHEN TRANSFERRING LIQUID OXYGEN. WE HAVE HAND TRUCKS DESIGNED TO CARRY H CYLINDERS AND THEY ARE CHAINED. COMPRESSED CYLINDERS ARE STORED UNDER CHAIN OR RACKS FOR THEIR DESIGN. -- Release Containment 04/03/1997 THE LIQUID IS NOT A HIGH PRESSURE SYSTEM. THE TANK HAS VALVES TO CONTROL LEAKS. WE DO NOT STORE LIQUID AT OUR'BRANCH IN LARGE QUANTITIES. CYLINDERS ARESELF-CONTAINED. -- Clean Up 04/03/1997 LIQUID OXYGEN WILL QUICKLY EVAPORATE INTO THE ATMOSPHERE. Other Resource Activation -4- 06/21/2000 F APRIA HEALTHCARE SiteID: 215-000-001767 Fast Format F Site EmerHency Factors Overall Site Special Hazards --Utility Shut-Offs 04/03/1997 A) GAS - MAIN SHUT OFF IN ALLEY ON W SIDE OF BLDG B) ELECTRICAL - 2 PANELS IN WAREHOUSE, 1 PANEL IN BACK OFFICE, MAIN BLDG PANEL IS IN ALLEY ON W SIDE OF BLDG C) WATER - MAIN SHUT OFF LOCATED SE SIDE OF BLDG D) SPECIAL - NONE E) LOCK BOX - NO -- Fire Protec./Avail. Water 04/03/1997 PRIVATE FIRE PROTECTION - WE HAVE FIRE EXTINGUISHERS IN ALL BUILDING SUITES AND VEHICLES. SECURITY SYSTEM IS ACTIVATED EVERYNIGHT AND RESPONSE IS GIVEN IF NO VOICE CONFIRMATION. NEAREST FIRE HYDRANT - THERE IS A HYDRANT S FROM THE BLDG ON THE S SIDE OF 34TH ST. BuildinH Occupancy Level -5- 06/21/2000 APRIA HEALTHCARE SiteID: 215-000-001767 Fast Format ~ Training Overall Site -- Employee Training 04/03/1997 WE HAVE,EMPLOYEES AT THIS FACILITY. WE DO HAVE MSDS SHEETS ON FILE. BRIEF SUMMARY OF TRAINING PROGRAM: WE FOLLOW PROCEDURES IN THE TOPS (TACTICAL OPERATING PROCEDURES AND STANDARDS), FDA (FOOD AND DRUG ADMINISTRATION, APRIAS POLICY AND PROCEDURE MANUAL, S.O.P. (STANDARD OPERATING PROCEDURES)./ NEW HIRES ARE TRAINED AND ANNUAL RETRAINING IS E E~UIR~. D.O.T. GUIDELINES FOLLOWED. EMREGENCY PREPARDNESS PLAN IN PLACE. ERGENCY PHONE NUMBERS LISTED ON MANIFEST. ~ Held for Future Use Held for Future Use -6- 06/21/2000 . _~ BAKER~JiELD CITY FIRE DEFi~TMENT  t/% OFFICE OF ENVIRONMENTAL SERVICES ;,%~.~J~' 1715 CHESTER AVENUE, 3RD FLOOR ~ ~- BAKERSFIELD, CA 93301 ~ H~RDOUS MATERIALS MANAGEMENT INSTRUCTIONS: ~.~' To~R~/~ RINTCV°iC fu~Tne~A NSW~s~cfi°n'IN ~eT~ r, ENG USH.:m'Js tocm within 30 C~ys ot 3. Answer the cuesTions Delow fa: ?,e aus~ness cs c wnoJe. By., '. ~e ~r;ef cnc concise cs SECTION ]' ~USINESSIDENTIFICATION DATA ¢,.;oiN ESS NAME' · SECTION .:: E.MERGENC',-' NC.T;F!CAT[QN: .... " ~zardous ~:[a[eriais Di~sio~ -.- _ HAZARDOUS MATERIALS MANAGEMENT PLAN '" , SECTION 3: TRAINING: NUMBER CF EMPLOYEES: II 't MATERIAL SAFETY DATA SHEETS ON FILE: 1~5 BRIEF SUMMARY OF TRAININ® PROC-RAM: SECTION 4: 5XEMPoTION REQUEST: ! CE.':,TiFY UNDER ?ENALTY CF PE:.RJURY THAT'MY BUSINESS 1S EXEMPT FROM THE ~.Nl,., CF C,-,~FTER :.v~, OF THE :'CALtF©RNIA mu,' ,Lira & "h'~ DC NOT HANDLE H, AL-',RDCUS MATERIALS. SF_.CTICN 5: CERTIFICATICN: MATiCN IS ACCURATE. I UNO~- '' cxS~ND THAT THIS INFORMATION WILL ~=~ USED TO ..... ~ '~ ' ~,~LIF~RNtA HEALTH AND ~,~r_~ CODE" fulfiL_ MY F:~M S OBLIGATIONS UNDEr, T~E .... ~ ~ ' ~:' ON ~A~&~DCUS MATER~AL~ (DtV. 20~m,~¢TER~"' 5.v~* ~C~=' .~==°~= .... ET~.~" ' ANO THAT NAC~uRAi= iNFORMATiON CONSTITUTES rERJURY. ~[~N TITLE DATE ---.-. HAZARDOUS. MATERIALS MANAGEMENT PLAN ',. _ ; .~'.~, ..~"~ SECTION 6: NOTIFICATION AND EVACUATION PROCEDURES: A. AGENCY NOTIFICATION PRCCEDURE$: ~" 3. EMPLOYEE NOTIFICATION AND E~?ACUAT1ON: · . - _-. _.~ . ,.. ~. U~L,C EVACUATION: .. '. ........................... 7¢~' ~--~r¢~'~'c~ ......... ____:.,. :... ! '-.. -:N'IERGZ.XI~'/,_, _, MED[CAL ,:LAN: Bakarsfiel& ' ":" : !'. Hazardous ~a~er~ats Db4sion ' ' ...... ' .... HAZARDOUS MATERIALS MANAGEMENT PLAN' SECTION 7: MITIGATION, PREVENTION AND ABATEMENT PLAN: A. R~..:,~.,c ?REVENTION STE?S' v LV¢~' SECTION 8: UTILITY SHUT-OFFS : ._,._.,._.,--.,,,,._,N CF SHUT-,OFFs. AT- , YOUR FACILITY) NATURAL C-AS/PROPANE: ~' ~/i0-~'' 0~' I&/ ~Lt, eh o~j ¢-¢g~$,~EoF' '.' ~FEC' ' · ,~L. 'C~''~ FE~ '- ~,% ~Cv' ~ 'y~ . ,x. ~ , _;, '_C'CAT~CN SECTION 9: PRIVATE FIRE ?ROTECTIC'N/WATER AVAILABILITY: 8. W~TE~ AVAILABILt~ (FIRE HYORANO: ' BAKER~IELD CITY FIRE DEP~RTMENT OFFICE OF ENVIRONMENTAL SERVICES 1715 CHESTER AVENUE, 3RD FLOOR :" ' :': "' ' - BAKERSFIELD, CA 93301 (805) 326-3979 HAZARDOUS MATERIALS INVENTORY FACILITY DESCRIPTION CHECK IF BUSINESS IS A FARM [ ] BUSINESS NAME ~ ~,~ ~-~ (--~'/~ FAC;LiTY NAME ~/?--4 ~ ~~~~ SITE ADDRESS I~ ~- A ~ V~ S~~ C~ ~1(~~ STATE ~Dl~~i~ ZiP ~01 S;C COOE ~ ~ A ~ DUN & B~DSTREET NUMBER ~ 7 ,- ~ iZ g ~ OWNER/OPERATOR ,.Z~--~L/ /~ -~-"'O MC-..J' PHONE MAIL!NG ADDRESS ~5~,~) /-~y~Jr~J~ 4V~--- ~ 0 EMERGENCY CONTACTS BUSINESS PHONE ~ ~"' 5"~ M-'"J '¢g" ~ "'] 24-HOUR PHONE NAME ~'0 ~"~ (.- ~.~~~ TITLE BUSINESS PHONE /~,.~" $2'~/-c/~'~-7 24-HOUR PHONE BAKERS.FJELD CITY FIRE DEP.a TMENT HAZJlIRDOUS MATERIALS INVENNIORY - Page._of_ usiness Name Address CHEMICAL DESCRIPTION 1) INVENTORY STATUS: New [ ] Addition [ ] Re-Sion [ ] Deletion { ] Check if chemical i~ a NON TRADE SECRET' [ '] ' TRADE SECRET [ ] 2) Common Name: 3) DOT # (optionaJ) Chemical Name: AHM [ ] CAS # 4) PHYSICAL & HEALTH PHYSICAL HEALTH HAZARD CATEGORIES Fire [ ] Reactive [ ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ ] Delayed HeeJ'th (Chronic) [ ] 5) WASTE CLASSIFICATION (3-digit code from DHS Form 8022) USE CODE 5) PHYSICAL STATE Solid [ ] Liquid [ ] Gas [ ] Pure [ ] Mixture [ ] Waste [ ] Radioactive [ ] 7) AMOUNT AND TIME AT FAClUTY UNITS OF MEASURE 8) STORAGE CODES Maximum DaJlyAmount: lbs [ ] gaJ [ ] /t3 [ ] a) Contmner. Average 0aJh/Amount: cunes[ ] b) Pressure: AnnuaJ Amount: c) Temperature: LaJ'gest Size'ContaJner: #Oays On Site Circle Which Months: All Yea/. J. F. M. A. M. J. J. A. S. O. N. D 9) MIXTURE: List COMPONENT CAS # % WT AHM the three most ha.za/clous 1 ). [ ] chemicaJ components or any AHM coml:K:)nents 2) [ 3) { l 10) Location CHEMICAL DESCRIPTION 1 ) INVENTORY STATUS: New [ ] Addition { ] Revision { ] Deletion [ ] Check if chemical is ,, NON TRADE SECRET [ ] TRADE SECRET [ ] 2) Common Name: 3) DOT # (option~J) Chemical Name: AHM [ ] CAS # 4) PHYSICAL & HEALTH. PHYSICAL HEALTH HAZARD CATEGORIES Fire [ ] Reactive [ ] Sudden Release of Pressure [ ] Immediate HeaJth (Acute) [ ] Delayed Hearth (Chronic) [ ] 5) WASTE CLASSlFICAT~ON (3-dig~ code from DHS Form 8022) USE CODE 5) PHYSICAL STATE Solid [ ] Licluid [ ] Gas [ ] Pure [ ] Mixture [ ] Waste [ ] Radioactive [ ] 7) AMOUNT AND TIME AT FAClUTY UNITS OF MEASURE 8) STORAGE CODES Maximum O='ly Amount: lbs [ ] ga [ [ ft3 [ ] a) ContaJner. Average Oa~ty Amount: cunee ( ] b) Pressure: AnnuaJ Amount: c) Temperature: LaJ'gest Size ContaJner: · ' Days On Site Circle Which Months: AJIYea/. J. F. M. A. M. J. J. A. S. O. N. D 9) MIX'TtJRE: List COMPONENT CAS # % WT ' AHM the three most haze/alDUS 1) [ ] chemicaJ components or any AHM components 2) [ ] I 3). [ 10) Locm~n ' :erofy under permJly of/aw. ~st t t?ave personalty exarnmeo eno am ~am~l~ar wiD~ ~e in~OmaDOn suOrni~ecl on ma and all atteched (~ocuments. I J3etieve ~t~mitted information is ~TUe, accurate, and complete. . -~ ~ '. elINT Name & TTtie of AulJ~nzect Company Representa~ve Signature Date BAKERSFII LD CITY FIRE DEPAI MENT HAZARDOUS MATERIALS INVENTORY Page_of_ BusinessName /~'J~ ~['~t.,,~ Address {~i't~-~ ~'~ ~~~' ~' ~ CHEMICAL DESCRI~ION 1) IN~NTORY STA~S: New [~dd.ion [ ] Revision [ ] ~letion { ] Check ~ chemi~ is a NON ~DE SECR~ [/~De SECR~ [ ] 2) CommonN~,: 0XY~ 3)~T~(optio~ gN/d 7Z 4) PHYSICAL & H~L~ / PHIAL / H~ H~RD CA~GORIES Fire [~Rea~ive [ ~ Sudden Rele~e of Pressure [~ Immedi~e He~h (Acme) [~ ~layed He~h (Chronic) [ ] ' 5) WAS~ C~SSIFICA~ON .(3~igR code from DHS Fo~ 8022) USE CODE 6) PHYSICAL STA~ Solid [ ] ~quid [ ] G~ [~ Pure [/aMum [ ] W~te [ ] R~io~e [ ] 7) AMOUNT AND ~ME AT FACIUW .//~ UNITS OF M~SURE / 8) STOOGE CODES M~imum Daly Amount: .... I~ [ ] ga [ ] R3 [~ a) Contaner: Average Dm~ Amount: ~¢~~ ~ ~V~ ~e cudes [ ] b) Pressure: ~gest Size'Contaner: · Days On Site ~ Circle~ich Months: ~ J, F, M, A, M, J, J, A, S, O, N, D 9) MI~URE: Ust COMPONENT CAS · % ~ AHM the throe most h~dous 1) [ ] chemi~ com~nen~ or ~y AHM com~nents 2) [ ] 3) [ ] 10) Loc~ion CHEMICAL DESCRI~ION / 1) IN~NTORY STA~S: New [~ddRion [ ] Revision [ ] Deletion [ ] Check ~ chemi~ is ~ NON ~DE SECR~ [ ~DE SECR~ [ ] 2) CommonN~e:~~ 0~'~ ~ ~0~;0~ ~ ~~~ ~a~ 3) ~T~(opfion~) 4) PHYSICAL & H~L~ / PH~ICAL H~L~ H~RD CA~GORIES Fire~ Rea~ive [~ Sudden Rele~e of Pressure [ ] Immedi~e He~h (Ac~e) [~layed He~h (Chronic) [ ] 5) WASTE C~SSIFICATION (~digit code from DHS Form 8022) USE CODE ' 6) PHYSICALSTA~ Solid [ ] Liquid [~G~ [ ] Pure [~Mi~ure [ ] W~te [ ] Radioa~e [ ] 7) AMOUNT AND TIME AT FACIU~ UNITS OF M~RE 8) STOOGE COONS M~imum Daily Amount: / ~ lbs [ ] ga [~ fi3 [ ] a) Contaner: Average Daly Amount: ~~ ~O~A/-Z~, cudes [ ] b) Pressure: Annum Amount: ~ ~~ ~&A~'~O~ ~ ~ c) Tem~r~ure: ~gest Size Contaner: · DaysOnS~e 3~ Circle ~ich Months: ~J, F, M, A, M, J, J, A, S, O, N, D 9) MITRE: Ust COMPONENT CAS · % ~ AHM the three most h~dous 1) [ ] chemi~ com~nenm or ~y AHM com~nents 2) [ ] 3) 10) Lo~ion ce~ under pen~ of law, ~at I have pe~on~ly examin~ ~d ~ f~i/i~ wi~ ~e infoma~on sub~ on ~is ~d ~1 a~ch~ documenm. I believe submi~ info~a~on is ~e, accumte, ~d complem. / ~ PRI~ N~e & Ti~e of A~odz~ Comfy Represen~five ~a~m ~ ' Dam BAKERSFIELD CITY FIRE DEP/ RTMENT HAZIRIRDOUS MATERIALS INVEI R3RY Page_of__ 3usine~,s NAme Address CHEMICAL DESCRIPTION 1) INVENTORY STATUS: New [ ] Addition [ ] Revision [ ] Deletion [ ] Check if chemical is a NON TRADE SECRET [ ] TRADE SECRET [ ] 2) Common Name: 3) DOT # (optional) Chemical Name: AHM [ ] CAS # 4) PHYSICAL & HEALTH PHYSICAL HEALTH HAZARD CATEGORIES Fire [ ] Reactive [ ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ ] Delayed Health (Chronic) [ ] 5) WASTE CLASSIFICATION (3-digit code from DHS Form 8022) USE CODE 6) PHYSICAL STATE Solid [ ] Liquid [ ] Gas [ ] Pure [ ] Mixture [ ] Waste [ ] Radioactive [ ] 7) AMOUNT AND TIME AT FAClUTY UNITS OF MEASURE 8) STORAGE CODES Maximum Dally Amount: lbs [ ] gal [ ] ~t3 [ ] a) Container: Average Dally Amount: cudas [ ] b) Pressure: Annual Amount: c) Temperature: Largest Size Container: # Days On Site Circle Which Months: All Year, J, F, M, A. M, J, J, A, S, O, N, D 9) MIXTURE: List COMPONENT CAS # % WT AHM the three most hazardous 1). [ ] chemical components or any AHM components 2). [ ] 3) [ ] 10) Location CHEMICAL DESCRIPTION 1 ) INVENTORY STATUS: New [ ] Addition [ ] Revision [ ] Deletion [ ] Check if chemical is 2) Common Name: 3) DOT # (optional) Chemical Name: AHM [ ] CAS # 4) PHYSICAL & HEALTH PHYSICAL HEALTH HAZARD CATEGORIES Fire [ ] Reactive [ ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ ] Delayed Health (Chronic) [ ] 5) WASTE CLASSIFICATION ,(3-digit code from DHS Form 8022) USE CODE ? 6) PHYSICAL STATE Solid [ ] Liquid [ ] Gas [ ] Pure [ ] Mixture [ ] Waste [ ] Radioactive [ ] If 7) AMOUNT AND TIME AT FACILITY UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount: tbs [ ] gal [ ] lt3 [ ] a) Container: Average Dally Amount: curies [ ] b) Pressure: Annual Amount: c) Temperature: Largest Size Container: # Days On Site Circle Which Months: All Year, J, F. M, A, M, J, J, A. S, O, N, D 9) MIXTURE: List COMPONENT CAS # % WT AHM the three most hazardous 1) [ ] chemical components or any AHM components 2), ~ [ ] 3). [ ] 10) Location r cer~y under penalty of law, that I have personally examined and am familiar with the infomalfon submitted on this and all aEached documents. I believe submitted information is true. accurate, and complete. PRINT Name & Title of Authorized Company I~epresentaUve Signature Date