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Home My WebLink AboutBUSINESS PLAN 10/15/2003 SITE DIAGRAM ~ FACr~,rrY DIAGRAM Bus/n~s Address: Hazardous Materials/Hazardous Waste Unified Permit CONDITIONSr OF'~PERMIT ON REVERSE SIDE .~ · . ', This 0ermit is issued for the followi, na: : ', .~ [] Hazardous Materials Plan " [] Underground 'Storage of Hazardous Materials "~': Permit ID #:: 015-000-001850 [] Risk Mana~ement Program · ':,,.' S U P RE M E AUTO [] Hazardous Waste On-Site Treatment LOCATION: ~01 BRUNDAGE LN T I~LD OFFICE OF ENVIRONMENTAL SERVICES'. ' 1715 Chester Ave., 3rd Floor Approved by: Issue Date Bakersfield, CA 93301 Officeoreviro~Services ~ Voice (661) 326-3979 FAX (661) 326-0576 Expiration Date:' 'June 30, 2003 ITE DLS. GRAM Business Name: Business Address: I · Bakersfield Fire Dept. Enironmental Services 1715 Chester Ave SECTION 1 Business Plan and Inventory Program Bakersfield, CA 93301 Tel: (661)326-3979 ADDRESS PHONE No. No. of Employees ~CiLiTYCONTACT"'~ Business lO Number . ~ :' ..'"' '. SectiOn 1: Busine~ plan and InVentory Program [~l~'outine [] Combined [] Joint Agency ~ Multi-Agency [] Complaint [] Re-inspection C V [C:Compliance'~ OPERATION . ~.V~Violation /. . ~I,~ ?~. %~% COMMENTS [;~' D APPROPRIATE PERMIT ON HAND ~ O VERIFICATION OF ,.VEN,ORY MATERIALS ............ ~ n VERIFICATION OF QUANTITIES ........ ~ ...... ~_ _~__~_0G_~ .............................................. ~ ~ VERiF~CATION OF LOCm~ON ._ .~lf[ ....................................................... ~ n VER,F,CAT,ON OF MSDS AVA,LAS,L,WE . ~_~ PROCEDORES / . ~.~ ~. ~ ~ EMERGENCY PROCEDURES ADEOUATE J __/___~ ............................ ~_~_[~__.__~_ ~ D HOUSEKEEPING ~ ~ F~ P.OTECT~ON ~ O S,TE DIA~RAU ADEQUATE & ON HANO ANY H~ARDOUS WAS~ ON SI~?: ~ YES EXPLAIN: o--~ Ins~~,'~ ~ ~ Badge No. B u si ness Site Responsible Party ~"'~W~h ~te -~n '~, a-~S;e~c_ed Yellow - S*.atio, Copy Pink - Business Copy L D Dear Business Owner: FIRE CHIEF RON FRAZE This notice is meant to act as a reminder that the California Health ADMINISTRATIVE SERVICES and Safety Code, Chapter 6.95, requires any handler of hazardous materials 2101 "H" Street Bakersfield, CA 93301 to revise their hazardous materials business plan within 30 days of any one VOICE (805) 326-3941 FAX (805) 395-1349 of the following events: SUPPRESSION SERVICES 2101 "H"Street (1) A 100 per cent or more increase in the quantity of a Bakersfield, CA 03301 previously-disclosed material. VOICE (805) 326-3941 FAX (805)395-1349 (2) Any handling of a previously-undisclosed hazardous PREVENTION SERVICES 1715 Chester Ave. material, subject to the inventory requirements of Chapter Bakersfield, CA 93301 VOICE (805) 326-3951 6.95. FAX (805) 326.0576 ENVIRONMENTAL SERVICES (3) Change in business ownership. 1715 Chester Ave. Bakersfield, CA 93301 VOICE (805) 326.3979 (4) Change in business address. FAX (805) 326-0576 TRAINING DIVISION (5) Change of business name. 5642 V~ctor Ave. Bakersfield, CA 93308 VOICE (805)399-4697 Any questions regarding these required revisions, please call the FAX (805) 399-5763 Hazardous Materials Division at (805) 326-3979. Sincerely yours, Director, Office of Environmental Services CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES "-'3 UNIFIED PROGRAM INSPECTION CHECKLIST / 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 FACILITY NAME ..~ ?.r'"e4'~.~_ /~t.~]-o · ~.~. INSPECTION DATE I 7_. ADDRESS ~'~/ /-~..,z~t~o.~ ~ ~ PHONE NO. -5 Z'z_ "'::i' ._q' ,fit FACILITY CONTACT ,<~,.~ t,~.~--,~ BUSINESS ID NO. 15-210- _,C~lzT_g-O INSPECTION TIME /~' i-~ · ~ 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 Verification of abatement supplies and procedures / Emergency procedures adequate Containers properly labeled Housekeeping Fire Protection Site Diagram Adequate & On Hand C=Compliance V=Violation nnyhazardouswasteonsite?: '~Yes '[]No ~j Explain: v~"/Z~ L~ o Questions reg~ding ~is inspection? Please call us at (661) 326-3979 sible Party _ White - Env. Svcs. Yellow - Station Co~y Pink - Business Copy Inspector: I ~ ~~ SUPREME AUTO ELECTRIC ===: --- SiteID: 015-021-001850 Manager : BusPhone: (661) 322-9541 Location: 801 BRUNDAGE LN M Map : 103 CommHaz : Low City : BAKERSFIELD Grid: 31D FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 06 SIC Code:7539 EPA Numb: DunnBrad: += Emergency Contact / ~.-T~tle Emergency Contact / Title KEN WOOD / OWNER DENISE WOOD / WIFE Business Phone: (661) 322-9541x Business Phone: (661) 322-9541x 24-Hour Phone : (661) 322-0640x 24-Hour Phone : (661) 322-0640x Pager Phone : (661) 333-7373xCELL Pager Phone : (661) 333-7373xCELL Hazmat Hazards: Fire Press ImmHlth DelHlth +- Contact : Phone: (661) 322-9541x MailAddr: 801 BRUNDAGE LN M State: CA City : BAKERSFIELD Zip : 93304 +- Owner KEN WOOD Phone: (661) 322-9541x Address : 801 BRUNDAGE LN M State: CA City : BAKERSFIELD Zip : 93304 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: Res: No Emergency Directives: += Hazmat Inventory One Unified List +== Alphabetical Order All Materials at Site .......................... _ ..... + ....... + ........... + ..... + .......... + .... +---+ Hazmat Common Name... ISpecHazlEPA HazardsI Frm I DailyMax lUnitlMCPl + ....... + ........... + ..... + .......... + .... +- - -+ ACETYLENE F P IH G 125.00 FT3 OXYGEN F IH DM G 155.00 FT3 Low WASTE OIL F DH 'L 55.00 GAL Low I, Do hereby certify that I h~ave (Ty~e or prin! revieweC~ ti~e at',ached hazai'dou~ materials merit p!an for and that it a~ong with -- (Name o~ Busings) any corre~ions constitute a complete snd correct man- agement plan for my facility. ======~ :=========+ siamese I '- D~ 01/22 / 2002 SUPREME AUTO ELECTRIC / SiteID: 015-021-001850 Manager : . / BusPhone: 322-9541 Location: 801 BRUNDAGE LN~P/ ~ Map : 103 CommHaz : Low City : BAKERSFIELD Grid: 31D FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 06 SIC Code:7539 EPA Numb: DunnBrad: Emergency Contact / Title Emergency Contact / Title KEN WOOD / OWNER DENISE WOOD ~ WIFE Business Phone: J~ 322-9541x Business Phone: (~_.) 322-9541x 24-Hour Phone : (~) 322-0640x 24-Hour Phone : (~) 322-0640x Hazmat Hazards: Fire Press ImmHl~th DelHlth Contact : Phone: (805) 322-9541x MailAddr: 801 BRUNDAGE LN T State: CA City : BAKERSFIELD Zip : 93304 Owner KEN WOOD Phone: (805) 322-9541x Address : 801 BRUNDAGE LN T State: CA City : BAKERSFIELD Zip : 93304 Period : to--~'~ ~'~*~%_ ~~t--TotalASTs: = Gal Preparer: ~ 2~.-~-~ ~ ! .~.--~-~ TotalUSTs: = Gal Certif'd: ' ( ~~ ~~---t-C_~ {,'~ / RSs: NO Emerge_~_cy Directives: ~/'}/{~~ "_t~Oq(¥~,i~'L,_~ I~.-q%.~~ ~(~t~ ~-7, = Hazmat Inventory One Unified List --Alphabetical Order All Materials at Site Hazmat Common Name... ISpocHazlEPA HazardsI Frm DailyMax IUnit MCP ACETYLENE F P IH G 125.00 FT3 Hi OXYGEN F IH DH G 155.00 FT3 Low WASTE OIL i, ..~ t,,.3CC.~d Do hereby ce~if~Fthm~. I haveDH L 55.00 GAL Low ~y~ or pdnt name) ~'eviewed the a~ached haza~ous materials msrmge- ment plan for ~C.~ ~ and th~ it along with (~me of Busine~) any corrections constitute a complete and correct man- agemen~ plan for my facili~. -1- 04/18/2001 SUPREME AUTO ELECTRIC SiteID: 015-021-001850 = Inventory Item 0002 Facility Unit: Fixed Containers at Site ACETYLENE Days On Site 365 Location Within this Facility Unit Map: Grid: INSIDE SW CORNER OF SHOP CAS# 74-86-2 Gas Pure Above Ambient Ambient PORT. PRESS. CYLINDER AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum Daily Average 125.00 FT3I 125.00 FT3 125.00 FT3 HAZARDOUS COMPONENTS 100.00 Acetylene Yes 74862 HAZARD ASSESSMENTS TSecretINO N~S BioHazINO Radioactive/AmountNo/ Curies FEPAp HazardsiH NFPA/// USDOT# HiMCP = Inventory Item 0001 Facility Unit: Fixed Containers at Site OXYGEN Days On Site 365 Location within this Facility Unit Map: Grid: INSIDE SW CORNER OF SHOP CAS# 7782-44-7 Gas Pure Above Ambient Ambient PORT. PRESS. CYLINDER AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum Daily Average 155.00 FT3I 155.00 FT3 155.00 FT3 HAZARDOUS COMPONENTS %Wt. ~S] CAS# 100.00 Oxygen, Compressed N 7782447 HAZARD ASSESSMENTS TSecret ~S BioHaz Radioactive/Amount I EPA HazardsI NFPA USDOT# I MCP No N No No/ Curies F IH DH / / / Low -2- 04/18/2001 SUPREME AUTO ELECTRIC SiteID: 015-021-001850 ~ Inventory Item 0003 Facility Unit: Fixed Containers at Site ~lV~Vl~ ~vl~ / ~ ± ~Y~J~ ~vl~ WASTE OIL Days On Site 365 Location within this Facility Unit Map: Grid: INSIDE S WALL OF SHOP CAS# 221 Liquid {Waste Ambient Ambient DRUM/BARREL-METALLIC AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum Daily Average 55.00 GAL{ 55.00 GAL 55.00 GAL HAZARDOUS COMPONENTS %Wt. RINoRSI CAS# 100.00 Waste Oil, Petroleum Based 0 HAZARD ASSESSMENTS TSecret ~SIBioHazI Radioactive/Amount I EPA HazardsI NFPA USDOT# MCP No N No No/ Curies F DH / / / Low -3- 04/18/2001 SUPREME AUTO ELECTRIC SiteID: 015-021-001850 Fast Format Notif./Evacuation/Medical Overall Site --Agency Notification O /20/1998 Public Notif./Evacuation Emergency Medical Plan -4- 04/18/2001 SUPREME AUTO ELECTRIC SiteID: 015-021-001850 Fast Format Mitigation/Prevent/Abatemt Overall Site ~ Release Prevention ~ Release nment --Clean Up,J~ ~~~~ ~/~P~ /~ ~~ ~6%-~ Other Resource Activation -5- 04/18/2001 SUPREME AUTO'ELECTRIC SiteID: 015-021-001850 Fast Format Site Emergency Factors Overall Site -- Special Hazards 02/20/1998 A) GAS - N END OF COMPLEX B) ELECTRICAL - E SIDE CENTER OF COMPLEX PARKING AREA C) WATER - ~ ~ D) SPECIAL - E) LOCK BOX - -- Fire Protec./Avail. Water 02/20/1998 PRIVATE FIRE PROTECTION - FIRE EXTINGUISHERS 6 04/18/2001 SUPREME AUTO ELECTRIC SiteID: 015-021-001850 Fast Format ~ Training Overall Site ~ Employee Training 02/20/1998 HOW MANY EMPLOYEES DO YOU HAVE AT THIS FACILITY?????????? DO YOU HAVE MATERIALS SAFETY DATA SHEETS ON FILE????????? GIVE A BRIEF SUMMARY OF YOUR TRAINING PROGRAM: V~r,'~-~ ~/,~f~ -- Page 2 --Held for Future Use Held for Future Use -7- 04/18/2001 \ cus~ ~ & NO. ~-~- I?0%_~ MISCELLANEOUS RECEIVABLES ADJUSTMENT , ADDRESS CHANGE CLOSE ACCT j : FINANCE CHARGE J ,/ · OTHER ADJ l"~X/ 1 MAILING ADDRESS SITE ADDRESS PARCEL NUMBER OF APPUC,~LE) ADJUSTMENT I CHG DATE I CHARGECODE I ADJUSTMENT.AMOUNT I REMARKS: / Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS OF PERMIT ON REVERSE SIDE .... ,~ ,:.~¢~ ~,i~,,,?.i~,~i~,~,,,~ ,,~, This - "permmt is issued for the followinn: .~,~,¢?'?:'i~: !~ ~ '~::'~'~<iiiiiiiii!iil;= ~: ilii iii;:?iliDiiU~e[ground Storage of Hazardous Materials LOCATION 801 ~["-.-..:'"~[ ,~ ....... '~,. i~,. ':~,-. -.- Issu~ by: B~ersfield Fke Depa~ment Approv~ by: ' B~e~fiel& CA 93301 Voice (805) 326-3979 F~ (~05)326~S76 ' Expiration Date: June 30, 2000 ,,.,o~,~ o~ ,-..~..L~'~ AirCond~ ~'ng ELECTR C Sta~ers ~' ~~ Troubl~ Shooting Nlworkdon~byo~erwho ~~ Antiq Ja Autos ~ lakes pride In his workl I ~ Power A~essori~ ~ :,~* KEN WOOD ~~ Trailer ~(a05) 322-9541 , ~ Motorcycle Boat W;ring ~ 801 Brundage Lane, Suite T ~~ Complete R~wiring j Bakersfiel~ California 933~ ~ Custom R~wiring CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave.,-Bak~ (805) 326-3979 1. To avoid ~nher actio~ re~ t~s fo~ ~n 30 days ofrecdpt. 2. T~E~ ~S~KS ~ ENGLISH. 3. ~swer the questions bdow for the bus~e~ ~ a whole. 4. Be ~ b~ef ~d condse ~ possible. SECTION 1: BUS.SS ~E~ICATION DATA BUSINESS NAME: LOCATION: SOt ~Ce.o~,.t(M~- ~ -F' MAILING ADDRESS: CITY: STATE: ~ ZIP: C~ ~-- PHONE: "3'L'Z - '~'5'-,4/ DUN & BRAI)STREET NUMBER: SIC CODE: PRIMARY ACTMTY: OWNER: MAIl.lNG ADDRESS: SECTION 2: EMERGENCY NOTIFICATION CONTACT TITLEBUS. PHONE 24 HR.. PHONE 1. t~ t,OOO~ O~::~,-- ~L2 - ~ff~t R zz - 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 EXCEED THE M~/IMUM REPORTING QUANTITIES. OTHER (SPECIFY REASON) SECTION 5: CERTIFICATION I, CERTIFY THAT THE ABOVE INFOKMATION 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 PERJURY. SIGNATURE 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: UTILITY SHUT-OFFS ('LOCATION OF SHUT-OFFS AT YOUR FACILITY)_ NATURAL GAS/PROPANE: ~J ~f> WATER: SPECIAL: LOCK BOX: YES/NO IF YES, LOCATION: SECTION 9: PRIVATE FIRE PROTECTION/WATER AVAILABILITY A. PRIVATE FIRE PROTECTION: B. WATER AVAILABILITY (FIRE HYDRANT): 4 . H~A~OUS ~TE~LS ~NT~Y Page , of ~ Business Name Address CHEMICAL DESCRIPTION I) INVENTORY STATUS: New [ ] Addition [ ] Revision [ ] Deletion [ ] Ch~ck if chemical is a NON Trade Secret [ ] Trade Secret 2) Common Name: (~)~)O~t~'~-'~') 3) DOT # (optional) Chamical Name: AHM [ ] CAS # 4) Physical & Health PHYSICAL Hazard Categories Fire [ ] Reactive~ Sudden Release of Pre~ Immediate Health (Acute) [ ] Delayed Health (Chronic) 5) WASTE CLASSI}'ICATION O-digit code from DHS Form 8022) USE CODE ~ 6) PHYSICAL STATE Solid [ ] Liquid [ ] Gas~;'''~] Pure [~ Mixture [ ] Waste [ ] Radioactive [ ] 7) AMOUNT AND TIME AT FACILITY UNITS OF MEASURE 8) STORAGE CODES q Maximum Daily Amount /~-ff--' Lbs[ ]Gall ]ft3~ a) Container: Average Daily Amount / fi-g-'- Curies [ ] b) Pressure: Annual Amount "2 -S" c) Temperature Largest Size Container / # Days on Site ~1~ ~" Circle Which Months: All Year, $, F, M, A, M, $, I, A. S, O, N, D 9) MIXTURE: List COMPONEWr CASS/ % WT AHM the three most haTardous 1) [ chemical components or 2) [ any AHM components 3) [ I)INVENTORYSTATUS:New[ ]Addition[ ]Revision[ ]Deletion[ ] Check ff chemical is a NOl~l Trade Secret [ ]TradeSecret[ 2) Common Name: /~<L~-w h/c- -b~,~ 3) DOT # (optional) Chemical Name: AHM [ ] CAS # 4) Physical & Health PHYSICAL HEALTH HazardGategories Fire[~;;qReactive[ ]S~4-,tenReleaseofPressure[~..~rImmediateHealth(Acute)[ ] Delayed Health (Chronic) [ 5) WASTE CLASSIFICATION (3-digit code from DHS Form 8022) USE CODE 4 '7._ 6) ?HYSICAL STATE Solia [ ] Liquia [ ] Cas [ ] Pure [ ] Mixture [ ] Waste [ ] Radioactive [ 7) AMOUNT AND TIME AT FACILITY UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount I 'z-%'- Lbs [ ] Gal [ ] fl3 ~ a) Containei~. Average Daily Amount l 7_ ~- Curies [ ] b) Pressure: Annual Amount ? ~-- c) Temperature Largest Size Container ! ~ ~'- # Days on Site %~' Circle Which Months: All Year, I, F, M, A, M, $, $, A, S, O, N, D 9) MIXTURE: List COMPONENT CAS# % WT AI-IM the three most hazardous 1) [ chemical components or 2) [ any AI-IM components 3) [ 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 ,, true. accurate and complete. /~~d PRINT Name & Title of Authorized Company Representative Signature Date BAZ~RDOUS MATERIALS INVENTO~ . Page of Business Name Address CItEMICAL i)ESCRIPTION 1 ) U,,WENTORY STATUS: New [ ] Addition [ ] Revision [ ] Ddetion [ ] Ch~k ifchamical is a NON Trade Secret [ ] Trade Sec~ [ ] 2) Common Name: t.A.J~c~ ~-"~- O t c~ 3) DOT # (optional) Chemical Name: AI-tM { ] CAS # 4 ) Physical & Health PHYSICAL HEALTH Hazard Categories Fir~]Reactive[ ]S,_,dd_e,JReleaseofPresstu'e[ ] lmm_,'~ti,,teHealth(Acut¢)[kt~]I~layedHealth(Chwuic)[ ] $) WASTE CLASSIFICATION O-digit cod~ lk, m DHS Form 8022) USE CODE 6) PHYSICAL STATE Solid [ ] Liquid [~]~ Oas [ ] Pure [ ] Mixture [ ] Waste,[~L~] Radioactive [ ] 7) AMOtmT AND TUvm AT FACU. n'Y tn, nu~ oF MF..~SUPm 8) STOt~,OE CODES Maximum Daffy Amount ~'~" Lbs[ ]Oal[ ]fU[ ] a)Contam~ Av~rase Daily Amount $ ~'- Curies [ ] b) Pressure: Annual Amount <- q" c) Temperature /-4- Larsest Siz~ Container ~ ~' # Days on Site Circle Which Months: All Year, I, F, M, A, M, I, I, A, S, O, N, D 9) MIXTURE: List COMPONENT CAS# % WT AHlVi the three most ),,,~,,'dous 1 ) [ ] chemical components or 2) [ ] any AHM components 3) [ ] {0)LOCATION l,d~,t~ ~ c~cc e>~c' ~4.~O(~ 1) [NVENTORY STATUS: New [ ]Addition[ ]Revision[ ]Deletion[ ] Checkifchen~calisaNONTrad~S(~'~[ ]Trad~[ ] 2) Common Name: 3) DOT # (optional) Chemical Name: AHM [ ] CAS # 4 ) Physical & Health PHYSICAL HEALTH ~Categories Fire[ ]Reactive[ ]S,_,dd_~JReleas~ofPresmIre[ ] lmm(~liateHealth(Acut~)[ ]DelayedHealth(Chroui¢)[ ] 5) WASTE CLASSIFiCATiON O-digit cod~ ~ DHS Form 8022) USE CODE 6) PHYSICAL STATE Solid[ ] Liquid[ ] Gas[ ] Pu~[ ] Mixture[ ] Waste[ ] Radioa~iv¢[ 7) AMOUNT AND TIME AT FACILITY UNITS OF MEASLrRE 8) STORAOE CODES Maximum Daffy Amount Lbs [ ] Oal [ ] ft3 [ ] a) Contaiu~ Av(mige Daily Amouut C~es [ ] b) Pressure: Annual Amount ¢) Temlx~rature Largest Siz~ Container # Days on Site Circle Which Mouths: All Year, $, F, M, A, M, I, I, A, S, O, N, D 9) MIXTURE: List COMPONENT CAS# % WT AHM the thre~ most hazardous 1) [ ] chemical components or 2) [ ] any AHM compouents 3) [ ] l 0 )LOCATION [ certify under penalty oflaw, that I have pem~onally examined and am familiar with the information on this and all atta~had documents. I believe the submitted information is true, accurate and complete. PRINT Name & Title of Author/zed Company Representative Signature Dale