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Home My WebLink AboutBUSINESS PLAN 2/18/2002Hazardous Materials/Ha~a:rdous Waste Unified permit . CONDITIONS OF-PERMIT:ON REVERSE SIDE Permit ID#:: 015-000-001906 BRAND DRY ICE INC DBA LOCATION: 2301 P ST This _permit is issued for the followin_o: [] H.,?=rdous Materials Plan [] Underground Storage of HazardOus Materials [] Risk Management Program [3 Hazardous Waste On-Site Treatment IsSUed by: Bakersfield Fire Depa,rtment ~ OFFICE OF ENVIRONMENTAL SER VICES' 1715 Chester Ave., 3rd Floor Bakersfield, CA 93301 Voice (661) 326-3979 FAX (661) 326-0576 Appmv'edby: . ~,~ Ralpl~Huey, 13~i · 3:' Office of Ev~ Services -' -:. '?' i:. i ' 'Expirati~flDate: "JUne 30, 2003 Issue Dat~ iTE DL~(;t~V~ ! Business Name: Business Address: ~AC~r~Y D~RA~ F ITE DIAGRA~ Business Name: Business Ad.ess: ~/ ~ ~ ~ ~~~ ~-~/ BRAND DRY ICE INC DBA Manager : MIKE BRAND Location: 2301 P ST City : BAKERSFIELD CommCode: BAKERSFIELD STATION 04 EPA Numb: SiteID: 015-021-001906 BusPhone: (661) 322-6001 Map : 102 CommHaz : Minimal Grid: 30B FacUnits: 1 AOV: SIC Code:4925 DunnBrad:02-787-0062 Emergency Contact / Title MIKE BRAND / PRESIDENT Business Phone: (661) 322-6001x 24-Hour Phone : (661) 322-6001x Pager Phone : (661) 428-0900xCELL Emergency Contact / Title CHARLES WOOD / MANAGER Business Phone: (661) 322-6001x 24-Hour Phone : (661) 322-6001x Pager Phone : (661) 428-0907xCELL Hazmat Hazards: Fire Press React ImmHlth Contact : MIKE BRAND MailAddr: PO BOX 1631 City : BAKERSFIELD Phone: (661) 322-6001x State: CA Zip : 93301 Owner MIKE BRAND Address : PO BOX 1631 City : BAKERSFIELD Phone: (661) 322-6001x State: CA Zip : 93301 Period : Preparer: Certif'd: ParcelNo: to TotalASTs: = TotalUSTs: = RSs: No Gal Gal Emergency Directives: -1- 07/15/2003 BRANDco Manager : Locatio~?P City : BAKERSFIELD CommCode: BAKERSFIELD STATION 01 EPA Numb: BusPhone: Map : Grid: SIC Code: DunnBrad: SiteID: 015-021-002315 (661) .~-r-~6001 CommHA z' -..~: FacUnits: 1 AOV: Emer~ge.ncy _ C_ontact / Title Business Phone: 24-Hour Phone : (&&/~)_~-. ~/x ~r-Ph>one - ': '~&/.)~/Z~' -~DD x _ L_ _ ...... :: ...................... ~azmat Hazards: Emergency Contact / Title Business Phone: :~(~; ) z~ _~el x 24-Hour Phone ,: (~7)3Z~_-&~a/' x · ::~2-~-~_ . :'- ...... £'- ...................... Contact : MIKE BRAND Phone: (661).~6001x MailAddr::~:p ST ~3~/ ,~J'~ State: CA City : B~KERSFIELD Zip : 93301 Owner ~-;~:~-~6 Phone: (b6l) $22- ~lx Address : ~3P ST 23~/ ~:2- State: CA City : BAKERSFIELD Zip : 93301 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No +- --+ Emergency.Directives: += Hazmat Inventory One Unified List + +== Alphabetical Order All Materials at Site + ................................. + + + ..... + .......... + .... +- - -+ Hazmat Common Name... ISpooHaz[EPA HazardsI Frm I DailyMax IUnitlMCPI ................................. + ....... + ........... + ..... + .......... +- - --+- _ -+ I, ~'~. w. ~,,.¢ Do hereby certify that i reviewed the .~.,.~.¢,c~ ~ me,it p~an f0r~~- and that it al0n~ w~th any corrections constitute a complete and correct man- agement plan for my facility, 02/12/2002 + BRANDCO SiteID: 015-021-002315 + Fast Format + += Notif./Evacuation/Medical +== Agency Notification 'l ~// + Overall Site + +=== Employee Notif./Evacuation + Public Notif + .... ./.~vacuaElon [ Emergency Medical Plan 2 02/12/2002 + BRANDCO + SiteID: 015-021-002315 + Fast Format + += Mitigation/Prevent/Abatemt +== Release Prevention Overall Site + +=== Release Containment +==== Clean Up =+ Other Resource Activation =+ -3- 02/12/2002 + BRANDCO SiteID: 015-021-002315 + Fast Format + += Site Emergency Factors +== Special Hazards Overall Site + =+ +=== Utility Shut-Offs ----+ ..... Fire Protec./Avail. Water Building Occupancy Level -4- · ,' ' ?~0 2 /12/2002 + BRANDCO SiteID: 015-021-002315 + Fast Format + += Training +== Employee Training +=== Page 2 Overall Site + + .... Held for Future Use Held for Future Use -5- 02/12/2002 FACILITY NAME "["~ ADDRESS ~2.. ~O ~ FACILITY CONTACT ~SPECTION TIME Section 1: Routine CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 INSPECTION DATE i - ~- PHONE NO. "b'2-'7 - (o BUSINESS ID NO. 15-210- NUMBER OF EMPLOYEES Business Plan and Inventory Program [] COmbined [] Joint Agency [] Multi-Agency [] Complaint [] Re-inspection OPERATION C V COMMENTS Appropriate permit on hand 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 ~Yes [] No ' Bu~ii{~s~ ~;ite R~nsible Party Any hazardous waste on site?: Explain: Questions regarding this inspection? Please call us at (661) 326-3979 White - Env. Svcs. Yellow - Station Copy Pink - Business Copy Inspecto~/~ ~----000'~ BRAND DRY ICE INC DBA BRANDCO Manager : ~,1~1~, ~~ Location: 2301 P ST City : BAKERSFIELD SiteID: 0152021-001906 BusPhone: (~ 322-6001 Map : 102 CommHaz : Minimal Grid: 30B FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 04 EPA Numb: SIC Code:4925 DunnBrad:02-787-0062 Emergency Contact / Title MIKE BRAND H~ / PRESIDENT Business Phone~l~9~) 322-6001x 24-Hour phone ~ (~8~ 322-6001x Pager Phone : {~&l )~ -~e x Emergency Contact / Title CHARLES WOOD &G f FOREMAN Business Phone~ ~ 322-6001x 24-Hour Phone & 322-6001x Pager Phone : ( ) - x Hazmat Hazards: Fire Press React Im~lth Contact : MIKE BRAND MailAddr: PO BOX 1631 City : BAKERSFIELD Owner MIKE BRAND Address : PO BOX 1631 City : BAKERSFIELD RECEIVED Phone: ~ 322-6001x State: CA Zip : 93301 Phone: ~ 322-6001x State: CA Zip : 93301 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No Emergency Directives: = Hazmat Inventory --As Designated Order Hazmat Common Name... FIRE EXTINGUISHERS AIR COMPRESSED CARBON DIOXIDE HELIUM DRY ICE NITROGEN ISpecHazI EPA HazardsI R G F P IH G F P IH G F P IH G IH S I, ~~~ f~J~ her;~b~ certi~ that I h'~e ~' (-rype or pdnt r~ame) reviewed the a~ached h~ardous mmedsls manage- ment plan for ~m and that it along wi~h (Name of Busine~) any corrections constitute a complete and corre~ man- One Unified List Ail Materials at Site Frm I DailyMax Unit MCP 4500.00 LBS UnR 300.00 FT3 Min 25000.00 LBS Min 4500.00 FT3 Min 27000.00 LBS Low 600.00 FT3 Min agement plan for my facility. 1 Ol~ ¢)'2'- O/ 02/01/2001 Signature Date BRAND DRY ICE INc DBA BRANDCO ~ Inventory Item 0001 -- COMMON NAME / CHEMICAL NAME FIRE EXTINGUISHERS Location within this Facility Unit ON STOCK SHELVES CENTER S WALL SiteID: 015-021-001906 Facility Unit: Fixed Containers at Site Map: Grid: Days On Site 365 CAS# rSTATE ~ TYPE Gas I Mixture PRESSURE TEMPERATURE CONTAINER TYPE IAbove Ambient Above Ambient I PORT. PRESS. CYLINDER Largest Container 300.00 LBS AMOUNTS AT THIS LOCATION Daily Maximum I 4500.00 LBS Daily Average 4500.00 LBS I%Wt. HAZARDOUS COMPONENTS RS CAS# TSecretI RS I BioHaz No . No No HAZARD ASSESSMENTS Radioactive/Amount I EPA Hazards No/ CuriesI · R NFPA /// USDOT# I MCP UnR = Inventory Item 0002 -- COMMON NAME / CHEMICAL NAME AIR COMPRESSED AIR PACKS Location. within this Facility Unit ON STOCK SHELVES S WALL FRONT Facility Unit: Fixed Containers at Site Map: Grid: Days On Site 365 CAS# 7782-44-7 FSTATE -- TYPE Gas Pure PRESSURE ~ TEMPERATURE Ambient ~Above Ambient Above CONTAINER TYPE PORT. PRESS. CYLINDER Largest Container 22.00 FT3 AMOUNTS AT THIS LOCATION Daily Maximum 300.00 FT3 Daily Average 300.00 FT3 %Wt. A 100.00 ir HAZARDOUS COMPONENTS N~S CAS# 0 ITSecret N~SIBioHaz No No HAZARD ASSESSMENTS Radioactive/Amount EPA Hazards No/ Curies F P IH NFPA/// I USDOT# MiL -2- 02/01/2001 BRAND DRY ICE INC DBA BRANDCO = Inventory Item 0003 · COMMON NAME / CHEMICAL NAME CARBON DIOXIDE SiteID: 015-021-001906 Facility Unit: Fixed Containers at Site Location within this Facility unit : INBOTH LIQUID & GAS FOPd~S IN CONTAINER TYPE 02-04-05 Days On Site 365 CAS# 124-38-9 F STATE ~ TYPE Gas /Pure PRESSURE TEMPERATURE CONTAINER TYPE I Above Ambient I Below Ambient I INSUL.TANK / CRYOGENIC Largest Container 14000.00 LBS AMOUNTS AT THIS LOCATION Daily Maximum I 25000.00 LBS Daily Average 3500.00 LBs %Wt. I 100.00 Carbon Dioxide HAZARDOUS COMPONENTS CAS# 124389 No No No HAZARD ASSESSMENTS Radioactive/AmountNo/ Curies I EPAF P HazardsiH NFPA /// USDOT# I MCP Min = Inventory Item 0004 -- COMMON NAME / CHEMICAL NAME HELIUM Facility Unit: Fixed Containers at Site Location within this Facility Unit Map: Grid: IN REAR OF BLDG BY W DOOR/I~ $%o~a~ ~%~ ~F ~&~ Days On Site 365 CAS# 7440-59-7 r STATE ~ TYPE Gas /Pure PRESSURE TEMPERATURE I Above Ambient I Ambient CONTAINER TYPE PORT. PRESS. CYLINDER Largest Container 244.00 FT3 AMOUNTS AT THIS LOCATION Daily Maximum 4500.00 FT3 Daily Average I 1500.00 FT3 %Wt. 100.00 Helium HAZARDOUS COMPONENTS N 7440597 TSecret No I RSiBioHaz No No HAZARD ASSESSMENTS Radioactive/Amount EPA Hazards No/ Curies F P IH NFPA /// USDOT# IMCP Min -3- 02/01/2001 BRAND DRY ICE INC DBA BRANDCO SiteID: 015-021-001906 ~ Inventory Item 0005 Facility Unit: Fixed Containers at Site ~U~IU~ ~Vl~ / ~£ ~-~.~ ~Vl~ DRY ICE Days On Site SOLID CARBON DIOXIDE 365 Location within this Facility unit Map: Grid: IN 36 BLOCK (50LB) BOXES SE FRONT OF BLDG CAS# STATE i TYPE PRESSURE i TEMPERATURE CONTAINER TYPE Solid Pure Ambient Below Ambient BIN Largest Container 1800.00 LBS AMOUNTS AT THIS LOCATION Daily Maximum 27000.00 LBS Daily Average 15000.00 LBS %Wt. I 100.00 Carbon Dioxide HAZARDOUS COMPONENTS CAS# 124389 TSecretNo N~S BioHazNo HAZARD ASSESSMENTS Radioactive/Amount I EPA Hazards No/ CuriesI IH NFPA /// USDOT# = Inventory Item 0006 -- COMMON NAME / CHEMICAL NAME NITROGEN Facility Unit: Fixed Containers at Site Location within this Facility Unit Map: Grid: IN REAR OF BLDG BY W DOOR/IH .! Days On Site 365 CAS# 7727-37-9 FSTATE ~ TYPE Gas /Pure PRESSURE TEMPERATURE CONTAINER TYPE .I Above Ambient I Above Ambient I PORT. PRESS. CYLINDER Largest Container 255.00 FT3 AMOUNTS AT THIS LOCATION Daily Maximum I 600.00 FT3 Daily Average 600.00 FT3 %Wt. 100.00 Nitrogen HAZARDOUS COMPONENTS S CAS# N 7727379 HAZARD ASSESSMENTS Radioactive/Amount I EPA Hazards No/ CuriesI F P IH NFPA /// USDOT# I MCP Min 02/01/2001 BRAND DRY ICE INC DBA BRANDCO .SiteID: 015-021-001906 Fast Format = Notif./Evacuation/Medical --Agency'Notification 911. Overall Site 01/13/1999 -- Employee Notif./Evacuation AS'PER SITE PLAN POSTED AT EXITS. 01/13/1999 Public Notif./Evacuation AS PER SITE PLAN POSTED AT EXITS. 01/13/1999 911. Emergency Medical Plan 01/13/1999 ] 5 02/01/2001 BRAND DRY ICE INC DBA BRANDCO SiteID: 015-021-001906 Fast Format ~ Mitigation/Prevent/Abatemt --Release Prevention N/A ALL INERT GASES. Overall Site 01/13/1999 -- Release Containment N/A ALL INERT GAS. 01/13/1999 Clean Up N/a. 01/13/1999 Other Resource Activation 6 02/01/2001 BRAND DRY ICE INC DBA BRANDCO SiteID: 015-021-001906 Fast Format F.Site Emergency Factors Special Hazards Overall Site Utility Shut-Offs A) GAS - NG AT W END INSIDE COVERED AREA. B) ELECTRICAL - N/W INSIDE OF BLDG BY SLIDING DOOR. C) WATER - W IN YARD BY SW GATE. D) SPECIAL - N/A E) LOCK BOX - NO, COMBO LOCK ON BLDG. 01/13/1999 -- Fire Protec./Avail. Water PRIVATE FIRE PROTECTION - HAND HELD FIRE EXTINGUISHERS. 01/13/1999 NEAREST FIRE HYDRANT - ON THE CORNER OF 24TH & P ST. Building Occupancy Level 7 02/01/2001 BRAND DRY ICE INC DBA BRANDCO SiteID: 015-021-001906 Fast Format = Training -- Employee Training WE HAVE 10 EMPLOYEES AT THIS FACILITY. WE DO HAVE MSDS SHEETS ON FILE. BRIEF SUMMARY OF TRAINING PROGRAM: MONTHLY SAFETY MEETINGS. HM 126 TRAINING/DOT TRAINING/IN HOUSE SAFETY MANUALS/NAFED TRAINING/BOC TRAINING. Overall Site 01/13/1999 Page --Held for Future Use Held for F~ture Use 8 02/01/2001 CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., Bakersfield, C 8~26-3979 1. To avoid further action, return this form within 30 days of receipt..~- l~ -~'~'V''/ 2. TYPE/PRINT ANSWERSIN 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 ~f BUSINESS NAME: LOCATION: MAILING ADDRESS: STATE: CITY: DUN & BRADSTREET NUMBER: SIC CODE: SECTION 2: EMERGENCY NOTIFICATION CONTACT TITLE BUS. PHONE 24 HR. PHONE HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 3: TRAINING NUMBER OF EMPLOYEES: MATERIAL SAFETY DATA SHEETS ON FILE: SECTION 4: EXEMPTION REQUEST I CEKTIFY 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 DO HANDLE HAZARDOUS MATERIALS, BUT THE QUANTITIES AT NO TIME EXCEED THE MINIMUM REPORTING QUANTITIES. OTHER (SPECIFY REASON) SECTION J CERTIFICATION I, f/'~//~/,b-,,%~ /t~20,~'~r~ CERTIFY ~T ~ ~O~ ~o~TioN I~ Acc~~. I ~ERST~ ~T ~S ~O~TION ~L BE USE~TO ~FmL ~ F~'S OBLIGATIONS ~ER ~ "C~O~ ~~ ~ S~TY C~E" ON ~~OUS ~~S ~. 20 C~~R 6.95 SEC. 25500 ET ~.) ~ ~T ~ACC~ ~O~TION CONSTI~S PE~Y. · /S!6N 2 HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 7: MITIGATION, PREVENTION AND ABATEMENT PLAN A. RELEASE PREVENTION STEPS: ,'~"/,~ Jif// .-.~-~~ / RELEASE CONTAINMENT AND/OR MINIMIZATION: C. CLEAN-UP PROCEDURES: SECTION 8: UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY)_ WATER:W SPECIAL: LOCK BOX: IF YES, LOCATION: SECTION 9: PRIVATE FIRE PROTECTION/WATER AVAILABILITY Ao PRIVATE FIRE PROTECTION: Bo WATER AVAILABILITY (FIRE HYDRANT): 4 HAZARDOUS ~MATERIALS MANAGEMENT PLAN SECTION 6: NOTIFICATION AND EVACUATION PROCEDURES AG AGENCY NOTIFICATION PROCEDURES: B. EMPLOYEE NOTIFICATION AND EVACUATION: Co PUBLIC EVACUATION: '~''(' D. EMERGENCY MEDICAL PLAN: CHEMICAL DESCRIPTION INVENTORY STATUS: New4 Addition [ J Revision [ ] Deletion [ ] Check if chemical is NON Trade Secret [ Trade Secret common ame: Chemical Name: 4) Physical & Health H~a_rd Categories 5) WASTE CLASSIFICATION PHYSICAL Fire [ ] Reactive [~ S,_,dd~ Release ofPressur~ [ / (3MiSit code riom DHS Form 8022) 3) DOT# (optional) AHM[ { CAS#~ ] Immediate Health (Acute) [ ] Delayed Health (Chronic) [ 6) PHYSICAL STATE Solid [ ] Liquid [ ] 7) AMOUNT AND TIME AT FACILITY Maximum Daily Amount ~_~'O~ Average Daily Amount ~-/'.~'<:~ Annual Amount Largest Size Container # Days on Site UNITS OF MEASURE Lbs,[~lCral[ IIU[ l curies [ ] Circle Which Mouths: Mixture [ ] wast~ [ ] Radioactive [ 8) STORAGE CODE,~ i a) Container:. .. 09' b) Pressure: ~. c) Temperature ~ 9) MIXXURE: List the three most hazardous 1) chemical components or 2) any AHM components 3) COMPONENT CAS# % WI' [ ] [ ] [ ) !) INVENTORY STATUS: New.,~Adaition [ ] Revision [ 2) Common Name: ~/}~-' PY~ L~S ] Deletion [ ] Check if chemical is a NON Trade Sec~ [ ] Trad~ 8ecl~t [ cas#. 4) Physical & Health Hazard Categories Fire [ PHYSICAL ] Reactive [~/] S,_,dden Rel~s~ of lCYessu~ [ / 5) WASTE CLASSIFICATION 6) PHYSICAL STATE Solid [ ] Liquid [ ] Immediate Health (Acute). [ O-digit eod~ fi'om DHS Form 8022) ] C, asJ/l'] Pm'e[] UNITS OF MEASURE Lbs[ ]Gal[ ]P3t/)"] Curies[ ]'~ 7) AMOUNT AND TIME AT FACILITY Maximum Daily Amount 200 Average Daffy Amount ~>0 0 Annual Amount ~,~:~Z:} Largest Size Container .~. # Days on Site ~ ~ Circle Which Months: ] Delayed Health (Chronic) [ ] USE CODE ~/tS~ Mixtur~ [ ] waste [ ] Radioactive [ ] 8) STORAGE CODES a) Container:.' b) ~ssu~.': c) Temperature AIl Year, I, F, M, A, M, $, $, A, S, o, N, D 9) MIX'HJRE: List the three most hmurdous I) chemical components or 2) any AH/vi components 3) COMPONENT CAS# % WI' [ { [ ] [ ] I 0)LOCATION · . .c c/d w T [ cmi~ =d= ~ of law, mt I ~ve ~ly exm~ md m f~ Mm me tab. don on ~s ~/~1 ~~mU. I Business Name I~RDOUS ~LATERIALS ENVENTOY Address .2.3~! /o.S 7- Pag or CHEMICAL DESCRIFHON I ) INVENTORY STATUS: New [ 2) Common Name: ~7~_.) .~ Chemical Name: 4) Physical & Health Hazard Categories ] Addition [ ] Revision [ ] Deletion [ ] 3) DOT # (optional) ] Immediate Health (Acute) [ (3-digit code from DHS Form 8022) USE CODE PHYSICAL Fire [ ] Reactive [/~] Sud&~a Release of Pressure [ 5) WASTE CLASSIFICATION Check ffchemical is a NON Trade Secret [ ] Trade Sec~-t [ J Delayed Health (Chronic) [ J 6) PHYSICAL STATE Solid [ ] Liquid IX] 7) AMOUNT AND TIME AT FACILITY Maximum Daffy Amount ,~ ~, ooo Average Daily Amount Annual Amount ,.~&Oa. ooo Largest Size Container # Days on Site Lbs,C~ICrBJ( 1~[ ] Curies ( ] Circle Which Months: Mixtm'e[ ] Waste[ ] Radio~tive[ ] 8) STORAGE CODES a) Contain~ b) Pressure: c) Tempeamture Ali Yem', J, F, M. A,'M, J, J, A. S, O, N, D 9) MIXTURE: List the three most buTurdous I) chemical components or 2) any AH/vi components 3) COMPONENT CAS# % WI' [ 1 [ ] [ ] 10)LOCATION i ) INVENTORY STATUS: New [~t] Addition [ ] Revision [ ] Deletion [ ] 2) Common Name: Chemical Name: Check ffchem/cal is a NON Trade Secra [ ] Trade Secret [ 3) # (option) / 4) Physical & He.a/th Ha?ard Categories Fire [ 5) WASTE CLASSIFICATION PHYSICAL HEALTH ] Reactive [,~] Sudden Release of Pressure [ ] Immediate Health (Acute), [ (3-digit code from DI--I~ Form 8022) USE CODE ] Delayed Health (Chronic) [ 6) PHYSICAL STATE Solid [ ] Liquid [ ] 7) AMOUNT AND TI1ME AT FACILITY Maximum Daily Amount z/,g'~d Average Daffy Amount /~',00 Annual Amount .~'4~ O0 Largest Size Container .~ Q,e./, # Days on Site 3 ~,~' c~J,,~'] Pure[ )Mitre[ ] waste( I ~ OF ~~ 8) STOOGE CODES L~[ ]~[ ]~] a)Con~ C~ [ y ' b) ~es~& c) T~e Cin;le WMch Months: AIl Year, J, F, M, A, M, $, $, A, S, O, N, D 9) MIXTURE: List COMPONENT CAS# % WT AHM the three most ha~urdous 1 ) [ ] chemical components or 2) [ ] ally AH~ components 3) [ ] I 0)LOCATION ! certify under penflty of law, that I imve personally examined and am familiar with the/nlb.nn~tion on tMsan~ all attached believe the,~sqlSn;~ted inform~ion is true. ac,~urate anlJ.pomplet~. ~ ~' // ., // ~ // PRINT~-~N///am///~ Ti/~fle~of^uthorized Cd'mpany epresenta"~ - // ..gna / lq~iness Name I~ARDOUS MATERIALS hNVENT~}Y Address ~-~o/ f) -gT- Page CHllMICAL DESCRIPTION I) INVENTORY STATUS: New [,~ddition [ ] Revision [ ] Deletion { Con=o. 4) Physical & Health PHYSICAL Hazard Categories Fire [ ] Reactive [ ] Sodd~ Release of Pressure [ ] 5) WASTE CLASSIFICATION ] Check ffchemical is a NON Trade Secret [ ] Trade Secrt~ [ 3) DOT# (optional) 6) PHYSICAL STATE SolidJ~] Liquid [ 7) AMOUNT AND TIME AT FACILITY Maximum Daily Amount Z 7~ Off& Average Daily Amount /~., Annual Amount Largest Size Container # Days on Site AHM[ 1 cass HEALTH Immediate Health (Acute) [ (3-digit code fx~m DHS Form $022) GasJ~'] Pure [ L~OF MEASURE Circle Which Months: USE CODE Delayed Health (Chronic) [ Mixture [ 8) STORAGE CODES .) contra= b) Pressure: c) Temperature Ail Yesr, J, ¥, lyf, A,'lVl- Y, J, A. S, O, N, D 9) MIXTURE: List the three most hazardous I) chem/cal components or 2) any AHM components 3) COMPONENT CAS# % WI' [ ] [ ] [ ] 10)LOCATION I) INVENTORY STATUS: NewJ~] Addition [ ] Revision [ ] Deletion [ 2) Common Name: ff ~' ] Check if chemical is a NON Trade Sea'et [ ] Trade Secr~ [ 3) DOT # (optional) /f ~ 4) Physical & Health Hazard Categories Fire [ 5) WASTE CLASSIFICATION /~0PHYSICAL ] Reactive [ Sudd~ Release ofPresst~ [ 6) PHYSICAL STATE Solid [ ] Liquid [ ] Immediate Health (Acute). [ (3-digit code ~rm DH~ Form 8022) ] Oas[~ Pure[ l UNITS OF ~UR~, Lt~t lc,~{ lfU[}/l c.rio { rI 7) AMOUNT AND TIME AT FACILITY Maximum Daily Amount Average Daily Amount Annual Amount 7 Largest Size Container # Days on Site Circle Which Months: USE CODE ] Delayed Health (Chronic) [ Mixture[ ] Waste[ ] Radioactive[ ] 8) STORAGE CODES' a) Contain~ b) PresSm~: _~._ c) Temperature AIl Yesr, J, F, M, A, M, $, J, A, S, O, N, D 9) MIXTURE: List the three most hazardous I) chemical components or 2) any AHM components 3) COMPONENT CAS# % WI' { ] [ I [ ] H~RDOU$ MATERIALS INVENT{ Page _.~.~o£__~/ CHEMICAL DESCRII~TION I) iNVENTORY STATUS: New~] Addition [ ] Revision [ ] Deletion [ 4) Physical & Health PHYSICAL Hmard Categories Fire [)/~ Reactive { ] Sudden Release of Pressure [ Check ffchemicai is a NON Trade Secret [ 3) DOT # (optional) /~M[ ] CAS# ] Immediate Health (Acute) [ ] Trade Secret [ ~o~ -~,/-~, Delayed Health (Chwnic) { ] 5) WASTE CLASSIFICATION 6)'PHYSICAL STATE Solid [ ] Liquid 7) :AMOUNT AND TIME AT FACILITY Maximum Daily Amount ! O Average Daily Amount AJlnual Amount lO I. mrgest Size Container # Days on Site (3-digit code from DHS Form 8022) cas[ ] Pure[ ) UNITS OF MEASURE Lbs[ )Gal0t~'fl.3[ ] curies [ ] Circle Which Months: USE CODE / q M/xture [ J Waste [ I P,m:l/oacfive [ I 8) STORAGE CODES a) Container:. b) Pressure: c) Temperature AIl Year, J, F, lVl, A, M, J, J, A, 8, O, N, D 9) MIXTURE: List the three most hazardous I) chemical components or 2) any AH!M components 3) COIVIPONENT CAS# % WI' [ ] [ ] [ ) 5) WASTE CLASSIFICATION Check if chemical is a NON Trade secret { ] Trade Secret [ 3) DOT # (optional) AHM[ ] CAS# /23o-~o-7 PHYSICAL ! HEALTH ] Sudden Release of Pressure [~ Immediate Health (Acute) [ O-digit code from DHS Form 8022) USE CODE ] Delayed Health (Chronic) [ ] 6) PHYSICAL STATE Solid [ ] Liquid~/] 7) AMOUNT AND TIME AT FAC/LITY Maximum Daily Amount Average Daily Amount Annual Amount L~est S~ze Cont~er # Days on Site 9) MIXTURE: List the three most hazardous 1 ) chemical components or 2) any AHM components 3) Gas~l 'Pure{ I Mixture&I Waste[ ] Radioactive[ UN1TS OF ,M,M,M,M~URE 8) STORAGE CODES Lbs [ ] Gal [)~l fi3 [ ] a) Container:. Curies [ ] b) Pressure: c) Temperature Cimle Which Months: All Year, J, F, M, A, M, J, J, & S, O, N, D COMPONENT CAS# % WT [ ] [ ! i 0)LOCATION I certify under penalty of law? that I have personally examined and am familiar w~ the intbnnatio~,n on this ~5~nd all believe the submitted information is true, accurate and complete. /// .// /1 !- R/N':F N~ne & Title of Authorized Company Representative Signature atlached documents. I Date