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HomeMy WebLinkAboutBUSINESS PLAN Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS OFPERMIT ON REVERSE SIDE ..... * This oermit is immed for Itm foJIowinp_: [] Hazardous Materials Plan [3 Underground Storage of H=~,rdous Materials Permit ID #:: 015-000-001707 [3 Risk Management Program STAR TRANSMISSION [] .,.-,.,do~ w,,.. o..s.,, LocATIoN: '!222 ECALIFORNIA AVE OFFICE OF ENVIRONMENTAL SER VICES' · 1715 Chester Ave., 3rd Floor Approvcdby: Bakersfield, CA 93301 Offic~ofEv.~ices....J Issuc Dam Voice .(661) 326-3979 FAX (661) 326-0576 ' . 'i:E~p~ti0n, Date: June 30. 2003 SITE DIAGi:I~M~r-c"~_ ' FACI I R M i~ustness Nome: ,,, ~T.~,P._ -TT'z./~£~ ~1 ~ Bu~ne~ AcCre~: I Z ~ ~- ~C t ~o~/A For O~ice Use Only First tn Stc~ton: Area Mc= # ~t tnsmec,'ton Stc,'ton: NORTH _~'"~ MISCELLANEOUS RECEIVABLES ADJUSTMENT ADDRESS CHANGE CLOSE ACCT j · FINANCE CHARGE I · OTHER ADJ CUSTOMER NAME, MAILING ADDRESS SITE ADDRESS PARCEL NUMBER (~F APPUCABL-'=) ADJUSTMENT I CHG DATE CHARGE CODE ,I ADJUSTMENT AMOUNT i . STAR TRANSMISSION SiteID: 215-000-001707 Manager : BusPhone: (805) 325-7408 Location: 1222 E CALIFORNIA AVE Map : 103 CommHaz : Moderate City : BAKERSFIELD Grid: 32B FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 02 SIC Code: EPA Numb: DunnBrad: Emergency Contact / Title Emergency Contact / Title DAVID VALENCIA / OWNER MARIA MALDONADO / WIFE Business Phone: (805) 325-7408x Business Phone: (805) 325-7408x 24-Hour Phone : (805) 326-8220x 24-Hour Phone : (805) 326-8220x Pager Phone : ( ) - x Pager Phone : ( ) - x Hazmat Hazards: Fire DelHlth Contact : phOne: (805) 872-2760x MailAddr: 4000 DANA ST State: CA City : BAKERSFIELD Zip : 93306 Owner ED WOLFE Phone: (HM-) NOS- 87x22760 Address : 4000 DANA ST State: CA City : BAKERSFIELD Zip : 93306 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No Emergency Directives: = Hazmat Inventory One Unified List -- As Designated Order Ail Materials at Site Hazmat Common Name... ISpooHazlEPA HazardsI Frm DailyMax lUnitlMCP ABANDONED UNDERGROUND TANK F L Mod SOLVENT F DH L 55 GAL Mod AUTOMATIC TRANSMISSION FLUID F DH L 65 GAL Low wa_~Ta_a~ ~9 ~y/D_ Do hereby, ce~i~ tDai ! have DH n 55 GAL Low m~i~d ~h~ a~ached hazardous materials manaQe- any corK®efforts c~r~$~itu~e a complete a~d ~K~ man- / ~ -~- ~o/=~/~e STAR TRANSMISSION SiteID: 215-000-001707 = Inventory Item 0001 Facility Unit: Fixed Containers at Site -- COMMON NAME / CHEMICAL NAME ABANDONED UNDERGROUND TANK Days On Site Location within this Facility Unit Map: Grid: N END OF PROPERTY BY FENCE CAS# 8006619  STATE i TYPE PRESSURE i TEMPERATURE I CONTAINER TYPE Liquid Pure Ambient Ambient D-NDER GROLTND TANK AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum I Daily Average HAZARDOUS COMPONENTS 100.00 Gasoline N 8006619 TSoo~otl RS BioHazl HAZARD ASSESSMENTS I I I Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F / / / Mod = Inventory Item 0002 Facility Unit: Fixed Containers at Site ~ -- COMMON NAME / CHEMICAL NAME ~ SOLVENT Days On Site 365 Location within this Facility Unit Map: Grid: NORTHEAST CORNER OF SHOP. CAS# 8030306 vSTATE TYPE PRESSURE i TEMPERATURE i CONTAINER TYPE Liquid PureIi Ambient Ambient OTHER - SPECIFY AMOUNTS AT THIS LOCATION Largest Container Daily Maximum I Daily Average GAL 55.00 GALI 55.00 GAL HAZARDOUS COMPONENTS 100.00 Naphtha N 8030306 HAZARD ASSESSMENTS TSecretl RSIBioHaz Radioactive/Amount [ EPA Hazards I NFPA IUSDOT# MCP No No No No/ Curies F DH / / / Mod -2- 10/21/1998 STAR TRANSMISSION siteID: 215-000-001707 = Inventory Item 0003 Facility Unit: Fixed Containers at Site -- COMMON NAME / CHEMICAL NAME AUTOMATIC TRANSMISSION FLUID Days On Site 365 Location within this Facility Unit Map: Grid: SOUTHWEST CORNER OF SHOP. CAS# 64742-56-9 Liquid Pure Ambient Ambient ABOVE GROUND TANK AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum Daily Average GALI 65.00 GAL 65.00 GAL HAZARDOUS COMPONENTS %Wt. ~S CAS# 100.00 Transmission Fluid (Petroleum-Based) N 0 HAZARD ASSESSMENTS TSecretI ~S BioHazI Radioactive/Amount EPA Hazards NFPA I USDOT# MCP No N No No/ Curies F DH / / / Low = Inventory Item 0004 Facility Unit: Fixed Containers at Site -- COMMON NAME / CHEMICAL NAME WASTE OIL Days On Site 365 Location within this Facility Unit Map: Grid: OUTSIDE AGAINST NORTH FENCE. CAS# 221 FSTATE TYPE PRESSURE i TEMPERATURE CONTAINER TYPE Liquid Waste Ambient Ambient DRUM/BARREL-METALLIC AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum Daily Average GAL [ 55.00 GAL 55.00 GAL %Wt. ~S CAS# 100.00 Waste Oil, Petroleum Based N HAZARD ASSESSMENTS TSecret RS BiOHaz Radioactive/Amount EPA HazardsNo No No No/ Curies F DH NFPA I USDOT# MCP -3- 10/21/1998 STAR TRANSMISSION ~~~~&&~&~~~ SiteID: 215-000-001707 Notif./Evacuation/Medical ~~~&~~~~~ Overall Site i~ A~ency Notification ~~~~~~~~~ 02/01/1996 TELEPHONE IN OFFICE AND SHOP TO CALL 9-1-1. VERBAL EXIT THROUGH OFFICE DOOR TO THE SOUTH FIRST AID KIT CLOSEST HOSPITAL -4- 10/21/1998 STAR TRANSMISSION ~~&~~~~~~ SiteID: 215-000-001707 Mitigation/Prevent/Abatemt ~~~&~~~~~ Overall Site i~ Release Prevention ~~~~~~~~~ 02/01/1996 CONTAINERS ARE LOCATED OUT OF THE WAY OF VEHICLE TRAFFIC AND WORK AREAS. ABSORBANT AVAILABLE TO SOAK UP SPILLS. WASTE OIL PICKED UP BY LICENSED HAULER. 5 10/21/1998 STAR TRANSMISSION ~~~~~&~&~ SiteID: 215-000-001707 Site Emergency Factors ~~~~~~~~ Overall Site A) GAS - B) ELECTRICAL - C) WATER - D) SPECIAL - E) LOCK BOX - PRIVATE FIRE PROTECTION - FIRE EXTINGUISHERS. ~EAREST FIR8 HYDR3aNT LOCATED - SW CORNER OF LOT. 6 10/21/1998 STAR TRANSMISSION ~~~~~~~ SiteID: 215-000-001707 Training ~~~~~~~~~~~ Overall Site i~ Employee Training ~~~~~~~~~ 10/21/1998 HOW MANY EMPLOYEES DO YOU HAVE???????? DO YOU HAVE MATERIAL SAFETY DATA SHEETS ON FILE?????????? GIVE A BRIEF SUMMARY OF YOUR TRAINING PROGRAM: i~ Held for Future Use 7 10/21/1998 ~E~Wm~-~ .... SiteID: 215-000-001707 STAR TRANSMISSION I x'~-~f2~l V ~:~i3i Manager : / SEP 21 7998 / BusPhone: (805) 326-8220 Location: 1222 E CALIFORNI~ AVE J Map : 103 CommHaz : Moderate City : BAKERSFIELD IBY:_ J Grid: 32B FacUnits: 1 AOV: EPAC°mmd°de:Numb: UST REMOVAL/NON-HANDLER DunnBrad:SIC Code,: ~~ Emergency Contact / Title Emergency Contact / Title DAVID VALENCIA / OWNER MARIA MALDONADO / WIFE Business Phone: (805) 325-7408x Business Phone: (805) 325-7408x 24-Hour Phone : (805) 326-8220x 24-Hour Phone : (805) 326-8220x Pager Phone : ( ) - x Pager Phone : ( ) - x Hazmat Hazards: Fire DelHlth Contact : Phone: ( ) - x MailAddr: 4000 DANA ST State: CA City : BAKERSFIELD Zip : 93306 Owner ED WOLFE Phone: (805) 872-2760x Address : 4000 DANA ST State: CA City : BAKERSFIELD Zip : 93306 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No Emergency Directives: = Hazmat Inventory One Unified List -- As Designated Order Ail Materials at Site Hazmat Common Name... SpooHazlEPA HazardsI Frm [ DailyMax lUnit MCP ABANDONED UNDERGROUND TANK F L Mod SOLVENT F DH L 55 GAL Mod AUTOMATIC TRANSMISSION FLUID F DH L 65 GAL Low F DH L 55 GAL Low WASTE OIL ~ ~:~ (,-)~-'~/ agement my '~;~'~ ' - -1- ~e 09/16/1998 STAR TRANSMISSION SiteID: 215-000-001707 Inventory Item 0001 Facility Unit: Fixed Containers at Site -- CO~ON NME / CHEMICAL NME ~ANDONED UNDERGROUND T~K Days On Site Location within this Facility Unit Map: Grid: N E~ OF PROPERTY BY FENCE CAS# 8006619 rSTATE TYPE PRESS~E i TEMPE~TURE i CONTAINER TYPE Li~id Pure A~ient A~ient UNDER GROUND T~K AMOUNTS AT THIS LOCATION Largest Container Daily Maximum I Daily Average HAZARDOUS COMPONENTS I 100.00 Gasoline N 8006619 HAZED ASSESSMENTS ITsecretl RSlBioHaz Radioactive/Amount EPA Hazards NFPA USDOT# I MCP No No No No/ Curies F / / / Mod ~ Inventory Item 0002 Facility Unit: Fixed Containers at Site ~ COMMON NAME / CHEMICAL NAME ! SOLVENT I Days On Site 365 Location within this Facility Unit Map: Grid: NORTHEAST CORNER OF SHOP. CAS# 8030306 STATE ~ TYPE PRESSURE TEMPERATURE CONTAINER TYPE FLiquid /Pure I Ambient I Ambient OTHER - SPECIFY AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average GAL 55.00 GAL 55.00 GAL HAZARDOUS COMPONENTS %Wt. ~S CAS# 100.00 Naphtha N 8030306 HAZARD ASSESSMENTS TSecret' RS'BioHaz' Radioactive/Amount EPA Hazards NFPA USDOT# MCP Mod No No No No/ Curies F DH / / / -2- 09/16/1998 STAR TRANSMISSION SiteID: 215-000-001707 = Inventory Item 0003 Facility Unit: Fixed Containers at Site ~lVUVl~ ~vl~ / ~1Vll ~,Z4..~ ~vl~ AUTOMATIC TRANSMISSION FLUID Days On Site 365 Location within this Facility Unit Map: Grid: SOUTHWEST CORNER OF SHOP. CAS# 64742-56-9 r STATE -- TYPE PRESSURE i TEMPERATURE i CONTAINER TYPE Liquid Pure Ambient Ambient ABOVE GROUND TANK I AMOUNTS AT THIS LOCATIONI Largest Container Daily Maximum Daily Average GAL 65.00 GAL 65.00 GAL HAZARDOUS COMPONENTS I i sl 100.00 Transmission Fluid (Petroleum-Based) N 0 HAZARD ASSESSMENTS TSecret ~S I BioHazI Radioactive/Amount EPA Hazards NFPA I USDOT# MCP No N No No/ Curies F DH / / / Low = Inventory Item 0004 Facility Unit: Fixed Containers at Site WASTE OIL Days On Site 365 Location within this Facility Unit Map: Grid: OUTSIDE AGAINST NORTH FENCE. CAS# 221 F STATE I TYPE PRESSURE i TEMPERATURE CONTAINER TYPE Liquid Waste 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 ~aste Oil, Petroleum Based N HAZARD ASSESSMENTS TSecretI ~SIBioHazI Radioactive/Amount I EPA HazardsI NFPA USDOT# MCP No N No No/ Curies F DH / / / Low -3- 09/16/1998 STAR TRANSMISSION ~~~~~~~ SiteID: 215-000-001707 Notif./Evacuation/Medical ~~~~~~~~ Overall Site i~ Agency Notification ~~~~~~~~~ 02/01/1996 TELEPHONE IN OFFICE AND SHOP TO CALL 9-1-1. VERBAL EXIT THROUGH OFFICE DOOR TO THE SOUTH i&&&&$ Emergency Medical Plan &~&&~&&&~&&~&&&~&~&~&~&&~&&~&~ 02/01/1996 FIRST AID KIT CLOSEST HOSPITAL -4- 09/16/1998 STAR TRANSMISSION ~~~~~~~ SiteID: 215-000-001707 Mitigation/Prevent/Abatemt ~~~~~~~ Overall Site i~ Release Prevention ~~~~~~~~~ 02/01/1996 CONTAINERS ARE LOCATED OUT OF THE WAY OF VEHICLE TRAFFIC AND WORK AREAS. i~ Release Containment ~~~~~~~~~ 02/01/1996 ABSORBANT AVAILABLE TO SOAK UP SPILLS. ~ASTE O~L PICKED UP BY LICENSED H~ULER. -5- 09/16/1998 STAR TRANSMISSION ~~~~~~~ SiteID: 215-000-001707 Site Emergency Factors ~~~~~~~~ Overall Site i~ Utility Shut-Offs ~~~~~~~~~ 02/01/1996 NATURAL GAS/PROPANE: N/A ELECTRICAL: INSIDE NE CORNER OF SHOP. ~e~e~~eeee~ee~ee~eee~~ee~e~e~e~eeeeeeee~eeeeeeee~~f i~ Fire Protec./Avail. Water ~~~~~~~ 02/01/1996 FIRE EXTINGUISHERS. FIRE HYDRANT LOCATED AT SW CORNER OF LOT. aeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee -6- 09/16/1998 i STAR TRANSMISSION ~~~~~~~ SiteID: 215-000-001707 · eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee Fast Format i~ Training ~~~~~~~~~~~ Overall Site ,i~ Employee Training ~~~~~~~~~ 02/01/1996 o o NUMBER OF EMPLOYEES: N/A o o o o o o o O 7 09/16/1998 "~" '- ' BAKEI~IELD CITY FIRE DEi~RTMENT HAZARDOUS MATERIALS DIVISION I715 -CHESTER'.A,V_E.; BAKERSFIELD, ca. 93301 HAZARDOUS MATERIALS MANAGEMENT'PLAN 1. To avoicl further action, return ;his form within 30 clays 2. ~PE/PRINT ANSWERS IN ENGLISH. 3. Answer the auestions Delow tar the ausiness cs a w~ole, 4. ~e Drier an~ conc~e cs SECTION 1' BUSINESS IDENTIFICATION DATA BUSINESS NAME: ~ ~ATiON: / M~,~:N~ ADDRESS: ._,-, .... ., __. JuN ~-' 'BRACSTREE-NUMBER: SiC 'CODE SECTION 2: EMERGENCY NOTiFiCATION: CONTACT TITLE BUS. PHONE 24 HR. PHONE U~:ardo~s M~aterials D£~sion O '" ' HAZARDO MATERIALS MANAGEMENT PLAN ' . SECTION 3: TI~AINING: NUMBER OF'EMPLOYEES: /'~//'~ MATERIAL SAFETY DATA SHEETS ON FILE: BRIEF SUMMARY OF TRAINING PROGRAM: SECTION 4: EXIEMPTICN REQUEST: ! CERTIFY UNDER PENALTY OF PE:,JURY-U -' "' ~,,A~ MY BUSINESS IS EXEMPT FROM THE 2E?ORTING REQUIREMENTS OF CHAPTER 6.95 OF THE "'CALIFORNIA HEALTH & SAFETY CODE" FOR THE r,..,'LLO NING REASONS NOT mANCLE HAZARDOUS MATERIALS. WE 'DOTM^' , - , ,,-,NDLE HAZARDC. US MATERIALS BUT ~HE GUANTtTiES AT NO T[MEE:<CEE'D tree MINIMUM R:?ORTING~. ~,UANTI?tc~. SECTION 5: CERTIFICATION: i, CERTIFY THAT THE ABOVE INFOR- MATION IS ACCURATE. I UNDERSTAND THAT THiS INFORMATiON WILL BE USED TO FULFILL MY F'RM S OBLIGATIONS UNDER THE "CALIFORNIA HEALTH AND SAFE,'Dr' CODE" ON HAZARDOUS MATERIALS (DIV. 20 CHAPTER 6.95 SEC. 25500 ET AL.) AND THAT ~-~'/~~x''x~~~ 'INACCURATE INFORMAT. iO,,N.CONSTiTUTES PERJURY. /' 3-~'~ SIGNATURE TITLE DATE. - ..... Hazardous Materials Division HAZARDOUS MATERIALS MANAGI::MENT PLAN SECTION 6: NOTIFICATION AND EVACUATION PEOCEDUEE$: A. AGENCY NOTIFICATION PROCEDURES: 3. EMPLOYEE NOTIFICATION AND EVACUATION: C. ,:UBL!C EVACUATION: ... -' : B~k~rsfietc~Fire Dept. ., Hazardou~ Mat~ri. ah Di~"i~ion HAZARDOUS MAIEEIALS MANAGEMENT PLAN SECII~N 7: MIII~AII~N, CR~VENII©N AND ~tAIEMI::lq? PLAN: A. RELEASE PREVENTION STEPS: B. RELEASE. CONTAINMENT AND/OR MINIMIZATION: :C . ~'L.':AN-UP ~ ,~,qOCE'DURE~: SECTION $: UTILITY SHUT-OFFS (LOCATION CF SHUT-OFFS AT YOUR FACILITY)' NATURAL '$AS/?RCPANE' ELECTR!C,-",L: l,,J~ '~ ~ -~ ,,Vm ~. SECTION 9: PRIVATE FIRE PROTECTION/WATER AVAILABILITY: A. PRIVATE FiRE pROTECT[ON: ~ ~---- B. WA?ER AVAILABILITY (FIRE HYDRANT)' BAKERSFIELD CITY FIRE DEPARTM!ENT . HAZ DOUS MATERIALS INVEI ORY Pago__.of._.' CHEMICAL DESCRIPTION 1) INVENTORY STATUS: New/;~ Addition J ] Revision [ ] Deletion ( ] Check if ehemir.,ai is a NON TRADE SECRET' [ ]"' TRADE SECRET 2) CemmonName: ~LJ~~J <T' 3) DOT # (opUenei) Chemical Name: AHM [ ] CAS # 4) PHYSICAL & HEALTH PHYSICAL HEALTH HAZARD CATEGORIES Fire ~ Reactive[ ] Sudden Release of Pressure [ ] Imme~iate Health (Acute) [ ] DelayedHeel~(Chronk=) [ 5) WASTE CLASSIFICATION (3-cligit code from DHS Form 8022) USE CODE ,~..~.~_~L~,J 6) PHYSICAL STATE Solid [ ] liquid [~] Gas [ ] Pure [4~ Mixture [ ] Waste [ ] Ra~ [ ] 7) AMOUNT AND TIME AT FAClUTY UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount ~"~" Ib~ [] gal [/] )13 [ ] a) Container. Average Daily Amount: ~'5'- curies [ ] b) Pressure: Annual Amount: ~ c) Temporatum: Largest Size'Container. # Days On Site ~ (o~'~ CimleWhich Months: All Year, J, F, M, A, M, J, J, A, $, O, N, D 9) MIXTURE: List COMPONENT CAS # % WT AHM the mree most hazamous 1) .~"~T..~,)'~/'~ ~L.j~'7''''7'~ (43(..~ [ ] chemical components or any AHM components 2). 3) [ ] CHEMICAL DESCRIPTION 1) INVENTORY STATUS: New ( ] Addition [ ] Revision [ ] Deletion { ] Check if chemical is a NON TRADE SECRET [ ] TRADE SECRET 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 Oaiiy Amount: ~"-- Ihs [ ] ga [,~ 1t3 [ ] a) Container: Average Daily Amount: ~--~'"- curies [ ] b) Pressure: Annuai Amount: '~C~c~ 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 tllree most hazardous 1) 2Z~· "~-'~ - ~=:~:~ ~,~2, ~ / 4.O¢.:.~ [] chemical components or any AHM components 2) [ 3) [ ~cerofy un(~er pena/~y of/aw, ~at / have persone//y exam~neet and am fam/~/ar w/~h ~e /nfomal~on su/~m/tted on rh/s an~ all ~rlJ~/;~ecJ ~o~u,-~en~. , PRINT Name & TiUe of Authorize~ Company Representa~fve Signature BAKERSF!- elrD CITY FIRE. DEPARTMENT ,,. HAZARBI3US MATERIALS INVENTOR"( Page_.of-- · usine$$ Name Address ' CHEMICAL DESCRIPTION ' 1) INVENTORY STATUS: NewJ~ Addil~m[ ] Revision[ ] Deletion[ ] CheckifchemieaIIS.&NON'rRADESECRET [ ] '.TRAI3ESECRET [ ] 2) com. , o 3) DOT · Che~ic,~ N~.'~: AHM [ ] CAS 4) PHYSICAL & HEALTH PHYSICAL HEALTH HAZARD CATEGORIES Fire ~ Reactive [ ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ ] 5) WASTE CLASSIFICATION ~'~,..-"L/ (3-digit code fi.om OHS Fon'~ 8022) USE CODE ~-----~(:~ 6) PHYSICAL STATE Solid [ ! Liquid ~ ~ [ ] Pure [ ] Mixture [ ] Waste ~ Radieactive [ ]. 7) AMOUNT AND TIME AT FAClUTY UNITS Of MEASURE 8) STORAGE CODES Maximum Daily Amount: ~-'~"' lbs [ ] gal ~ f~3 [ ] a) Conteinen Average Daily Amount: ~ curies [ ] b) Pressure: Annual Amount: ~" c) Temperature: L~gest Size Container: # DaysOn Site '~oS-- ¢irCleWhich Monthe: AIIYear, J, F, M, A, M, J, J, A, S, O, N, D ~) MIXTURE: List COMPONENT CAS # % ~T AHM the three most hazm'dous 1) (~,,t.,)~,.c~ ~ (~:)~---- ~"'~0 ~. ~-"=Y~//)'~' (~.3f..~ [ ] chemical components or any AHM components 2). [ [ CHEMICAL DESCRIPTION 1) INVENTORY STATUS: New [ ] Addition ( ] Revision [ ] Deletion [ ] Check if chemical is a NON TRADE SECRET [ ] TI=fADE 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 [ ] RadioactNe [ ] ~ 7) AMOUNT AND TIME AT FACIIJTY UNITS OF MEASURE 8) STORAGE CQDES Maximum Daily Amount: lbs [ ] gal [ ] 1t3 [ ] a) Containe~ Average Daily Amount: curies [ ] b) Pressure: Annual Amount: c) Temperature: L~rgest 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 # % VVT AHM the three most hazardous 1 ) [ ] chemica~ components or any AHM components 2) [ ] 3) [ ] 10) Location cerdly under penal~y of '/aw, that / have persona//), exam/ned and am familiar w~th the infomadon su/~mitted on th/s and all ,~bm/tted /nformet/on /s m~e, accurate, and comp/em. ' RINT Name & 77tie of Au~hoi~zed Company Represenia~ve Signature