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Home My WebLink AboutBUSINESS PLAN 11/18/2002 Hazardous 'Materials/Hazardous Waste Unified Permit .~ CONDITIONS OF.-PERMIT ON REVERSE SIDE [] Hazardous Materials Plan [3 Underground Storage of HazardOus Materials Permit ID #:: 015-000-000723 [3 Risk Management Program [3 Hazardous Waste On-Site Treatment CARROLLS TIRE AND WAREI 'LOCATION: 3001 BRUNDAGE LN Issued by: Bakersfield Fire Department . W 1715 Chester Ave., 3rd Floor Lp~',~y:~ ~s~ [~ Bakersfield, CA 93301 -' 'Omc¢ofEv~S~vic~s - Voice' (661) 326-3979 ,:-'::'"'" ' "' FAX (661) 326-0576 . Expiration'Date: 'June 30:2003 Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS OF PERMIT ON REVERSE SIDE Thi__~_Eermit is issued for the following[. Bus Materials Plan Storage of Hazardous Materials agement Program PERMIT ID# 015-021000723 ~. Waste CARROLLS TIRE AND LOCATION 3001 '%, ..._]~. '.~' "~.. - .... j~.- Issued by: Bakersfield Fire Department Approved by: _ 1715 Chester Ave., 3rd Floor Bakersfield, CA 93301 Voice (SOS) 326-3979 gxpirationDate: June FAX (805) 326-0576 , .~,'~UT,,D-FARM- TRUCK-CUSTOM W"=.ELS ~C~rroll's Tire Wareho~.~ 3001 Brundage Bakersfield, CA 93301 Work Phone: (805) 324-5040 ITE DIAGRAM r ~ FACILR'¥ DIAGRAM Business Nome: ~'c~3~-~5 'T~r~ ~.x~z_~o,,~ For Office Use Only Firsf In Station: Area Moo ,~ of Inspection Station: NORTH ,~ CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 ADDRESS ~'"~{"~ I 0t~Ll, lt~lOtlit~ b~' . i~I~. P_H.O,_NE NO. ~ e~"q~ .~JOt40 ~'~.FACILITY' CoN:FAC,T...'~O~a~-~/~- ~aa.~"'~NESS ID NO.. I~.-.~..I'0- INSPECTION TIME I_~/~?~.%J-~_-- ' %r-~ ,NUMBER OF EMPLOYEES · , . -- - --- ~Section I: Business Plan and Inventory Program [~~outine I~ Combined I~ Joint Agency 1~1 Multi-Agency ~ Complaint I~ Re-inspection OPERATION C V COMMENTS Appropriate permit on hand I,,' Business plan contact information accurate Vz Visible address Correct occupancy V Verification of quantities ~ Verification of location " ~/ ' ' Proper segregation of material Verification of MSDS availability I~'- Verification of Haz Mat training Verification of abatement supplies and procedures V Emergency procedures adequate ~ , . Containers properly labeled Housekeeping Fire Protection ~ Site Diagram Adequate & On Hand v/ C=Compliance V=Violation Any hazardous~waste on site?: ~es [~ No Explain: {,'/6/~[ ~ , f~~'~,i//~io~%- Questions regarding this inspection? Pi,ue call us at (661) 326-3979 B' s~ess Sig:; ReCs¥ons~bl'e Party Wh,te- Env. Svcs. ¥,l,ow - Smio. Copy Pink - Business Copy C ITY OF BAKERSFIELD CLAIM VOUCHER Vendor No. I certify that this claim is correct and valid, and is a proper charge against the City Agency and account indicated. CLAIMANT'S NAME AND ADDRESS: Carrolls Tire Warehouse (AUTHORIZED SIGNATURE OF CITY AGENCY) 3001 Brundage Ln Bakersfield, CA 93307 9-27-00 Initials of Preparer: ED CITY DEPARTMENT: PLEASE PROVIDE SHORT EXPLANATION OF PAYMENT: (Including Contract Number if Applicable) This business made a duplicate payment on their hazardous materials billing leaving them with a credit of $161.50 which we will fully refund. Dept. Base El / Objt Project # Invoice # Amount Comments on check stub 0000 123 7900 161.50 VOUCHER TOTAL $161.50 SECTION 72, PENAL CODE 'FINANCE DEPT. USE ONLY Section 72, Presenting False Claims. Every person who with intent to defraud, p~esents for allowance or for payment to any state board or officer, or any county, town, city district, ward or village board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, Examined & Approved for Payment Amount or writing, is guilty of a felony. ~/~R43~I07 CITY OF BAKERSFIELD 9/21/00 scellaneous Receivables I~iry 09:29:18 Customer ID . . . : 5264 Name: CARROLLS TIRE WAREHOUSE Last statement : 9/01/00 Addr: 3001 BRUNDAGE LN Last invoice : 0/00/00 BAKERSFIELD, CA 93301 Current balance : 161.50- Pending ..... : .00 A ACTIVE ENVIRONMENTAL SERVICES Type options, press Enter. Combined Detail 5=Display Chg Bnk G Opt Trans Date Code Description Amount Balance Typ Cd L 9/01/00 stmrn Statements Processed .00 161.50- 8/18/00 PAYMENT 161.50- 161.50- 00 Y 8/08/00 PAYMENT 161.50- .00 00 Y 8/01/00 stmrn Statements Processed .00 161.50 6/01/00 stmrn Statements Processed .00 161.50 6/01/00 SS001 CA STATE SURCHARGE 10.00 161.50 A 6/01/00 HM017 HAZ MAT ANNUAL INSPE 50.00 151.50 A 6/01/00 HM005 }{AZ MAT HANDLING FEE 110.00 101.50 A 5/01/00 stmrn Statements Processed ~00 8.50- + F3=Exit F12=Cancel * = Pending ~TATEMENT OF ACCOUNT P D BDX 20D7 BAKERSFIELD, CA ~2202-2057 (661) 326-3979 TO: CARROLLS TiRE WAREHOUSE DATE: 9/01/00 300i BRUNDAQE LN' BAKERBFiELD, CA 93301 CUSTOMER NO' 5264 CUSTOMER TYPE: ES/ 5264 ~"~' '*~ . REF-NUMBER DUE DATE TOTAL AMOUNT 8/0i/00 BE~iNNIN~ BALANCE l&l.50 8/08/00 PAYMENT 1&1.50- 8/i8/00 PAYMENT 1&1.50- FOR ~UESTIONS OR CHANGES TO YOUR PLEASE CALL THE NUMBER AT THE TOP OF THIS STATEMENT. CURRENT OVER 30 OVER 60 OVER 8. 50- DUE DATE: 10/0~/00 PAYMENT DUE' 1&1. 50- TOTAL DUE' $161. 50- . ~ , ~, . .., ~ , ., . -.-, , , ~.,~ ~ "~;~L~,~;~.,',~,-~,~ :~,~ ,~ ~C~r~ REMIT AND MAKE CHECK PAYABL~ TO: C lTV OF BAKERSFieLD PO BOX ~057 BAKERSFIELD OA ~3~03-~057 (~i) CUSTOMER NO: 5~4 CUSTOMER TYPE: ES/ 5~4 TOTAL DUE: $1~1.~0- CARROLLS TIRE AND WAREHOUSE SiteID: 215-000-000723 Manager : ~ BusPhone: (800) 994-5040 Location: 3001 BRUNDAGE LN Map : 123 CommHaz : Low City : BAKERSFIELD Grid: 0lA FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 03 SIC Code:5531 EPA Numb: DunnBrad: Emergency Contact / Title Emergency Contact / Title RANDALL CARROLL / OWNER K.C. WEST / MANAGER Business Phone: (800) 994-5040x Business Phone: (800) 324-5040x 24-Hour Phone : (209) 784-3167x 24-Hour Phone : (209) 979-1332x Pager Phone : ( ) - x Pager Phone : ( ) - x Hazmat Hazards: Fire DelHlth Contact : Phone: ( ) - x MailAddr: 981 W NORTH GRAND AVE State: CA City : PORTERVILLE Zip : 93277 Owner RANDALL CARROLL Phone: (805) 324-5040x Address : 981 W NORTH GRAND AVE State: CA City : PORTERVILLE Zip : 93277 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No Emergency Directives: ~ Hazmat Inventory One Unified List -- Alphabetical Order Ail Materials at Site Hazmat Common Name... ISpecHazlEPA HazardsI Frm DailyMax UnitlMCP AUTOMATIC TRANSMISSION FLUID F DH L 55 GAL Low CHEVRON SOLVENT F DH L 55 GAL Mod MOTOR OIL F DH L 200 GAL Min WASTE ANTIFREEZE F DH L Low Q0 hereby ce~i~ th~ ~ have CARROLLS TIRE AND WAREHOUSE SiteID: 215-000-000723 ~ Inventory Item 0002 Facility Unit: Fixed Containers on Site AUTOMATIC TRANSMISSION FLUID Days On Site 365 Location within this Facility Unit Map: Grid: STORAGE AREA INSIDE WEST INTERIOR OF SHOP. CAS# 64742-56-9 F STATE I TYPE PRESSURE --[ TEMPERATURE CONTAINER TYPE Liquid Pure Ambient Ambient DRUM/BARREL-METALLIC AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum Daily Average GALI 55.00 GAL 55.00 GAL HAZARDOUS COMPONENTS %Wt. ~S CAS# 100.00 Transmission Fluid (Petroleum-Based) N 0 HAZARD ASSESSMENTS TSecret RS BioHaz, Radioactive/Amount , EPA Hazards NFPA USDOT# MCP No N°lINo No/ Curies F DH / / / Low ~ Inventory Item 0003 Facility Unit: Fixed Containers on Site CHEVRON SOLVENT Days On Site 365 Location within this Facility Unit Map: Grid: STORAGE ARE INSIDE WEST INTERIOR OF SHOP. CAS# 8030306 F STATE TYPE PRESSURE TEMPERATURE CONTAINER TYPE Liquid /Pure~ I Ambient I Ambient I OTHER - SPECIFY AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum I Daily Average GALI 55.00 GALI 55.00 GAL HAZARDOUS COMPONENTS 100.00 Stoddard Solvent N 8030306 HAZARD ASSESSMENTS TSecret oRS BioHaz Radioactive/Amount EPA Hazards NFPA I USDOT# I MCP No N No No/ Curies F DH / / / Mod -2- 06/29/1999 CARROLLS TIRE AND WAREHOUSE SiteID: 215-000-000723 ~ Inventory Item 0001 Facility Unit: Fixed Containers on Site -- COMMON NAME / CHEMICAL NAME MOTOR OIL Days On Site 365 Location within this Facility Unit Map: Grid: STORAGE AREA INSIDE WEST INTERIOR OF SHOP. CAS# 8020835 F STATE ~ TYPE PRESSURE TEMPERATURE CONTAINER TYPE Liquid /Pure I Ambient I Ambient I ABOVE GROUND TANK AMOUNTS AT THIS LOCATION Largest Container Daily Maximum I Daily Average GAL 200.00 GAL I 160.00 GAL HAZARDOUS COMPONENTS %Wt. ~S CAS# 100.00 Motor Oil, Petroleum Based N 8020835 HAZARD ASSESSMENTS ITSecretlNo NoRSlBioHazINo Radioactive/Amount I EPANo/ Curies F Hazards I NFPADH / / / IUSDOT# MinMCP -- Inventory Item 0005 Facility Unit: Fixed Containers on Site 9 -- COMMON NAME / CHEMICAL NAME WASTE ANTIFREEZE Days On Site 365 Location within this Facility Unit Map: Grid: CAS# 107-21-1 STATE TYPE PRESSURE --~ TEMPERATURE CONTAINER TYPE Liquid Waste Ambient Ambient PLASTIC CONTAINER AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum Daily Average HAZARDOUS COMPONENTS 30.00 Ethylene Glycol N 107211 HAZARD ASSESSMENTS TSecretI RSIBioHaz Radioactive/Amount EPA Hazards NFPA I USDOT# [ MCP No No No No/ Curies F DH / / / Low -3- 06/29/1999 F CARROLLS TIRE AND WAREHOUSE SiteID: 215-000-000723 ~ Inventory Item 0004 Facility Unit: Fixed Containers on Site WASTE OIL Days On Site 365 Location within this Facility Unit Map: Grid: OUTSIDE REAR DOOR OF SHOP CAS# 221 ESTATE I TYPEAmbientPRESSURE --~ TEMPERATUREAmbientDRuM/CONTAINER TYPEBARREL - METALL I C Liquid Waste AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum Daily Average 55.00 GALI 220.00 GAL 55.00 GAL HAZARDOUS COMPONENTS %Wt. ~S CAS# 100.00 Waste Oil, Petroleum Based N 0 -- HAZARD ASSESSMENTS No N°llNo No/ Curies F DH / / / Low -4- 06/29/1999 CARROLLS TIRE AND WAREHOUSE SiteID: 215-000-000723 Fast Format Notif./Evacuation/Medical Overall Site -- Agency Notification 10/13/1995 SIX PHONES THROUGHOUT SHOP AND OFFICE TO CALL OUT FOR EMERGENCY RESPONSE. 10/13/1995 Employee Notif./Evacuation INTERCOM SYSTEM ALLOWS INDIVIDUAL COMMUNICATION TO EACH SHOP PHONE. 10/13/1995 , Public Notif./Evacuation WORD OF MOUTH IS SUFFICIENT A PUBLIC WAITING ROOM IS INSIDE OFFICE. EXIT DOORS TO SOUTH OF WAITING ROOM OR MAIN DOOR TO NORHT OF SHOWROOM. Emergency Medical Plan 10/13/1995 PROCEDURES POSTED ON SAFETY BULLITEN BOARD BEHIND SINKIN STORAGE AREA. SIERRA MEDICAL 3761 BERNARD 873-2000 -5- 06/29/1999 F CARROLLS TIRE AND WAREHOUSE SiteID: 215-000-000723 Fast Format ~ Mitigation/Prevent/Abatemt Overall Site --Release Prevention 10/13/1995 DRIP/SPILL PANS BENEATH DRUMS ~ Release Containment 10/13/1995 ALL OIL DRUMS EQUIPED WITH CYTRIFICAL PUMPS. Clean Up Other Resource Activation 6 06/29/1999 F CARROLLS TIRE AND WAREHOUSE SiteID: 215-000-000723 Fast Format ~ Site Emergency Factors Overall Site Special Hazards --Utility Shut-Offs 10/13/1995 NATURAL GAS/PROPANE: OUTSIDE SOUTH EAST CORNER OF BUILDING. ELECTIRCAL: OUTSIDE SOUTH EAST CORNER OF BUILDING. WATER: OUTSIDE EAST SIDE OF BUILDING. SPECIAL: GUARD DOG IN REAR. LOCK BOX: NO. -- Fire Protec./Avail. Water 10/13/1995 PRIVATE PROTECTION: FIRE EXTINGUISHERS THROUGHOUT AND SMOKE DETECTORS IN CONJUNCTION WITH BURGLER ALARM. WATER AVAILABITY (FIRE HYDRANT): ACCROSS NORTH EAST ADJACENT CORNER. Building Occupancy Level 7 06/29/1999 CARROLLS TIRE AND WAREHOUSE ~~~~~ SiteID: 215-000-000723 Training ~~~~~~~~~~~ Overall Site i~ Employee Training ~&~~&&~~~&~~~~ 10/13/1995 NUMBER OF EMPLOYEES: 5 MATERIAL SAFETY DATA SHEETS: YES BRIEF SUMMARY OF TRAINING PROGRAM: MONTHLY SAFETY MEETINGS AND ANNUAL TRAINING PROVIDED THROUGH ZENITH INSUR3tNCE WORKMANS COMP. BAKERSFIELD CITY FIRE DEPARTMENT HAZARDOUS MATERIALS DIVISION 1715 -CHESTER AVE'. BAKERSFIELD, CA. 9330'1 HAZARDOUS MATERIALS MANAGEMENT PLAN INSTRUCTIONS: ~" 1. To avoid further action, return this form within 30 days of receipt, ~EC~JVEE) 2. TYPE/PRINT ANSWERS IN ENGLISH. 3. Answer the questions below for the business as a whole. 01~T ~j ~. t99,5 4. Be brief and concise as possible. HAZ, MAT. DIV. SECTION 1: BUSINESS IDENTIFICATION DATA BUSINESS NAME: ~,~,¢-.¢-0/..6. t5 '"'"T¢~ LOCATION: ~:)O MAILING ADDRESS: ~'1 L,J. CITY' t;~¢-.."r-C.-4.~/~u-C___. STATE: dA- ZiP: ,~3"z.?? PHONE: ~2__4-~'O,drO DUN & BRADSTREET NUMBER: SIC CODE: PRIMARY ACTIVITY' ..,~--o¢.~'r',,.,'¢__. ,/"T',r~G ..~C__...,.~/,c._~ OWNER: ~,a,-~. ~ d~A,¢-/~,.~o MAILING ADDRESS: '~'~'f f,.~D, ~, ~~ ~ SECTION 2: EMERGENCY NOTIFICATION: CONTACT TITLE BUS. PHONE 24 HR. PHONE .~, .: Bakersfield Fire Dept. .dous 1V~at.erials Division HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 3: TRAINING: NUMBER OF EMPLOYEES: MATERIAL SAFETY DATA SHEETS ON FILE: BRIEF SUMMARY OF TRAINING PROGRAM' SECT[ON 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 E)O HANDLE HAZARDOUS MATERIALS, BUT THE QUANTITIES AT NO TIMEEXCEEO THE MINIMUM REPORTING QUANTFr. IES. OTHER (SPECIFY REASON) SECTION .5' CERTIFICATION: MATiON 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 SIGNATURE TITLE DATE. Bakersfield Fire Dept Hazardous Materials Divi~ HAZARDOUS MATERIALS MANAGEMENT PLAN Fc~cilify Unit Name: SECTION 6: NOTIFICATION AND EVACUATION PROCEDURES: A. AGENCY NOTIFICATION PROCEDURES' B. EMPLOYEE NOTIFICATION AND EVACUATION: 'TO ~o_~c_~ _~oP PNc_~u~. C. PUBLIC EVACUATION' oOoccr~ 04= O. EMERGENCY MEDICAL PLAN' _. B n]~ers~_eld. Fire Dept. Hazardous l~aterials Division 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' ELECTRICAL: c~ tr~ LOCK BOX: YESES) IF YES, LOCATION' SECTION 9: PRIVATE FIRE PROTECTION/WATER AVAILABILITY: A. PRIVATE FIRE PROTECTION: ~-r~_. B. WATER AVAILABILt~ (FIRE HYDRANt: . BAKEI FIELD CITY FIRE DEI RTMENT ., HAZARDOUS MATERIALS INVENTORY 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: ~ ~ (~ I 4-~ 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 FACIUTY UNITS OF MEASURE 8) STORAGE CODES Maximum Dally Amount: ~_CK~) lbs [ ] gal.,J~] 1t3 [ ] a) Container: Average Dally Amount: ~/~"~ curies [ ] b) Pressure: Annual Amount: ~' ~ c) Temperature: Largest Size'Container: 5; ~- # Days On Site '~0'3" Circle Which Months: AllYear, J, F, M, A, M, J, J, A, S, O, N, D 9) MIXTURE: List COMPONENT CAS # % WT AHM the three most hazardous 1 ) ~:).~,~ C.)-t ~. ('~ [ ] chemical components or any AHM components 2) [ ] 3) [ ] lO) Location ~-~~ ~ //U~;,~' (.~..). I,'J~-~_..-~./oP,.._ ~ CHEMICAL DESCRIPTION 1) INVENTORY STATUS: New [ ] Addition [ ] Revision [.] Deletion [ ] Check if chemical is a NON TRADE SECRET [ ] TRADE SECRET [ ] 2) Com.,on.amc:' 3) DOT# <o,t onai Chemicai 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 FAClETY UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount: ~'~J~ lbs [ ] gal ~ ft3 [ ] a) Container: Average Daily Amount: ~- ~'- curies [ ] b) Pressure: Annual Amount: ! ~'.5'- c) Temperature: Largest Size Container: ~7'~"' # 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 # % INT AHM the ,three most hazardous 1) ~C"C4~,,t~ Crt ~ /~ [ ] chemicai components or any AHM components 2) "~* [ ] 3) 10) Location ~ '7-~_~.~ ~ //~,~J ~, / ti~---- (.~ /,~-'rL--r~c { 0/~.. ~ ~ cern'fy uncfer penalty of law, that I have personally examined and urn familiar with the infornation submitted on this and all attached documents. I believe the subroitted infoz~natlon i, true, accurate, and complete. ..... PRII~ ~/ame & Title of Authorized Corn~ny Representative ~ Signa re Date BAKERSFII D CITY FIRE DEPARtmENT HAZARDOUS MATERIALS INVENTORY Page_of_ Business Name ~V'~o'~C.<~ -T--i/"CI~ Address CHEMICAL DESCRIPTION 1) INVENTORY STATUS: New [ lJ Addition [ I Revision [ I Deletion [ ] Check if chemical is a NON TRADE SECRET [ ] TRAOE SECRET [ ] 2) Common Name: C J~l~."'~}/'7-,C..3~ .~;;V._L./~..,"J'1" 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 FACILITY UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount: ~'~" lbs [ ] gal ~' 1~3 [ ] a) Container: Average Daily Amount: ~' ~ curies [ ] b) Pressure: Annual Amount: I ~ ~' 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: IJst COMPONENT CAS # % WT AHM the three most hazardous 1 ) ~'TO (~ {~/~_.('~ .~c.'-t_ tJ'C_-'-,.J 'I-- ~'(~ [ ] chemical components or any AHM co,mponents 2) [ ] 3) [ ] 10) Location ~-[b. CC~ ,Z~E-~w"~ i,nO<j~D~-- C.x.). /~,?C_-~'~o~ ~-~ CHEMICAL DESCRIPTION 1) INVENTORY STATUS: New [ ]~ Addition [ ] Revision [ ] Deletion [ ] Check if chemical is a NON TRADE SECRET [ ] TRADE SECRET [ ] 2) Common Name: ~J/~-~3-(~_.. ~)~ /'---- 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 ~."7_ I (3-digit code from DHS Form 8022) USE CODE ~ C) 6) PHYSICAL STATE Solid [ ] 'Liquid [¢~ Gas [ ] Pure [ ] Mixture [ ] Waste [ ] Radioactive [ ] 7) AMOUNT AND TIME AT FACIMTY UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount: ~'-~'-' lbs [ ] gal [~] fl~3 [ ] e) Container: Average Daily Amount: ~-~'- curies [ ] b) Pressure: Annual Amount: / ~'-~/__~ c) Temperature: Largest Size Container: # Days On Site '~'- Circle Which Months: All Ye~, J, F, M, A, M, J, J, A, S, O, N, D 9) MIXTURE: List COMPONENT CAS # % WT AHM the three most hazardous 1) ~1..~.z~,~ "~ ' ~::'~'/ZO~ ~U~ ~7~) [] chemical components or any AHM components 2), "~ [ ] 3). [ ] ~o) Lo~on ~%,,~F_~ ~Zc.,~. '-'0~0~ OC- r cer~fy under penalty of law, that I have personally examined and am familiar with the infomaSon submitted on this and allajtached~ocuments. I believe th~ PRJ~rr-Name & Title of Authorized-Company Repres~nta~Y~/~' ~.~ Date