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Home My WebLink AboutBUSINESS PLAN FINANCE DEPARTMENT CITY OF BAKERSFIELD P.O. BOX 2057 BAKERSFIELD, CALIFORNIA 93303 R~RN SERVICE REQUESTED STATEMENT OF ACCOUNT ~TTV~.~,, OF BAKERSFIELD P 0 BOX 2057 · .(261 ) ~" .. · DATE' &/O1/O0 TO: V &. A AUTO REPAIR &' TOWIN~ i6,JU -~ CALiFORNiA 'AVE ~' BAKERSFieLd, ~ ~A 93~07 ~ CU.~r,= B- = ~=°~m*lON,~ REF-NUMBER DUE DATE TOTAL AMOUNT ~T 5/0i/00 ~"~ ~-~' ~,~Ni~ ~AL:ANCE 248. 50 HMO05 &/Oi/O0 HAZ MAT HANDL.iN~ FEE E iiO. O0 ~SO0i 6/0i/00 CA:.STATE BURCHARgE i0. OO FOR OUESTiONS OR ~HAN=E~ TO YOUR ACCOUNT PLEASE CALL THE NUMBER AT THE TOP OF THIS STATEMENT. CURRENT OVER 30 OVER &O OVER 90 130.00 248. 50 ......... DUE DATE: 7/03/00 PAYMENT DUE: 368.50 TOTAL DUE: $368.50 STATEMENT OF ACCOUNT CITY OF BAKERSFIELD P 0 BOX 2057 BAKERSFIELD, CA 93303-~057 (661) 326-3979 DATE: 8/01/00 TO: V & A AUTO REPAIR & TOWINQ 1603 E CALIFORNIA AVE BAKERSFIELD, CA 93307 CUSTOMER NO: 17007 CUSTOMER TYPE: ES/ 20543 CWARCE . '- "I!pTTON ...... R E F -Nt~zlBER~UE--DAT E TO-T-AL--AMOUNT 6/01/00 BEQINNINQ BALANCE 368. O0 FOR QUESTIONS OR CHANQES TO YOUR ACCOUNT PLEASE CALL THE NUMBER AT THE TOP OF THIS STATEMENT. CURRENT OVER 30 OVER 60 OVER 90 120.00 248.50 TOTAL DUE: $368.50 CUSTOMER NO' 17007 CUSTOMER TYPEi ES/ 20543 TOTAL DUE: $368. 50 CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 ADDRESS IGO.~ t5. ~./~t...t~--t. rcoo~ PHONE NO. FACILITY CONTACT BUSINESS ID NO. 15-210- INSPECTION TIME NUMBER OF EMPLOYEES Section 1: Business Plan and Inventory Program {~ Routine ~.Combined {~l Joint Agency ~ Multi-Agency 1~ Complaint [~l Re-inspection OPERATION C V COMMENTS Appropriate permit on hand O..)~C_~ ~05 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 Any hazardous waste on site?: ~'Yes ~] No Questions regarding this inspection? Please call us at (661) 326-3979 Business Site Responsible Party White - Env. Svcs. Yellow - Station Copy Pink - Business Copy Inspector: CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 Section 4: Hazardous Waste Generator Program EPA ID # [] Routine /~ Combined [] Joint Agency [] Multi-Agency [] Complaint [] Re-inspection OPERATION C V COMMENTS Hazardous waste determination has been made ~CC-4~E <2/kt..t- ~6~ - ~:~00 EPA ID Number (Phone: 916-324-1781 to obtain EPA ID #) 'T'cb 'TA:t~E: bo'~l'~' rD fc~ -FO Authorized for waste treatment and/or storage /-~'~-! Reported release, fire, or explosion within 15 days of occurrence Established or maintains a contingency plan and training Hazardous waste accumulation time frames Containers in good condition and not leaking ~¢c~ Containers are compatible with the hazardous waste Containers are kept closed when not in use ~T'~ Weekly inspection of storage area Ignitable/reactive waste located at least 50 feet from property line Secondary containment provided Conducts daily inspection of tanks Used oil not contaminated with other hazardous waste Proper management of lead acid batteries including labels Proper management of used oil filters Transports hazardous waste with completed manifest Sends manifest copies to DTSC Retains manifests for 3 years Retains hazardous waste analysis for 3 years Retains copies of used oil receipts for 3 years Determines if waste is restricted from land disposal C=Compliance V=Violation Inspector: Lt~} t Office of Environmental' Services (661) 326-3979 Business Site Responsible Party White - Env. Sves. Pink - Business Copy MI$CEM.~NEOU$ RECEIVABLES ADJUSTMENI ADDRESS CHANGE CLOSE ACCT · FIN~CE C~GE I . OTHER ~J CUSTOMER NAME ~¢ g ~~ ~ MAILING ADDRESS t ¢0 ~ ~ ~; ~ r' ¢; ~ SITE ADDRESS PARCEL NUMBER (~F ADJUSTMENT ~ CHG DATE CHARGE CODE ADJUSTMENT AMOUNT l Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS OF PERMIT ON REVERSE SIDE This permit is issued for the following: ~:"'-..."-.~Li: ~ %-,..~ } - ............ ::,¢. ~z~i,~?gl~ ~:.~{lp . . , j ~ i~ ~',~,~ ~.i '~=~ ip....--.,=i ~{:,,.:"'"-:~ ,. 14. ,e~":'. · , ........... ~ ., :~. ~ .~ · ,. : --=.~.~ ~ ~ ..... . %1::.-~" ~ih,. Issu~ by: O~ICE OFE~RO~AL S~ 1715 Chewer Ave., 3rd Floor B~e~el~ gA 93301 Voice {805) F~ (*05),2~057~ Exp~tionDate: · June 30, 2000 V & A AUTO REPAIR & TOWING SiteID: 215-000-001848 Manager : BusPhone: (805) 327-9820 Location: 1603 E CALIFORNIA AVE Map : 103 CommHaz : Low City : BAKERSFIELD Grid: 29D FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 02 SIC Code:7538 EPA Numb; DunnBrad: Emergency Contact / Title Emergency Con'ct / Title VICTOR CASTANEDA / OWNER ~5(~ SAMUEL MOT~ / CO TENANT Business Phone: (805) 327-9820x Business Phone: (805) 327-9820x 24-Hour Phone': (805) 873-9744x 24-Hour Phone : (805) 366-4817x Pager Phone : ( ) - x Pager Phone : ( ) - x Hazmat Hazards: Fire DelHlth Emergency Directives': = Hazmat Inventory One Unified List -- MCP+DailyMax Order Ail Materials at Site Hazmat Common Name... ISpecHazlEPA HazardsI Frm DailyMax Unit MCP WASTE OIL F ~~ DZ L 55 GAL Low WAST~.F~ ~O ~%_~.--~-~ ~7. ~ F DH S 100 UnR [:)o h~by cs,!ify that ~ hav~ merit plan for ~o~> and tha~ it alon~ w~th ~ement plan for my -1- 02/20/1998 V & A AUTO REPAIR & TOWING SiteID: 215-000-001848 = Inventory Item 0001 Facility Unit: Fixed Containers at Site -- COMMON NAME / CHEMICAL NAME WASTE OIL. · '. Days On Site 365 Location within this Facility Unit Map: Grid: UNDER SW CORNER OF SHOP IN BACK CAS# 221 STATE~ TYPE PRESSURE TEMPERATURE CONTAINER TYPE Liquid I Waste. I Ambient I Ambient I DRUM/BARREL-METALLIC AMOUNTS AT THIS LOCATION Largest COntainer I Daily Maximum I Daily Average . 55.00 GAL 55.00 GAL 55.00 GAL %Wt.''' HAZARDOUS COMPONENTS I CAS# 100.00 Waste Oil, Petroleum Based N~S 0 TSecret S BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No N No No/ Curies F DH / / / Low = Inventory Item 0002 Facility Unit: Fixed Containers at Site ~lv~vlu~ ~Vl~ /. ~I~.-~.D ~vl~ WASTE TIRES Days On Site 365 Location within this Facility Unit Map: Grid: IN SE CORNER OF PROPERTY CAS# Solid OTHER AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum Daily Average 100.00 I 100.00 100.00 HAZARDOUS COMPONENTS · %Wt. RS CAS# HAZARD ASSESSMENTS lTSecret No No. I Radioactive/Amount I EPA HazardsI NFPA USDOT# MOP No . RS BioHaz No/ Curies F DH / / / UnR 2 02/20/1998' ItAZAR1)OUS MATERIALS MANAGEMENT PLAN SECTION 7: MITIGATION, PREVENTION AND ABATEMENT PLAN A. RELEASE PREVENTION STEPS: B. RELEASE CONTAINMENT AND/OR MIN'IM~ZATION: 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: ]C7~.~ St-~ B. WATER AVAILABILITY (FIRE HYDRANT).~ ~ 4 ltAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 6: NOTIFICATION AND EVACUATION PROCEDURES A. AGENCY NOTIFICATION PROCEDURES: ~ ~dd c~ ¢// B. EMPLOYEE NOTIFICATION AND EVACUATION: C. PUBLIC EVACUATION: D. EMERGENCY MEDICAL PLAN: Auto Repair & Towing :: '= Estimaciones Gratis - Free Estimates ~ 24 Hours a Day Service at Address ~ · !, 24 Horas al Dia Servicio a Domicillo~,~.7'~'~Z{ ~1~0'~ Sh~p (805) ~ -2-6e4 E. California Ave. Res. (805) 873-9744 Bakersfield, CA 93306 Beeper (805)~11111~1 CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., Bakersfield, CA (805) 326-3979 INSTRUCTIONS: 1. To avoid further action, return this form within 30 days of receipt. 2. TYPE/PRINT ANSWERS IN ENGLISH. 3. Answer the questions below for the business as a whole. 4, Be as brief and concise as possible. SECTION 1' BUSINESS IDENTIFICATION DATA osn ss LOCATION: MAILING ADDRESS: CITY: STATE: ~ ZIP: PHONE: DUN & BRAI)STREET NUMBER: SIC CODE: PRIMARY ACTIVITY: OWNER: MAILING ADDRESS: ,,~z,I /~4-,~ct_ $c/e_~ Eeo SECTION 2: EMERGENCY NOTIFICATION CONTACT TITLE BUS. PHONE 24 ~ PHONE HAZARDOUS MATERIALS MANAGEMENT PLAN " SECT[ON 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 EXEMlYr 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 EXCF. F.D 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: HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 7: MITI(~ATION. pREVENTION AND ABATEMENT PLAN A. RELEASE PREVENTION STEPS: B. RELEASE CONT~ 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: B. WATER AVAILABILITY (FIRE HYDRANT): 4 HAZARDOUS MATERIALS INVENTORY Page of Busincss Name Address CHEMICAL DESCRIPTION i) INVENTORY STATUS: New [ ] Addition [ ] Revision [ ] Deletion [ ] Check il'chemical is a NON Trade Secret [ ] Trade Secret [ ] 2) Common Name: f_~sc~7~ ~ t ~ 3) DOT # (optional) ChCnUcal Name: AHM [ ] CAS # 4) Physical & Health PHYSICAL HEALTH Hazard Categories Fire ~rReactive [ ] So__dd~_ Release of Pressure [ ] Immediate Health (Acute) [~ Delayed Health (Chronic) [ ] 5) WASTE CLASSIFICATION (3.<ligit code from DH8 Form 8022) USE CODE 6) PHYSICAL STATE Solidi ] Liquid~ Gas[ ] Pur~[ ] Mixture[ ] Waste~ Radioactive[ ] 7) AMOUNT AND TIME AT FACILITY UNITS OF MEASURE 8) STORAGE CODES Maximum Daffy Amount ~ Lbs [ ] Cml ~ ] ~ [ ] a) Container:. Average Daily Amount ~'C' Curies [ ] b) Pressure: Annual Amount ,<7(" c) Temperature Largest Size Container ' ~' %-- # Days on Site 'v~Y' Circle Which Months: All Year, J, F, M, A, lVl, 5, $, A, S, O, N, D 9) MIXTURE: List COMPO~ CAStt % WT AI'IM the three most h~,,-xlous 1) [ ] chemical components or 2) [ ] any AI-IM components 3) [ ] 10)LOCATION (J ~N] I') ~4r~ _~ Io,.) C_.c'~ M/~.. ~ .~,d~O I~' fao ~'~ 1) INVENTORY STATUS: New [ ]Addition[ ]Revision[ ]Deletion[ ] Chec. lrifchemicaflisaNONTrad~socret[ ]Tn~[ ] 2) Common Name: ~%T~ -~C--~ 3) DOT # (o~tio,~l) Chemical Name: AHM [ ] CAS # 4) Physical & Health PHYSICAL HEALTH Hazard Categories Fir~ [ ] Reactive [ ] S;_,,~__~m Release ofPressur~ [ ] Imm~li~te Health (Acute) [ ] Delayed Headth (Chronic) [ ] ~) WASTE CLASSIFICATION (~-ai~it ~ from DHS Form 1~.2) USE CODE ~) PHYs~c~ STA~ So,id [ ] Liquid [ ] C,~ [ ] ~ [ ] ~ [ ] W~-te [ ] P.~io~i,e [ ] 7) AMOUNT AND TIME AT FACILITY UNITS OF ME,~URE 8) STORAGE CODES Maximum D~ily Amount ) ~ Lbs [ ] Cai [ ] fi3 [ ] a) Container:. Average D~ily Amount ) OO Curies [ ] 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# % ~ AHM the three mos~ haz~lom 1) [ ] chemical componont~ or 2) [ ] any AHM components 3) [ ] ,O)LOCATION /~ _s~' /--..~/~-- ~ t'~--~C:~-~r/ ~_, _ £ ¢¢ni£y under l~'nally ofl~w, thai I have personally e~mim:d ~gl am f~'niliar with ~¢ informati~J~on ~!~f and sll atlached documents. belie ye ,c submitted info--ti, is true, acc umtc and complete. ///~. c.~ PRINT Name & Tide of Authorized Company Repr~'.sentstive ~/~'S~nature Date RAZARDOUS MATERIALS INVENTORY Page of, Business Name Address CltEbilCAL DES~ON I ) INVENTORY STATUS: N~w [ ] Addition [ ] Revision [ ] Deletion [ ] Check if chemical is a NON Trad~ Secret [ ] Trad~ S~'mt [ ] 2) Common Name: 3) DOT # (optional) Chemical Name: AHM [ ] CAS # 4) Physical & Health PHYSICAL HEALTH Hazard Categories Fire [ } Reactive [ ] Sudde~ Relesz~ ofPressure { I Immediate Health (Acute) [ ] Delayed Health (Chronic) [ ] 5) WASTE CLASSIFICATION (a-digit ¢od~ fi,,... DHS Form S022) USE CODE 6) PHYSICAL STATE Solidi ] Liquid[ ] Cras[ } Pur~[ ] Mixture[ ] Waste[ ] Radioactive[ ] 7) AMOUNT AND TIME AT FACILITY' UNITS OF MF..AS~ 8) STORAGE CODES Maximin Daily Amount Lbs [ l ~ [ ] ~ [ ] a) Contains. Average Daily Amount Curies [ ] b) Pressu~: Annual Amount c) Temperatm~ Largest Size Container # Days on Site Cimle Which Montha: AIl Year, $, F, M, A, M, $, I, A, S, O, N, D 9) MIXTURE: List COIVIPONENT CAS# % WT AHM the three most hazardous1) [ ] chemical ~ts or 2) [ ] any AHM compot~ms a) [ ] 10)LOCATION I)IlqVENTORYSTATUS:New[ ]Additiun[ ]Revision[ ]Deletion[ ] Cher. kifchemicalisaNONTrad~Seoret[ ]Tradosoc~t[ ] 2) Common Name: 3) DOT # (optiosal) Chemical Name: AHM [ ] CAS # 4 ) Physical & Health PHYSICAL HEALTH Ha-ardCategories Fire[ ]Reactive[ ]SuddenReleaseofPreasm~[ ] rmm_-al,t~Health(Acut,,)[ }DelayedHealth(Chnmi¢)[ ] 5) WATS CL~SSn~C^T~Olq (a-disit co~ f~m Offs Form ~rZ2) USE CODE 6) PHYSICAL STATE Solid [ ] Liquid [ ] Oas [ ] Put~ [ I Mixtm-e [ ] Waste [ ] Radion~tive [ ] 7) AMOUNT AND TIME AT FACR.ITY UNITS OF MF. ASURE 8) STORAGE CODES Maximin Daily Amount Lbs [ ] Gal [ ] fl3 [ ] a) Containec. Average Daily Amount Curies [ ] b) Pr~su~: Annual Amount ¢) Temperature Largest $iz~ Container # Days un Site Circle Which Months: All Year, J, F, M, A, M, ~ $, A, $, O, N, D 9) MIXTURE: List COMPONElqT CAS# % VfF AHM the three most hazardous 1) [ ] chemical componeats or 2) [ ] any AHM components 3) [ ] 10 )LOCATION [ certify under penalty of law, that ! have personally examim~ and am familiar with tho information on this and all attar, heal doctmmnts. I believe the submitted infommtion ia tru~ accurate and complete. PRIIWI' Name & Title of Authorized Company Repre~ntative $ignatur~ Date HAZARDOUS MATERIALS ~NVENTORY Page __ of' Business Name Address ~ ~ CI~MICAL DESCRIPTION 1 ) I2,PgENTOR¥ STAlq. IS: New [ 1 Addition [ ] Revision [ ] Dclctio~ [ ~ Check il'chemical is a NON Trade Secret [ 2) Common Name.' 3) DOT # (optional) Chemical Name: AHlvi [ ] CAS # 4) Physical & Health PHYSICAL HEALTH Hazard Categorie~ Fire [ ] Reactive [ ] Sudden Rele~.~ of Prea~ [ ] Immediate Health (Acute) [ ] Delayed Health (Chnmi¢) [ ] 5) WASTE CLASSI~CATION (3-digit code from DHS Form 8022) USE CODE 6) PHYSICAL STATE Solidi ] Liquid[ ] Oas[ ] Pur~[ ] Mixture[ ] Waste[ ] Radioactive[ ] 7) AMOUNT AND ~ AT FACILITY UNY~ OF MEASURE 8) STORAGE CODES Maximum Daily Amount Lb~ [ ] Gal [ ] ft3 [ ] a) Container:. Average Daily Amount Curia [ ] b) ~.' Aunual Amount ¢) Larg~ Siz~ Conmin~ # Days on Site Circle Which Months: AIl Year, $, F. M. A, M, $, $. A, S. O, N, D 9) MIXTURE: List COMPONENT CAS# % WT AHM the thr~ most haz. a~lous 1) chemical compone~te or 2) [ ] any AHM components 3) [ ] 10)LOCATION I)~ORYSTATUS:N~w[ ]Addition[ ]Revision[ ]Del~ion[ ] Ch~kifchemicalisaNONTrad~Sec~t[ ]Tradesocre~[ ] 2) Common Name: 3) DOT # (optional) Chemical Name: AHM [ ] CAS # 4) Physical & Health PHYSICAL HEALTH HazardCategorie~ Fire[ ]Reactive[ ]Sudde~Rel~a.~ofPre~u~[ ] lmm~tiateHealth(Acute)[ ]DelayedHe~lth(Chtoni¢)[ ] 5) WASTE CLASSIFICATION (3-digit code from DHS Fo..a ~022) USE CODE 6) PHYSICAL STATE Solidi ] Liquid[ ] C-as[ ] Pure[ ] Mixture[ ] Was~[ ] Radioa~ve[ ] 7) AMOUNT AND TIME AT FACILrrY UNITS OF MF_.ASUR~ 8) STORAGE CODES Maximum Daily Amount ... Lb~ [ ] Cml [ ] fD [ ] a) Container:. Average Daily Amount Curia [ ] b) Pressure: Annual Amount c) Temp~'atur~ La,est Siz~ Contains' # Days on Sit~ Ci~le Which Munth~: All Year, $. F. M. A. M, I, $, A, S. O, N, D 9) MIXTURE: List COMPONENT CAS# % WT AHM the thr~ mo~ hazardous I) [ ] chemical compon~nf~ or 2) any AHM compon~ 3) [ ] 0 )LOCATION ceftin/und~ penaity of law. that ! hav~ p~r,..o~mlly e~mlined and am familiar with the information on this and all atlached docum~lts. I believe ~he submitted inf'ormation is true. ar. curate and complete. PRRVI' Name & Title of Authorized Company l~.-pt~mtative Signatur~ Date H~RDOUS MATERIALS INVENT(~Y Page of_...~ Business Name Address CHEMICAL DESCRIPTION I ) INVENTORY STATUS: New [ ] Addition [ ] Revision [ ] Deletion [ ] Check ifchemical is a NON Trade Secret [ ] Trade Secret 2) Common Name: 3) DOT # (optional) Chermcal Name: 4) Physical & Health PHYSIC^L HEALTH HaTurd Categories Fire [ ] Reactive [ ] $,_,d_~__ Releas~ of Pressure [ ] Iw~ate Health (Acute) [ $) WASTE CLASSII:ICATION (3-digit code ~om DHS Form 8022) USE CODE 6) PHYSICAL STATE Solidi { Liquid[ ] C, as[ ] Pure[ { bfixture[ ] V~raste[ ] Radioactive[ ] 7) AMOUNT AND TI~ AT FACHA'I'Y UI~ OF IV~URE 8) STORAGE CODES Maximum Daily Amount Lbs [ { C.,I [ ] l~ [ ] a) Conts~. Average I]~ily ^mouut Curies [ ] b) Pressure: Annual Amount c) T=nperature Larsest Size Container # Days on Site Circle V~ich Months: All Year, $, F, ~ A, 1V~ .l', $, A, 8, O, N, D 9) MIXTURE: List COMPOICENT the ti=cc most hazardous 1) [ chemical components or 2) [ any A~ components 3) 10)LOCATION 1) IHVEHTOR¥ STATUS: New [ ]Addition[ ]Revision[ ]Deletion[ ] Chcckit'chcmicalisaNOl~TmdeScctct[ ]TradcScca*ct[ 2) Common Name: 3) DOT # (optional) Chcm/cal Name: ~ [ ] CAS # 4) Physical & Health P~$ICAL HEALT~ HazanlCategories Fire[ ]Reactive[ ]SuddenRclcaseofPressure[ ] Immcd/ateHcalth(Acute)[ ]DelayedHcalth(Chrunic)[ 5) wASTE eL~SSn~C^T~Ot~ (3.disit code fi~m DHS Form 8O=2) USE CODE 6) PHYSICAL STATE Solidi ] Liquid[ ] Gas[ ] Pure[ ] IV~[ ] Waste[ ] Radioactive[ ] ?) AMOUNT AND ~ ^T F^¢ILITY UNITS OF MEASURE 8) STORAOE CODES Maximum Daily Amount Lbs [ ] ~ [ ] ~ [ ] a) Contain=:. Average Daily Amount Curies [ ] b) Pressure: Annual Amount c) Tcmporature LarSest $~z= Cuntain~- # Days on Site Circle Which Months: 9) tV~: List COMPO~ CAS# % '~ AHM thc ~ most hazardous I) [ ] chemical compononts or 2) [ ] any AH]Vi components 3) [ ] 10)LOC^T~ON ! certify u~dcr penalt~ o£1aw, that ! have personally exa~ and mn familiar with the iztt'ormation on this and all attached decon~mts. ! bciieve the submitted information is true, accurate and complete. PRINT Name & Tide ot*Authorized Company Represen*-tive SiSnature Date HAZARDOUS ~TERIALS UNVENTORY Page _ . of__ Business Name Addre~ ~ ~ CltEI~41CAL DE$CRIFTION I ) IZ;VE~ORY STATUS: New [ ] Addition [ ] Revision [ ] l~lction [ ] Check if chemical is a NON Trade Secret [ ] Trad= Scc~t [ ] 2) Common Nam=: 3) DOT # (optional) ,, Chemical Nam=: AHM [ ] CAS # 4) Physical & H~alth PHYSICAL HEALTH Hazard Cat~orie~ 5) WASTE CLASSIFICATION (3~ligit cod~ fi~m DHS Form 8022) USE CODE 6) PHYSICAL ST^TE SoUa 7) AMOUNT AND ~ AT FACILITY UNITS OF MEASURE 8) STORAGE CODF~ Maximum D~ily Averse D~y Amou~ Curi~ [ ] b) Pr~sur~ Annml Amount ¢) T~~ Largest Size ContOur # D~YS on Sim CimlcWlfichlVlmtl~: AIIYear, I,F,M.A,M.I,I,A,S,O,I~I,D ~) MIX'I-tIRE: List COMPO~ CAS// % WT AI-IM thc three most hazardous I) [ ] chemical componant~ or 2) [ ] any AHM componmt~ 3) [ ] 10)LOCATION I)INVENTORYSTATUS:New[ ]Addition[ ]Revision[ ]Deletion[ ] Check if chemical is a NON Trade Secr~ [ ]Trad~[ ] 2) Common Nan.: 3) DOT # (optional) Chemical Nme: AHM [ ] CAS # 4) Physical & Health PHYSICAL HF. AL~ HazardCat_,~orie~ Fire[ ]Reactive[ ]SuddenRcleaseofPressure[ ] l,,--,.~!,t,~Health(Acute)[ ]DelayedHealth(Chrm~)[ ] 5) WASTE CLASSIFICATION , (3~ligit cod~ from DHS Form S022) USE CODE 6) PHYSICAL STATE Solid[ ] Liquid[ ] Gas[ ] Pure[ ] Mixture[ ] Waste[ ] Radioactive[ ] 7) AMOUNT AND TIME AT FACILITY UNITS OF MEASUR~ 8) STORAGE CODES Maximum Daily Amount Lb~ [ ] C-al [ ] fl3 [ ] a) Container.. Averse Daily Amount Curie~ [ ] b) Pre~mre: Annual Amount ¢) Temperature Lmr~ Size ConmL~er # Days on Site Circle Which Montl~: All Year, $, F. M, A, M, I, l, A, S, O, N, D 9) MIXTTJP~: List COMPONENT CAS# % WT AHM U~c ~ree mo~ I~z~rclous I) chemical component, or 2) [ ] any ~ compon~ts 3) [ ] 10 )LOCATION ~ certify under penalty of'law. believe the su~m~/~l Jzt/'oml~on is IZtw, ~¢ur~te and complcu~. PRJ~NT Ne. me & Title or' Authorized Company Repre~enl~l~ve $i~mture HttZARDOUS ~IATERI. AL$ I~VENTORY Page .. of..__~ Bus~ness Name Add.q~ CI~MICAL DESCIUI)TION . I ) I)~WENTOR¥ STATUS: N~w [ ! Addition [ I Re%ion [ I Deletion [ I Check it'chemical is a NON Trade Secret [ I Trade Secs~ 2) Common Name: 3) DOT # (optional) ChC~Ucal Name: AI-[M [ ] CAS tt 4) Physical & Health PHYSICAL HEALTH [g,,,,-xt Categories F~ [ ] R~active [ ] Suddon Rel~ o£~ [ ] Imm~di~t~ Heaith (Acute) [ ] Delayed Heal~ (Clu~ic) [ ] s) WASTE Ct,~SS~HC^T~O~ O-digi~ code ~ DHS Fora S0~) USE CODE ~) ~HYS~CAL ST^TE SOUd [ ] Liquid [ ] Os~ [ ] Pu~ [ ] Mixture [ ] Was~ [ ] I~Uo~iv~ [ ] 7) AMOUNT AND TIME AT FACILITY UNF~ OF MEASURE 8) STORAGE CODES Maximum Daily Amoum I.bs [ ] ~ [ ] ~ [ ] a) Contatu~. Average Daily Amoum Curies [ ] b) Pressure: A~ual Amoum c) Temperatu~ # Days on Site Civic Wltich Montl~ AU Year. l. F. M. A. M. $. $. A. S. O, N. D 9) MIXTURE: List COIvllaONENT CAS# % WT AHM the three most ~,,,'--,dous 1) [ ] chemical components or 2) [ ] ~ny AI-IM components 3) [ ] 10)LOCATION I)[NVENTORYSTATUS:New[ ]Additi~[ ]Revision[ ]Deleliun[ ] CheckifchcrrdcalisaNONTradcS~'ct[ ]Tradgsocr~[ ] 2) Common Name: 3) DOT # (optional) Chemical Name: AHM [ ] CAS # 4) Physical & Health PHYSICAL HEALTH HmardC~_t~ories Fire[ ]Restive[ ]S,,,4d,~Releaseof~[ ] rmm~s_t,,-Health(Acute)[ ]DelayedHeal~h(~)[ ] 5) WASTE Ct.~SS~CAT~ON (a-diSit ~ ~ DHS Form a0::) USE CODE 6) PHYSICAL STATE Solidi ] Liquid[ ] Gas[ ] Pure[ ] Mixture[ ] Was~[ ] l~ndionctive[ ] 7) AMOUNT AND TIME AT FACILITY UNIT8 OF MEASURE 8) STORAGE CODES Maximum Daily Amount Lbs [ ] Gal [ ] ~ [ ] a) Container:. Average Daily Amount Curies [ ] b) Pressage: Annual Amount ¢) Tempentture Largest Size Container # Days on Site Circle Which Mont~: All Yenr, $, F, M, A, M, I, $, A, S, O, N, D 9) MIXTURE: List COMPONEI~ CAS# % WT AHM the three most I,,,-,,,'dou$ 1) [ ] chemical components or 2) [ ] any AI-IM compommt$ 3) [ ] 0)LOCATION certify trader penalty of law, tlmi! have pgrsonally examined sad am familiar with the reformation on this and ~11 sttached documgats, I believe thc subrmttcd information is me, accurate and complete. PIZINT Nnme & Title of Authorized Company Representative Signature IMm SITE DIAGRAM __ FACUAT~iAGRAM [ ! Business Name: Business Address: