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Home My WebLink AboutBUSINESS PLAN Hazardous Materials/Hazardous Waste Unified Permit . . CONDITIONS OF .PERMIT ON REVERSE SIDE This oermit is Issued for the following: 12I Hazardous Materials Plan D Underground Storage of HazardOus Materials Permit ID #:: 015-000-001882 [] Risk Management Program BIG VALLEY MACHINERY C{ [] Hazardous Waste On-Site Treatment LOCATION: 2508 E BRUNDAGE LN C ELD ~.. ,. !, OFFICE OF ENVIRONMENTAL SER VICES' ' 1715 Chester Ave., 3rd Floor Approved by: ~-Ralph/Huey'D~'~i2~'~i Issue Date Bakersfield, CA 93301 OffieeofEv~Serviees Voice (661) 326-3979 ' ' FAX(661) 326-0576 '..ExpirationDate:" .'June30= 2003. ·" cus~ & ~o. ~~-/~~ MISCELLANEOUS RECEIVABLES ADJUSTMENT DATE ~-~- (~ NEWACCOUNT ADDRESS CHANGE CLOSE ACCT 'FINANCE CHARGE i ~ OTHER ADd MAILING ADDRESS P~CEL NUMBER ADJUSTMENT I CHG DATE CHARGE CODE I Ai~,4USTMENT AMOUNT ITE DIAGRAM [ ] I~ACIIATY DIAGRAM Business Name: Business Address: BIG VALLEY MACHINERY SiteID: 015-021-001882 Manager : .?-, BusPhone: (661) 861-9490 Location: 2508 E BRUNDAGE LN C .~%~ Map : 124 CommHaz : Moderate City : BAKERSFIELD ~ Grid: 04B FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 06 SIC Code: EPA Numb: DunnBrad: Emergency Contact / Title Emergency Contact / Title ~q~y~ CARRIZALES / FOREMAN JEANETTE CARRIZALES / OWNER Business Phone: (661) 861-9490x Business Phone: (661) 861-9490x 24-Hour Phone : (661)-~-9~f~5-4~x 24-Hour Phone : (661) Pager Phone : ( ) SZ&r~4~lxHo~ Pager Phone : ( ) - Hazmat Hazards: Fire Press ImmHlth DelHlth Contact : Phone: (661) 861-9490x MailAddr: PO BOX 71176 State: CA City : BAKERSFIELD Zip : 93387 Owner JEANNETTE CARRIZALES Phone: (661) 861-9490x Address : 2508 E BRUNDAGE LN C State: CA City : BAKERSFIELD Zip : 93307 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: JULY 9TH NEW BUSINESS PER JEANETTE. ED ~, ¢~D'r .6~4.~~3 Do hereby certify that ~ have (T~¢e ,~;. ~, iht, ame~ reviewed the attache~ ~mzardod.~ m~terials manage- merit plan tot B~¢.I .nd that it a!o~g with ~~'6~si,~ ' any ~(feoti0ns ~0nstitute a complete and coffe~ mare ~ement plan ~0r my f~ili~. 1 07/15/2003 BIG VALLEY MACHINERY SiteID: 015-021-001882 Fast Format ~ Training Overall Site -- Employee Training 07/14/1998 WE HAVE-i-~EMPLOYEES AT THIS FACILITY. WE HAVE MSDS SHEETS ON FILE. BRIEF SUMMARY OF TP~AINING PROGRAM: Page 2 --Held for Future Use Held for Future Use -11- 07/15/2003 U'l Postage _n Certified Fee 2 · 10 · I:r' postma~ Return Receipt Fee i · 5 0 Here r~ (Endorsement Required) ru ~:3 Restricted Detlvery Fee 1:::3 (Endorem'nen*;Requlred) r-"t Total postage & Fees 3 · 9 4 Machin CA 9 · O; 9te ~tems 1, 2, and 3. Aisc complete A. '~Received by (P/ease Print Clear/y) B. Date of Delivery · ite~r~if Restricted Delivery is desired. · Print your name and address on the reverse nat,,,~ so that we can return the card to you. C. Sig ~ · Attach this card to the back of the mai{piece, X~,~/~ ~/.,~-~. ~/ [] Agent , or on the front if space permits. ~ ../~..~../_ ,..x..-~.--~,. [] Addressee · . t from item 1. 1. Article AddreSSed to: ' ' If~, enter delivery a~ress below: [] No '.., Big Val. ley Machinery Jeannette Carrizales P.O. Box 71176 Bakersfield CA 93387 3. Service Type [~ Certified Maid [] [] Registered Merchandise [] insured Mail 2. Article Number (Copy from service label) PS F~811, July 1999 Domestic Return Receipt ~'~.~~'' '~-"'"'~ ~.,1~2595-99-M.1789 Augustl, 2001 Big Valley Machinery Jeannette Carfizales W,E C,~EF P.O. BOX 71176 RON FRAZE Bakersfield, CA 93387 ADMINISTRATIVE SERVICES VIA CERTIFIED MAIL 2101 "H' Street Bakersfield, CA 93301 vO,CE (661) 326-3941 Subject: Revocation of Big Valley Machinery_; Permit to Operate FAX (661) 395-1349 SUPPRESSION SERVICES Dear Ms. Carfizales: 2101 "H" Street Bakersfield, CA 93301 VOICE (661) 326-3941 Your "Permit to Operate" at 2508 E. Brundagc Ln., known as Big Valley FAX (661)395-1349 Machinery is being revoked effective Monday, August 13, 2001, at 5:00 p.m. PREVENTION SERVICES This "Permit to Operate" is being revoked due to failure to pay current as well as 1715 Chester Ave. past due fees. Bakersfield, CA 93301 VOICE (661) 326-3951 lAX (661) 326-0576 This action can be avoided by bringing your account current prior to that time. If ENVIRONMENTAL SERVICES you have any questions, please call me at (661) 326-3979. 17 f 5 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3979 --- -.Sincerelv, FAX (661) 326-0576 TRAINING DIVISION 5642 Victor Ave, Bakersfield, CA 93308 VOICE (661) 399-4697 FAX (661) 399-5763 Ralph E. Huey, Director Office of Environmental Services R~db cc: Walter Porr, Jr., City Attorneys Office Steve Underwood, Environmental Services Esther Duran, Environmental Services Drew Sharpies, Treasury MR430101 ~ CITY OF BAKERSFIELD ~ 8/01/01 · M~ellaneous Receivables In~z-f 16:48:11 C~stomer ID . . . : 31161 Name: BIG VALLEY MACHINERY Last statement : 6/30/01 Addr: P O BOX 71176 Last invoice : 0/00/00 BAKERSFIELD, CA 93387 Current balance : 397.00 Pending ..... : .00 A ACTIVE ENVIRONMENTAL SERVICES Previous balance : 397.00 Deposit balance : .00 Type options, press Enter. Open Activity 1=Select Opt Code Description Current Overdue Total due HM009 HAZ MAT HANDLING FEE I .00 324.00 324.00 - HM017 HAZ MAT ANNUAL INSPECTION .00 53.00 53.00 - SS001 CA STATE SURCHARGE .00 20.00 20.00 Bottom F3=Exit F7=Pending activity F8=Charge hsty F9=Payment hsty F10=Combined detail F11=Invoice inquir~ F12=Cancel F13=Auto charges F14=Deposit detail F21=Other tasks JUN--09--2000 10 .'48 AM BIG VALLEY MACHINERY CO 661 861 9492 Location: 2508 E BR~AGE LN ~ .p : 12~ Co--az : Moderate City : B~ERSFIELD ~rid: 04B FacUnits: I AOV: CommCo~e: B~ERSFIELD STATION 06 SIC Co~e= EPA NU~: ~nnBrad: T Contact / Title Emergency Contact / Title Business Phone: (661) ~-9490 Business Phone: {661) 24-Hour Phone : (6~)%Qq ~0~ x~ 24-Hour Phone : (661) 836-1400x Pa~er Phone : ( ') - x Pager Phone : ( ) - x Hazmat Hazards: Fire Press Im~lth DelHlth MailAddr: 2508 E BR~A~E LN ~ ~ State: CA City : B~RSFIELD Zip ~ q %%%7 Address : 2508 E BR~AGE ~ ~ ~ State: city : B~ERSFIELD Zip ~ 93307 Period : to TotalASTs: = ~al Preparer: T°talUST~: - Gal Certif'd: RSs: No Emergency Directives: ---- Hazmat Inventory ,.~,, One Unified List -- AS Designated Order Ail Materials at Site ...... 1>' "I ]' Hazmat Common Name... pecHa EPA Hazards Pm DailyMax Unit M ACETYLENE F P I~ G 500.00 FT3 STAR,ON F P IH G 3000.00 FT3 Low OXYGEN F IM DH G 5000.00 FT3 Low ~BON DIOXIpE F P IH G 850.00 FT3 Min PROPYLE~ ~,.. DO hereby oe~ba~ave ~ 435. oo FT3 ~ev]ewed ~he a~acbed b~a~ous ms~e6a~s ment p[ar~ fo~ and that it alo~ with [N~ ~) ' - any corre~lon$ constitute a complete an~ ~rre~ man- agement plan for my facili~. JUN--09--2000 10 :48 AM I~IG VALLEY MACHINERY CO 661 851 9492 P. 01 FAX COVER SHEET BIG VALLEY MACHINERY COMPANY BILLING: PO BOX 71f76 (93387) SHIPPING: 2508 E. BRUNDAGE LANE, UNIT "C" BAKERSFIELD, CA 93307 BUSINESS: (661) 861-9490 T~taf I;~g~s, i~ COMMENTS if you've'received this transmission In error, PI.ease notify us by telephone Immediately and ... .. destroy~the o. riginal transmission. Thank you' Big Valley'.Machlne~f Company- , . . OFFI~E OF ENVIRONMENTAL SE~rVICES 1715 Chester Ave., CA 93301 (661) 326-3979 BUSINESS OWNER / OPERATOR IDENTIFICATION FACILITY INFORMATION Page Of F ACILI~,D, ~ ~ ' Year Beginning 10o Year Ending BUSI~SS NAME (Same as FACILI~ NAME or DBA- Doing B~in~s ~) 3 BUSINESS PHONE ~02 SITE ADDRESS CI~ ~ CA ZiP DUN & ~06 SIC CODE ~o7 B~DSTREET (4 Digit ~) COUN~ OPE~TOR NAME ~ OPE~TOR PHONE ~0 OWNER NAME ~ O~ER PHONE ,~2 O~ER ~ILING ADDRESS ~3 Cl~ ~ STATE ~s ZIP 1~6 CONTACT NAME 1~7 CONTACT PHONE CONTACT ~ILING ADDRESS CI~ ~20 STATE ~2~ ZIP TITLE ~~ ~25 TITLE ~% BUSINESS PHONE ~ ~ _ ~ ~ 1,s BUSINESS PHONE 131 24-HOUR PHONE "7 2n-HOUR PHONE ~¢~ ' (400 PAGER ~ 128 PAGER ~ 133 CeAificaaon: Based on my inqui~ of ~ose individuals responsible Dr ob~ining ~e info~ation, I ~i~ under penal~ of law ~at I have personally examin~ and am amiliar with the information submiEed in ~is invento~ and believe the info~ation is ~e, a~umte, and ~mple~. E OF O~OP~O. DATE ,~ NAME OF DOCUMENT PREPAR~. '~OF OWNE~OPE~TOR (print[ / '3. TITLE OF OWNE~OPE~TOR '3, UPCF (7199) S:\CUPAFORMS\OES2730.TV4.wpd MISCELLANEOUS RECEIVABLES ADJUSTMENT DATE ~-/~-~ NEWACCOUNT J ADDRESS CHANGE CLOSE ACCT j · FINANCE CHARGE J · OTHER ADJ MAILING ADDRESS ~~-~ ~ ~co~a~ SITE ADDRESS PARCEL NUMBER (~F,a~PPUCABI. E) ADJUSTMENT J CH___.~G DATE I CHARGE CODE I ADJUSTMENT AMOUNT I REMARKS: ~-T~ .~~ ~o ~~ ~ ~)~o ~ ~ / CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3r" Floor, Bakersfield, CA 93301 FACILITY NAME S~.~ k[/~J"'('~ , INSPECTION DATE ~--'-//t%/~'~5~ ADDRESS ;25-Og-- ~'~ f'~P. Oo/a~tr~ PHONE NO. ~"7..{ -'--~/-'~O FACILITY CONTACT E.~AP--~$ ,k/'A'I~'3C-'"--- BUSINESS ID NO. 15-210- INSPECTION TIME [~> ~ NUMBER OF EMPLOYEES Section 1: Business Plan and Inventory Program l~ Routine [~l Combined ~ Joint Agency {~l Multi-Agency [] Complaint ~l Re-inspection OPERATION C V COMMENTS Appropriate permit on hand t,/ Business plan contact intbrmation accurate Visible address Correct occupancy Verification of inventory materials v/ Verification of quantities t/ Verification of location , t/ 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 t,/ Site Diagram Adequate & On Hand C=Compliance V=Violation AnYExplain:hazardous waste on site?: [] Yes ~'No ~~/d/'/7/~ Questions regarding this inspection? Please call us at (805) 326-3979 Busin~ Sit~ Respoffsible Party White-Env. Svcs. Y,,ellow- Station Copy Pink - Business Copy Inspector:<Z~/~J t ~ V A L L Y M A N U F A C T U R I N, ~ CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., Bakersfield, CA (805) 326-3979 1. To avoid ~nher a~io~ re~ t~sT(~t~n 30 days of receipt. 2. T~E~ ~S~RS ~ ENGLISH. 3. ~swer the questions below for ~e bus,ess ~ a whole. 4. Be ~ briefed ~ncise ~ possible. us ss LOCATION: '~O ~ ~ ~ C~--~7 CITY: STA~: Z~: ~ PHO~: D~ ~ B~S~ET ~ER: SIC CODE: P~Y ACT~TY: ~(~ O~R: ~~G ~D~S S: SECTION 2: E~RGENCY NOTWICATION CO. ACT TI~E BUS. PHO~ 24 ~. PHO~ i. ~C~ C~tz~c~5 o~ ~t,-3~qO 363 HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 3: TRAINING OF EMPLOYEES: ! MATERIAL SAFETY DATA SHEETS ON FILE: c~-~ 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 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 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: ~£~r /)rt~) ~K.~ ~,~i ~:X~ HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 7: MITIOATION. 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: ELECTRICAL: WATER: SPECIAL: LOCK BOX: YES/NO IF YES, LOCATION: SECTION 9: PRIVATE FIRE PROTECTION/WATER AVAILABILITY A. PRIVATE FIRE PROTECTION: ~o-~"FAP>c~- ~-'~0~oO-a (-k5o5 : B. WATER AVAILABILITY (FIRE HYDe): !. 4 H~~OUS MATERIALS INVENTO~ Page of. Business 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 First, ill']Reactive[ ]SuddenReleaseofPressm, e[dp~ImmediateHealth(Acute)[ ]DelayedHealth(Chrunic)[ 5) WASTE CLASSIFICATION (3-digit code from DHS Form 8022) USE CODE 6) PHYSICAL STATE Solid [ ] 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 c) Tempexature Largest Size Container # D~ys on Sit~ "3~ _~-~ Circle ~nich Months: All Yva~r, $, F, lVl, A, 1~ $, J, A, S, O, lq, D 9) IvflXTURE: List ¢OMPONI~IT CAS# % ~ AffM the three most lmzardous 1) [ chemicafl components or 2) [ · ny AHM components 3) [ 1)INVENTORYSTATU$:~ew[ ]Addition[ ]Revision[ ]Deletion[ ] Check if daemic~l is ~ NON Tr~de Secret [ ]Tr~teSectet[ 2) Common 3) DOZ # (oVtion ) Chemieafl Name: AHM [ ] CAS # 4) Physical & He&Ith PHYSICAL HEALTH Hazard Categories Fire [ ] Rea~efive [ ] Sudden Relm~e ofPressure [ ] ~mrnecli~te Heaflth (Acute) [ ] Del~yed Health (Chronic) [ 5) WASTE CLASSIFICATION (3-digit cod~ f~m DHS Form 8022) USE CODE 6) ?Hys~¢~ ST^T~ So~ia [ ] ~iquia [ ] O~ [ ] Pure [ ] Mixture [ ] W~ste [ ] m~io~ve [ ] 7) AMOUNT AND TIME AT FACILITY LrI~IT8 OF MEASLTRE 8) STORAGE CODES M~ximum D~ily Amount ~.-~c.~ Lbs [ ] ~ [ ] ~ ~ ~) Contains: Average Daily Amount Curies [ ] b) Pressure: Annual Amount e) Temperature Ia~rgest Size Container # D~ys on Site Circle Which Months: All Year, $, F, M, A, M, $, $, A, S, O, lq, D 9) MIXTURE: Li~t ~ ~ ~ ~O~APONENT CA~# % the three most lmz~xlous I) ~ [ ehemi~ com~nents or 2) ~_~e_.~40 te~;~3~ [ any ~ ~mponents 3) O~,ffc,~'..~ [ 10 )LOCATION ! certify under penalty oflaw, that I have pexsonally examin~ and am familiar with the infonnation on this and all attached documents. I pRINT Nam~ & Tide of Authorized Company Representative - ' Date [~DOUS MATERIALS INVENT~Y Page of,. Business Name Addrr~ CHI;MICAL IH~SCRIFrION 1 ) INVENTORY STATUS: New [ ] Addition ( ] Revision [ ] l~letion [ ] Ch~ck if chemical is a NON Trade Secret [ ] Trade Sec~t [ ] Chemical Name: AI-IM [ ] CAS # 4) Physical & Health PHYSICAL HEALTH Hazard Categories Fire [ ] Reactive~-S~d_a__on Release ofPressure {~:2] lmmol'liste Health (Acute) [ ] D~layed Health (Chrollic) [ ] 5) WASTE CLASSIFICATION (3-digit code from DHS Form 8022) USE CODE 6) PHYSICAL STATE Sotid [ ] Liquid [ ] C-as ~ eur~ ~ Mixture [ ] Waste [ ] Radioactive [ ] 7) AMOUNT AND TIME AT FACILITY UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount ~ Lbs [ ] Cai [ ] fi3 ~] a) Containec. Average Daily Amount ~ Curies [ ] b) Pressure: Annual Amount ~ ¢) Temperature Largest Size ConU~iner ~-~'/ # Days on Site .. ~ ~ Cixcl¢ Which Months: All Year, $, F, lVl, A, M, $, $, A, 8, O, N, D 9) MIXTURE: List COMPONENT CAS# % WT AHM the three most hazardous 1 ) [ ] chemical components or 2) [ ] any AHM components 3) [ ] I)INVENTORYSTA~S:N~[ ]Addition[ ]Revision[ ]Deletion[ ] Check ffchemical is a NON Trade Secret [ ]TradeSecret[ ] Chemical Name: t ~)~).:t:P~ AHM [ ] CAS # 4) Physical & Health PHYSICAL HEALTH Hazard Categories Fire[ ]Reactive[ ]SuddenReleaseofPres,vt~re[ ] Immediate Health (Acute) [ ]DelayedHealth(Chroni(0[ ] 5) wAsTE CLASSn~C^~'iO~ (3-~isit cod~ from DHS Form S0~) USE CODE 6) PHYSICAL STATE Solid[ ] Liquid[ ] Gas[ ] Pure[ ] Mixture[ ] Waste[ ] Radioactive[ ] 7) AMOUNT AND TIME AT FACILITY UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount Lbs [ ] Gal [ ] R3 [ ] a) Container:. Average Daily Amount Curies [ ] b) Pressure: Annual Amount c) Temperature Largest Size Container # Days on Site Cixcle Which Months: All Year, I, F, M, A, IV~ $, $, A, S, O, N, D 9) MIX'ITJRE: List COMPONENT CAS# % WT AHM the three most hazardous I) [ ] chemical components or 2) [ ] any AI-IM components 3) [ ] 0>LOC^nO O,,J [ certify under penalty of law, that I have personally examined and am familiar with the information on this and all attached docum~ts. I believe the subrnit)~d information is ~ accurate and complete. PRIIqT Name & Title of Authorized Company Repres(mtative Signature Date BA~OUS MATERIALS INVENTO Page of Business Name Address CB~MICAL BI~.SCRIPTION 1 ) INVEIN-I'ORY STATUS: New [ ] Addition [ ] Revision [ ] Deletion [ ] Check if chemical is a NON Trade Secret [ ] Trade Secret 2) Conunon Name: ~'~tt/C~--~/~ 3) DOT # (optional) Chemical Name: AHM [ ] CAS # 4) Physical & Health PHYSICAL HaTsrd Categories Fire~,] Reactive [ ] S~ 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~ ~¥toum' ~ ~vm AT FAcn.rr~ cu~rrs OF M~SOaE S) STORAOE CODES Maximum Daily Amount Z~'~'~ Lbs[ ]Gall ]f13~.~-] a) Container: Average Daily Amount , 4:.~ ~'~, Curies [ ] b) Pressure: Annual Amount , ~ c) Temperature # 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 l~dous 1) [ chemical components or 2) [ any AHM components 3) [ 10)LOCATION ~3~.~,~ [-~ ~ ~ ~)~ t~ 1) INVENTORY STA~S: New [ ]Addition[ ]Revision[ ]Deletion[ ] Check if chemical is a NON Trade Secret [ ]TmdeSea~[ 2) Common Name: 3) DOT # (optional) Chemical Name: AHIVl [ ] CAS # 4 ) Physical & Health PHYSICAL HEALTH HazardCate§ofies Fire[ ]Reactive[ ]SuddenReleaseofPressure[ ] lmmediateHealth(Acute)[ ]DelayedHealth(Chron/c)[ f) WASTE CLASSIFICATION (S-d/git code from DHS Form 8022) USE CODE 6) PHYSICAL STATE Solidi ] Liquid[ ] Gas[ ] Pure[ ] Mixture[ ] Waste[ ] Radio~tive[ ] 7) AMOUNT AND TIME AT FACILITY UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount Lbs [ ] Gal [ ] fl3 [ ] a) Container:. Average Daily Amount Cur/es [ ] 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# % WT AHM the three most lumrdous 1) [ chemical components or 2) [ any AHM components 3) [ 10)LOCATION ! cert/l~ under penalW of law, that I have personally examined and am familiar with the information on this and all attached documents. believe the submitted information is true, a~curate and complete. PRINT Name & Title of Author/zed Company Repr~entetive Signature Date