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Home My WebLink AboutBUSINESS PLAN 12/1/1998 ITE DIAGRAM FACILITY DIAGRAM First In Station: Area MaD # of Inst~ection Station: NO FtT-H CITY OF BAKERSFIELD "'"~ : ~'"/ '" "~ ': :':--';~ P.O. BOX 2057 ,. .... BAKERSFIELD, CALIFORNIA 93303 RETURN SERVICE REQUESTED STATEMENT OF ACCOUNT CITY OF BAKERSFIELD 1501 TRUXTUN AVE BAKERSFIELD, CA 93301-5201 DATE: 1~/01/98 TO: AL i AUTOMOTiVE 505 MiNO AVE BAKERSFIELD, CA c~3307 ~ ~, ~. · CUSTOMER NO: 3~O& 11/01/'8 BEOINNINO BALANCE FOR QUESTIONS OR CHANGES TO YOUR ACCOUNT PLEASE CALL THE NUMBER AT THE TOP OF THIS STATEMENT. CURRENT OVER 30 OVER &O OVER 90 DUE DATE: 1~/31/~8 PAYMENT DUE: 5&7. 86 TOTAL DUE: $567. 86 FINANCE DEPARTMENT CITY OF BAKERSFIELD Please... To: ~ Read ~ Handle ~ Approve And... / T ~ Fo~ard From: ~ Return ~' Keep or Toss ~ Review with Me Date: STATEMENT OF ACCOUNT CITY OF BAKERSFIELD 1501TRU×TUN AVE BAKERSFieLd, CA 9330i-520i (805) 326-3979 DATE: I0/01/98 TO: ALI AUTOMOTIVE 505 MINg AVE BAKERSFIELD, CA 93307 CUSTOMER NO' 3906 CUSTOMERfTYPE: ES/ 3906 CHARGE DATE DESCRIPTION REF-NUMBER DUE DATE TOTAL AMOUNT 9/'01/98 BEgINNINg BALANCE 567. 86 FOR GUESTIONS OR CHANGES TO YOUR ACCOUNT PLEASE CALL THE NUMBER AT THE TOP OF THIS STATEMENT. CURRENT OVER 30 OVER 60 OVER 90 110.00 457.86 DUE DATE: t!/02/98 PAYMENT DUE: 587. 86 TOTAL. DUE: $567. 86 FIRE DEPARTMENT M E MO RAN D U M:" DATE: February 7, 1997 TO: Drew Sharpies, Financial Investigator FROM: Esther Duran, Environmemal Services SUBJECT: Ali Automotive Ali Automotive was originally located at 402 S. Chester Ave. (1994). Sometime in 1995 he moved to 521 E 19* Street. In 1996 he relocated to 220 Oak Street and then to 500 Oak Street. Apparently his lease there didn't work out and he was only there for one month. He is currently, at 205 E 5th Street. His phone number is 322-8359. He currently has an outstanding de~t including the 95, 96 and 97 years. I sure hope this helps. /ed STATEMENT DF ACCDUNT CITY OF BAKERSFIELD 1501 TRUXTUN AVE BAKERSFIELD, CA ~3301-0000 (805) 326-3979 DATE' 10/01/~6 TO: ALi AUTOMOTIVE 521 ~ I~TH ST B~KERS~I~LD, CA ~3305 CUSTOMER NO: 3~06 CUSTOMER TYPE: ES/ 3~0~ FINANCE DEPARTMENT CITY OF BAKERSFIELD P.O. BOX 2057 BAKERSFIELD, CALIFORNIA 93303 ADDRESS CORRECTION REQUESTED RETURN TO SENDER :ALT HOTOR 5ROP BA~<ERSF IELD CA RETURN TO SENDER STATEMENT OF ACCOUNT CITY OF BAKERSFIELD 1501TRUXTUN AVE BAKERSFIELD, CA 93301-0000 (805) 326-3979 DATE: 9/01/95 TO: ALI AUTOMOTIVE CUSTOMER NO: 3906 CUSTOMERiTYPE: ES/ 3906 CHARGE DATE DESCRIPTION REF-NUMBER DUE DATE TOTAL AMOUNT 6/01/95 BEGINNING BALANCE 110.00 NEW STATEMENTS! Please call 326-3979 if you have questions or changes regarding your account. CURRENT OVER 30 OVER 60 OVER 90 110.00 DUE DATE: 9/01/95 PAYMENT DUE: 110.00 TOTAL DUE: $110.00 :i{!i{i' ~iCuS'TOMER 'NO:' '...,- :':':: ,.3!9'0'~:~ ~>~ CUSTOMER TYPE: ES/ 3906 · . , TOTAL DUE: $110.00 TO DATE AM ~.. co ..... --,~ SIGNED IPHONED~BAcKCALL ~ CALLRETURNED ~SEEYouWANTS~ ~ AGAINWILLCA[L the only record of your play(s), ~'~/[~'1.,/ A 163322880 NAME (print) ADDRESS (print) SIGNATURE Save this ticket; you must present it to c!.a,)m a prize: Check this ticket carefully; it is the only record of your'play(s). Ticket '~oi~ if e, gered, STATEMENT OF ACCOUNT CITY OF BAKERSFIELD 1501 TRLIXTUN AVE BAKERSFIEL),- CA 93301°0000 ; :: , )ATE: 9/0!/96 TO: ALI AUTDMOIIVE · 52! E 1_?TH ST BAKE. RSFIELDe CA 93505 CUSTOMER NO:,?~,~: J. ~ ' ~TYPE: ESI 3906 CHARGE DATE DESCRIPTION REF-N~HBER DUE DATE TOTAL AMOUNT 8/01/96, BEGINN~tNG BALAN(E 310.46 HMO05 ~/01/96~,,:FI ~ ANCE CHARGE FCOll ~ HMOlZ 9/01/95 FINANCE CHARGE .50 FCOII PBOi7 9/0i/95 FINANCE CHARGE 1.10 FCOIt ' FOR QUESTIONS OR CHANGES TO YOUR ACCOUNT PLEASE CALL THE NUMBER AT THE TOP OF THIS STATEMENT. CURRENT OVER 30 OVER 60 OVER 90 2.70 2~o4! 1.60 28!.45 DUE DATE: 9F 02/96 PAYMENT DUE: 313.16 TOTAL DUE: $313.16 ALI AUTOMOTIVE 402 S. Chester/Terrace Way Bakersfield, CA 93304 ~ (805) 397-9475 Beside BP Station BAKERSFIELD CITY FIRE DEPARTMI-3 T__ HAZARDOUS MATERIALS DIVISION 1715 'CH ESTE R{ A,V£.; NO V BAKERSFIELD, CA. 93301 .--_ HAZARDOUS MATERIALS_ MANAGEMENT PLAN l. To avoid further action, return this form within 30 days of receipt. ~ ~ , 2. ~PE/PRINT ANSWERS IN ENGLISH. 3. Answer the questions below for the business as a whole. 4. Be brief and concise as po~ible. SECTION 1: BUSINESS IDENTIFICATION DATA LOCATION: MAILING ADDRESS: DUN & ~EADSTEEET NUMBER; SIC CODE; P~IMA~Y ACTIVITY' SECTION2: EMERGENCY CONTACT TITLE BUS. PHONE 24 HR. PHONE Bi IKERSFI ELD Fl DEPARTMENT HAZARDOUS MATERIALS DIVISION` 1715 ,CHESTER~AVE~.. ' .. BAKERSFIELD. CA. 93,301 (805) ,326-2979 HAZARDOUS MATERIALS INVENTORY INSTRUCTIONS FACILITY DESCRIPTION: , Check if your business is a farm. Enter the full lega] name and site address of your business. Do not use post office box numbers. Give a brief description of the nature your business activities. Enter the Standard Industrial Ciassification (SIC) number for your business. Each type of business has a Standard Industrial Classification code number. Some common SIC codes are listed on page 4. Other SIC codes may be obtained from your worker's compensation insurance forms, the State of California Employment Development Depaxtment by giving them your employer numDer, from the U.S. Labor Department or from the Standard Industrial Classification Manual. Enter the Dun & Bradstreet or federaJ tax identification number for your business. Enter the name of the owner, their maqing address and phone number. EMERGENCY CONTACTS: List two persons who have full access to the facility, including locked areas, and that are knowledgeable aJ2out your materials and process. CHEMICAL DESCRIPTION: M&l<e as many copies cf the chemic~ description form as necessary to report your entire inventory of hazardous materials. Reoort every hazardous material handled in quantities equal to or exceeding 55 gallons of a liquid, 500 pounds of a solid or 200 cubic feet of a gas. Enter the full legal name and site location of your business at the top of the form. Enter the page number in the right hand corner. _. E~c,~ of the instructions below correspond to the entry field with the same number on the chemical description form. 1. Check the approprime box for a new inventory or for additions, revisions or-deletions to an existing inventory, Check nontrade secret unless the chemical compositian,-'~eets the criteria for trade secret status, per Section 6254.7 of the California Government Cbde and Section 1060 of the California Code of Evidence. Copy trade secret pages:onto yellow paper before submitting your inventory so that they will be easily identified. 2. Enter the common name or the manufacture's product name. Enter the stand~d chemical name. If'a pure material is an acutely hazardous material (AHM), check the box labeled AHM. Report the components of mixtures under item 9 below. 3. Enter the Dept. of Transportation (DOT) identification number and the Chemical Abstract Service (CAS) number for this chemical. CAS numbers ~e commonly found, on Material Safety Data Sheets. 4. Check the box(es) which describe the' physical and health hazards associated with the chemical. 5. if the material is a waste, enter the appropriate three-digit California waste code. California's nonrestricted waste cod'es are listed on page 4 of these instructions. Questions regarding the waste classification codes and requests for hazardous waste manifest form #8022 may be addressed to the Department of Health Services, Toxic Substances Control Program at (916) 322-3670. Enter the appropriate use code from the following list. USE CODES 01. Additive 20. Fungicide 39. Washing 02. Adhesive 21. Gdnding 40. Waste 03. Aerosol 22. Heating 41.. Water Treatment 04. Anesthetic 23. Heri2lcide '42. Wetding/soldenng 05. Bactericide 24. Insecticide 43. Well iniectton 06. Blasting 25. tnsu'ucuonat 44. O[I treatment 07. Catalyst 26. LuPric,~nt 45. Resale 08. Cleaning 2,7, Medic, a{ aid/process 48. Aircraft systems 09. Caoian[ 28. Neutraiizer 47. Battery electrolyte 10. Ccoiing 29. P~inting 48. Breatl~ing air 1 1. Drilling 30. Pesticide 49. Drafting aid 12. Drying 31. Plating ,50. Finished product 13. Emulsifier/demulsifier 32. Preserval:ive 51. Fire protection 14. Etclqing 33. ~efining 52. Hycirautic ec!uil3ment 15. F_xoerimental 34. Sealer 53. Roa(31Hw~ maintenance 16. Fabrication 35. Spraying 54. Testing 1 7. Fertilization 36. Steniizer 55, Wholesale ci~emicals 18. FormuiaUcn 37. Storage 9g. Other - sDecifY 19. Fuel 38, Stn~per Check the boxes which describe the .physical state of the chemical; Pure materials are 100% of the cl~emical listed in item ~.2. Chemicals that have been diluted with .Water or combinations of two or more chemicals should be reported as mixtures.and the components listed in under item #9. ~- 7. Enter the maximum daily amount, the average daily amount and the total annual amount of material in storage or use at your facility. Enter the largest container size and the number of days/year that the material is on site. Circle the months that the material is on site. Enter the units of measure. Report soliCs in pounds, liquids in gallons, gases in cubic feet and radioactive materials in curies. 8. Select the appropriate storage codes from the lists below. a) CCNTAINER'CCOES 01. Underground tank 09. Glass container(s) 02, Aboveground tank 10. Pfas[ic container(s) 0,3. Fixed Pressurizec~ tank : 1. Box(es) 04. Portauie ,~ressunzed cylinders :2. Bag(s) 05. Insulate<3 tank 13. Metal containers (not drums) (inclu(3es cryogenics) 14. In machinery or processing C6. Drums or barrels - metaJlic edui,Dmem 07. Crums cr Darreis- non-metaLlic ",5. Bin(s) 08. C&rocy(s) g9. Cther- specify b) P~ESSURE COOES 1 - The matenat is stored at ambienl: (normai atmcsahenc) pressure. ~ - The materiat is store(~ at greater than amoient pressure. 3 - The materials is store~ at. less than amDient pressure. c) TEMPERATURE C~OES 4 - The material is stored et ami=lent (surrounding_) temperature. 5 - The material is stored a[ greater than ami;iota ;em~)era~ure. 5 - The material is score<3 a[ less than amoiem tem0era~ure. 7 - The. ma[anal is store<3 under cryogenic conditions 9. Enter the maximum % concentration by weight cf the three MOST hazardous components in th, e material. Round up to the neares; wnoie number percentage. Enter the CAS numJuer for each componen~ of the mix, ute. If the component is ~-n acutely hazardous material, c~ecK t~e box labeled AHM. 10. Briefly describe the location of the material within the building/facility using compass direc',ions and obvious landmarks. COMMON STANDARD INDUSTRIAL CLASSIFICATION (SIC) CODE~ 0111 W~eat pm4ucuon 72¢ Cottonginnmg ~ G174 C~s ~ 42~ Cold st~r~e UD~tl~ 0179 O~ef ~ee ~ & n~ ~ Auto~Ddes~vage 75~ Au~o e~t re~ 01~ Gene~ ~. pn~ cm~ 5169 Chem~ sup9~ 7~ A~o g~l re~ ~41 O~ ~ ~t 1 Moterve~cie aeaem (n~ & usea) 7~7 A~ ~m=tmn ~e~r Q252 ChicXen eggs 5521 Motorvenicie (use~ on~ 7~ Gene~ ~ re~ 02~ Tu~ey e;~ 5~1 A~o & home suopiy s~ores 7~2 C~ w~nes 28~1 P~n~ m~u~mre 5~1 G~oline se~cest~ons 8071 Chem~ ~r~ow a291 Genera ~. pn~ livestoc~ & NONRESTRICTED WASTE CODES .C~de Oescnotion Code Oescno(ion I nor~an~cs 111 Ac=o solution 2< ~H <7 wffh me[as ( ~timony, ~emc. 272 Po~mehc resin w~te ~um.~e~lium. ~mfum. chromium, co~m~ cap~r. 281 Adheswes mercu~, many.chum, nicKat, selenium, s~Ner, thaiium, 291 ~ex v~aaium ~a z]nc) 311 Ph~aceu~i~ 112 Ac[a so~lon ~tho~ 113 Unsoec~ea ec~a sateen 321 Sewage siuage 322 BiologicN w~e o~er th~ sewage sludge ~21 AJ~m~ne so~uuon DH > 12.5 ~ me,as (see 111) ~1 Off-s~c, ag~ or su~lus org~i~ 1~ Alkmine so~on ~o~ ~23 Unsoec~ea akaiine soiuaon 341 Org~ic liquids (no~oWenm)~ ~e~ 3~ Uns~c~ea org~m liquid m~ure 1 31 A~ueous so~ut~on {2<~H<12.51 careening repletions ~10rg~ic solids ~ h~oge~ percnlor~e ~a sulfide 132 A~ueous so~uuon ~ mer~ (see 111) Sludges 411 Alum ~d ~um s~ge 1 ~ A~ueous soi~on ~t~ to~ oeg~ic residues 10% or more ~21 ~me siuage 134 Aaueous sol--on ~ to~a o~ic resmues tess m~ 10% 1 ~ U~eo a~ueous sot~ion ~1 Phosphor sludge ' ~1 Suer sluage 1 ~1 Cff-s~c. ag~. or su~lus ino~i~ 451 Oegre~ing sludge 151 ~Destos ~ntmnmg w~ce 4~1. P~nt sludge ~ 71 ~4e~m siuage {see ~ 11 ) ~1 Te~rae~ lead sludge 172 Me(a aus~ ~a machining w~e (see 111) 491 U~pe~ea studge w~te ~ 81 C~ner ,nor~tc so,d w~e MJsceJl~eous Or~,~ Sl ~ Emp~ pesacide ~mmnem 30 ga or more 2~ ~ ~mogenacea soivems 512 O~er emgW co~nem 30 g~ or more 513 (memymne ¢nlonae. c~to~o~m. TCZ. TCA) 531 Chem~ 213 H~roc~on soiven~ (s~o~a soiveni. ~lene) ~1 Photo c~em~p~oto Drocessing w~ce 214 Uns~c:~eo so,vent m~gure 551 ~r~oWw~te cnem~c~s 221 W~te od ~ m,xea od 551 ~targem~a ~22 ~ll~er se~on siuaGe 571 P~y ~n. ~am.n. ~d retaken 223 Uns~ec~ea oil - contmnmg w~te 581 G~ scmO~r w~te 231 Pes:~czae nnse water 591 ~ag~ouse 232 Pes~c~es ~a o~er 51 ~ C~nt~mmea sod ~m s~te crab.ps w~te ~socz~ea w,m pesuc:~e proaucuon 512 2~t S~ll ~cms Mtn nmo~en~e~org~t~ 2~2 Qtner suII ~gomw~te 251 PC3's ~a m~enm concmning PCS's (Restncteaw~te caaes 271 Cr~,c ~anomerw~te (Jncluoes unra~ea BAKI ISFIELD CITY FIRE DI PARTMENT HAZARDOUS MATERIALS DIVISION !TI5 CHESTER AVE. BAKERSFIELD, CA. 93301 (805) 326-3979 HAZARDOUS MATERIALS INVENTORY FACILITY DESCRIPTION CHECK IF BUSINESS IS A FARM [] BUSINESS NAME FACILITY NAME SiTE ADDRESS CITY STATE ZIP NATURE OF BUSINESS SIC CODE DUN & BRADSTREET NUMBER owNER/OPERATOR PHONE MAILING ADDRESS CITY STATE ZIP EMERGENCY CONTACTS NAME TITLE BUSINESS PHONE 24-HOUR PHONE NAME TITLE BUSINESS PHONE 24-HOUR PHONE ~ecxemoef 33. 1992 I:~-GION¥ t..E:PC STANOAFD F BAKERSFI rD CITY FIRE DEPARtS/lENT HAZARi I3US MATERIALS INVENT Page_of~ ~usiness 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 # {optioneJ). Chemical Name: AHM [ ] CAS # 4) PHYSICAL & HEALTH PHYSICAL HEALTH HAZARD CATEGORIES Fire [ ] Reactive [ ] Sudden Release of Pressure [ ] Immediate Health (Acute) 5) WASTE CLASSIFICATION (3-digit code from DHS Form 8022) USE CODE 6) PHYSICAL STATE Solid [ ] Uquid [ ] Gas [ ] Pure [ ] Mixture [ ] Waste [ ] Radioactive [ ] 7) AMOUNT AND TIME AT FACILITY UNITS OF MEASURE 8) STORAGE CODES Maximum Dally Amount: lbs [ ] gal [ ] fi3 [ ] a) Container: Average Dally Amount: curies [ ] b) Pressure: Annual Amount: c) Temperature: Largest Size'Container: # Days On Site Circle Which Months: All Yea~, 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) 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 HeaJth (Chronic) [ ] 5) WASTE CLASSIFICATION (3-digit code from DHS Form 8022) USE CODE 6) PHYSICAL STATE Solid [ ] Uquid [ ] Gas [ ] Pure [ ] Mixture [ ] Waste [ ] Radioactive [ ] 7) AMOUNT AND TIME AT FACIUTY UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount: lbs [ ] gal [ ] 1t3 [ ] a) Container: Average Dally Amount: cudes [ ] b) Pressure: Annual Amount: c) Temperature: L.~rgest Size Container: # Days On Site Circle Which Months: All Yea~, 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 a~y AHM components 2) [ 3) 10) Location ~ cerbfy un(~er penaJty of/aw, that I have personalty examined and am familiar with ~he infomatJon submitted on this and all attactled document. I believe submitted information is me, accurate, and complete. PRINT Name & Title of Authorized Company Representative Signature Date -" BAKER :IELD CITY FIRE DEP i ITMEN'T HAZ/tRDOUS MATERIALS INVEI~I'ORY Page/ofl /B~siness Name' Address . ~./ CHEMICAL DESCRI~ION / 1) IN~NTORY STA~S: New ~ Addition [ ] Revision [ ] ~l~tion [ ] Check E.chemi~ is · NON ~DE SECR~ [ ] ~E SECR~ [ ] H~RD CATEGORIES Fire Reactive [ ] Sudden Rele~e of Pressure [ ] Immedi~e He~h (Ac~e) [ ] ~l~yed He~h (Chronic) 5) WAS~ C~SSIFICA~ON (3-digit code from DHS Fo~ 8022) USE CODE 6) PHYSICAL STA~ Solid [ ] Liquid [ ] G~ [ ] Pure [ ] M~ure [ ] W~te [ ] R~ioa~e [ 7) AMOUNT AND ~ME AT FAClU~ ~ UNITS OF ~URE 8) STOOGE CODES M~imum Daiy Amount: Average Daily Amount: ~ curi~ [ ] b) Pressure: / Annu~ Amount: ~gest Size'Cont~ner: ~j · Days On Site Circle~ich Months: , F, M, A, M. J, J. A. S, O~ N, D 9) MI~.E: ~st ~~ C~~ CAS,' ~ AHM the three most h~dous 1 ) chemi~ com~nen~ or ~y AHM com~nen~ 2) [ ] 3) [ ] lO) Location CHEMICAL DESCRI~ION 1) INVENTORY STA~S: New [ ] Addition [ ] Revision [ ] Deletion [ ] Check~chemi~ is a NON ~DE SECR~ [ ] ~E SECR~ [ ] 2) Common N~e: 3) ~T · (o~on~ Chemic~ Name: AHM [ ] CAS 4) PHYSICAL & H~L~ PHYSICAL H~L~ H~RD CATEGORIES Fire [ ] Rea~ive [ ] Sudden Rele~e of Pressure [ ] Immedi~e He~h (Ac~e) [ ] ~layed He~ (Chron.) [ ] 5) WASTE C~SSIFICATION .(~digit code from DHS Form 8022) USE CODE 6) PHYSICALSTA~ Solid [ ] Liquid [ ] G~ [ ] Pure [ ] Mi~um [ ] W~te [ ] R~io~ive [ ] 7) AMOUNT AND TIME AT FACIM~ UNITS OF M~SURE 8) STOOGE CODES M~imum Daily Amount: lbs [ ] gN [ ] ~3 [ ] a) Contaner: Average Daily Amount: curies [ ] b) Pressure: Annual Amount: c) Tem~r~ure: ~gest Size Container: · DaysOnSite Cimle~ichMonths: ~lYe~, J, F, M, A, M, J, J, A, S, O. N. D 9) MITRE: ~st COMPONENT CAS · % ~ ~M the three most h~dous 1) [ ] chemi~ com~nen~ or ~y AHM com~nents '2) [ ] 3) [ ] 10) Lo~ion ce~ under pen~ of law, ~at I have pe~onatly examin~ submi~ info~a~on is ~e, accu~te, ~d complete. PRINT Name & Title of Authorized Company t~epresenta~ve Signature Date BAKERSFI i[.D CITY FIRE DEPA ENT -. .... HAZARDOUS MATERIALS INVENT01 ( Pagetof._ 9usiness 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 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 T1ME AT FAClUTY UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount: lbs [ ] gal [ I ~t3 [ ] a) Container;. Average Daily Amount: curies [ ] b) Pressure: Annual Amount: c) Temperature: Largest Size Container: # Days On Site CimleWhich 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 HeeJth (Chronic) [ ] 5) WASTE CLASSIFICATION .(3-digit code from DHS Form 8022) USE CODE 6) PHYSICAL STATE Solid [ ] Liquid [ ] Gas [ ] Pure [ ] Mixture [ ] Waste [ ] Radiosctive [ ] 7) AMOUNT AND TIME AT FAClUTY UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount: lbs [ ] gal [ ] ~t3 [ ] a) Container: Average Dally 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 # % WI' AHM the three most hazardous 1), [ ] chemical components or any AHM components 2) [ ] 3) [ ] 10) Location ' ca.fy unciar penafly of law, that I have personally examined and am familiar with the infomaton submitted on this and all at~ached documents. I believe the submitted inforrnaton is ~ue, accurate, and comp/em. PRINT Name & Title of Authorized Company Representative Signature Date