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HomeMy WebLinkAboutHAZ-BUSINESS PLAN 1/16/2002 · , ? UNIFIED PROGRAM CONSOLIDATED FORM FACILITY INFORMATION BUSINESS ACTIVITIES ~ FACILITY ID # (Agency Use Only) BUSINESS NAME (Same as Facility Name or DBA - Doing Business As) AUTQZONE# 533S- ~ \ q ~1 ßf # ~lj'i' Page 1 of 1 EPA ID # (Hazardous Waste Only) CAL 000 2.. 0'<0 % 17 2, 3, ,Have on site (for any purpose) hazardous materials at or above 55 gallons for liquids, 500 pounds for solids, or 200 cubic feet for compressed gases (include liquids in ASTs and USTs); or the applicable Federal threshold quantity for an extremely hazardous substance specified in 40 CFR Part 355, Appendix A or B; or handle radiological materials in quantities for which an emergency plan is required pursuant to 10 CFR Parts 30, 40 or 70? B, UNDERGROUND STORAGE TANKS (USTs) I. Own or operate underground storage tanks? 2. Intend to upgrade existing or install new USTs? 3. Need to report closing a UST? C. ABOVE GROUND PETROLEUM STORAGE TANKS (ASTs) Own or operate ASTs above these thresholds: ---any tank capacity is greater than 660 gallons, or ---the total capacity for the facility is greater than 1,320 gallons? D. HAZARDOUS WASTE I. Generate hazardous waste? ' 2. Recycle more than 100 kg/month of excluded or exempted recyclable materials (per HSC §25143.2)? 3. Treat hazardous waste on site? 4. Treatment subject to financial assurance requirements (for Permit by Rule and Conditional Authorization)? 5. Consolidate hazardous waste generated at a remote site? 6. Need to report the closure/removal of a tank that was classified as hazardous waste and cleaned onsite? E, LOCAL REQUIREMENTS 12?1 YES D NO 4, DYES 12?1 NO 5, DYES 181 NO 6, D YES 181 NO 7. D YES 181 NO 8. 181 YES D NO 9, DyES 12?1 NO 10, DYES ~ NO 11. DYES ~ NO 12, DYES 12?1 NO 13, DYES 12?1 NO 14, HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION (OES 2731) UST FACILITY (Formerly SWRCB Form A) UST TANK (one page per tank) (Formerly Form B) UST FACILITY UST TANK (one per tank) UST INSTALLATION - CERTIFICATE OF COMPLIANCE (one page per tank) (Formerly Form C) UST TANK (closure portion - one page per tank) NO FORM REQUIRED TO CUPAs EPA ID NUMBER - provide at the top of this page RECYCLABLE MATERIALS REPORT (one pC.. recycler) ON SITE HAZARDOUS WASTE TREATMENT - FAC ILITY (Formerly DTSC Forms 1772)' ONSITE HAZARDOUS WASTE TREATMENT - UNIT (one page per unit) (Formerly DTSC Forms 177Z A,B,C,D and L) CERTIFICATION OF FINANCIAL ASSURANCE (Formerly DTSC Form 1232) REMOTE WASTE I CONSOLIDATION SITE ANNUAL NOTIFICATION (Formerly DTSC Form 1196) HAZARDOUS WASTE TANK CLOSURE CERTIFICATION (Formerly DTSC Form 1249) (You may also be required to provide additional information by your CUPA or local agency,) IS, UN-020 - JI17 www.unidocs.org Rev. 01116102 I ç UNIFIED PROGRAM CONSOLIDATED FORM FACILITY INFORMATION BUSINESS OWNER/OPERA TOR IDENTIFICATION FACILITY ID # (Agel!cy Use Only) . BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Busincss AJ) AUTO ZONE # 5 35 BUSINESS SITE ADDRESS . I 0 ( LûJ.< ( ¿IHNAt . CITY fbtrI/ûz5 rti-t-j::, DUN & BRADSTREET 15-723-3511 COUNTY Pa e I of 1 100, ENDING DATE 101. 3, 102. 103. 1M, IOS. 107. . 108. 109. BUlINESS OP. ERA. TOR.,J:HONE -1!tIf (P(, - ..:J77--5703 110. II. BUSINESS OWNER OWNER NAME AUTOZONE INC OWNER MAILING ADDRESS 123 SOUTH FRONT STREET CITY MEMPHIS 111, OWNER PHONE 901-495-6500 112. 113. CONTACT NAME F ARLON WILLIAMS CONTACT MAILING ADDRESS· 123 SOUTH FRONT STREET, DEPT 8190 CITY MEMPHIS ,sTATE TN ENVIRONMENTAL CONTACT 117. 114, liS. ZIP CODE 38103-3607 116. III. CONTACT PHONE 901-495-7217 118. 119. -PRIMARY- NAME Ì)g.v\~ ål/1t(.j( TITLE DISTRICT MANAGER BUSINESS PHONE _ (p(p 1-3Cf 7- S?D3 24-HOUR PHONE* 1-800-313-9693 PAGER # NA ADDITIONAL LOCALLY COLLECTED INFORMATION: Property Owner: Billing Address: STATE TN IV. EMERGENCY CONTACTS 120, 121. ZIP CODE 38103-3607 -SECONDARY.,. 122. 123, NAME 128. ALARM CENTRAL 124, TITLE 129. AUTOZONER ON DUTY 125. BUSINESS PHONE 130. 1-800-313-9693 126, 24-HOUR PHONE* 131. 1-800-313-9693 127, PAGER # 132. NA 133. Phone No.: Certification: Based on my inquiry of those individuals responsible for obtaining the information, I certify under penalty of law that I have personally examined and am fa~liaT with the informatiOJýsubmitted and believe the infonnation is true, accurate, and complete, SIGI'¥'\Pè.JRE OF OWNERtoj?Ì'.Rf:TOR OB--DESIGNATED REPRESENTATlVE DATE I·'M './ ,i., ...' 6/15/04 M OF SIGNER (pr ) 136, TITLE OF SIGNER 134, NAME OF DOCUMENT PRJ:.PARER 135, F ARLON WILLIAMS 137, F ARLON WILLIAMS * See Instructions on next page, ENVIRONMENTAL SPECIALIST UN-020 - 5/17 www.unidocs.org Rev. 01/16/02 ~ ... Date: 06/1512004 Non-Waste Hazardous Materials Inventory Statement' For use by Unidocs Member Agencies or where approved by your Local Jurisdiction Business Name: AUTOZONE Type of Report on This Page: Page 10fl (Same as Facility Name or DBA) o Add; 0 Delete; 181 Revise (One page per bniJding or area) Chemical Location: SALES FLOOR I EPCRA Confidential Location? DYes; [g No I Facility ID # I :::!'Jrl II i¡::j::::: I I I (BuiJdinglStorage Area) Trade Secret Information? DYes; [g No (Agel1cyUseOnly) 1. 2. 3. 4. 5. 6. 7. 8. ? Map and Hazardous Components Type Quantities Storage Codes Grid or (For, mixtures only) and Haz. Location Chemical % Physical Max. Average Largest Storage Storage Hazard Class Code Common Name Name Wt. EHS CAS No. State Dailv Dailv Cont. Units Pressure Temp. Catee:ories COR 1 BATTERY FLUID-ACID SULFURIC ACID 34 181 7664-93-9 L!pure 600 300 4 ~ gallons ~ ambient ~ ambient ~ fire , 0 181 mixture pounds >amb. >amb. ¡.. . reattlve cu, feet o < ambo <ambo pressure release . 0 ~sOlid Cnries: Dav. On Sto..... o tons o cryogenic 18 acute ~eahh . IZI EHS 0 liquid (lfradåoactive) SiÉ: Container:- chrome heahh CAS No,: o gas 0 365 R o radioactive 7664-93-9 0 . TOX 2 ANTI-FREEZE ETHYLENE GLYCOL 95 0 107-21-1 L!pure 90 75 1 ~ gWIDns EI ambient ~ ambient fire DIETHYLENE GLYCOL 5 0 111-46-6 181 mixture pounds >amb, >amb, reactive cu.feet o < amb, <ambo pressure release 0 ~SOlid Curies: Days On Stora.. o tons o <:r}\"Jgenic acute heahh OEHS 0 liquid (If radioactive) Sit.: Container:* chronic heahh CAS No,: o gas 0 365 N o radioactive' 107·21-1 0 FLA 3 WINDSHIELD WASHER METHYL ALCOHOL 47 0 61-65-1 bdpure 50 30 1 ä gallons ~ ambient ~ambient ~ fife SOLVENT 0 181 mixture pounds >amb, >,amb, I- reactive CU, fœt o < ambo <ambo pressure release 0 BSOlid Curies: . Dav. On Sto.....; o tons o <:r}\"Jgenic i= acute health liquid (lfradioacti\'c) ~: Container: * i= CAS No,: o EHS 0 0 365 N chronic heahh 0 o gas o radioactive FLA 4 MOTOR OIL SOL VENT REFINED, 80 0 64742-54-7 '=Jpure 2400 1800 1 B~IIDns, B ambi..u B ambient fife HYDROTREATED HEAVY· 0 [g] mixture pounds >amb. >amb, :-= reactive cu. feet o < amb, <ambo ¡.. pressure release PARAFFINIC DISTILLATE . 0 BsOlid Curies: !2m.Qn ~ o tons o <:r}\"Jgenic ¡.. acute heahh liquid (Ifradioactivc) Site: Container:· CAS No,: OEHS 0 0 365 N chronic health o gas o radioactive 64742-54-7 , 0 0 bdpure ~ gallons tJ ~bient ~ ambient fife 0 o mixture pom >amb. >amb, reactive cu, feet o < amb, <amb, pressure release 0 BSOlid Curies: Davs On Sto....e o !Dns ,0 <:r}\"Jgenic acute health DEBS 0 liquid (If radloaalve) ~: Container:* chronic heahh CAS No,: o gas o radioactive 0 0 bdpure ~ galIDns ~ ambient IJ ambient fire 0 o mixture pounds >amb. B > amb, reactive cu. feet o < amb, <amb, pressure release D BSOlid Cnri.s: DRYS On ·Sto..... o !Dns o ",?"genic acute health, ' o EllS 0 liquid (Ifradloaalve) Site: Container: . chronic health CAS No,: o gas . o radioactive 0 I * Code Stora2e Tvoe A Aboveground Tank B Bclowground Tank C rank Inside Building Code Storaee Tvne D Steel Drum ~ StOrftl!C Tvne G Carboy H Silo Fiber Drum Code Stonee Tvoe Code Storal!c Tvne J Bag M Glass Bottle or lug K Bo, N Plastic·Bottle or Jug L Cylinder 0 Tote Bin !d!!!1 StorRe:e Tvne P Tank Wagon Q Rail Car R Other If EPCRA, sign below: E PlasticINon-metallic Drum F Can UN-020-7/17 www.unidocs.org Rev. 01116102 -~ .' ... Hazardous Waste Inventory Statement , Date: 6/1512004 For use by Unidocs Membèr Agencies or where approved by your Local Jurisdiction . \ Business Name: AUTOZONE Type of Report on This Page: Page lofl (Same as Facilily Name or DBA) o Add; 0 Delete; 1251 Revise (One page per building or area)' Chemical Location: STOCK ROOM I EPCRA Confidential Location? DYes; r8I No Facility ID II I Ii';!' 'il I I [;;3: I I I I (Building/Slorage Area) Trade Secret Information? DYes; 1251 No (Agency Use Only) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. ,., Map and Hazardous Components Type Quantities Storage Codes Grid or and Annual Haz. Location Chemical % Physical Max. Average Largest Waste Storage Storage Hazard Class Code Waste Stream Name Name Wt. EHS CAS No. State Dailv Dailv Cont. Amount Units Pressure Temp. Categories FLA A WASTE ABSORBENT WASTE ABSORBENT 50 0 8002-05-9 12$1 waste 440 220 440 1320 ~ gmloœ ~ ambient a .ambient ~ fife 0 pounds >amb. >amb. f= reactive . cu.feet o <,ambo <ambo f= pressure release Mana!!ement Method: 0 ~SOlid Curies: Davs On Sloraee ~ Otoœ o cryogenic I- acute heahh I8J Shipped Off·sile 0 liquid (Ifradioacti\'c) Site: Container:- Waste Code: chronic heah.h o Recycled On-site Dgas O' 365 D 352 o radioactive D Trealed On-sile 0 COR B USED BATIERY SULFURIC ACID 34 181 7664-93-9 181 waste 160 80 4 8320 ~ ,gmlOœ ~ ambient a :ambient 1= fire FLUID- ACID 0 pounds >amb, >amb. "" reactive aI. feet o < amb, <ambo 5< pressure release Mana!!emen! Method: 0 ~SOlid Curies: Davs On Sloraee Slale o toIlS o cryogenic IIQJte heakh I8J Shipped Off-site 0 liquid (lfrndloactlve) ~: Container:· Wasle Code: cbronic heakh o Recycled On-site Dgas 0 365 R 791 o radioactive D Treated On-site 0 FLA C WASTE OIL PETROLEUM OIL 99 0 8002-05-9 12$1 waste 220 110 220 5720 ~:Ioœ ~ ambient ~ ambient :x fire \ pounds >amb. >amb, reactive 0 ai, feet o < ambo <amb, = pressure release Mana!!emen! Method: 0 ~SOlid Curies: nm..I1n StOrDt!e ~ Otoœ o cryogenic '" IIQJte beakh I8J Shipped Off-site 0 liquid (If radioactive) Sile: Container:· Wasle Code: cbronic health D Recycled On-site o gas 0 365 P 221 o radioactive D Treated On-site 0 0 12$1 waste ~ gallollS ~ ambient ~ ambient = fire , 0 powuls >amb, >amb. = reactIve aI. feet o < amb, <ambo = pressure release Manaeement Method: 0 BSOlid Curies: Dovs On Stomee ~ Otoœ , _0 cryogenic = aalle heakh D Shipped Off-site 0 liquid (lfradioadivc) Sile: Container:"" Waste Code: cbronic heakh D Recycled On-site o gas o radioactive o Treated On-site 0 . 0 ~ waste '~ :Iloœ IJ ambient ~ ambient. = fire, I 0 pounds >amb. >amb. ' reactIVe aI. feet o < ambo <amb, pressure release Mana!!ement Method: 0 8 solid Curies: Davs Ou Slomee State Otoœ o cryogenic IIQJte health , D Shipped Off-site 0 liquid (lfradioaC1lvc¡ ~: Contniner:a Woste Code: o cbronic heahb D Recycled On-site Dgas o radioadive D Treated On-sitè 0 . i 0 ~ waste ~ :gaJ!oœ t:j ambient ~ambient fire I 0 pounds >amb, >amb, ¡.. reactive cu. feet o <amb, <amb_ F= pressure release Mana!!ement Method: 0 . BSOlid Cnries: Davs On Slom.. Slale Otoœ o cryogenic IIQJte heakh I o Shipped Off-site 0 liquid (lfrndloactlvc) Site: Container: .. Waste Code: cbronic bealtb o Recycled On-site Dgas o radioactive I o Treated On-site 0 * Code Storat!e Tvoe Code Storal!e TVDe Code Stone TVDe Code StOrBl!C Tvoe Code Stone Tvoe Q!!!£ Stomee Tvue If EPCRA, sign below: A Aboveground Tank D Steel Drum G Carboy J Bag M Glass Bottle or Jug P Tank Wagon B Belowground Tank E PlaslicINonmelallic Drum H Silo K Box N Plastic Bottle or Jug Q Rail Car C Tank Inside Building F Can I Fiber Drum L Cylinder 0 Tole Bin R Other I UN-020 - 9/17 , www.unidocs.org Rev. 01/16/02 Emergency Response/Contingency Plan (Hazardous Materials Business Plan Module) Authority Cited.' HSC, Section 25504(b); Title 22, Div. 4.5, Ch: 12, Art. 3 CCR Page 1 of5 All facilities that handle hazardous materials in specified quantities must have a written emergency response plan. In addition, facilities that generate 1,000 kilograms or mere of hazardous waste per month, or accumulate more than 6,000 kilograms of hazardous waste on-site at anyone time, must prepare a contingency plan. Because the requirements are similar, they have been combined in a single document, provided below, for your convenience. This plan is a required module of the Hazardous Materials Business Plan (HMBP). If you already have a plan that meets these requirements, you should not complete the blank plan, below, but you must include a copy of your existing plan as part of your HMBP. This site-specific Emergency Response/Contingency Plan is the facility's plan for dealing with emergencies and shall be implemented immediately whenever there is a fire, explosion, or release of hazardous materials that could threaten human health and/or the environment. At least one, copy of the plan shall be maintained at the facility for use in the event of an emergency and for inspection by the local àgency. Within Santa Clara County, hospitals and police agencies have delegated receipt of these plans to the local agencies administering Hazardous Materials Business Plaps, so additional copies need not be submitted. However, a copy of the plan and any revisions must be provided to any contractor, hospital, or agency with whom special (i.e. contractual) emergency services arrangements have been made (see section 3, below). 1. Evacuation Plan: a. The following alarm signal(s) will be used to begin evacuation of the facility (check all that apply): o Bells; 0 Homs/Sirens;[g Verbal (i.e. shouting); 0 Other (specify) b, [g Evacuation map is prominently displayed throughout the facility. Note: A properly completed HMBP Site Plan satisfies contingency plan map requirements. This drawing (or any other drawing that - shows primary and alternate evacuation routes, emergency exits, and primary and alternate staging areas) must be prominently posted throughout the facility in locations where it will be visible to employees and visitors. 2. a. Emergency Contacts*: Fire/Police/ Ambulance ........................................ . Phone No. 911 State Office of Emergency Services b. Post-Incident Contacts*: ............................. . Phone No. (800) 852-7550 Fire Department Hazardous Materials Program .................. . Phone No.: ~ County Hazardous Materials Compliance Division California EP A Department of Toxic Substances Control Phone No. ( ) ........... . Phone No. (510) 540~3739 Phone No. (408)452-7288 Phone No. (415) 771-6000 Cal-OSHA Division of Occupational Safety and Health Air Quality Manageme~t District ............. . ....................... . Regional Water Quality Control Board . . . . . . . . . . . . . . . . . . . . . . . . . . . Phone No. (510) 622-2300 * TlIese telepltone numbers are provided as a general aid to emergency notification. Be advised tllat additional agencies may be required to be notified. c. Emergency Resources: Poison Control Center ...................................... . Phone No. (800)876-4766 Phone No.: (M,' ) ~ 3~ -sot/CO City: ~/é/i!' 5/' /£~ í) Nearest Hospital: Name: fY\f[A.l~Á,.f H-6:51' ¡,-,:¡L Address: d [)If 5' 'Ît2,t.\.,,¡ r¡,.u,l ,4Vf' , 3. Arrangements With Emergency Responders: If you have made special (i.e, contractual) arrangements with any police department, fire department, hospital, contractor, or State or local emergency response team to coordinate emergency services, describe those arrangements below: STORE WILL CONTACT 3E COMPANY AT 1-800-313-9693 TO COORDINATOR EMERGENCY. UN-020 - 13/17 www.unidocs.org Rev. 01116/02 Emergency Response/Contingency Plan Page 30f5 7. Emergency Equipment: 22 CCR §66265.52(e)[as referenced by 22 CCR §66262.34(a)(4)] and the Hazardous Materials Storage Ordinance require that emergency equipment at the facility be listed. Completion of the following Emergency Equipment Inventory Table meets this requirement. EMERGENCY EQUIPMENT INVENTORY TABLE 1. 2. 3. 4. Equipment Equipment Category Type Locations * Description ** Personal o Cartridge Respirators Protective o Chemical Monitoring Equipment (describe) Equipment, ~ Chemical Protective Aprons/Coats BATT CHG ACID APRON Safety o Chemical Protective Boots Equipment, ~ Chemical Protective Gloves BATTCHG 2 PAIR OF RUBBER GLOVES and o Chemièal Proteétive Suits (describe) First Aid' o Face Shields Equipment ~ First Aid Kits/Stations (describe) REST RM ONE LARGE FIRST AID STATION , o Hard Hats o Plumbed Eye Wash Stations . ~ Portable Eye Wash Kits (i,e, bottle type) BATT CHG TWO 32 OZ EYE WASH BOTTLES o Respirator Cartridges (describe) ~ Safety Glasses/Splash Goggles BATTCHG SLASH GOGGLES (GLASSES-MINI-TUNE) o Safety Showers o Self-Contained Breathing Apparatuses (SCBA) o Other (describe) Fire o Automatic Fire Sprinkler Systems Extinguishing o Fire Alarm Boxes/Stations , Systems o Fire Extinguisher Systems (describe) o Other (describe) Spill ~ Absorbents (describe) . SALES FLR 8-1040 LB BAGS Control o BermslDikes (describe) Equipment o Decontamination Equipment (describe) and. o Emergency Tanks (describe) Decontamination o Exhaust Hoods . Equipment o Gas Cylinder Leak Repair Kits (describe) ~ Neutralizers (describe) BATT CHG 30 LB BUCKET SODA ASH o Overpack Drums o Sumps (describe) o Other (describe) Communications o Chemical Alarms (describe) and o Intercoms/ P A Systems Alarm o Portable Radios Systems ~ Telephones COUNTER 5-6 HARD LINE PHONES o Underground Tank Leak Detection Monitors o Other (describe) Additional ~ 55 GALLON STEEL DRUM STOCK RM Equipment ~ MOPS, BROOMS, MOP BUCKETS STOCK RM (Use Additional ~ TRASH BAGS, SALES BAGS Pages if Needed.) 0 0 0 Use the map and grid numbers from the Storage Map prepared earlier for your HMBP, ** Describe the equipment and its capabilities, If applicable, specifY any testing/maintenance procedures/intervals, Attach additional pages, numbered appropriately, ifneeded. * UN-020 -15/17 www.unidocs.org Rev. 01116/02 Employee Training Plan (Hazardous Materials Business Plan Module) Authority Cited: HSC, Section 25504(c); Title 22, Div, 4,5, Ch. 12, Art. 3 CCR Page 40f5 All facilities that handle hazardous materials must have a written employee training plan. This plan is a required module of the Hazardous Materials Business Plan (HMBP). A blank plan has been provided below for you to complete and submit if you do not already have such a plan. If you already 'have a brief written description of your training program that addresses aU subjects covered below, YQU are not required to· complete the blank plan, below, but you must include a copy of your existing document as part of your HMBP. Check all boxes that apply. [Note: Items marked with an asterisk (*) are required.]: 1. Personnel are trained in the following procedures: IðJ IðJ o o o o (e.g. "Quarterly", etc.) oint locations* Plan 2. Che~ical Handlers are additionally trained in the following: IðJ o o [8] IðJ IðJ inhalation, ingestion, 3. Emergency Response Team Members are capable of and engaged in the following: o o o o ~ o (e.g. "Quarterly", etc.) UN-020 -16/17 www.unidocs.org Rev. 01116/02 Record Keeping (Hazardous Materials Business Plan Module) Page 50f5 All facilities that handle hazardous materials must maintain records associateq with their management. A summary of your recordkeeping procedures is a required module of the Hazardous Materials Business Plan (HMBP). A blank summary has been provided below for you to complete and submit if you do not already have such a document. If you . already- have a brief written description of your hazardous materials recordkeeping systems that addresses all subjects covered below, you are not required to complete this page, but you must include a copy of your existing document as part of your HMBP. Check all boxes that apply. The following rècords are maintained at the facility. [Note: Items marked with an asterisk (*) are required.): ~ ~ ~ ~ ~ ~ ~ o Description and documentation of facility emergency res onse drills Note: The above list of records does not necessarily identify every type of record required to be maintained by the facility. A copy of the Inspection _ Check Sheet(s) or Log(s) used in conjunction with required routine self- inspections of your facility must be submitted with your HMBP. (Exception: Available from your local agency is a Hazardous Materials/Waste Storage Area Inspection Form that you may use ifyoù do not already have your own form. If you use the example provided, you do not need to attach a copy.) Check the a TO riate box: o We will use the Unidocs "Hazardous Materials/Waste Storae Area Ins ection Form" to document ins ections. OWe will use our own documents to record ins ections. (A blank co 0 each document used must be attached to this HMBP. UN-020 -17/17 www.uoidocs.org Rev. 01/16/02 Facility Site Plan/Storage Map (Hazardous Materials Business Plan Module) Site Address: n D I lJjJ-.( 1T'£ . ~é:. '~s¡?ld~ Date Map Drawn: ~ / ~ 0 1. Map Scale: NOT TO SCALE Page 10f1 1 2 3 4 5 6 7 8 9 10 ---:--; ~ ... '-".. ·-·--t · '......... 11 , 12 \ 'W" 13 14 15 16 17 18 19 20 21 22 -,-= \. 23 r . 24 rOOD::, .. 25 D. 26 1----- , ABC D E F G H I J K L M N 0 P Q R S T V V W x y z .....' ~.J . . \¡,. f-\ [ì1f: t ¡y. ....Ii£. . . ---... ~ ~3 U rr Q....t[ 0 ^ )k,;( ~ ~~L=Li ,I [Q]~ µ /11-' IH.··.J' 'f! 1/ III II I r!] ",fr..' I...l.' I ..~/. ß! , fI l' { hi' I·; i,j / j j .11 , fL:!/ /: / , 1 " ! , eJ b , :t: I i i I . A I '~ ! j -------- - /Ì' I \ 'ª~ ^ 1\, f~ a h tí Ir1K """ ',~: " . g :,,_ ~~ (?) CD~ FF~E~ I=I:=I·-:+=r==~ ft °ri,=:: mn - ~ . a ~~~I! I 'ª~ t E::E:::I::-~~I . I . 'ª~ 1 E:E:FI----l I ~-J=:~EI ~ Jf ¡=I~ :::±::~I \ J @ I¥' l=Lr=:=E~1 ®_ ©æC~i~ r----r---ilI 1~'ì¥d~J---:-..I~ ~ [I~ -=- ---- -~~I ,r=c=: . ........JI ~~ I . f- ¡.tD «I t. - , IV f! rl't'Sl! I .'" '""" ' ~ U" ...., ~ 27 28 Instructions are printed on the following page. UN-020 -11117 www.unidocs.org Rev. 01116/02