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Home My WebLink AboutBUSINESS PLAN 6/19/2003 L .,-r-"' '7'" , ' t .,;£. . .. ..' ." 5/Tt (0 *¡q<6~ :ur::~~ rrzj 11 J/J(e-o 1P'þJ<; FACILITY DIAGRAM ( I. Bulin.. Address: '660) LVII Ql. LAN£: ' ~ . () "2 fJJHITt LAtJ[ SoNIc, vl<.JV£If] "0 I " AAMCD Tf¿Ari5 C. ~o5S p."t>!lfJ5 .A¡jfO eEflf[Tt .~ :. AS~[ - P-IJ ,. I '1 ~ I ~ ~ .... f:/ Q ~ ......... ."...- J ~a ,. , 'e ~ I ! ~ I 1. ~I ¡ :1 1 !: " I l, ,\ 1 ..I sm DIAG~ t f Business Name: _ Business AddrbsS: l ! J '~ :'!',. I \ I: , ,I I' ~ 'J :¡' :¡ -t', 8 '\ ). II -I III :~ - , ) I ~ ~ FACILITY DIAQRAM t ì ¡ r r I. .1 ! r , , ¡; j !! ~ \ .~ j: , I ¡ I , ~ SITE DIAGRAM ~I _ FACILITYtllAGRAM r I Business Name: -.I AjMc() ¡(LAN5.. . Business Address: ~(;ð I WiHT[ L ¡. N t. ~ ßX 5) ell ?_S3 D9 , 0 ht.~fI~fJl\flliî ~ ,,()G-i.( W AW- £Œ c.Îþ.\ <::-- SHvi off ~ <J;A'! ;' ií 0 't' r' --.... 0 5~u ;" SS ¡;,-A:¡JT ~ 0 (}/...U~ j ¡t,flS ~t'-'~ .¿. P e:!'¡'" "LID í.J.l ~I IT t. l.. A N [ o wAí£~ SHoi ùrF IL 1 . t ! t N N . "'I WAff£ OLL k' 2)~b 6~ L- .--t G-A1~ ¡ ~A rt:___1_J :;- ---- . AAMCO TRANSMISSION . // . SiteID: 015-021-00:~;2 ~~- Manager : WOODY WIYNINGER Location: 6601 WHITE LN City BAKERSFIELD BusPhone: Map : 123 Grid: 16D (661) 398-0400 CommHaz : Low FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 09 EPA Numb: SIC Code: DunnBrad:77-022-1558 Emergency Contact JOHN WHITE Business Phone: 24-Hour Phone : Pager Phone : / Title / OWNER (661) 398-0400x (661) 873-0905x ( ) - x Emergency· Contact / ' Title WOODY WIYNINGER / MANAGER Business Phone: (661) 398-0400x 24-Hour Phone : (661) 835-8481x Pager Phone : ( ) - x Hazmat Hazards: Fire DelHlth Contact : MailAddr: 6601 WHITE LN City : BAKERSFIELD Phone: (661) 398-0400x State: CA Zip : 93309 Owner Address : City JOHN WHITE 3612 BRAEBURN DR : BAKERSFIELD Phone: (661) State: CA Zip : 93306 - 87x30905 Period : Preparer: Certif'd: parcelNo: to TotalASTs: = TotalUSTs: = RSs: No Gal Gal Emergency Directives: _./ ~)ÔH:JJ l..u µ I t. Do hereby certi1y that I have II ~ w (fvpe or print name) reviewed the attached hazardolAs materials manage- ment plan for _11 tJ¡ru<¡ ~nd that it along with ~lNe.meof~) any col1'6dions constitute a complete and correct man- agement plan for my facility. -fvV Si re Þ!I~03 -1- 06/16/2003 ,'Ì' <Þ , F AAMCO TRANSMISSION p= Hazmat Inventory p== MCP+DailyMax Order . .SiteID: 015-021-001982 ì By Facility Unit ì Fixed Containers at Site ì Hazmat Common Name... SpecHaz EPA Hazards DailyMax MCP F DH L 55.00 GAL Mod F DH L 240.00 GAL Low F DH L 220.00 GAL Low SOLVENT TRANSMISSION FLUID WASTE TRANSMISSION FLUID -2- 06/16/2003 '"" F AAMCO TRANSMISSION f= Inventory Item 0001 F== COMMON NAME / CHEMICAL NAME SOLVENT ORGANIC SOLVENT Location within this Facility W SIDE OF BLDG¡ OUTSIDE . · SiteID: 015-021-001982 ì Facility Unit: Fixed Containers at Site ì Days On Site 365 Unit Map: Grid: CAS# STATE - TYPE Liquid Pure PRESSURE Ambient TEMPERATURE Ambient CONTAINER TYPE DRUM/BARREL-METALLIC Largest Container 55.00 GAL AMOUNTS AT THIS LOCATION Daily Maximum 55.00 GAL Daily Average 30.00 GAL %Wt I 100.åo Naphtha HAZARDOUS COMPONENTS CAS # I 8030306: ~ TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F DH / / / Mod HAZARD ASSESSMENTS Ag.Defined1: MISC. LOCAL AGENCY DATA Ag.Defined2: Ag.Defined3: Ag.Defined4: Ag.Defined5: Ag.Defined6: Ag.Defined7: Ag.Defined8: Ag.Defined9: Ag.Define10: - Ag.Define11 -3- 06/16/2003 "'" . . SiteID: 015-021-001982 ì Facility Unit: Fixed Containers at Site ì F AAMCO TRANSMISSION p= Inventory Item 0002 F== COMMON NAME / CHEMICAL NAME TRANSMISSION FLUID Days On Site 365 Location within this Facility Unit W SIDE OF BLDG, OUTSIDE Map: Grid: CAS# o STATE - TYPE Liquid Pure PRESSURE Ambient TEMPERATURE Ambient CONTAINER TYPE ABOVE GROUND TANK Largest Container 240.00 GAL AMOUNTS AT THIS LOCATION Daily Maximum 240.00 GAL Daily Average 200.00 GAL %Wt. RS CAS# 100.00 Transmission Fluid (Petroleum-Based) No 0 HAZARDOUS COMPONENTS TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F DH / / / Low HAZARD ASSESSMENTS Ag.Defined1: MISC. LOCAL AGENCY DATA Ag.Defined2: Ag.Defined3: Ag.Defined4: Ag.Defined5: Ag.Defined6: Ag.Defined7: Ag.Defined8: Ag.Defined9: Ag.Define10: - Ag.Define11 -4- 06/16/2003 ...,. . . F AAMCO TRANSMISSION f= Inventory Item 0003 F== COMMON NAME / CHEMICAL NAME WASTE TRANSMISSION FLUID SiteID: 015-021-001982 9 Facility Unit: Fixed Containers at Site 9 Days On Site 365 Location within this Facility Unit SE CORNER OF BLDG, INSIDE Map: Grid: CAS# 221 STATE - TYPE Liquid Waste PRESSURE Ambient TEMPERATURE Ambient CONTAINER TYPE ABOVE GROUND TANK Largest Container 220.00 GAL AMOUNTS AT THIS LOCATION Daily Maximum 220.00 GAL Daily Average 100.00 GAL %Wt. RS CAS# 100.00 Transmission Fluid (Petroleum-Based) No 0 HAZARDOUS COMPONENTS TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F DH / / / Low HAZARD ASSESSMENTS Ag.Defined1: MISC. LOCAL AGENCY DATA Ag.Defined2: Ag.Defined3:" Ag.Defined4: Ag.Defined8: Ag.Defined6: Ag.Defined7: Ag.Defined9: Ag.Define10: Ag.Defined5: I- Ag. Define11 -5- 06/16/2003 F AAMCO TRANSMISSION f= Inventory Item 0003 . · SiteID: 015-021-001982 ì Facility Unit: Fixed Containers at Site ì WASTE DATA ~. Treated On Site CA Code US Code GAL Generated/Mo. GAL Generated/Yr. No Treatment UnitID: I Unit Type: Agency-Defined Text Label -6- 06/16/2003 F AAMCO TRANSMISSION I f= Notif./Evacuation/Medical r=: Agency Notification ~IRE DEPT CALL 911. ~ Employee Notif./Evacuation L:RBAL. I Public Notif./Evacuation VERBAL. . . ... SiteID: 015-021-001982 ì Fast Format ì Overall Site ì 08/12/19991 1 ] 08/12/1999 08/12/1999 Emergency Medical Plan 08/12/1999 MING & ASHE MEDICAL IS THE CLINIC WE WOULD USE. -7- 06/16/2003 v.:> . . SiteID: 015-021-001982 9 Fast Format =¡ Overall Site 9 08/12/1999 F AAMCO TRANSMISSION I p= Mitigation/Prevent/Abatemt Release Prevention ALL MATERIALS ARE IN STEEL CONTAINERS, OIL DOUBLE WALL, SOLVENT STORED OUTSIDE OF BLDG. Clean Up 08/12/1999 08/12/19991 1 I ~ Release.containment ~OOR DRY WOULD BE USED. FLOOR DRY WOULD BE USED. Other Resource Activation -8- 06/16/2003 i:.~ . . SiteID: 015-021-001982 ì Fast Format ì Overall Site ì I F AAMCO TRANSMISSION I p= Site Emergency Factors r== Special Hazards Utility Shut-Offs 08/12/1999 A) GAS - NW CORNER OF BLDG B) ELECTRICAL - NW CORNER OF BLDG C) WATER - AT SIDEWALK IN FRONT OF D) SPECIAL - NONE E) LOCK BOX - NO BLDG Fire Protec./Avail. Water 08/12/1999 PRIVATE FIRE PROTECTION - NEAREST FIRE HYDRANT - AT THE CORNER IN FRONT OF BLDG. Building Occupancy Level -9- 06/16/2003 .' . . ",", SiteID: 015-021-001982 ì Fast Format ì Overall Site ì 08/12/1999 F AAMCO TRANSMISSION I F Training Employee Training WE HAVE 8 EMPLOYEES AT THIS FACILITY. WE DO HAVE MSDS SHEETS ON FILE. BRIEF SUMMARY OF TRAINING PROGRAM: PROGRAM SET UP BY SAFETY-KLEEN AND AAMCO TRANSMISSION INC. Page 2 [ I I Held for Future Use Held for Future Use -10- 06/16/2003 ,~ .-'~ ~ ".;.... ..ði.:. , - -- . CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., Bakersfield, CA (805) 326-3979 INSTRUCTIONS: 1. To avoid further action, return this fonn within 30 days of receipt. 2. TYPEIPRINT ANSWERS IN 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 BUSINESS NAME: /lI/Mca TR.A/II S . . LOCATION: b t 0 I W /~ IfF I- AN [ .-/ MAILING ADDRESS: g AM t:. CITY: JlAi£tS¡;/fJJ) STATE:ç:]LZIP:1MPHONE: .1ìr -tJ'/ò{) - It: SIC CODE: T/!/INSA(I:J510N5 DUN & BRADSTREET NUMBER: PRIMARY ACTMTY: II U 10 t2£PA I~ OWNER: lYolJ1J/ {v/! /¡E MAILING ADDRESS: SAM L SECTION 2: EMERGENCY NOTIFICATION CONTACT ...-/ 1. uo'bJA1 tJlIlTt 2. ÙJODD;I tU'Yf/IfI/ 6£P- TITLE BUS. PHONE 3Zf --oWO 3~~- tJ<!Dð 24 HR. PHONE 073 -tJ~tJ.S ~3S-- ~4~1 ój~)/elè {VtGtz... . 1 d ~. f!I I ~~ - e .;.:~~ HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 3: TRAINING NUMBER OF EMPLOYEES: ~ MATERIAL SAFETY DATA SHEETS ON FILE: y f 5 BRIEF SUMMARY OF TRAINING PROGRAM: PQDúfZßM sti' uP ßÝ S¡(f£'7//-¡{¿.t£N 'i' AI1/IÆe-C; Tf!!IJJS /JlIc, . 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 TIME EXCEED TIlE MINIMUM REPORTING QUANTITIES. OTHER (SPECIFY REASON) SECTION 5: CERTIFICATION - I, JÒU J¡j Lulll r t CERTIFY THAT TIlE ABOVE INFORMATION IS ACCURATE. I UNDERSTAND THAT TInS INFORMATION Wll..L 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 ET AL.) AND THAT INACCURATE INFORMATION CONSTITUTES PERJURY. SIIfi~ ()7JVP^- TITLE J'/::Þð /97 ( DÁTE 2 ~.. ~ r":::. , ~ ..¡........,~ e e HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 6: NOTIFICATION AND EVACUATION PROCEDURES A. AGENCY NOTIFICATION PROCEDURES: fIRe DEfT c.A LL c¡ l( B. EMPLOYEE NOTIFICATION AND EVACUATION: jE(tI3A L C. PUBLIC EVACUATION: VE1tl3A L D. EMERGENCY MEDICAL PLAN: '.d. ~ W"- ~ ¡.u¡..IL' 11lU' -r0-# ~ ~ ~ 3 ------:;>~, . ..;(~ e -- ':'t'f-4'-¡::;;-~;"''''' HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 7: MITIGATION. PREVENTION AND ABATEMENT PLAN A. ~~EASE ~~fITION S~S: .fI-. 0 (~ ;J-. ~ ~ {};.JU<- ~ ()A1L µV ~ ) ~~~(Ø~ ' ' B. RELEASE CONTAINMENT AND/OR MINIMIZATION: }~ cÞ-¡ ~ Þ- pµ-i¿ C. CLEAN-UP PROCEDURES: ~ /1lA..- ß. SECTION 8: UTll.ITY SHUT -OFFS (LOCATION OF SHUT -OFFS AT YOUR FACILITY) NATURAL GAS/PROPANE: AI.W ~1.~ l/ iI WATER: ELECTRICAL: ~~·µVfJ(~ SPECIAL: LOCK BOX: YEB'/NO IF YES, LOCATION: SECTION 9: PRIVATE FIRE PROTECTION/WATER AVAILABILITY <. A. PRIVATE FIRE PROTECTION: B. WATER AVAILABILITY (FIRE HYDRANT): ~ "2- I ~~ CAA/ pß 4 - '-.--$ - t ~' e e '1- CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., Bakersfield, CA (805) 326-3979 ~qßJ-l f(ð5' -pr;L\':L HAZARDOUS - LS INVENTORY ¡.yrê FACILITY DESCRIPTION ~ ~¡;:rr:'f;;:r¡n";;;fiF'~ ô-::'- \ft ~/~~;;~"~"IJ; CHECK IF BUSINESS IS A FARM [] \ q L l'/;;:f?f'" "c~'J~C"~ BUSINESS NAME AAMcð T!<.IJ/IIJ. ~'lH;.. FACILITY NAME .s-I/ I'A [ SITE ADDRESS 66 ð I Lu/.J lTC J-N CITY ß4t{f{<5Fi~LJ) STATE C A ZIP? J 3 t> 7 NATURE OF BUSINESS 1l<ANSMlS~ jò!J «EPA/R./ AuTO ~ rì?.lJc6 SIC CODE 77-ÓLL/0S-t DUN & BRADSTREET NUMBER OWNER/OPERATOR U<JtJAl IY# ITt PHONE 773 - o90~ MAILING ADDRESS 3(.fL ß~~ D~ I CITY (3~~ STATE Cc;.../ ZIP 933tJ6 EMERGENCY CONTACTS NAME Oo8N W~ l1f BUSINESS PHONE 31 r - 0 t01J NAME úJ()OVy tJlrNlfi/&Ef- BUSINESS PHONE 3 ~ f - o1.fo D TITLE OLJNE~ 24 HOUR PHONE 't1J ~ c) 9ðŠ TITLE MG-¡¿" , 24HOURPHONE ?3~- f48-(_ 1 Business Name ~OUS MATERIALS IN~RY «~ .' Address ~6¿j1 ·wU ;£..., ./ J .~:::z.-~ - ~ ;~" '4 Page -f- of _ CHEMICAL DESCRIPTION 1) INVENTORY STATI1S: New (v1'Áddition ( J Revision ( ] Deletion ( ] Check ifchemical is a NON Trade Secret [0'Trade Secret [ 2) Common Name: O~ ~ . 3) DOT # (optional) VN 12. 6.r . ChemicalName:~ 1 p~ ~~ AHM[ ] CAS# ~ ~ I 4) Physical & Health PHYSICAL HEAL rn Hazard Categories Fire [2.] Reactive [ò] Sudden Release of Pressure [0] Immediate Health (Acute) [.:l] Delayed Health (Chronic) [OJ 5) WASTE CLASSIFICATION ;2./1 (3-digit code from DHS Fonn 8022) USE CODE () 7 6) PHYSICAL STATE Solid [ ] Liquid [v( Gas [ ] Pme [ Mixture [vi' Waste [ ] Radioactive [ ] 7) AMOUNT AND TIME AT F ACll..ITY - UNITS OF ME.A§URE 8) STORAGE COW, I 06 - n. J . Maximum Daily Amount S ~ Lbs [ ] Gal [V] ft3 [ ] a) Container: :zt!iuM S"j ~ Average Daily,Amount J ð __ Cwies[ ] b) Pressure: Annual Amount J},ð Z> c) Temperature Largest Size Container SJ.. 1# Days on Site .jtS Circle Which Months: ~ J, F, M. A, M. J, J, A, S, 0, N, D 9)~: Li~ the three most hazardous chemical components or any AHM components ~NENf ~ 1) UA , M=t. . 2) 3) CAS# %Wf AHM [ ] [ ] [ ] 10)LOCATION W~ ~ "'5 ~ ~ 1) INVENfORY STATI1S: New [4ddition [ ] RevisCJn [ ] Deletion [ 2)CommonName:-ÂVTO 7PJ1tlS FLUID Chemical Name: fJ £ ¡p.¿;LE U M '- t/¡J AI c..A IÝT Check if chemical is a NON Trade Secret [~ Secret [ 3) DOT 1# (optional) --' AHM [ ] CAS 1# MI X TV /<. t:- 4) Physical & Health PHYSICAL HEAL rn Hazard Categories Fire [I] Reactive [0] Sudden Release of Pressure [0] Immediate Health (Acute) [I] Delayed Health (Chronic) [ 5) WASTE CLASSIFICATION .2-1- I (3~git code from DHS Form 8022) USE CODE -26 6) PHYSICAL STATE Solid [ ] Liquid [0 Gas [ ] Pme [ Mixture [¿,.f' Waste [ ] Radioactive [ 7) AMOUNT ANDTIMEATFAC~L¿) UNITS OF MEA§URE 8)STO~GECOQiS 1)0-.7 I Maximum Daily Amount 2....""f Lbs [ ] Gal [a/) ft3 [ ] a) ContaIner: ~ ~ Average Daily Amount :J,..ð¿:.' Cwies [ ] b) Pressme: Annual Amount @O c) Temperature Largest Size Container . :;J. <¡.o 1# Days on Site ~~r Circle Which Months: ~J, F, M. A, M. J, J, A, S. 0, N. D 9)~: Li~ the three mo~ hazardous chemical components or i any AHM components l)~~ 2) 3) CASI# %Wf AHM [ ] [ ] [ ] IO)LOCATION W.ß<iA ~ ~ I certify under penalty of law, that I hay y' ed and am familiar with the information on this and all attached documents. I believe the submitted infonnation is true, accurate and complete. PRINT Name & Title of Authorized Company Representative Signature Date '.- £ ~ 'J ,1"'.. I Busu1ess Name ~OUS MATERIALS INVENTORye Address Page !J- of Þ- CHEMUCALDESCannnON /' I) INVENTORY STATUS: New [4ddition [ 2) Common Name: -ÍI U ì D 7fI.A N'::, Chemical Name: JCTf2.ólEUµ' J Revision [ J Deletion [ FLU 1) LU1šJZIc.~NT Check if chemical is a NON Trade Secret [ ] Trade Secret [ 3) DOT /I (optional) ./' ARM [ J CAS /I M I XTvp..l 4) Physical & Health PHYSICAL HEAL TII Hazard Categories Fire [ I] Reactive [OJ Sudden Release of Pressure [OJ Immediate Health (Acute)[ ( J Delayed Health (Chronic)[ 5) WASTE CLASSmCATION :2-)... , (3-digit code &om DHS Fonn 8022) USE CODE Lfò 6) PHYSICAL STATE Solid [ J Liquid [~ Gas [ J Pw-e [ Mixtw"e U Waste [ J Radioactive [ J 7) AMOUNT AND TIME AT FACll..ITY2. Maximum Daily Amount .:J. D Average Daily Amount I ð 0 Annual Amount / ¿ t> D Largest Size Container i 1- ~ # Days on Site hS UNITS OF ~ Lbs [ ] Gal [V} ft3 [ ] Curies [ ] '. 8) STORAGE CODES a) Container: 0 2- b) Pressure: c) Temperature ~ J, F, M, A. M, J, J, A. S, 0, N, D Circle Which Months: 9)~: Li~ the three most hazardous chemical components or any ARM components l)~~ 2) 3) CAS/I %wr ARM [ ] [ ] [ ] JO)LOCATIO~~ µj'·~1 ~ J ~ 1) INVENTORY STATUS: New [ ] Addition [ ] Revision [ ] Deletion [ ] Check ifchemical is a NON Trade Secret [ ] Trade Secret [ ] 2) Common Name: 3) DOT 1# (optional) Chemical Name: ARM [ ] CAS /I 4) Physical & Health PHYSICAL HEAL TII Hazard Categories Fire [ ] Reactive [ ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ ] Delayed Health (Chronic) [ 5) WASTE CLASSIFICATION (3-digit code &om DHS Form 8022) USE CODE 6) PHYSICAL STATE Solid [ Liquid [ J Gas [ ] Pw-e [ Mixture [ ] Waste [ Radioactive [ 7) AMOUNT AND TIME AT FACILITY Maximum Daily Amount Average Daily Amount Annual Amount Largest Size Container # Days on Site UNITS OF MEASURE Lbs[ ]Gal[ ]ft3[] Curies [ ] 8) STORAGE CODES a) Container: b) Pressure: c) Temperature Circle Which Months: All Year, J, F, M, A. M, J, J, A., S, 0, N, D 9)~: Li~ ,·the three most hazardous I) chemiCal components or 2) any ARM components 3) COMPONENT CASI# %wr AHM [ ] [ ] [ J lO)LOCATION [ certify under penalty of law, that I have personally examined and am familiar with the intònnaûon on this and all attached documents. I believe the submitted infonnation is true, accurate and complete. PRINT Name & Title of Authorized Company Representative Signature Date .., tþ\zARoous MATERIALS INVE.RY -' "''\. w ' \. Business Name Page_of_ Address CHEMICAL DESCRIPTION ( ) INVENTORY ST A ruS: New [ ] Addition [ ] Revision [ ] Deletion [ ] Check if chemical is a NON Trade Secret [ ] Trade Secret [ ] 2) Common Name: 3) DOT 1# (optional) Chemical Name: ARM [ ] CAS f# 4) Physical & Health PHYSICAL HEAL 1H Hazard Categories Fire [ ] Reactive [ ] Sudden Release of Pressure l ] Immediate Health (Acute) [ ] Delayed Health (Chronic) [ 5) WASTE CLASSIFICATION (3-digit code from DHS Form 8022) USE CODE 6) PHYSICAL STATE Solid [ Liquid [ Gas [ J Pure [ Mixture [ ] Waste [ J Radioactive [ 8) STORAGE CODES a) Container: b) Pressure: c) Tempetature 7) AMOUNT AND TIME AT FACn..lTY Maximum Daily Amount Average Daily Amount Annual Amount Largest Size Container 1# Days on Site UNITS OF MEASURE Lbs[ ] Gal [ ]ft3[ ] Curies [ J Circle Which Months: All Year, J, F, M, A, M, J, J, A, S, 0, N, D 9)~: Li~ the three most hazardous 1 ) chemical components or 2) any ARM components 3) COMPONENT CASI# %Wf ARM [ ] [ ] ( ] 10)LOCATION ¡) INVENTORY STAruS: New [ ] Addition [ ] Revision ( J Deletion [ ] Check ifchemical is a NON Trade Secret [ ] Trade Secret [ ] 2) Common Name: 3) DOT 1# (optional) Chemical Name: ARM [ ] CAS 1# 4) Physical & Health PHYSICAL HEAL 1H Hazard Categories Fire l ] Reactive l ] Sudden Release of Pressure l ] Immediate Health (Acute) l ] Delayed Health (Chronic) l 5) WASTE CLASSIFICATION (3-digit code from DHS Form 8022) USE CODE ¡"', 6) PHYSICAL STATE Solid [ Liquid [ Gas [ ] Pure [ Mixture [ ] Waste [ ] Radioactive [ 8) STORAGE CODES a) Container: b) Pressure: c ) Temperature 7) AMOUNT AND TIME AT F ACn..ITY Maximum Daily Amount Average Daily Amount Annual Amount Largest Size Container /I Days on Site UNITS OF MEASURE Lbs l ] Gall J ft3 [ J Curies [ ] Circle Which Months: All Year, J, F, M, A, M, J, J, A, S, 0, N, D 9)~: Li~ the three most hazardous 1 ) chemical components or 2)' any AHM components 3) COMPONENT CASI# %Wf ARM [ ] [ ] [ ] lO)LOCATION I certify under penalty of law, that I have pcrsona.11y examined and am tàmiliar with the information on this and all attached documents. I believe the submitted infonnation is true, accurate and complete. PRINT Name & Title of Authorized Company Representative Signature Date