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Home My WebLink AboutBUSINESS PLAN M M P PLA MAP SITE DIAGRAM Business Name: Business Address: F--E-I FACILITY DIAGRAM Panama-Buena Vista Union School District 5901Schirra Ct. 93313 For Office Use Only First In Station: Inspection Station: Area Map # of NORTH . SCHIRRA CT. OFFICE Automatic Sprinklers in office and shop ASSEMBLY AREA ~tl-~.qe 4oor~ Butler Building PANAMA BUENA VISTA UNION SCI1OOL DISTRICT 5901 S~hirra Ct. CENTER ! Center 1. 2. 3. 4. 6. Oas Main Water Main (Office) Water Main (Shop) Electrical Mal~ Fire Hydrant Fire Sprinkler shut-off $CHIRRA CT. A/ PANAMA BUENA VISTA UNION SCHOOL DISTRICT 5901 Schirra Ct. OFFICE SHdP Automatic Sprinklers in office and shop ASSEMBLY AREA Butler Building TECH CENTER Parent Resource Center 1. Gas Main 2. Water Main (Office) 3. Water Main (Shop) 4. Electrical Main 5. Fire Hydrant 6. Fire Sprinkler shut-off John Anderson Supervisor of Maintenance/ Grounds and Operations 805-397-2207 FAX: 831-7704 5901 Schirra Court Bakersfield, CA 93313 $ 10/08/96 PANAMA BUENA VISTA UNION SCHOOL 215-000-000144 Overall Site with i Fac. Unit General Information 1 ! Location: 5901SCHIRRA CT Map:123 Haz:2 Type: 3 ~ City : BAKERSFIELD Grid: 05C F/U: 1 AOV: 0.0 Contact Name Title DAVID GEORGE / DIRECTOR M.O.T. Business Phone: (805) 397-2200x 24-Hour Phone : (805) 664-9586x Pager Phone : ( ) - x Contact Name JOHN ANDERSON Business Phone: 24-Hour Phone : Pager Phone : Administrative Data Mail Addrs: 4200 ASHE RD City: BAKERSFIELD Comm Code: 215-009 BAKERSFIELD STATION 09 Title / SUPERVISOR M&O (805) 397-2207x (805) 831-4095x ( ) - x D&B Number: 95-600-0412 State: CA Zip: 93313- SIC Code: 8211 Owner: PANAMA BUENA VISTA UNION SCHOOL Phone: (805) 397-2200 Address: 4200 ASHE RD State: CA City: BAKERSFIELD Zip: 93313- Summary ~0 10/08/96 Pln-Ref PANAMA BUENA VISTA UNION SCHOOL 215-000-000144 Hazmat Inventory List in MCP Order 02 - Fixed Containers on Site Name/Hazards Form Max Qty Page MCP 2 02-004 WASTE OIL · Fire, Delay Hlth Liquid 55 Low GAL 02-001 LUBRICATING OIL, MOTOR OIL · Fire, Delay Hlth Liquid 55 Minimal GAL 02-002 GREASE · Fire, Delay Hlth Liquid 55 Minimal GAL 02-003 GEAR LUBRICANT · Fire, Delay Hlth Liquid 55 Minimal GAL 10/08/96 PANAMA BUENA VISTA UNION SCHOOL 215-000-000144 02 - Fixed Containers on Site Hazmat Inventory Detail in MCP Order Page 3 02-004 WASTE OIL · Fire, Delay Hlth Liquid 55 Low GAL CAS #: 221 Form: Liquid Daily Max GAL 55 Storage DRUM/BARREL-METALLIC Type: Waste -- Conc~ Components 100.0% IWaste Oil, Petroleum Based Trade Secret: No Days: 365 Use: WASTE Daily Average GAL I Annual Amount GAL I 10.00 100.00 Press T Temp Location IAmbientlAmbientlSE CORNER OF BLDG - EXTERIOR MCP ---TGuide IL°w / 27 02-001 LUBRICATING OIL, MOTOR OIL · Fire, Delay Hlth Liquid 55 Minimal GAL CAS #: 64742-54-7 Form: Liquid Type: Pure Daily Max GAL Storage DRUM/BARREL-METALLIC Trade Secret: No Days: 365 Use: LUBRICANT Daily Average GAL 10.00 ] Annual Amount GAL -- 100.00 Press T Temp Location Above ~AmbientlSE CORNER OF BLDG - EXTERIOR -- Conci Components 100.0% IMotor Oil, Petroleum Based MCP ----~Guide IMinimal I 27 02-002 GREASE · Fire, Delay Hlth Liquid 55 Minimal GAL CAS #: 64742-54-7 Form: Liquid Type: Pure Daily Max GAL 55 Storage DRUM/BARREL-METALLIC -- Conc 100.0% IGrease Trade Secret: No Days: 365 Use: LUBRICANT Daily Average GAL [ Annual Amount GAL 10.00 100.00 Press T Temp Location Above I AmbientlSE CORNER OF BLDG - EXTERIOR MCP ----TGuide Components {Minimal ~ 10/08/96 PANAMA BUENA VISTA UNION SCHOOL 215-000-000144 02 - Fixed Containers on Site Hazmat Inventory Detail in MCP Order Page 4 02-003 GEAR LUBRICANT · Fire, Delay Hlth Liquid 55 Minimal GAL CAS #: 64742-54-7 Trade Secret: No. Form: Liquid Type: Pure Days: 365 Use: LUBRICANT Daily Max GAL55 I Daily Average10.00GAL Annual Amount GAL 100.00 Storage DRUM/BARREL-METALLIC Press T Temp Location Above I AmbientlSE CORNER OF BLDG - EXTERIOR -- Conc~ Components 100.0% ILubricating Oil (Petroleum-Based) MCP ----~uide Minimal I 27 10/08/96 PANAMA BUENA VISTA UNION SCHOOL 215-000-000144 Page 00 - Overall Site <D> Notif./Evacuation/Medical <1> Agency Notification DIAL 911. <2> Employee Notif./Evacuation FOLLOW PROCEDURES ESTABLISHED IN DISTRICTS DISASTER PREPAREDNESS PLAN I.E., EVACUATE BUILDING, MEETIN ASSEMBLY AREA, ACCOUNT FOR PERSONNEL, ADMINISTER FIRST AID AS NECESSARY, EVACUATE SITE IF NECESSARY. <3> Public Notif./Evacuation N/A <4> Emergency Medical Plan DIAL 911. GIVE EMERGENCY FIRST AID AS NECESSARY UNTIL HELP ARRIVES. 10/08/96 PANAMA BUENA VISTA UNION SCHOOL 215-000-000144 Page 00 - Overall Site <E> Mitigation/Prevent/Abatemt <1> Release Prevention 55 GALLON DRUMS CONTAINING OIL, GREASE, AND GEAR LUBE ARE STORED IN A FENCED ENCLOSURE. MATERIALS ARE DISPENSED THROUGH OVEHEAD REELS AND HOSES. DRUMS AND DISPENSING SYSTEM ARE INSPECTED REGULARLY. <2> Release Containment DISPENSING SYSTEM CAN BE SHUT DOWN BY DISCONNECTING AIR SUPPLY OR SHUTTING DOWN COMPRESSOR. ABSORBENT MATERIAL AVAILAAABLE TO CONTAIN ANY SPILLS. <3> Clean Up ABSORBENT MATERIAL TO CLEAN UP SPILLS. PROPER DISPOSAL. MATERIAL COLLECTED IN CONTAINERS FOR <4> Other Resource Activation 10/08/96 PANAMA BUENA VISTA UNION SCHOOL 215-000-000144 00 - Overall Site <F> Site Emergency Factors Page 7 <1> Special Hazards <2> Utility Shut-Offs A) GAS - NW CORNER OF BUILDING AT FENCE B) ELECTRICAL - ELECTRICAL PANEL ROOM IN SHOP ON E WALL AT ROLL-UP DOOR C) WATER - NW CORNER OF BLDG AND E SIDE OF BLDG UNDER STAIRS D) SPECIAL - FIRE SPRINKLER SHUT-OFF ON NW CORNER OF PROPERTY E) LOCK BOX - NO <3> Fire Protec./Avail. Water PRIVATE FIRE PROTECTION - FIRE SPRINKLERS THROUGHOUT MAIN BUILDING AND SHOP NEAREST FIRE HYDRANT - ON THE S SIDE OF SCHIRRA CT., APPROXIMATELY 100 FT E OF THE W PROPERTY LINE. <4> Building Occupancy Level 10/08/96 PANAMA BUENA VISTA UNION SCHOOL 215-000-000144 Page 00 - Overall Site <G> Training <1> Employee Training WE HAVE 16 EMPLOYEES AT THIS FACILITY'. WE DO HAVE MSDS SHEETS ON FILE. BRIEF SUMMARY OF TRAINING PROGRAM: TRAINING AS OUTLINED IN THE DISTRICTS OCCUPATIONAL ILLNESS AND INJURY PREVENTION PROGRAM AND DISASTER PREPAREDNESS PROGRAM. TRAINING INCLUDES STORAGE AND HANDLING OF CHEMICALS, MSDS, PERSONAL PROTECTIVE EQUIPMENT, SPILL RESPONSE, AND CODE OF SAFE PRACTICES. <2> Page 2 <3> Held for Future Use <4> Held for Future Use 10/08/96 PANAMA BUENA VISTA UNION SCHOOL 00 - Overall Site <M> Inspections M. GALAGAZA 10/28/93 OK / / ROBERTS 11/16/95 OK / / 03 384 4200ASHE 10/05/94 UST inspection. / / 215-000-000144 Page 9 10/08/96 PANAMA BUENA VISTA UNION SCHOOL 215-000-000144 O0 - Overall Site Page 10 <M> Inspection Summary M. GALAGAZA 10/28/93 OK / / ROBERTS 11/16/95 OK / / 03 384 4200ASHE 10/05/94 UST inspection. / / Bakersfield Fire D?pt. Hazardous Materials Division 2130 "G" Street Bakersfield, CA. 93301 HAZARDOUS MATERIALS MANAGEMENT PLAN INSTRUCTIONS: 1. To avoid further action, return this form within 30 days of receipt. 2. TYPE/PRINT ANSWERS IN ENGLISH. RECEIVED 3. Answer the questions below for the business as a whole. 4. Be brief and concise as possible. '~PR I .}~.~ ... ~AZ. MAT. DIV. sECTiON ]: BUSINESS IDENTIFICATION DATA BUSINESS NAME: Panama-Buena Vista Union School District LOCATION: 5901 Schirra Court MAILING ADDRESS: 4200 Ashe Road CITY: Bakersfield STATE' CA ..ZIP' 93313 PHONE' 805-397-2200 Fed Tax ID ~ DUN & BRADSTREET NUMBER: 956000412 SIC CODE: 8211 PRIMARY ACTIVITY: Administrative offices, maintenance, grounds OWNER' Panama-Buena Vista Union School District MAILING ADDRESS: same as above SECTION 2: EMERGENCY NOTIFICATION: CONTACT ]. David George 2. John Anderson TITLE Director M.O.T. BUS. PHONE 397-2200 24 HR. PHONE 664-9586 Supervisor M.&O. 397-2207 831-4095 akersfield Fire Dept. :ardous Materials Division HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 3: TRAINING: NUMBER OF EMPLOYEES' Sixteen (16) MATERIAL SAFETY DATA SHEETS ON FILE: Yes BRIEF SUMMARY OF TRAINING PROGRAM: Tra-ining as outlined in the district's Occupational Illness and Injury Prevention Program and Disaster Preparedness program. Training includes $.to,rage and handling of chemicals, MSDS, personal protective equipment, spill response, and code of safe practices. SECTION 4: EXEMPTION REQUEST: I CERTIFY 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 TIMEEXCEED THE MINIMUM REPORTING QUANTITIES, OTHER (SPECIFY REASON) C ERTIFI C ATI O N: SECTION 5: David L. George 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 SAFETY CODE" ON HAZARDOUS MATERIALS .(DIV. 20 CHAPTER 6.95 SEC. 25500 E'T AL.) AND THAT INACCURATE INFORMATION CONSTITUTES PERJURY. SIGNATURe/ TITLE DATE FDI5(X3 Bakersfield Fire Dept. Hazardous Materials Division" HAZARDOUS MATERIALS MANAGEMENT PLAN Facility Unit Name: District Office East - 5901 Schir, ra Ct. SECTION 6: NOTIFICATION AND EVACUATION PROCEDURES: AGENCY NOTIFICATION PROCEDURES: Dial 911 B. EMPLOYEE NOTIFICATION AND EVACUATION' Follow procedures established in district's Disaster P.rep~edness Plan i.e., evacuate building, meet in assembly area, account for personnel, administer first aid as .necessary, evacuate site if necessary. C, PUBLIC EVACUATION: N/A EMERGENCY MEDICAL PLAN' Dial 911. Give emergency first aid as necessary until help arrives. Bakersfield Fire Dept. Hazardous Materials Division HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 7: MITIGATION, PREVENTION AND ABATEMENT PLAN: A. RELEASE PREVENTION STEPS: 55 gallon drums containing oil, grease, and.gear lube are stored in a fenced enclosure. Materials are dispensed through overhead reels and hoses. Drums and dispensing system are inspected regularly. B, RELEASE CONTAINMENT AND/OR MINIMIZATION: Dispensing system can be shut down by disconnecting air supply or shutting down compressor. Absorbent material available to contain any spills. C, CLEAN-UP PROCEDURES: Absorbent material to clean up s~ills. containers for proper disposal. Material collected in SECTION 8: UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY): NATURAL GAS/PROPANE: ~ corner of building at fence ELECTRICAL: Electrical panel room in shop on East wall at roll-up door. WATER'. NW corner of building and East side of building under stairs. SPECIAL: Fire Sprinkler shut-off on NW corner of property. LOCK BOX: YESES") tF YES, LOCATION' SECTION 9: PRIVATE FIRE PROTECTION/WATER AVAILABILITY: A. PRIVATE FIRE PROTECTION: Fire Sprinklers throughout main building.and shop B. WATER AVAILABILITY (FIRE HYDRANT): On the south side of Schirra Court, approsimately 100 feet east of the west property line. 4. BAKERSFIELD CITY FIRE DEPARTMENT HAZARDOUS MATERIALS DIVISION 2130 "G" STREET BAKERSFIELD, CA. 93301 (805) 326-3979 HAZARDOUS MATERIALS INVENTORY FACILITY DESCRIPTION CHECK IF BUSINESS IS A FARM [ ] BUSINESS NAME Panama-Buena Vista Union School District FACILITY NAME District Office East SITE ADDRESS 5901 Schirra Court CITY Bakersfield STATE ZIP 93313 NATURE OF BUSINESS Elementary School District '- -~- 8211 SiC CODE ~'-.-~ Fed Tax ID # DUN & BRADSTREET NUMBER 956000/,, 12 OWNER/OPERATOR Panama-Buena Vista Union Sch6ol District PHONE MAILING ADDRESS 4200 Ashe Road 805-831-8331 CITY Bakersfield STATE CA ZIP 93313 NAME David George EMERGENCY CONTACTS TITLE Director, M.O.T. BUSINESS PHONE 397-2200 24-HOUR PHONE 664-9586 NAME John Anderson TITLE BUSINESS PHONE 397-2207 Supervisor, M.& O. 24-HOUR PHONE 831-4095 Se~emOer 30, 1~2 REGIONV LEPC .E, TANDARDFORM Name BAKERSFIF D CITY FIRE DEPAR IENT HAZARDIgUS MATERIALs INVENTO Panama-Buena Vista Sch. Dist. Address 5901Schirra Court Paget__of 2__ CHEMICAL DESCRIPTION ~] Addition { ] Revision [ ] Deletion [ ] / 1) INVENTORY STATUS: New 2) CommonN~me: Lubricating oil, motor oil Check if chemical is a NON TRADE SECRET [ ] TRADE SECRET 3) DOT # (optional) Chemical Name: Petroleum hydrocarbon AHM [ ] CAS # 64742-54-7 4) PHYSICAL & HEALTH PHYSICAL HEALTH HAZARD CATEGORIES Fire ~] Reactive [ ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ ] Delayed Health (Chronic) ~ ] 5) WASTE CLASSIFICATION N/A .(3-digit code from DHS Form 8022) USE CODE 26 6) PHYSICAL STATE Solid [ ] Liquid [X] Gas { ] Pure [ ] Mixture [~ Waste [ ] Radioactive [ ] 7) AMOUNT AND TIME AT FACIUTY UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount: 55 lbs [ ] gal ~] 1t3 [ ] a) Container: 06 Average Daily Amount: ~ cudes [ ] b) Pressure: ? Annual Amount: IUD c) Temperature: 4 L~rgest Size Container: 55 # Days On Site 365 CimleWh. ich Months: .. AIIYeer, J, F, M, A, M, J~ J, A, S, O, N, D 9) MIXTURE: List COMPONENT CAS # % WT AHM the three most hazardous 1) ['efined petroleum 64747-~A-7 ? [ ] chemical components or any AHM components 2) [ ] 3) [ ] lO) Location SE corner of building - exterior CHEMICAL DES,(~ON 1) INVENTORY STATUS: New[X] Addition[ ] Revision[ ] Deletion[ ] Check if chemical is a NON TRADE SECRET [ ] TRADE SECRET ~] 2) Common Name: Grease Chemical Name: Petroleum hydrocarbon .3) DOT # (optional) AHM [ ] CAS # 6/4.742-54-7 4) PHYSICAL & HEALTH PHYSICAL ' HEALTH HAZARD CATEGORIES Fire ~] Reactive [ ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ ] Delayed Health (Chronic) [~] 5) WASTE CLASSIFICATION N/A (3-digit code from DHS Form 8022) USE CODE ~) 6) PHYSICAL STATE Solid [ ] Liquid ~] Gas [ ] Pure [ ] Mixture I~] Waste [ ] Radioactive [ ] 7) AMOUNT AND TIME AT FACIUTY UNITS OF MEASURE 8) STORAGE COOES Maximum Daily Amount: 55 lbs [ ] gal [~ ~t3 [ ] a) Container: 06 Average Dally Amount: 1 0 cubes [ ] b) Pressure: 2 Annual Amount: ] 00 c) Temperature: 4 L.~'gest Size Container: 55 # Days On Site ~65 Circle Which Months: AIIYeaL J, F, M, A, M, J, J, A, S, O, N, D 9) MIXTURE: List the three most h~zardous chemical components or any AHM components COMPONENT CAS # % WT AHM 1) P~n~d pP~r~l ettm 64742-54-7 [.] 2). [ ] 3) ' [ ] ! 10) Location SE corner of building - exterior PRINT Name & Title of Authorized Company Representative Signature ~f CI Date BAKEREI IELD CITY FIRE DEP. iITMENT HAZARDOUS MATERIALS INVENTORY Page 2__of_z._ Business Name Panama-Buena Vista Sch. Dist. Address 5901 Schirra Ct. CHEMICAL DESCRIPTION 1) INVENTORY STATUS: New Ix] Addition [ 1 Revision [ ] Deletion [ ] .~"'" Check if chemical is a NON TRADE SECRET [ ] TRADE SECRET 2) Common Name: Gear Lubricant V 3) DOT # (optioneJ) ChemicalName: PmYro]p~lrn hvHr~mr~n AHM [ ] CAS# 64742-54-7 PHYSICAL & HEALTH PHYSICAL HEALTH HAZARD CATEGORIES Fire [~] Reactive [ ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ ] Delayed Health (Chronic) IX] WASTE CLASSIFICATION N/A ,(3-digit code fi.om DHS Form 8022) USE CODE 26 6) PHYSICAL STATE Solid [ ] Uquid [~ Gas [ ] Pure [ ] Mixture g] Waste [ ] Redioactive [ ] 7) AMOUNT AND TIME AT FACIUTY . , Maximum Dally Amount: Average Daily Amount: Annual Amount: ~ Largest Size Container: # Days On Site 365, 9) MIXTURE: Dst the three most hazardous chemical components or any AHM components UNITS OF MEASURE 8) STORAGE CODES lbs .[ ] gal IX] tt3 [ ] a) Container: 06 cudes [ ] b) Pressure: Z c) Temperature: 4 Circle Which Months: COMPONENT 1) Rmf~nmH pmrrml ml]m I All Year, J, F, M, A. M, J, J, A, S, O, N, D CAS # ' % WT AHM 2) [ ] 3) [ ] lO) Location SE corner of building - exterior CHEMICAL DE~ON 1) INVENTORY STATUS: New ~] Addition [ ] Revision [ ] Deletion [ ] Check if chemicaJ is a NON TRADE SECRET ~ ] TRADE SECRET [ ] 2) Common Name: Waste Oil 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 221 ' (3-digit code from OHS Form 8022) USE CODE 6) PHYSICAL STATE Solid [ ] Liquid IX] Gas [ ] Pure [ ] Mixture :~] Waste [ ] Radioactive [ ] 7) AMOUNT AND TIME AT FACIUTY UNITS OF MEASURE 8) STORAGE CODES Maximum Dally Amount: 55 lbs [ ] gaJ ~] ft3 [ ] a) Container: 06 Average Dally ~mount: ~ cu~es [ ] b) .ressur.: ~. Annual Amount: lDO c) Temperature: Largest Size Container: 5 5 # DaysOn Site ~65 CircteWhich Months: AllYear, J, F, M, A, M, J, J, A, S, O, N, D 9) MIXTURE: List the three most hazardous chemicaJ components or any AHM components COMPONENT CAS # % WT AHM 1) Refined Petroleum [ ] 2) , -" [ ] 3) [ ] 10) Location SE corner of building - exterior ' cern'fy under penalty of law, that I have personally examined and am familiar with the infoma~on submitted on this and afl attached documents. I befieve David L. George, Director of M.O.T. April 1 ~'Sign~tur~ ~ ~ PRINT Name & Title of Authorized Company Representative (J Date BAKERSFiii irD CITY FIRE DEPAR T ENT HAZARi )US MATERIALS INVENTO] rY Business Name Address Page_of_ CHEMICAL DESCRIPTION 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 FACILITY Maximum Daily Amount: Average Daily Amount: Annual Amount: Largest Size Container: # D~,ys. On Site UNITS OF MEASURE 8) STORAGE CODES lbs [ ] gal [ ] ~t3 [ ] a) Container: curies [ ] b) Pressure: c) Temperature: Circle Which Months: All Year, J, F, M, A, M~ J, J, A,..S., O, N, D 9) MIXTURE: List the three most hazardous chemical components or any AHM components COMPONENT CAS# %WT AHM 1) [] 2) [ ] 3). [ I 1 O) 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 COOE PHYSICAL STATE Solid [ ] Liquid [ ] Gas [ ] Pure [ ] Mixture [ ] Waste [ ] Radioactive [ ] 7) AMOUNT AND TIME AT FACIUTY Maximum Daily Amount: Average Dally Amount: Annual Amount: Largest Size Container: # Days On Site UNITS OF MEASURE 8) STORAGE CODES lbs [ ] gal [ ] 1t3 [ ] a) Container: curies [ ] b) Pressure: c) Temper~ure: CircleW~ich Months: All Year, J, F, M, A, M, J, J, A, S, O, N, D 9) MIXTURE: List the three most hazardous chemic~ components or any AHM components 2) 3) COMPONENT CAS.# % WT AHM (! [] [] lO) Loc.,a~ion submitted informat~'on is true, accurate, and complete. I believe PRINT Name & Title of Authorized Company Representative Signature Date