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Home My WebLink AboutBUSINESS PLAN 2/16/1999 ·~ -- . CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES /1fl~.J) UNIFIED PROGRAM INSPECTION CHECKLIST LYU ~ '::> . 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 C/·-- FACILITY NAME Ah f~'CA,j 1'107tJRj ADDRESS 5""3'1 S- .ßUTN' (J¡JlÓÑ A-v, FACILITY CONTACT-t16Hf\"'''~b ßAfR)P. INSPECTION TIME ! (J f1) ~ . INSPECTION DATE / ) / / 6/ c¡ 7 PHONE NO. tJ 31- 'J e':J I BUSINESS ID NO. 15-210- NUMBER OF EMPLOYEES S- Section 1: ~ Routine Business Plan and Inventory Program o Combined o Joint Agency o Multi-Agency o Complaint ORe-inspection ........... OPERATION C V COMMENTS -, Appropriate pennit on hand ~~- Business plan contact ~on accurate· Visible address ~ ~ _-v i Correct occupancy ~ CJ \(ñ~ IAOA. I ......... --- Verification of inventory materials ~ \ V'-----'" '- Verification of quantities '" f".... Verification of location Ì' ......... 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 I jJð /J LJ!'T. OX'1 G-f¡V ¡:;U ~ fJ -- t)ß /Jr INJJ" /J-aJ ~FSJ, JlJUf),J/;"'J ¡- /1 /~ ð V J ¡.) ¿.... Any hazardous waste on sit4 .: 0 Yes ONo Explain: )i'V fAt-J, ï6 .r(luï1~ of fÃ //l.V>'f¿J.. Questions regarding this inspectio ? Please call us at (805) 326-3979 Business Site Responsible Party White· Env, Svcs, ellow . Station Co Pink· Business Co Ins ector: L?æ~ py py p + FOR ( ~c- , - ~...-:::::>' "'.> PHONE CAl~ ) I TIME t-<ÐS- ~ I i TELEPHONED RETURNED YOUR CALL PLEASE CALL WILL CALL AGAIN CAME TO SEE YOU WANTS TO SEE YOU ~ SC 11540 'M OF -- . L 1_",.,. _. :"'__ ...-... _.... '. ( - .....' . L ,. r:" - - .; , -~- ~ -:-,-,,-~---~-~- - - ~~~~~~"~.. ~---~- .- -'::-~-..·T-- "'-......--.,.-~~....~.,~~;;; .:...-~ ,/,:,__.:"'~"..-.- /~' -----;..~j_ ...- .- ~~~-~:"'" ~~<;: J?' - -- ., .... '< (NOTES·-C~/ {)( / ./ .j. " , I I ! " ,- -. " - I i-I , '. 'Ii - j~ ",....~-'"'..M;'t;tft.~ ' ^' . . -"~'r.ç;~ /.~,',' ../ "/ e'e -e ",' CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 "'V , , FACILITY NAME ~/ïFR1,^1~ Âf)7t))'f ADDRESS .r-rLjr fu~~~~~~ FACILITY CONTACT () As HH, INSPECTION TIME / (J /¡JNOTr'.r ' INSPECTION DATE 1/ j /9 CJ PHONE NO. gr )-79.1 I BUSINESS 10 NO. 15-210- NUMBER OF EMPLOYEES ~-"3 ,.1 Section 1: rd Routine Business Plan and Inventory Program '.. o Combined o Joint Agency o Multi-Agency o Complaint ORe-inspection " OPERA TION C V COMMENTS J Visible address Correct occupancy ..~~~~ {p ~. i r- D~ ~ \ V" ~",' (, I 19'~ -\:x~{ ¡ \ ð~ V--"\.r 'êð" V eritication of inventory materials Veritication of quantities Veritication of location Proper segregation of material Verification ofMSDS availability Verification ofHaz Mat training Veritication of abatement supplies and procedures Emergency procedures adequate Containers properly laheled I;" Housekeeping " <'~ I'" Fire Protection ¡' . ,. Site Diagram Adequate & On Hand C=Compliance V=Violation , ) Any hazarJ¡¡:s w.aste~ site~ _ ¡Yes 0 No Explain: Rf J' ('-¡. hJlðUS C)t..J~f;1t ~, I' > ~' ,~ . v! .~. Questions regarding this inspection? Please call us at (805) 326-3979 '.,.: ~(,:;:: White - Env, Sves, Yellow - Station Copy Pink - BlI~iness Copy Business Site Responsible Party Inspector: <:::?t?' ~_ ,', - -- .. \ iI5 CUST.1 & NO. . - f7CDl:· - MISCELLANEOUS RECEIVABLES ADJUSTMENT DATE3 - I b-~ NEW ACCOUNT ! ADDRESS CHANGEi cl.ose ACCT I : FINANce CHARGE , OTHER ADJ I CUSTOMER NAME . ·/àmUí C~ rY\.o+Oc~ ( ~ »\~ Ö {\ ~ v e ~ C, -A- ZIP CODE q~ 2JJ ì MAILING ADDRESS S~4C;..5 CITY fjal~(~tl ~\ri STATE SITE ADDRESS PARCEL NUMBER (lFAPPUCABlE) ADJUSTMENT R~~S:b~: m ~ùrck~~ sloJ\cÁ'v~ APPAOVEDBY 4~· Per it to Operate Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS OF PERMIT ON REVERSE SIDE PERMIT ID# 015-021.001847 AMERICAN MOTORS LOCATION Issued by: Bakersfield Fire Department OFFICE OF ENVIRONMENTAL SER VICES 1715 Chester Ave., 3rdFloor Bakersfield, CA 93301 Voice (805) 326-3979· FAX (805) 326-0576 5345 S UNION This permit is issued for the fOllowing: '::f.iª~ardous Materials Plan round Storage of Hazardous Materials qagement Program "'. Waste Approved by: *~- ph Huey, . ffice of ental Servi es Expiration Date: June 30, 2000 ~ --~ - . 1\ res 1. 2. 3. 4. \ ¡<îsL\ ì ~ ..-- INSTRUCTIONS: ~c::. t 7000 !3L\-\qQ To avoid further action, return this form within 30 days of receipt. .---- 0--..- TYPEIPRINT ANSWERS IN ENGLISH. J fJ Answer the questions below for the business as a whole. Be as brief and concise as possible. CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., Bakersfield, CA (805) 326-3979 ^~ .. µfì1ør SECTION-I: BUSINESS IDENTŒ1CA TION DATA BUSINESS NAME: AMGlùU,.J MO-rOcz.S LOCATION:, ';-34 S- S, UN ,()nJ MAILING ADDRESS: CITY: STATE: ZIP: PHONE: DUN & BRADSTREET NUMBER: SIC CODE: PRIMARY ACTMTY: OWNER: MAILING ADDRESS: 3boq ,- E ÄL.- C7 T?o4 SECTION 2: EMERGENCY NOTIFICATION CONTACT TITLE BUS. PHONE 24 HR. PHONE 1. M.ôftÄfV7MA--D ßt\S'HI rL. ðt....J....J IE' /L. ~s 1-7)('"1/ "]0,6 - ì~Lq 2. ¡bvr I tL ßAs lof. fL _~dAJ l/l ~ 1 . ,. · - ÐAZARDOUS MATEmALS MANAGEMENT PLAN SECTION 3: TRAINING NUMBER OF EMPLOYEES: MATERIAL SAFETY DATA SHEETS ON FILE: BRIEF SUMMARY OF TRAINING PROGRAM: SECTION 4: EXEMPTION REOUEST I CERTIFY UNDER PENALTY OF,PER1URY 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 5: CERTIFICATION I. CERTIFY THAT THE ABOVE INFORMATION IS ACCURATE. I UNDERSTAND THAT THIS INFORMATION WILL BE USED TO FULFll.L MY FIRM'S OBLIGATIONS UNDER THE "CALIFORNIA HEALTH AND SAFETY CODE" ON HAZARDOUS MATERIALS (DIY. 20 CHAPTER 6.95 SEC. 25500 ET AL.) AND THAT INACCURATE INFORMATION CONSTITUTES PERJURY. SIGNATURE TITLE DATE 2 1"",. - . HAZARDOUS MATERIALS MANAGEMENT PLAN . SECTION 6: NOTIFICATION AND EVACUATION PROCEDURES A. AGENCY NOTIFICATION PROCEDURES: B. EMPLOYEE NOTIFICATION AND EVACUATION: C. PUBLIC EVACUATION: " '", , ~ <' '-( .' , ] . , - ,',' " D. EMERGENCY MEDICAL PLAN: ;~':'~ÂMfRICAN ,.'.'>:,U; . . "",~ ;.. ~ MOTØRS'" ': '. . " :.. . . "" ;"'::.,-,;:;'~',':'" :,::' ", .' .:~./ .;·:i '. . . '.. " J . .,' - '., '.. 'u' . . ' ~. ." .' ~, .,'. .:; ~ I 'Š34fsollrH UNION AVE. .~ .'. ~':~':. r ,n J ~ "~I :. ,:ÙKtRSFIElD, CÀ 93307 '. .~.. '.;''; _J805J83f~783f": .-" ^ 1 / 3 · - HAZARDOUSMATE~LS~AGEMENTPLAN SECTION 7: MITIGATION. PREVENTION AND ABATEMENT PLAN A. RELEASE PREVENTION STEPS: B. RELEASE CONTAINMENT AND/OR MINIMIZATION: C. CLEAN-UP PROCEDURES: SECTION 8: UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY) NATURAL GAS/PROPANE: ELECTRICAL: WATER: SPECIAL: LOCK BOX: YES/NO IF YES, LOCATION: SECTION 9: PRIVATE FIRE PROTECTION/W ATER AVAILABILITY A. PRIVATE FIRE PROTECTION: B. WATER A V AILABll..ITY (FIRE HYDRANT): 4 HAZARDOUS MA TERIALSINVENTORY . Address . Business Name Page_of_ CHEMICAL DESCRIPTION .,. I ) [NVENTOR Y ST A ruS: New [ ] Addition [ ] Revision [ ] Deletion [ ] Check if chemical is a NON Trade Secret [ ] Trade Secret [ ] 2) Conunon Name: ð)LV~ 3) OOT /I (optional) Chemical Name: AHM [ ] CAS II 4) Physical & Health PHYSICAL HEAL 1H Hazard Categories Fire [ ] Reactive.-[v] Sudden Release of Pressure [~ Immediate Health (Acute) [ ] Delayed Health (Chronic) [ 5) WASTE CLASSŒ1CATION 6) PHYSICAL STATE Solid [ Liquid [ 7) AMOUNT AND TIME AT FACn.rry Maximwn Daily Amount Z-4Cf Average Daily Amount "2. 4 e:¡ Annual Amount '2 '1 Largest Size Container 1..- 't Cf f# Days on Site <, (" « 9)~: Li~ the three mo~ hazardous I) chemical components or 2) any AHM components 3) (3-digit code &om DHS Form 8022) USE CODE Gas [~] Pure [&0] Mixture [ ] Waste [ ] Radioactive [ UNITS OF MEASURE Lbs [ ] Gal [ ] ft3 ~ Curies [ ] 8) STORAGE CODES a) Container: b) Pressure: c) Temperature 4 'Z q. Circle Which Months: All Year, J, F, M, A, M, J, J, A, S, 0, N, D COMPONENT CASf# %Wf AHM [ ] [ ] [ ] 10)LOCATION INÇ, ,r>~ f\JC; c..R.N(2.. ðÇ. S#tJ¡> I) INVENTORY STATUS: New [ ] Addition [ ] Revision [ ] Deletion [ ] Check Ü chemical is a NON Trade Secret [ ] Trade Secret [ ] 2) Common Name: ACE:. 7 yLé'NE 3) DOT II (optional) Chemical Name: AHM [ ] CAS II 4) Physical & Health PHYSICAL HEAL 1H Hazard Categories Fire ~ Reactive [ ] Sudden Release of Pressure [1Ii'i Immediate Health (Acute) [ ] Delayed Health (Chronic) [ ] 5) WASTE CLASSIFICATION 6) PHYSICAL STATE Solid [ Liquid [ 7) AMOUNT AND TIME AT F ACll..ITY Maximwn Daily Amount I (Ù Average Daily Amount 1(1) Annual Amount I ( ð Largest Size Container I ( Ô II Days on Site '«0 <;'" 9)~: Li~ the three mo~ hazardous I) chemical components or 2) any ARM components 3) (3-digit code &om DHS Form 8022) USE CODE ~~ Pure~ Mixture [ ] Waste [ ] Radioactive [ UNITS OF MEASURE 8) STORAGE CODES 4 Lbs [ ] Gal [ ] ft3 ~ a) Container: Curies [ ] b) Pressure: '2. c) Temperature 4- Circle Which Months: All Year, J, F, M, A, M, J, J, A, S, 0, N, D COMPONENT CASII %wr ARM [ ] [ ] [ ] IO)LOCATION _ I ( IV S I ð 6- NË CIZ AI'(¿ t>-F s4JJ.f' [certify W1der penalty of law, that I have personally examined and am familiar with the int1:honnationthis and all attached docwnents. I believe the submitted infonnation is true, accurate and complete. ~ A ..14 a/ (/"" 1/- ~ éJ- ?>-' PRINT Name & Title of Authorized Company Representative ' Signature Date HAZARDOUS MATERIALS INVENTORY . Address- Business Name CHEMICAL DESCRIPTION Page_of~ I ) rNVENTOR Y STATUS: New [ ) Addition [ ) Revision [ ] Deletion [ ] Check if chemical is a NON Trade Secret [ ] Trade Secret [ 2) Common Name: (jJ ÆÇí£ TII?-f:;S 3) OOT /I (optional) Chemical Name: AHM [ ] CAS /I 4) Physical &: Health PHYSICAL HEAL rn Hazard Categories Fire [ ] Reactive [ ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ J Delayed Health (Chronic) [ J 5) WASTE CLASSIFICATION (3-digit code from DHS Form 8022) 6) PHYSICAL STATE Gas [ ] Pure [ Solid [ Liquid [ 7) AMOUNf AND TIME AT FACILITY Maximum Daily Amount 5"ð'O Average Daily Amount ~ Annual Amount Largest Size Container II Days on Site "]6 S- 9)~: Li~ the three most hazardous I) chemical components or 2) any AHM components 3) IO)LOCATION ~C"VZ.. 1.t'Ali..t;) W e>r:- s+Ic>P Circle Which Months: COMPONENT USE CODE Mixture [ ] Waste [ ] Radioactive [ 8) STORAGE CODES a) Container: b) Pressure: c) Temperature All Year, J, F, M, A. M, J, J, A. S, 0, N, D CASII %WT ARM [ ] [ J [ ] ·1) INVENTORY STATUS: New [ ] Addiûon [ ] Revision [ ] Dc1cûon [ ] Check if chemical is a NON Trade Secret [ ] Trade Sec:Iet [ ] 2) Common Name: 3) OOT II (optional) Chemical Name: ARM [ ] CAS II 4) Physical &: Health PHYSICAL HEAL rn Hazard Categories Fire [ ] Reactive [ ] Sudden Release of Pressure [ ] Tmml'1fi8te Health (Acute) [ ] Delayed Health (Chronic) [ 5) WASTE CLASSIFICATION (3-digit code ûom DHS Form 8022) 6) PHYSICAL STATE Ou[ ] Pure [ Solid [ Liquid [ 7) AMOUNf AND TIME AT FACILlTY Maximum Daily Amount Average Daily Amount Annual Amount Largest Size Container II Days on Site UNITS OF MEASURE Lbs[ ] Gal [ ]ft3[ ] Curies [ ] Circle Which Months: 9)~: List the three mo~ hazardous 1) chemical components or 2) any ARM components 3) IO)LOCATION COMPONENT USE CODE Mixture [ ] Waste [ ] Radi08CÛve [ 8) STORAGE CODES a) Container: b) Pressure: c ) Temperature All Year, J, F, M, A. M, J, J, A. S, 0, N, D CASII %wr ARM [ ] [ J [ J r certitÿ under penalty of law, that I have personally examined and am familiar with the infonnation on this and all attacMd documents. I believe the submitted infonnation is true, accurate and complete. PRINT Name &: Title of Authorized Company Representative Signature Date HAZARDOUS MATERIALS INVENTORY :Susmess Name . Address :I: CHEMICAL DESCRIPTION Page_of_ . I) INVENTORY STATUS: New [ ) Addition [ ) Revision [ ) Deletion [ ) Check if chemical is a NON Trade Scc:ret [ ) Trade Seaet [ ] 2) Common Name: 3) DOT /I (optional) Chemical Name: AHM [ ] CAS /I 4) Physical & Health PHYSICAL HEAL TII Hazard Categories Fire [ ] Reactive [ ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ J Delayed Health (Chronic) [ 5) WASTE CLASSIFICATION· (3-digit code &om DHS Form 8022) 6) PHYSICAL STATE Pure [ Liquid [ Gas [ ] Solid [ 7) AMOUNT AND TIME AT FACn.ITY Maximum Daily Amount Average Oaily Amount Annual Amount Largest Size Container II Days on Site UNITS OF MEASURE Lbs [ ] Gal [ ] ft3 [ Curies [ J. Circle Which Months: 9) MIX11JRE: List the three most hazardous 1) chemical components or 2) any AHM components 3) COMPONENT / lO)LOCATION USE CODE Mixture [ ] Waste [ ] Radioactive [ 8) STORAGE CODES a) Container: b) Pressure: c) Temperature All Year, I, F, M. A. M. I, I, A. S, 0, N, D CASII %Wf AHM [ ] [ ] [ ] I) INVENTORY STATUS: New [ ] Addition [ ] Revision [ ] Deletion [ ] Check if chemical is a NON Trade Secret [ ] Trade Seem [ ] 2) Common Name: 3) DOT II (optional) Chemical Name: AHM [ ] CAS II 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) 6) PHYSICAL STATE Liquid [ Pure [ Solid [ Gas [ ] 7) AMOUNT AND TIME AT FACILITY Maximum Daily Amount Average Daily Amount Annual Amount Largest Size Container II Days on Site UNITS OF MEASURE Lbs [ J Gal [ ] ft3 [ Curies [ ] Circle Which Months: 9)MIX11JRE: List the three most hazardous 1 ) chemical components or 2) any AHM components 3) COMPONENT USE CODE Mixtw'e [ J Waste [ ] Radioactive [ 8) STORAGE CODES a) Container: b) Pressure: c) Temperature All Year, 1, F, M. A. M.I, I, A. S, 0, N, D CASII %Wf AHM [ ] [ ] [ ] IO)LOCA TION [ certify Wider penally of law, that I have personally examined and am familiar with the infonnation on this and all attached documents. I believe the submitted infonnation is true, accurate and complete. PRINT Name & Title of Authorized Company Representative Date Signature _RDOUS MATERIALS INVEN.Y Address Page - of-.:.1 Business Name CHEMICAL DESCRIPTION I ) INVENTOR Y STATUS: New [ J Addition [ J Revision [ J Deletion [ J Check if chemical is a NON Trade Secret [ ] Trade Secret [ ] 2) Common Name: 3) DOT II (optional) Chemical Name: AHM [ ] CAS II 4) Physical &. Health PHYSICAL HEAL 1H Hazard Categories Fire [ ] Reactive [ ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ ] Delayed Health (Chronic) [ ] 5 ) WASTE CLASSlFICA TION (3-digit code from DHS Fonn 8022) USE CODE 6) PHYSICAL STATE Solid [ Liquid [ Gas [ ] Pure [ Mixture [ ] Waste [ ] Radioactive [ 8) STORAGE CODES a) Container: b) Pressure: c) Temperature All Year, 1, F, M, A. M, 1,1, A. S, 0, N, D 7) AMOUNT AND TIME AT FACILITY Maximum Daily Amount Average Daily Amount Annual Amount Largest Size Container 1# Days on Site UNITS OF MEASURE Lbs[ ] Gal [ ]ft3[ ] Curies [ ] Circle Which Months: 9) MIX11JRE: List the three most hazardous 1 ) chemical components or 2) any AHM components 3) COMPONENT CASt# %wr ARM [ ] [ ] [ ] IO)LOCATION 1) INVENTORY STATUS: New [ ] Addition [ ] Revision [ ] Deletion [ ] Check if cl1em.ical is a NON Trade Secret [ ) Trade Secret [ ] 2) Common Name: 3) DOT t# (optional) Chemical Name: ARM [ ] CAS 1# 4) Physical &. Health PHYSICAL HEAL rn Hazard Categories Fire [ ] Reactive [ ] Sudden Release of Pressure [ ] JœmP.diate Health (Acute) [ ] Delayed Health (Chronic) [ S) WASTE CLASSIFICATION (3-digit code 1tom DHS Form 8022) USE CODE 6) PHYSICAL STATE Solid [ ] Uquid [ Ou[ ] Pure [ Mixture [ ] Waste [ ] Radioactive [ ] 8) STORAGE CODES a) Container: b) Pressure: c) Temperature 7) AMOUNT AND TIME AT FACILITY Maximum Daily Amount A verage Daily Amount Annual Amount Largest Size Container II Days on Site UNITS OF MEASURE Lbs[ ] Gal [ ]ft3[ ] Cwies [ ] Circle Which Months: All Year, 1, F. M, A, M. 1, 1, A. S, 0, N, D 9)MIX11JRE: List the three most hazardous 1 ) chemical components or 2) any AHM components 3) COMPONENT CASt# %wr AHM [ ) [ ] [ ] IO)LOCATION I certify under penalty of law, that I have personally examined and am familiar with the infonnation on this and all attached documents. I belic:ve the submitted infonnation is true, accurate and complete. Date PRINT Name &. Title of Authorized Company Representative Signature HAZARDOUS MATERIALS INVENTORY Busaness Name . Address ~ . ~ CHEMICAL DESCRIPTION Page_of_ . I ) INVENTOR Y ST A ruS: Nf:W ( I Addition [ ) Rcvision [ I Deletion ( ) Check if chemical is a NON Trade Secret [ ] Trade Secret ( ] 2) Common Name: 3) DOT /I (optional) Chemical Name: AHM [ ) CAS 1# 4) Physical &; Health PHYSICAL HEAL rn Hazard Categories Fire [ ] Reac;tive [ ] Sudden Release oCPressure [ ] Immediate Health (Acute) [ ] Delayed Health (Chronic) [ 5) WASTE CLASSIFICATION (3~git code from DHS Fonn 8022) 6) PHYSICAL STATE Solid [ Liquid [ Ga[ J Pure [ 7) AMOUNT AND TIME AT FACIUIY Maximum Daily Amount Average Daily Amount Annual Amount Largest Size Container 1# Days on Site UNITS OF MEASURE Lbs[ ]Gal[ ]ft3[ ] Curies [ ] Cirde Which Months: 9) MIXTURE: List the three most hazardous I) , chemical components or 2) any AHM components 3) COMPONENT lO)LOCATION USE CODE Mixtw'e [ J Waste [ ] Radioactive [ 8) STORAGE CODES a) Container. b) Pressure: c) Temperature AJ1 Year. I. F. M. A. M. I. I. A. S. O. N. D CAStI %wr AHM [ ] [ ] [ ] 1) INVENTORY STATUS: New [ ] Addition [ ] RcvisÏon [ ] Deletion [ ] Check if chemical is a NON Trade Secret [ ] Trade Secret [ ] 2) Common Name: Chemical Name: 3) OOT tI (optional) AHM [ ] CAS tI 4) Physical &; Health PHYSICAL HEAL 1H Hazard Categories Fire [ ] Reactive [ ] Suddc:n Release oCPressure [ ] TmmNtillte Health (Acute) [ ] Delayed Health (Chronic) [ 5) WASTE CLASSIFICATION (3-digit c:ode tiom DHS Form 8022) 6) PHYSICAL STATE Solid [ Liquid [ Ga[ ] Pure [ 7) AMOUNT AND TIME AT FACIUIY Maximmn Daily Amount Average Daily Amount Annual Amount Largest Size Container 1# Days on Site UNITS OF MEASURE Lbs [ ] Gal [ ] ft3 [ ] Curies [ ] Circle Which Months: 9) MIXI1JRE: List the three most hazardous 1 ) chemical components or 2) any AHM components 3) IO)LOCATION COMPONENT USE CODE Mixture [ ] Waste [ ] Radioactive [ ] 8) STORAGE CODES a) Container. b) Pressure: c) Temperature AJ1 Year. I. F. M. A. M. I. I. A. S. O. N. D CAStI %wr AHM [ ] [ ] [ ] r certify under penalty of law, that I have personally examined and am familiar with the information on this and all attllCMd documents. I believe the submitted information is r:rue., accurate and complete. PRlNT Name &; Title of Authorized Company RcprcaentAtive Sipatw'C Date HAZARDOUS ~1A TERlALS INVENTOR.Y Business ~ame . Address . Page _ of _ J ~I CBEMŒCALDESCRDnnON ~ I) INVENTOR Y ST A ruS: New ( J Addition [ J Rcvision [ ) Deletion [ ) Check if chemical is a NON Trade Secret [ ) Trade Secret ( 2) Corrunon Name: 3) DOT /I (optional) Chemical Name: ARM [ J CAS /I ~) Physica! &: Health PHYSICAL HEAL rn Hazard Categories Fire [ ] Reactive [ ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ ] Delayed Health (Chronic) [ 5) WASTE CLASSŒ1CATION (34git code £rom DHS Form 8022) USE CODE 6) PHYSICAL STATE Solid ( Liquid [ Gas ( ] Pure [ Mixture ( J Waste [ J Radioactive [ 8) STORAGE C.ODES a) Container: b) Pressure: c) Temperature All Year, I, F, M. A. M. I, I, A, S, 0, N, D 7) AMOUNT AND TIME AT FACILITY Maximum Daily AmOUDt Average Daily Amount Annual Amount Largest Size Contaiaer fI Days 011 Site UNITS OF MEASURE Lbs[ ]Gal[ ]ft3[ ] Curies [ ] Circ1e Which Months: 9) MIX11JRE: List the three most hazardous I) chemical components or 2) any AHM components 3) lO)LOCATION COMPONENT CASfI %wr ARM [ ] [ ] [ ] 1) INVENTORY STA1US: New [ ] Addition [ ] Revision [ ] Deletion [ ] Check if chemical is a NON Trade Secret [ ] Trade Seœ:t [ ] 3) DOT fI (optional) ARM [ ] CAS fI 2) Common Name: Chemica! Name: 4) Physica! &: Health PHYSICAL HEAL rn Hazard Categories Fire [ ] Reactive [ ] Sudden Release ofPressuœ [ ] Tmmediate Health (Acute) [ ] Delayed Health (Chronic) [ 5) WASTE CLASSŒ1CATION (Ui¡it code £rom 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 II 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.I, J, A. S, 0, N, D 9) MIX11JRE: List the three most hazardous I) chemica! components or 2) any AHM components 3) COMPONENT CASfI %wr AHM [ ] [ ] [ ] IO)LOCATION I certify under penalty of law, that I have pcrsona1ly ex,mined and am flJl1i1iar with the infonnation on this and all attached documents. I believe the submitted infonnation is ttUC, accurate and complece. PRINT Name &: Title of Authorized Company Representative Signature Date ;¡ 1/ t N . SITE DIAGRAM r 1 Business Name: Business Address: FACILITY "GRAM I ?'O-<' «OJIL P.M'[' Aum Ò I Sý..(1.,,;-rV oV(:r ,.- -y - x ~ )I - ,..... -?C 7'- .>e-' v c.Á.f¿ SAt...£s (.0, >t '& ¿ ~ F IV) Jf c s~p '¢ ~ \U ~ -:? <::? ~ ~ "I¡) ø - ( :¥- ~~ 2Æ 9 .( "2 J )' ....¿ - 'v- -y- -y 't/ ........ yt-,. I,¡tL -y -v"_ V'- V"- t4/1.fPý ?-kJ "'" (£ .s ~ J M081(..<: f...(oM~ ~L£> ~ V\ FÅ'JLV'~ AJ