HomeMy WebLinkAboutBUSINESS PLAN Hazardous Materials/Hazardous Waste Unified Permit
... CONDITIONS OF *PERMIT ON REVERSE SIDE
This ~ermit is issued for the fOllowing:
E! H=~nrdous ~ls Plan
[3 Underground Storage of HazardOUS Materi~s
Permit ID #:: 015-000-001722 n Risk Management Progmm
HOUSE OF MANNA" [],--~.~o~. w~t. O.-S~.Tr~-~t
LOCATION: 5300 CALIFORNIA AVE 1
OFFICE OF ENVIRONMENTAL SER VICES-
1715 Chester Ave., 3rd Floor Approved by:
Bakersfield, CA 93301 ;. . Of~lceofE.~im~aema.~ices~.,,, issue Date
Voice (661) 326-3979 ,:: :
FAX (661) 326-0576 EXpirati°nDate: 'June 30. 2003
..:-.~ ~ -:' ,'-- ":,~
ITE DIAGRA'M ~ FACILITY DIAGRAM
Business Name:
For O~ice Use Only
First In Stction: Area Mc~ # cf
lnscec:ton Stc,ion: NORTH Z~
HOUSE 'OF MANNA ,, SiteID: 015-021-001722
Manager : TONY ALVAREZ ~/-~--~usPhone: (661) 633-5322
Location: 5300 CALIFORNIA AVE 1 / Map : 102 CommHaz : Moderate
City : BAKERSFIELD~' Grid: 34D FacUnits: 1 AOV:
CommCode: BAKERSFIELD STATION 11 ~ SIC Code:
EPA Numb:~ DunnBrad:
Emergency Contact / Title Emergency Contact / Title
TONY ALVAREZ JR / MANAGER EMILIO ESCOBAR / ASSISTANT MGR
Business Phone: (661) 633-5322x Business Phone: (661) 633-5322x
24-Hour Phone : (661) 872-7942x 24-Hour Phone : (661) 328-9309x
Pager Phone : '(661) 354-8802x Pager Phone : (661) 336-4391x
Hazmat Hazards: Fire Press ImmHlth
Contact : GLADYS HOLLINGSEAD Phone: (661) 845-2415x
MailAddr: 5300 CALIFORNIA AVE 200 State: CA
City : BAKERSFIELD Zip : 93309
Owner PACIFIC HEALTH EDUCATION CENTER Phone: (661) 633-5300x
Address : 5300 CALIFORNIA AVE 200 State: CA
City : BAKERSFIELD Zip : 93309
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,I DailyMax IUnitlMcP
HELIUM F P IH G 250.00 FT3 Min
PROPANE E F P IH G 385.00 FT3 Hi
-1- 06/24/2002
HOUSE OF MANNA SiteID: 015-021-001722
~ Inventory Item 0002 Facility Unit: Fixed Containers at Site
-- COMMON NAME / CHEMICAL NAME
HELIUM Days On Site
365
Location within this Facility Unit Map: Grid:
WHERE IS IT LOCATED?????????????????? CAS#
7440-59-7
Gas Pure Above Ambient Ambient PORT. PRESS. CYLINDER
AMOUNTS AT THIS LOCATION
Largest Container I Daily Maximum Daily Average
250.00 FT3I 250.00 FT3 250.00 FT3
HAZARDOUS COMPONENTS
100.00 Helium N 7440597
HAZARD ASSESSMENTS
[TSecretl ~slBioHaz Radioactive/Amount I EPA Hazards NFPA I USDOT# MCP
No N No No/ Curies F P IH / / / Min
~ Inventory Item 0001 Facility Unit: Fixed Containers at Site ~
PROPANE Days On Site
365
Location within this Facility Unit Map: Grid:
SW OF CORNER PARKING LOT CAS#
74-98-6
Gas {Pure Above Ambient Ambient FIXED PRESS. CYLINDER
AMOUNTS AT THIS LOCATION
Largest Container { Daily Maximum I Daily Average
385.00 FT3I 385.00 FT3I 200.00 FT3
HAZARDOUS COMPONENTS
%Wt. RI RSI CAS#
100 00 Propane{Yes{ 74986
HAZARD ASSESSMENTS
TSecretl oRS BioHazNo N No Radi°active/Am°unt I EPA HazardsNo/ Curies F P IH NFPA/// USDOT# I MCPHi
-2- 06/24/2002
F HOUSE OF MANNA SiteID: 015-021-001722
Fast Format
~ Notif./Evacuation/Medical Overall Site
--Agency Notification 01/29/1996
TELEPHONE AVAILABLE INSIDE STORE AND A PAY PHONE IS LOCATED OUTSIDE BETWEEN
HOUSE OF MANNA AND THE IRS OFFICE.
-- Employee Notif./Evacuation 01/29/1996
CELLULAR PHONES AVAILABLE FOR OUTDOOR USE BETWEEN PROPANE TANKAND STORE.
Public Notif./Evacuation 01/29/1996
TANK IS LOCATED IN PARKING LOT AREA AWAY FROM STORE AND IN ISOLATION OF
VEHICLE TRAFFIC.
Emergency Medical Plan 07/26/2000
FIRST AID KITS ON SITE AND/OR SAN JOAQUIN HOSPITAL.
3 06/24/2002
HOUSE OF MANNA SiteID: 015-021-001722
Fast Format
~ Mitigation/Prevent/Abatemt Overall Site
-- Release Prevention 07/26/2000
VALVES ARE LOCKED AND HOSE SECURED BEHIND GATE ON TANK WHEN NOT IN USE.
-- Release Containment 01/29/1996
TANK AREA IS PROTECTED BY GUARD POSTS.
-- Clean Up 07/26/2000
N/A.
Other Resource Activation
-4- 06/24/2002
F HOUSE OF MANNA SiteID: 015-021-001722
I Fast Format
F Site Emergency Factors Overall Site
Special Hazards
--Utility Shut-Offs 07/26/2000
A) GAS - OUTSIDE NE CORNER OF BLDG
B) ELECTRICAL - OUTSIDE NW CORNER OF BLDG
C) WATER - OUTSIDE SE CORNER OF BLDG
D) SPECIAL - NONE
E) LOCK BOX - NO
-- Fire Protec./Avail. Water 07/26/2000
PRIVATE FIRE PROTECTION - FIRE EXTINGUISHER BY PROPANE TANK.
NEAREST FIRE HYDRANT - ??????????????????
Building Occupancy Level
-5- 06/24/2002
HOUSE OF MANNA SiteID: 015-021-001722
Fast Format
~ Training Overall Site
-- Employee Training 07/26/2000
WE HAVE 7 EMPLOYEES AT THIS FACILITY.
DO YOU HAVE MATERIALS SAFETY DATA SHEETS ON FILE??????????????
BRIEF SUMMARY OF TRAINING PROGRAM: SUBURBAN PROPANE PROVIDES CERTIFICATION
FOR HANDLING PROPANE TO HOUSE OF MANNA EMPLOYEES.
Page 2 I
Held for Future Use
Held for Future Use
6 06/24/2002
CITY OF BAKERSFIELD
CLAIM VOUCHER
IVendor No, I certi~ that this claim is correct and valid, and is a proper
charge against the City Agency and account indicated.
CLAIMANT'S NAME AND ADDRESS:
House Of Manna (AUTHORIZED SIGNATURE OF CITY AGENCY)
5300 California Ave
Bakersfield, CA 93309 Date: 04-01-99 Initials of Preparer:
CITY DEPARTMENT: FINANCE
PLEASE PROVIDE SHORT EXPLANATION OF PAYME (Including Contract Number if Applicable)
This customer made a duplicate payment on this years Haz Mat bill in the amount of $226.50.
We have since made an adjustment to the California State surcharge in the amount of $8.50
leaving them with a credit of $235.00.
Dept. El / Objt Project # Invoice # Amount Date of Invoice
0000 7900 $235.00
VOUCHER TOTAL $235.00
SECTION 72, PENAL CODE FINANCE DEPT. USE ONLY
Section 72, Presenting False Claims. Every person who with intent to defraud,
presents 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.
STATEMENT OF' ACCOUNT
CITY OF BAKERSFIELD
1501TRUXTUN AVE
BAKERSFIELD, CA 93301-5201
">:" .... DATE' 4/01
TO: HOUSE OF MANNA,
5300 CAL IFOR~ ......... >,
.... ~"~ ,'' ES/ 1
CUSTOMER NO:
CHAROE DATE iD~ES~RIP,TIONt~ ~'" ;:::~ ~::~ ?? ~'~,~ %E ~NUMBE ~, E TOTAL AMOUNT
R~ DUE D'~T
3/0i/~ ~. ~,, ~ · O0
2/l&/~ ,~:,: ...... ~'"" ~ '~,,-. 22&. 50-
50-
~.~ ....... { ~ ~:~:. b~ ~.7, ,? ~ ~ ~.~.'C' ~.~; '
..... .,:::,.,..:,.:~ : ., .),:: {. ~., ..
F~R GUEST~ON~ ~R CN~ES"-'T~ YOUR ACCOUNT
CALL TNE NU~ER AT TNE T~P ~F TH~S ~TATE~ENT.
CURRENT OVER 30 OVER 50 OVER 90
8, 50-
DU~ DATE: O/03/VV PAYMENT DUE:
TOTAL DUE: $~35.00--
MISCELLANEOUS RECEIVABLES ADJUSTMENT
DATE ..~-II-~ NEW ACCOUNT
ADDRESS CHANGE
CLOSE ACCT
*FINANCE CHARGE
OTHER ADJ
CITY C._~ ~ ~ STATE ZIP CODE
SITE ADDRESS
PARCEL NUMBER
(IF APPUCABLE)
ADJUSTMENT
i CHG DATE CHARGE CODE ADJUSTMENT AMOUNT
APPROVED BY~ /
Hazardous Materials/Hazardous Waste Unified Permit
CONDITIONS OF PERMIT ON REVERSE SIDE
.......... ,,~:.~,,~,~,~?~,¥,~,~ ...... This permit is issued for the following:
PERMIT
ID~
015-021001722
LOCATION 5300 CALIFORN~
~ % '".:~ ~F ~ ~.~ .............................. ~' ! ~, ~ .. '---.~.
]ssu~ by:
O Bakersfield Fire Depa~ment Approved by:
OFFICE OF E~R ONe.AL
1715 Chewer Ave., 3rd Floor ce of~~
B~e~fiel~ CA 93301
Voice (805) 326-3979
F~ (80s)~26~S76 Expiration Date: ~n~ ~O~ ~O00
Aug-25-97 06:17P John Altsman 805-633-0422 P.01
HOUSE OF MANNA SiteID: 215-000-001722
Manager : BusPhone: (805) 633-5322
Location: 5300 CALIFORNIA AV 1 Map : 102 CommHaz : Moderate
City : BAKERSFIELD Grid: 34D FacUnits: 1 AOV:
CommCode: BAKERSFIELD STATION 11 SIC Code:
EPA Numb: DunnBrad:
Emergency Contact / Title Emergency Contact / Title
TONY ALVAREZ JR / /4¢~.-[ DANIEL GONZALEZ / S~ 6~.'~
Business Phone: (805) 633-5322x Business Phone: (805) 633-5322x
24-Hour Phone : (805) 872-7942x 24-Hour Phone : (805) 835-0149x
Pager Phone : ( ) - x Pager Phone : ( ) - x
Hazmat Hazards: Fire Press ImmHlth
Agency-Defined Topic Title
-- Hazmat Inventory One Unified List
~ MCP+DailyMax Order Ail Materials at Site
Hazmat Common Name... ISpecHazlEPA Hazards[ Frm DailyMax lUnit MCP
PROPANE F P IH G 385 FT3 Hi
re;.,;~gwe'J the,:.,.,:...,"""v'h""~,,~,., hazardous rr',stefials man.age-
n",:;,-,t p:r:n 'tor ~ O"("~lU~ar, d that it along with
any. ~... r,',' 'e,..,,.) n.,""', ~' con¢,~,ute' "~" a complete and correct man-
agement r...i~n ~'or my facility.
-1- 08/14/1997
AugJ25-97 06:17P John Altsman 805-633-0422 P.02
F HOUSE OF MANNA SiteID: 215-000-001722
Fast Format
~ Notifo/Evacuation/Medical Overall Site
--Agency Notification 01/29/1996
TELEPHONE AVAILABLE INSIDE STORE AND A PAY PHONE IS LOCATED OUTSIDE BETWEEN
HOUSE OF MANNA AND THE IRS OFFICE.
Employee Notif./Evacuation 01/29/1996
I CELLULAR PHONES AVAILABLE FORI OUTDOOR USE BETWEEN PROPANE TANK AND STORE.
~ Public Notif./Evacuation 01/29/1996
TANK IS LOCATED IN PARKING LOT AREA AWAY FROM STORE AND IN ISOLATION OF
VEHICLE TRAFFIC.
Emergency Medical Plan 01/29/1996
FIRST AID KITS ON SITE.
SAN JOAQUIN HOSPITAL.
-2- 08/14/1997
AugJ25-97 06:18P John Altsman 805-633-0422 P.03
F HOUSE OF MANNA SiteID: 215-000-001722
Fast Format
= Mitigation/Prevent/Abatemt Overall Site
--Release Prevention 01/29/1996
VALVES ARE LOCKED AN HOSE SECURED BEHIND GATE ON TANK WHEN NOT IN USE.
-- Release Containment 01/29/1996
TANK AREA IS PROTECTED BY GUARD POSTS.
-- Clean Up 01/29/1996
N/A
Other Resource Activation
-3- 08/14/1997
Aug 25-97 06:18P John Altsman 805-633-0422 P.04
HOUSE OF MANNA SiteID: 215-000-001722
Fast Format
~ Site Emergency Factors Overall Site
m Special Hazards 01/29/1996
NATURAL GAS/PROPANE: NATURAL GAS, OUTSIDE NORTHEAST CORNER OF BUILDING.
ELECTRICAL: OUTSIDE N/W CORNER OF BUILDING.
WATER: OUTSIDE SOUTHEAST CORNER OF BUILDING.
SPECIAL: NONE
LOCK BOX: NO
~ Utility Shut-Offs 01/29/1996
PRIVATE FIRE PROTECTION IS A FIRE EXTINGUISHER LOCATED BY PROPANE TANK.
Fire Protec./Avail. Water
Building Occupancy Level
-4- 08/14/1997
Aug 25-97 06:18P John Altsman 805-633-0422 P.05
HOUSE OF MANNA SiteID: 215-000-001722
Fast Format
= Training Overall Site
-- Employee Training 01/29/1996
NUMBER OF EMPLOYEES: 7
MATERIALS SAFETY DATA SHEETS ON FILE: ???
BRIEF SUMMARY OF TRAINING PROGRAM: SUBURBAN PROPANE PROVIDES CERTIFICATION
FRO HANDLING PROPANE TO HOUSE OF MANNA EMPLOYEES.
-- Page 2
-- Held for Future Use I
Held for Future Use I
-5- 08/14/1997
'" BAKEi FIELD CITY FIRE DEPARTMENT
HAZARDOUS MATERIALS DIVISION ¢/
1715 -CHESTER .A,V.E;
BAKERSFIELD, CA. 93301 (~/~,-~[ (
HAZARDOUS MATERIALS MANAGEMENT PLAN
1. To avoid further action, return this form within 30 clays of receiDt. /j, ~ ~--
· 2. ~PE/PRINT ANSWeRs IN ENGUSH.
-I
3. Answer the Questions below for the Cusiness as a whole.
Be brief and conc~e cs Oo~ible.
SECTION 1' BUSINESS IDENTIFICATION DATA
BUSINESS NAME:
LOCATION'
MAILING ADDRESS'
C;TY' STATE: ~ ZIP: '~<t PHONE:
DUN & BRAC, STREET NUMBER: SIC CODE:
?RIMARY ,ACTIVITY: '"~..~'./ ~.-,,~ ~
SECTION 2: EMERGENCY NOTIFICATION:
CONTACT TITLE BUS. PHONE 24 HR. PHONE
.: na~ersneia ~'Lre Dept. :
-- ,t-~rdous Materials Division
HAZARDOUS MATERIALS MANAGEMENT PLAN
SECTION 3: TRAINING:
NUMBER OF EMPLOYEES: '7
· MATERIAL SAFETY DATA SHEETS ON FILE:
· ,' BRIEF SUMMARY OF TRAINING PROGRAM:
SECT[ON 4: EXEMPTION REQUEST:
! CERTIFY UNDE~ PENALTY OF PERJURY THAT'MY BUSINESS iS EXEMPT FROM THE
RE?ORTING REQUIREMENTS OF CHAPTER 6.95 OF THE "CALIFORNIA HEALTH &
~AF=.YCOD FOR THE FOLLOWING REASONS:
WE gQ NOT HANDLE HAZARDOUS MATERIALS.
WEOO HANDLE HAZARDOUS MATERIALS, BUT THE QUANTITIES AT NO
TiMEEXCEED THE MINIMUM RE?ORTING QUANTITIES.
OTHER (SPECIFY REASON)
SECTION 5: CERTIFICATION:
I, CERTIFY THAT THE ABOVE INFOR-
MATION IS ACCURATE. I UNDERSTAND THAT THIS INFORMATION WILL BE USED TO
FULFILL MY FIRM'S OBLIGATIONS UNDER THE "CALIFORNIA HEALTH AND SAFE~ CODE"
ON HAZARDOUS MATERIALS (DIV. 20 CHAPTER 6.95 SEC. 25500 ET AL.) AND THAT
INACCURATE INFORMATiON.CONSTITUTES PERJURY.
.SIGNATURE DATE
Hazardous 1Vfateri~ls ID[v~sion~.
I-IAT.~RDOU8 I~IERIALS MANAGI::MI::NI ~LAN
unit Name:
SECTION ,5: NOTIFICATION AND EVACUATION PROCEDURES:
A. AGENCY NOTIFICATION PROCEDURES:
8. EMPLOYEE NOTIFICATION AND EVACUATION:
C. ?UBL!C EVACUATION'
O. E..'vlE~GENCY MEDICAL FL,aN: 'sr- ~,.,:j ~,~ ~
B akersfietd Fire Dept.
Hazardous Materials Division
HAZARDOUS MATERIALS MANAGEMENT PLAN
SECTION 7: MITIGATION, PREVENTION AND ABATEMENT PLAN:
A. RELEASE PREVENTION STEPS:
B. RELEASE. CONTAINMENT AND/OR MINIMIZATION'
CLEAN-UP PROCEDURES'
SECTION 8: UTILITY SHUT-OFFS ('LOCATION OF SHUT-OFFS AT YOUR FACILITY)'
~~ROPA'I ' ''~ NE:
WATER' ~'U~ ,~
S?EC~AL.
' ~ "-vc~- LOCATION:
LOC',< BCX ',"=... !r ....
SECTION 9' PRIVATE FIRE PROTECTION/WATER AVAILABILITY: 'Z.
A. PRIVATE FIRE PROTECT[ON:
B, WATER AVAILABILITY (FIRE HYDRANT): :
BAKERSFIELD CITY FIRE DEP RTMENT
' HA3 RDOUS MATERIALS INVER'I'ORY Page_of_
~, ,
Bu~siness Name ~ ~ /1~./~J/,/,,3 Address ~3o0 ---. !
CHEMICAL DESCRIPTION
1) INVENTORY STATUS: New~J Addition [ ] Revision [ ] Deletion [ ] Check if chemical is a NON TRADE SECRET [ ] TRADE SECRET [ ]
2) Common Name: ~>~-.C~Z~'t'~- 3) DOT # (optional)
Chemical Name: AHM [ ] CAS #
4) PHYSICAL & HEALTH PHYSICAL HEALTH
HAZARD CATEGORIES Fire ~ Reactive [ ] Sudden Release of Pressure [ ] Immediate HeaJth (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 [ ]
UNITS OF MEASURE 8) STORAGE CODES
7) AMOUNT AND TIME AT FACIUTY ~ ~.-
Maximum Daily Amount: lbs [ ] gal ~1 tt3 [ ] a) Container:
Average Daily Amount: -7..x3~ cudes [ ] b) Pressure:
Annual Amount: ~_.0o C) c) Temperature:
Largest Size'Container:
# Days On Site '~,-~S-' Cimle Which Months: All Year, J, F, M, A, M, J, J, A, S, O, N, O
9) MIXTURE: List
the three most hazardous 1) (..~./j.~j.~_ COMPONENT CAS # % WT' AHM[]
chemiceJ components or
any AHM components 2) [ ]
3) [ ]
10) Location ~C~ C. i~J (~. oC~ ~>A/'C~,,J~-
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)
ChemicaJ 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 FACIIJTY UNITS OF MEASURE 8) STORAGE CODES
Maximum Daily Amount: lbs [ ] gal [ ] ~t3 [ ] a) Container:
Average Daily Amount: curies [ ] b) Pressure:
Annual Amount: 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 three most hazardous 1) [ ]
chemicaJ components or
any AHM components 2) [ ]
3) [
10) Location
certify under penel~y of law, that I have personally examined and am familiar with the infoma#on submitted on this and etl attached documents. I believe th~
submitted inff~?rnat~9_n ~. a"ue_~ec~urata, and complete.
PRINT e & Title of Authon'zed Company Representative Signature Date
BAKERSFII D CITY FIRE DEPARtS/lENT
HAZARLTOUS MATERIALS INVENTOR'f Page_of__'
3usiness 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 Fire [ ] Reactive [ ! Sudden Release of Pressure [ ] Immediate Health (Acute) [ ] Delayed HeaJth (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 FAClMTY UNITS OF MEASURE 8) STORAGE CODES
Maximum Dally Amount: lbs [ ] gal [ ] t13 [ ] a) Container: /
Average Daily Amount: curies [ ] b) Pressure:
Annual Amount: 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 three most hazardous 1) [ ]
chemical components or
any AHM components 2) [ ]
3) [ ]
10) Location
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 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 FACIMTY UNITS OF MEASURE 8) STORAGE CODES
Maximum Daily Amount: lbs [ ] gal [ ] fi3 [ ] a) Container:
Average Daily Amount: cudes [ ] b) Pressure:
Annual Amount: 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 # % WI' AHM
the three most hazardous 1) [ ]
chemical components or
any AHM components 2) [ ]
3) [ ]
10) Lo~ion
r cor~fy under penalty of law, that I have personally examined and am familiar with the infomabon submitted on this and all altached documents. I believe
submitted informaUon is flue, accurate, and complete.
PRINT Name & Title of Authorized Company Representative Signature Date