Loading...
HomeMy WebLinkAboutBUSINESS PLAN 7/7/2004 ·' ".~ (4 ê 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# . 5335""". ~ \ q ~1 tl ()) ¿iA, . V If ¿rlf- ~U~ , Page 1 of I EPA ID # (Hazardous Waste Only) CAL DOC> :( 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 fór which an emergency plan is required pursuant to 10 CFR Parts 30, 40 or 70? B. UNDERGROUND STORAGE TANKS (USTs) 1. 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 1. Generate hazardous waste? - 2. Recycle more than 100 kg/month of excluded or exempted recyclable materials (per HSC §25143.2)? Treat hazardous waste on site? 3. 4. Treatment subject to financial assurance requirements (for Permit by Rule and Conditional Authorization)? Consolidate hazardous waste generated at a remote site? 5. 6. Need to report the closure/removal of a tank that was classified as hazardous waste and cleaned onsite? E. LOCAL REQUIREMENTS [8 YES D NO 4. DYES [8 NO s. DYES [8 NO 6. DYES [8 NO 7. DYES [8 NO 8. 181 YES o NO 9. DYES [8 NO 10. DYES C83 NO II. DYES C83 NO 12. DYES 181 NO 13. DYES 181 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 poroon - one page per tank) NO FORM REQUIRED TO CUPAs EPA ill NUMBER - provide at the top of this page RECYCLABLE MATERIALS REPORT (one pCr recycler) ONSITE HAZARDOUS WASTE TREATMENT - FAC ILITY (Formerly DTSC Forms 1772) ONSITE HAZARDOUS WASTE TREATMENT - UNIT (one page per unit) (Fnrmerly DTSC Forms 1772 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,) 15. UN-020 - 3/17 www.unidocs.org Rev. 01116/02 'Ý " UNIFIED PROGRAM CONSOLIDATED FORM FACILITY INFORMATION BUSINESS OWNER/OPERATOR IDENTIFICATION FACILITY ID # (Agency Use Only) BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business AJ) AUTOZONE # 5 '35 BUSINESS SITE ADDRESS . I WJ.i , L-¡tW-JÉ- CITY ~S r,¡i.t-]) DUN & BRADSTREET 15-723-3511 COUNTY Pa e I of! 100. ENDING DATE 101. 3. 102. 103. 104. IOS. 107. 108. 109. BUK..INESS OP. ERA. TORl:HONE -?It lP"l- 67 7--~o3 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 III. ENVIRONMENTAL CONTACT 117. 114. lIS. ZIP CODE 38103-3607 116. CONTACT PHONE 901-495-7217 118. 119. -PRIMARY - NAME Ì)cfv¡ð. dJl!/1(.j( TITLE DISTRICT MANAGER BUSINESS PHONE _ (p(p 1-3t¡ 7- 5?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.: 134. NAME OF DOCUMENT PR",PAREJ( 135, 136, 6/15/04 TITLE OF SIGNER ENVIRONMENTAL SPECIALIST F ARLON WILLIAMS 137. F ARLON WILLIAMS * See Instructions on next page. UN-020 - 5/17 www.unidocs.org Rev. 01116/02 Date: 0611512004 '\ ., Non-Waste Hazard'ous 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 lofl (Same as Facility Name or DBA) D Add;D Delete; ~ Revise (One page per building or area) Chemical Location: SALES FLOOR I EPCRA Confidential Location? DYes; ~ No I Facility ill # I ¡-r I' I i::f:::: I I I I (Buildiu ¥'Storage Area) Trade Secret Information? DYes; ~ No (Agency Use Only) 1. 2. 3. 4. S. 6. 7. 8. 9. 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. Categories COR I BATTERY FLUID-ACID SULFURIC ACID 34 181 7664-93-9 b!pure 600 300 4 ~ gullom ~ ambient ~ambient ~ fire . D 181 mixture pounds >amb. >amb. 1== . reactive ai, feet D < amb. <amb. pressure release D . ~SOlid Curies: Dav, On Stol11.e o tom o cryogenic ~ acute health I2š] ERS D liqtÚd (If mdioactive) Sitt: Container: * chronic"heatth I CAS No.: o gas 0 365 R D rndioactive 7664-93-9 . D TOX 2 ANTI-FREEZE ETHYLENE GLYCOL 95 0 107-21-1 b!pure 90 75 1 ~:wm B ambient ~ambient ~ ftre DIETHYLENE GLYCOL 5 D 111-46-6 I2š]mixture powds >amb, >amb, 1= reactive aL feet o < amb, <amb, pressure release D ~SOlid Curies: DaY! On Stora.. OIDm o Cl}Ugenic ~ acute heahh (If mdioacrlve) Site: Container: * F" DERS D liquid cIuonic heahh CAS No.: o gas 0 365 N D rndioactive· 107-21-1 D FLA 3 WINDSHIELD WASHER METHYL ALCOHOL 47 D 61-65-1 b!pure 50 30 I ,~gullono ~ amhient ä ambient ~ fire , SOLVENT D 181 mixture powds >amb, >,amb, reactive , ai, feet ' D <amb, <amb, = pressure release D Bsolid Curies: - Da.. On StoraS!e OIDns o Cl}Ugenic = acule health DEHS D liquid (If mdloactÏ\'c) Site: Container:* cIuonic health CAS No.: o gas 0 365 N o radioactive D FLA 4 MOTOR OIL SOLVENT REFINED, 80 0 64742-54-7 b!pure 2400 1800 I B gallono . tJ ambieOt ~ ambient fire HYDROlREATED HEAVY 0 I2š] mixture pounds >amb. >amb, _ reactive aI. feel o < amb. <ambo = pressure release PARAFFINIC DISTILLATE 0 BSOlid !d!rin: !!mQn ~ DIDm D Cl}Ugenic aalte heahh DEliS 0 liquid (lfmdioaClive) Sile: Container:" cIuonic heahh CAS No.: Dgas 0 365 N D rad~active 64742-54-7 0 . 0 b!pure ~gallono B ambient ~ ambient = fire. 0 o mixture pom >amb. >amb. = reactIve ai, feet o < amb. <amb. _ pressure release . D BSOlid Curies: . Dav, On Stora.e OIDno ' 0 Cl}Ugenic = aarte health CAS No.: DEliS 0 liquid (lfmdioacllve) . Sitt: Container: ~ cIuonic heahh 0 Dgas D rndioactive 0 b! pure . ~galWno tJ :ambient ä ambient = fire , 0 D mixture pounds >amb, >amb. _ reactIve cu. feet o < amb, <amb, _ pressure release 0 BSOlid Curies: Da.. On ·Stora.e o IDns o ",?genic aalle heallh·' , DEliS 0 liquid (lfradioacllve) Sitt: Container:* cIuonic heahh ~: Dgas D .rndioaClive 0 * Code Stora2'e Tvoe A Aboveground Tank B Belowground Tank C Tank ¡noide Building UN-020 - 7/17 Code Storae:e Tvoe ~ StOr32'C Tvoe D Steel Drum G Carboy E PlasticINon-metaJlic Drum H Silo F Can I Fiber Drum Code StOrHsre Tvne J Bag K Box L Cylinder Code Storae:e Tvoc M Glass Bottle orIug N Plaslic·Bottlo or Jug o Tote Bin www.unidocs.org ~ Stora2'e Tvoe P Tank Wagon Q Rail Car R Other Rev. 01116102 If EPCRA, sign below: \ .. . Date: 6/1512004 Hazardous Waste Inventory Statement For use by Unidocs Member Agencies or where approved byy~ur Local Jurisdiction Business Name: AUTOZONE Type of Report on This Page: Page 1 of 1 (Same as Facility Name or DBA) o Add; 0 Delete; ~ Revise (One page per building or area)' Chemical Location: STOCK ROOM I EPCRA Confidential Location? o Yes; ~ No I Facility ID # I I':: 'il I I life:, I I I I (Building/Storage Area) Trade Secret Information? DYes; ~ 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 TernD. Categories FLA A WASTE ABSORBENT WASTE ABSORBENT 50 0 8002-05-9 181 waste 440 220 440 1320 ~ gaJloœ ~ambient ~ ambient "" fire . pounds >amb. >amb. ~ reactive 0 cu, feet o <amb. <amb_ ~ pressure release Manaeement Method: 0 ~SOlid Curies: Doys On Storoee Stote o tons o cryogenic _ acute heakh 181 Shipped Off-site 0 liquid (lfradJoaclJ"e) ~: Container:1It Waste Code: chronic heakh o Recycled On-site o gas o· 365 D 352 o radioactive D Treated On-site 0 COR B USED BA TfERY SULFURIC ACID 34 !81 7664-93-9 !81 waste 160 80 4 8320 ~~lIoœ ~ ambient - ä ambient i= fore FLUID- ACID 0 pounds >amb_ >amb, ~ reactive CU, feet o < amb. <amb_ pressure release M1!lli!J!:ement Method: 0 ~SOlid Curies: Dov. On Storoee §!!!!: o tons o cryogenic ~ acute beakh 181 Shipped Off-site 0 liquid (lfradioacûve) ~: Container:* Waste Code: F chronic heahb o Recycled On-site o gas 0 365 R 791 o radioactive o Treated On-site 0 FLA C WASTE OIL PETROLEUM OIL 99 0 8002-05-9 181 waste 220 110 220 5720 ~~lIoœ ~ ambient . ~ ambient ;?,:¡ fire \ pounds >amb. >amb. reactive 0 cu. reet o < amb. <ambo - pressure reiease Manaeement Method: 0 ~SOlid !Ju:ig: J!uILQn S1m:m SInk Dtoœ o cryogenic = acute health 181 Shipped Off-site 0 liquid (lfradJoaclivc) ~: Container:* Waste Code: '" chronic health o Recycled On-site o gas 0 365 P 221 D radioactive o Treated On-site 0 0 !81 waste ~ gWwœ ~ambient ~ ambient ~ fire. 0 pounds >amb_ >amb. ~ reactIve cu_ feet o <amb_ <amb, '" pressure release Mana!!ement Method: 0 Bsolid Curies: Dovo On Storoee ~ Otoœ ~ 0 cryogenic ~ acute heakh D Shipped Off-site 0 liquid (IfradJoacIive) ~: Container:* Woste Code: chronic heakh o Recycled On-site o gas o radioactive o Treated On-site 0 0 -181 waste .~ gaJloœ ~ ambient § ambient ~ fire . 0 pounds >amb. >amb. ' reactIVe cu. feet o < amb. <amb. pressure release Manaeement Method: 0 BSOlid Curies: Davs On ~ Stote Dtoœ o cryogenic = acute health o Shipped Off-site 0 liquid (lfradJoaclive) ~: Container:* Waste Code: chronic beahb o Recycled On-site o gas o radioaétive o Treated On-site 0 0 ~ waste § :Ions 8 ambient § .ambient I- fire _ 0 pounds >amb. >amb. reactive cu_ reel o < amb_ <ambo pressure release Mana!!ement Method: 0 . BSOlid Curies: Days On Storoee §!!!!: Dtoœ o cryogenic I- acute beakh o Shipped Off-sile 0 liquid (lfradJoacllve) ~: Container:* Waste Code: chronic bea~b o Recycled On-site o gas o radioactive o Treated On-site 0 . Code eT * Stor.v: VDe A Aboveground Tank B Belowground Tank C Tank Inside Building Code Storal!e Tvøe J Bag K ~ox L Cylinder Code Storal!e Tvoe D Steel Drum E PlasticINonmetallic Drum F Can ~ StOnl2e Tvøe G Carboy H Silo I Fiber Drum UN-020 - 9/17 www.unidocs.org Code St0r82e Tvoe M Glass Bottle or Jug , N Plastic Bottle adug· o Tote Bin Q!!!£ Sto...e TVÐe r Tank Wagon Q Rail Car R Other Rev. 01116102 If EPCRA, sIgn below: -r 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 m0re 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 shaH 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;~ Verbal (i.e. shouting); 0 Other (specify) b. ~ 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*: FirelPolicel 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.: LJ County Hazardous Materials Compliance Division Phone No. ( ) I" California EP A Department of Toxic Substances Control Cal-OSHA Division of Occupational Safety and Health Air Quality Management District ......."'... . Phone No. (510) 540-3739 Phone No. (408)452-7288 Phone No. (415) 771-6000 Phone No. (510) 622-2300 ."'......."'... . . . . . . . . ~ . . . . . . . . . . . . . . . . Regional Water Quality Control Board .......................... . * These telephone numbers are provided as a general aid to emergency notification. Be advised that additional agencies maybe required to be notified. c. Emergency Resources: Poison Control Center ...................................... . Phone No. (800)876-4766 Phone No.: ((;6f ) t 3~ -SOCb City: ~Fé/Z S~/fr¿; Q Nearest Hospital: Name: fY\r6'tC-<.f H- 6.} I' I-;-,:¡L Address: d C>2/ ') 'ì 12..l.ty' 1'1,.,[ Iv} At!'€ , 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 ..r 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 : :loots Equipment, ~ Chemical Protective Gloves BATT CHG 2 PAIR OF RUBBER GLOVES and o Chemiéal Proteètive 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 Berms/Dikes (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 Modul~) 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 all subjects covered below, you 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: ¡g ¡g o o o o Plan (e.g. "Quarterly", etc.) 2. Che~ical Handlers are additionally trained in the following: ¡g o o ¡g ¡g ¡g inhalation, ingestion, 3. Emergency Response Team Members are capable of and engaged in the following: 0 Personnel rescue procedures 0 Shutdown of operations 0 Liaison with responding agencies 0 Use, maintenance, and replacement of emergency response eQuipment ¡g Refresher training, which is provided at least annually * 0 Emergency response drills, which are conducted at least (specifY) (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 recor<;lkeeping 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 records are maintained at the facility. (Note: Items marked with an asterisk (*) are required.]: [8J ~ ~ ~ ~ [8J ~ o Descri tion and documentation of facili 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 if you do not already have your own form. If you use the example provided, you do not need to attach a copy.) UN-020 -17/17 www.unidocs.org Rev. 01/16/02 ,,~c I · Facility Site Plan/Storage Map (Hazardous Materials Business Plan Module) Site Address: n D I 4.Jt-lIT'£ . ~é:. '~S~/db . Date Map Drawn: { / ~ 0 1. Map Scale: NOT TO SCALE Page 1 of 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 1 2 3 4 --1\ . 1\1 . ~ r-\. ~~ , IY: i-Jt£ , ·Q/I Þ Q 5;=:~'~~ ~ ^J .à ~ .....,....- I $U{7rTr --- . --t I\M. ,.. .- - ----- - ~- - -- --- - I ,\;../ , ~ it I i1, í 'n ,../II ! ~ '¡:VII \ I ¡ ¡ I fJ , hi I ~! ! (§Jê: a ffj Æ' >- 1\, f~ 'f i;'i t_ li _ ^ tí WK (IJG-> ", íÇt;i :t: ~t;i í tr""~ G = I (§Jê: . CD~ i & e·-I-=:! . 1= Ilf.i -._=--=>-.....,..,.- I~~I-~-=I· +=:~ 1= , .--. -- I O~ttL. ___I i ~¡-=:::r··· m -n - 1- 1- ~ I 1!1!:.1 _ J F.' ~~I I [ [9èj E:E=E::=:·\ . I I- [9'j . I E:±:=]~:::::J-"=.1 i E:C-~{:E...I N : --¡-±-I' ~p ~ I. F=--~ I i CEJ· fI' . J _ r 8-I=EJ ~ ©".~r r JOD ~ ~í'II t. ~_l -. ~ , I--T-UI=LT:L:::"_I=-J . ~.:; [!:'J IV~' __.__ . .-----. --c-- ~ ,~ ~- f) ,-"- ~~ I rm~ ..--. ." u·· l 1--- -.- -- - -. b.n ~ ! L ! 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 . 24 25 26 27 28 Instructions are printed on the following page. UN-020 -11117 www.unidocs.org Rev. 01/16/02