The URL can be used to link to this page

Home My WebLink AboutBUSINESS PLAN ~, H M~l P ., .f:' " " 'J -P LA..N .- 1 Y.l1\.t' SITE DIAGRAM I FACILITY DIAGRAM Business Name: 1=kr64 Ol$couNl M070/l..S Business Address: 7'2 'ð 5:" UN (oAl For Office Use Only FirST In Stction: Inspection Station: @) Area Mco ;; of NORTH 0 ¡ LlX.1< <¡J 7 MJ"ll..l<l5r I E.~. ~EL<..-f; f-( l(;- fot QISCoJN{ f'o1e>wRS ':;CR..AP (\'\. C-ï At..- o/Aft-f/ CÆNA(... v.Á - O( SC.~AP f'VI t, A. <..- S-¡vc<A-C;€ ')\ ~ ~ y Pf0f'ð,A16 Pð > '}\ v "" ? J <& r"2.é t-l~!)I2ÞN'í " VI I I I I r ! - TGrL~~ Tel: (80f' -"11-3210 Fax: (80U1-3212 JUAN HERNANDEZ Manager 728 S. Union Avenue Bakersfield, CA 93307 ~ a) CCNTAINE~'CCOES -- - f ... ""-.- 01. Underground tanK 02. Aboveground tank 03. Fixed PressuriZed tank 04. ?oræcle pressuriZed cylinders as. Insulated tanK (includes cryogenics) C6. Drums or barreis - metailic 07. Crums or barrels - non-metallic oa. Carcoy(s) eg. Glass container(s) 10. Plastic container(s) ~ ,. 8ox(es) ~ 2. 8ag(s) 13. ,~etal containers (not drums) 1 4. In machinery or processing equioment ~ 5. 3in(s) 99. Cther· specify b) PRESSURE CODeS , . The material is stored at ambient (normai atmosoheric) pressure. 2 - The matenal is storeo at greater than amcient pressure. 3 . ihe materials is storeo at less than ambient pressure. c) :E:v1P'=::A TURE ceoes 4. 7he matenal is stored at ambient (surrounoing) temceratur~. :: - 7he materiai is stored at greater than amoienc ,emceratura. 5 . 7he materIal is s.ored at less than ameient ~=mcerature. 7 - 7he' matenal is storeo under cryogenic ~cnc:ticns ---- -.---....- USE CeDES i 4. E~::;¡ing 1 5. :''(oer1mental , 6. Facncatlon 17, Fertilization 18, i=crmuiatIcn 19. Fwel 20. ~'Jngicide 21, Grincing 22. HeatIng 23. Herclc:ce 24, Insectlclce 25. !nstrUctlonai 26. L'JOnC2nt 27. MeciC21 alc/crocess 28. NeutraHz:r 29. ?:IMong 30. Pestlc:ce 31, Plaung 32. PreservatIVe 33, Reiining 34, Sealer 35. ScraYIMg 3S. Steniizer 37. Storage 38. Stncper 39. Washing 40. Waste 41. Water Treatment 42. Weldingisoldering 43. Well injection 44. Oil treatment 45. Resale 46. Aircraft systems 47. Battery elecuclyte .:.a. Breathing air 49. Oratting alo =0. Finisned product 51. Fire erotect1on 52. Hydrauiic eouipment 53. Roao/Hwy maintenance 54, i estlng 55. Whoiesale chemicals 99. ather· seec:ty 01. Additive C2. Aoheslve ':3. Aerosol :)4, Anestnetic as. Eac:encide CS. 81astlng 87, CQ,tãIYSC C8. C:eanlng ~g. C':olanc 1 O. C':cling i 1, Grilling 12. Drying 13. Emuislfier/demuls¡fier 2· qQQNV I.2i'C ST~ 1'0"" ~JQ.lggz STATEMENT OF ACCOUNT CITY OF BAKERSFIELD POBOX 2057 BÄKERSFIELD, CÄ 93303-2057 (661} 326-3979 DATE: 11/01/00 TO: JUAN HERNANDEZ POBOX 2053 SOUTH GATE, CA 90280-9053 CUSTOMER NO: 5268 CUSTOMER TYPE: ES/ 5268, CHARGE DATE DESCRIPTION REF-NUMBER DUE DATE TOTAL AMOUNT ------ -------- ------------------------- ---------- -------- -------------- 10/01/00 BEGINNING BALANCE 158.00 FOR GUESTIONS OR CHANGES TO YOUR ACCOUNT PLEASE CALL THE NUMBER AT THE TOP OF THIS STATEMENT. -------------- -------------- -------------- -------------- CURRENT OVER 30 OVER 60 OVER 90 -------------- -------------- -------------- -------------- 158.00 DUE DATE: 12/01/00 PAYMENT DUE: ïOTÄL DUE: 158.00 $158.00 CUSTOMER TYPE: TOTAL DUE: STATEMENT OF ACCOUNT CITY OF BAKERSFIELD POBOX 2057 BAKERSFIELD, CA 93303-2057 DATE: 10/01/00 TO: JUAN HERNANDEZ /, POBOX 2053 \ .' , gO.iUT. H'. r·:.. T::: :-.10-' \·~~O\:::>QO····1·...;Q~0·5'~i/ . _ ~M . _I _n", ~.' _c. --7. W-' .-, \' CiJ5Tm'lER NO: 5268;" REF.,-NUMBER DUEDA;E 1 ,~::..._";,".:..-.:oo:-~-~--~ _,~___~.:...._, ______________ CiJSTOMER TYPE: ESí ,; ~~___~~~,-"""".--=--o. " ' '" " v " ' , 1 ~. < ~, ," . 5268 TOT AL M'1OUNT .4>-, CHARGE D:ESÓRÌPT:i:ON . . DATE ------ -~~~.:.----++"-._~~^~~~--~;;.;.;."~.,~,,7'<-~,~ -------- 9/01/00 " ~ _r , ¡ i FOR GUESTIONS OR CHANGES TO YOUR ACCOUNT PLEASE CALL THE NUMBER AT THE TOP OF THIS STATEMENT. -------------- -------------- -------------- -------------- CURRENT OVER 30 OVER 60 OVER 90 -------------- -------------- -------------- --------------- 15S.00 DUE DATE: 10/31/00 PAYMENT DUE: TOTAL DUE: 158.00 158.00 $i58,OO $158.00 STATEMENT OF ACCOUNT CITY OF BAKERSFIELD POBOX 2057 BAKERSFIELD, CA 93303-2057 (661) 326-3979 DATE: 8/01/00 TO: ~UAN HERNANDEZ POBOX 2053 SOUTH GATE, CA 90280-9053 CUSTOMER NO: 5268 CUSTOMER TYPE: ES/ 5268 ---------------------------------------------------------------------------- CHAR@£ BATE DE8CRIrTIÐN REF~NUMBER D~E-~---T~TAL AMGYNT ------ -------- ------------------------- -------~-- ~------- -------------- 6/01/00 BEGINNING BALANCE 158,00 FOR QUESTIONS OR CHANGES TO YOUR ACCOUNT PLEASE CALL THE NUMBER AT THE TOP OF THIS STATEMENT. -------------- -------------- -------------- -------------- CURRENT OVER 30 OVER 60 OVER 90 -------------- -------------- -------------- -------------- 158.00 [i1.:JF,.-,- Dr, TE: - 8/31/-0fd PAYl':lE-Þ4~- TOTAL DUE: .t-58..-00, --=-~ $158,00 CUSTOMER TYPE: TOTAL DUE: STATEMENT OF ACCOUNT CITY OF BAKERSFIELD 1501 TRUXTUN AVE BAKERSFIELD, CA 98301-0000 (805) 326-3979 DATE: 3/01/97 TO: HIGH DISCOUNT MOTORS 728 S UNION AVE BAKERSFIELD. CA 93307 CUSTOMER NO: 5268 CUSTOMER TYPE: ES/ 5268 ------------------------------~~~~----~----~~-~- . -. . - -. +, CHARGE DATE DESCRIPTION REF-NUMBER DUE DATE TOTAL AMOUNT ------ -------- ------------------------- ---------- -------- -------------- 0/00/00 BEGINNING BALANCE 175.53 HM009 2/13/97 Charge adjustment 2/13/97 15. 95-- ADMIN SERVICE FEE HM009 2/13/97 Charge adjustment 2/13/97 1. 58-- FINANCE CHARGE FOR GUESTIONS OR CHANGES TO YOUR ACCOUNT PLEASE CALL THE NUMBER AT THE TOP OF THIS STATEMENT. -------------- -------------- -------------- -------------- CURRENT OVER 30 OVER 60 OVER 90 -------------- -------------- -------------- -------------- . - --- 158, 00 DUE DATE: 3/31/97 PAYMENT DUE: TOTAL DUE: 158.00 $158.00 DATE: 3/01/97 DUE DATE: 3/31/97 r~~---·--~·-·-"-~~:·"-·~··~··-·-~·~··-·,,..~..·-"--..-~-·-..~---....-..-~-~.....-..,-..-..-.--.--...-..~..-.------.----.~--. .1 PLEASE DETACH AND SEND THIS COpy WITH REMITTANCE REMIT AND MAKE CHECK PAYABLE TO: CITY OF BAKERSFIELD P.O. BOX 2057 BAKERSFIELD CA 93303-2057 CUSTOMER NO: 5268 CUSTOMER TYPE: ESI TOT AL DUE: 5268 $158.00 STATEMENT OF ACCOUNT CITY OF BAKERSFIELD 1501 TRUXTUN AVE BAKERSFIELD, CA 93301-0000 ( 809)32,6~3979 '/:,1: þ "ð¿~é,/~,?: TO: HIGH DISCOUNT M01:0~S;;j>, '\" ..... ,'. 728 S UNION AVE:: \ ,;¡/" BAKERSF I ELD, ,C,Á\h7'330T i :¡ ¡'-;/ ~ '~, ./( , . \ DATE: 1/01/97 /'i""r"'J ;'...... <.,," \\.:::' -"/-'<~ ." I ( '>:' -'!/---':;':::: ''",~''<,\ CUSTOi"1ER NO: i,:~268i\ CUSJ:0MEff 'T,y1PE: ES/ 5268 ------------ ------:~:...:-,-~-.;..:...- ::.::-:---,-:::--ë--'-----------...;--:::---.-/:::--'!'-----'----------- CHARGE DA=FE--ÐFPC~Jr;T,IONi~v~:. .....,,:,i; ii,:! ¡R-Efë':'J~.~MB-ER_cJt¡VE/P(\~-T-G.i+Ab-At400N-T ------ -------- -,:-~:~-:-Tt--:t:~S~~·~,~,~~~~;7\§:-, Ii T1:--,:-~.L-,-- ~:_:-~Li."';:~ -------------- 12/01/96 BE:G:INNING BALÄhÎC1¡::n \1 n; .00 ":. '''<'' '__ _ -~.-.., '" ,,~;_ ¡',,j''' .....J;,.._ '__ _:': ' HM009 1/01/97 HAZ:MAT \¡l¡ANDL:ING'::FEE,1i 158.00 ~. ~,,_._- '?' ''0''_ '<~:~,.:,>< 0 ," ~<, --<~':':»~,'~,,} ~--~/, ".- (' -, - -,/ FOR GtJESTIÒNSi'OR' CHANGES TO YOUR ACCOUNT PLEASE CALL THE NUMBER AT THE TOP OF THIS STATEMENT. -------------- -------------- -------------- ------------~- CURRENT OVER 30 OVER 60 OVER 90 -------------- -------------- -------------- -------------- 158,00 DUE DATE: 1/01/97 PAYMENT DUE: TOI AL DUE: 158.00 $158. 00 STATEMENT OF ACCOUNT CITY OF BAKERSFIELD POBOX 2057 BAKERSFIELD. CA 93303-2057 (661) 326-3979 DATE: 5/01/00 TO: JUAN HERNANDEZ POBOX 2053 SOUTH GATE. CA. 90280-9053 CUSTOMER NO: ·5268 CUSTOMER TYPE: ES/ f· 5268 _____________________________________M_______________________________________ ==-=-CftARGE DA I E uti!::)!,'; Kit" TIUI\I .. . ,. REF-NUMBER DUE DATE TOTAL AMOUNT ------ -------- -~~-----~---------------- ---------- -------- -------------- . , 4/01/00 BEGINNING BALANCE 158.00 FOR QUESTIONS OR CHANGES TO YOUR ACCOUNT PLEASE CALL THE NUMBER AT THE TOP OF THIS STATEMENT. -------------- -------------- -------------- -------------- CURRENT OVER 30 OVER 60 OVER 90 -------------- -------------- -------------- -------------- 158.00 DUE DATE: 5/31/00 PAYMENT DUE: TOTAL DUE: 158.00 $158.00 STATEMENT OF ACCOUNT CITY OF BAKERSFIELD POBOX 2057 BAKERSFIELD, CA 93303-2057 . (661) 326-3979 DATE: 9/01/00 TO: JUAN HERNANDEZ POBOX 2053 SOUTH GATE, CA 90280~9053 . ,'-, CUSTor'1ER NO: 5268 CUSTOMER TYPE: ES/ 5268 ~?i1 ------------------------------~----------------------~-----~---------------- -eH';R:;E DATE D~8~RIPTION REF NU/'1BER DUE pATE ,¡"',. ---------- -------- T8TAl::-At10UNT ------ -------- ------------------------- -------------- 8/01/00 BEGINNING BALANC~ 158.00 FOR QUESTIONS OR CHANGES TO YOUR PLEASE CALL THE NUMBER AT THE TOP OF THIS STATEMENT. -------------- -------------- -------------- -------------- CURRENT OVER 30 OVER 60 OVER 90 -------------- -------------- -------------- -------------- 158.00 DUE DATE: 10/02/00 PAYMENT DUE: TOTAL DUE: 158.00 $158.00 ~ BAKEIFIELC·CITY FIRE CE'ARTMENT HAZARDOUS MATERIALS DIVISION 1715 -CHESTER AVE~ \ BAKERSFIELD, CA. 93301 \ dr¡, 10 í) ç;1'é (~'b HAZARDOUS MATERIALS MANAGEMENT PLAN 1. To avoid further action. return this form within 30 days of receipt. 2. ìYPEJPRINT ANSWERS IN ENGUSH. 3. Answer the questions below for the business as a whole. 4, Be brief and concise as possible. ~~ . ~ (!ÝoM ~ INSTRUCTIONS: SECTION 1: BUSINESS IDENTIFICATION DATA BUSINESS NAME: ~ ~ Ðt ::>wJ.,J 1"' fVLC>7ões. LOCATION: 72.'ð os , () ¡V 1t><J Av MAILING ADDRESS: ~ 93':>07, CITY: STATE:_Z!P: PHONE: 3'2-(-32.(0 DUN & 8RACSiRE::ï NUMBER: SIC CODE: PRIMARY AC~iV\TY: -c''''V(rtVe; RE-&(jIL,')/~ OWNER: ~UA,J ¡...{C-fZ.NA-¡JD6- MAILING ADDRt: 7~20 /-towER.V Sf S:xJ~E cA 90'2-&ó SECTION 2: !:MERGENCY NOTIFICATION: CONTACT TITLE l. ..J U AN H Gz.NA-A.J óez.... vt-t6K- 2. M~~JA t+c-0JAtJ f)E""2- 0>t y~ BUS. PHONE S.?-I- 3<..,10 24 HR. PHONE '310! 4ðf5 - 07:?(; 'S I 0/40 f5 - ð7 'Sf, , 1 . .. . . Hakersfield Fire Dept. reardous Materials Di~sion e HAZARDOUS MATERIALS MANAGEMENT PLAN T SECTION 3: TRAINING: NUMBER OF EMPLOYEES: MATERIAL SAFETY DATA SHEETS ON FILE.: 1J!4. &~çrG 010 BRIEF SUMMARY OF TRAINING PROGRAM: . -' 8v:r^-'''C--<t... of'&A TG-O &10'-4/ SECTION 4: EXEMPTION REQUEST: I CéRTIFY UNDER PENALTY OF PERJURY THA í MY BUSINESS IS EXEMPT FROM THE REPORTING REQUIREMENTS OF CHAPTER 6.95 OF THE "CALIFORNIA HEALTH & SAFETY CODE" FOR THE FOLLOWING RE.A.SONS: WE 00 NOT HANDLE HAZARDOUS MATERIALS. WE DO HANDLE HAffiROOUS MATERIALS, BUT THE QUANTITIES AT NO TiMEEXCEED THE MINIMUM REPORTING QUANTmES. OTHER (SPECIFY RE.~SON) SECTION 5: CERTIFICATION: I, CERTIFY THAT THE ABOVE INFOR- MATION IS ACCURATE. ¡ UNDERSTAND THAT THIS INFORMATION WILL BE USED TO FULFILL MY F!RM'S OBLIGATIONS UNDER THE "CALIFORNIA HEALTH AND SAFETY CODE" ON HAZARDOUS ivÍATERIALS (DIV. 20 CHAPTER 6.95 SEC. 25500 ET AL.) AND THAT INACC IE INFORMATlONCONST!TUTES PERJURY. RE- ~ TITLE /o-OJ-~J' DATE 'J .. ~.-.... . _ A. Bakersñ~ld Fire Dept. . Hazardous Materials DivisioJt ""If HAZARDO us. MATERIALS MANAGEMENT PLAN Facility Unit Name: .fJ-(Gµ. [)15<:.ourJ( MÖ~S SECTION 6: NOTIFICATION AND EV ACUATION PROCEDURES: A. AGENCY NOTIFICATION PROCEDURES: ?~s M'.ð.cH..Aßé.£ ¡NSLPE c>Fç(cG i Al-~ çy,> -rEM... ~CM.J (TO R..Gf) ß~ ADT- 8. ~MPLOYE= NOTIF!C.-\TION AND EVACUATION: LJd<.D oC ~u~ (S suFhoG--YI '5~~-N ðFF, cc ft Y A4...D ( E:)( I T ?e2ðP&t.--rY Tð ~-r -r~ VNlo--J .Au C. PUBLIC EVACUATION: R Gc:C-P1<õ-N/ Mc""'Ä v.J t+-I I,..J6- / !2òò""- e5L (TS TòwM..() Ul'oireH0 AJ O. EMERGENCY MEDICAL PLAN: ~ ($ MCO,CAL- Dt!x::foR.. tjÙI'Iì{ D~-£ R~ ON\ JC-fLS,OÀ-O J)'VllCJ{DACA,JA, ~ j~c),~ ~fL(AL Gt..<::>sC~'Î &p/ ,.tJrl- (S ~ :Mlc..· e BakersfieldFire Dept. e Hazardous Materials Division ""_... T HAZARDO'US MATERIALS MANAGEMENT PLAN SECTION 7: MITIGATION, PREVENTION AND ABATEMENT PLAN: A. RELEASE PREVENTION STEPS: C--r0G.-,trlt!3s AtE KGPT UP{2.(~T "Tò fl4:;.....JG~ e'l(..... SP((..(..5 3. RELEASE· CONTAINMENT AND/OR MINIMIZATION: WAS T E ø ,(... 'D (2..<.> IV1 I <; U::>C./.1.:TC3D AT ~<SL\R- OF Y Nl.D , Ðù'T ~ n+E P4TH oF /l2Ll- PFIG. C. CLEAN-UP PROCE~URES: Aß~~T AV~r<-Ä-ß(..e '\'b ~DJC uP SaPI,-<-S SECTION 8: UTILITY SHUT-OFFS (LCCA TION OF SHUT-OFFS AT YOUR FACILITY): NATURAL GAS/~ ~AN2 ~k.: At sE CèJ<'ùUC-<'L ~ (SLOG ELECTRIC,.\L: (JúTs((.)E E <5(0[3 e,¡::. ~LO&, ,Â-T" .(ê:C~ , WAïE~: N'!:..<t."í ,0 'S,c{.....ù Po~T ßY CftNAL- - G-A-TG;" SPECIAL: LOCK BOX: YES/NO iF YES. LOC..\ïION: SECTION 9: PRIVATE FIRE PROTECTION/WATER A V AlLABllITY: A. PRIVATE FIRE PROTECTION: ~,,126 ~Ti~I~-I2.../,.j g(.ï,)C> B. WATER AVAILABILITY (FIRE HYDRANT): 5¿)· u.fi.-rJC-\L oÇ PRàPC~T<¡J f\IE;"'T (C Ç2'lcE n" _ BAKERS.f.IELD CITY FIRE DEPARTMENT HAZtIIDOUS MATERIALS INVEtllbRY ..,.-' . 3usiness Name "µ'1&,J.- OIS(DU.l\l~ ~ Address CHEMICAL DESCRIPTION 1) INVENTORY STATUS: New ( I Addition ( ) Revision ( ) Deletion ( ) W~S T€ I i 2) Common Name: I I Chemical Name: 4) PHYSICAL & HEALTH HAZARD CATEGORIES 5) WASTE CLASSIFICATION Page_of_ c::>lc Check if chemical is a NON TRADE SECRET () TRADE SECRET ( ) 3) DOT # (optional) AHM ( ) CAS # PHYSICAL Fire ~ Reactive () Sudden Release of Pressure [ J 2-'Z( 40 HEALTH Immediate Health (Acute) [) Delayed Health (Chronic) ø. (3-digit code from DHS Form 8022) USE CODe 6) PHYSICAL STATE Solid [) Liquid ~ Gas ( ) Pure [) Mixture () Waste. CHECl<ALL THAT N>PlY 7) AMOUNT AND TIME AT FACIUTY Maximum Daily Amount: Average Daily Amount: Annual Amount: Largest Size Container: # Days On Site 9) MIXTURE: List the three most hazardous chemical components or any AHM components ! 10) Location ðùTS/O£ s-s- ~ç ~S- s;S- '3b'r UNITS OF MEASURE Ibs [ ) gal 4 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 1 ) 2) 3) W4~TE COMPONENT 0(<...,.. CAS # MA...Ns'( (5 F6-Vc£ CHEMICAL DESCRIPTION Radioactive ( ] 6 L %WT AHM [ ) [ ] [ ) Check if chemical is a NON TRADE SECRET [) TRADE SECRET [ ) 1) INVENTORY STATUS: New [ ) Addition ( ) Revision [ ) Deletion [ ) 2) Common Name: $0 LÚ C.-.v r 3) DOT # (optional) Chemical Name: AHM [ ) CAS # 4) PHYSICAL & HEALTH HAZARD CATEGORIES USE CODE ~ HEALTH Immediate Health (Acute) [) Delayed Health (Chronic) ( ) ~ PHYSICAL Fire [J Reactive [) Sudden Release of Pressure [ ) 6) PHYSICAL STATE 5) WASTE CLASSIFICATION ~ (3-digit code from DHS Form 8022) ,- Solid [] Liquid ~ Gas [ ) Pure IiiJ Mixture [) Waste CHECK AU. THAT APPt Y 7) AMOUNT AND TIME AT FACIUTY ~ Maximum Daily Amount: Average Daily Amount: Annual Amount: Largest Size Container: # Days On Site 3Þ <or l~ I~ 1'2( 3D UNITS OF MEASURE Ibs [ ) gal _ ft3 [ ) curies [ ) 8) STORAGE CODES a) Container: b) Pressure: c) Temperature: 9) MIXTURE: List the three most hazardous chemical components or any AHM components Radioactive [ ) b , q. 1) COMPONENT S'rD DPIV2.O ~¡/C-;(./'Í CAS # Circle Which Months: All Year. J, F, M, A, M, J, J, A. S, O. N, D %WT AHM [ ) [ ) [ ) 2) 3) I öelleve ttle - Date I 10) Location (;N""(ScD6 ¡..JG Cf:;:;IStN~ ðC=- ßLrx;. ~ I certify under penalty of law, ttlat I have personallyexarmned and am faml/Jar with the ¡nfomation submltted~ em9 an~ all attached documents. submitted information is true, accurate, and complete. (~ Ð J ~J¡)rJt.--7 ~~! h?'Þ1'?~'è:t 6 Y ~~ :me & Title of Authorized Company RepresentEtfîve 5'>#'7 AEGKJrtV l£PCSTANDMDFæU BAKERSFy¡L.D CITY FIRE DEPAFliMENT HAZARWOUS MATERIALS INVENT~Y Page_of_ r Business Name Address CHEMICAL DESCRIPTION 1) INVENTORY STATUS: New [ ] Addition [ ] Revision [ ] Deletion [ ] Check if chemical is a NON TRADE seCRET [ ] TRADE SECRET [ ] 2) Common Name: ?~ "~"E 3) DOT # (optional) Chemical Name: AHM [ ] CAS # 4) PHYSICAL & HEALTH PHYSICAL HEALTH HAZARD CATEGORIES Fire [ ] Reactive r ] 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 [ ] CHECK AU. THAT APPlY 7) AMOUNT AND TIME AT FACIUTY 56i) UNITS OF MEASURE 8) STORAGE CODES 4 Maximum Daily Amount: IOO[]gal[] ft3 ~ a) Container:. Average Daily Amount: '>l"7D curies [ ] b) Pressure:, z.. Annual Amount: ') c) Temperature: 4- ~ Largest Size'Container: ç'ðQ # Days On Site '3~~ Circle Which Months: All Yeer. J. F. M. A. M. J. J. A. S. O. N. D 9) MIXTURE: List P R.ò P AA/"G-COMPONENT " CAS # %WT AHM the three most hazardous 1 ) [ ] chemical components or any AHM components 2) [ ] 3) [ ] 10) Location øu p; , ()r:; SE Co~c:I'L' af: ßLD~ CHEMICAL DESCRIPTION 1) INVENTORY STATUS: New [ ] Addition [ ] Revision [ ] Deletion [ ] chéck if chemical is a NON TRADE SECRET [ ] TRADE SECRET [ ] 2) Common Namè: 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 [ ] , CHECK ALL THAT APPlY 7) AMOUNT AND TIME AT FACIUTY UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount: 100 [ ] gal [ ] ft3 [ ] a) Container: Average Daily, Amount: curies [ ] b) Pressure: Annual Amount: c) Temperature: Largest Size Container: # Days On Site Circle Which Months: All Year. J, F. M. A, M, J. J. A. S. O. N, D 9) MIXTURE: List COMPONENT CAS # %WT AHM the three most hazardous 1) [ ] chemical components or any AHM components 2) [ ] 3) [ ] 10) Location ~ corltfy und., p._ of law, ..., I ""'" """""OJIy .......... end em femil<er wi.. ... ,ntome...;5..... im ... end ell ."C." dOC",""",,, J believe the submitted information is true, accurate, and complete. -,' -TV ;)-V( dI J-/trn ¿>t-.lck? '" ~ J PRINT Name & fitle oiAuthorized Company Representative Siptfature ) Date Sd'enø.r3Q 11.;1 AeQlDrfV lEPCST.llNDMDFæ"