Loading...
HomeMy WebLinkAboutBUSINESS PLAN~ AUTO SHOPPER OF AMERICA 911 OAK STREET r, Prevention Services .UNIFIED PROGRAM INSPECTION CHECKLISTj~i E_R s_F_I 900TruxtunAve., suite zlo J I, 8--- ---D °= =--°-----°----- --°---~-====-=__==-_= ~ Fine Bakersfield, CA 93301 ~~~ ~ ~ e rM r Tel.: ~~ (661) 326-3979 SECTION 1: Business Plan and Inventory Program 11'i L ~ Fax: (661) 872-2171 • FACILITY NAME INSPECT N DA £ INSPECTION TIME o !`0 23 O~ ADDRESS PHO E J ~~r,~ ~ 7 NO O~ EytPLOYEES ~ I ~ FACILITY CONTACT . ~- ~ BUSINESS ID NUMBER Q, 15-021- Qa 2~ ~ ~, p ~ ~ ~ ! 7 Section 1: Business flan and Inventory Program ROUTINE ^ COMBINED ^ JOINT AGENCY ^ MULTI-AGENCY ^ COMPLAINT ^ RE-INSPECTION C V ~ C=Compliance OPERATION V=Violation COMMENTS ,~ /- 1.~' ^ APPROPRIATE PERMIT ON HAND ^ BUSIneSS PLAN CONTACT INFORMATION ACCURATE ^ VISIBLE ADDRESS ~^ CORRECT OCCUPANCY ~^ VERIFICATION OF INVENTORY MATERIALS ^ VERIFICATION OF QUANTITIES "`R ~ ~ •~ - - / ~ Lim. ^ VERIFICATION OF LOCATION ^ 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 ^ I-IOUSEKEEPING ^ ^ FIRE PROTECTION ^ SITE DIAGRAM ADEQUATE & ON HAND ANY HAZARIDO/US WASTE ON SITE? EXPLAIN: ~/ ~ c. 'YES ^ NO !~ ^or oV" QUESTIONS REGA~R/DING THIS INSPECTION? PLEASE CALLrUS AT (661) 326-3979 Inspector ( ease Print) Fire Prevention 1 In /Shift of Site/Station # White -Prevention Services Yellow -Station Copy .Pink -Business Copy ~~ V FD 2155 (Rev. 09/05 Bakersfield Fire Dept. UNIFIED PROGRAM INSPECTION CHECKLIST' Enironmental services ;x -.. _ ,, :. ~ x ~ 1715 Chester Ave SECTION 1 Business Plan and Inventory Program Bakersfield, CA 93301 Tel: (661)326-3979 FACILITY NAME INSPEC ION D TE INSPECTION TIME ADDRESS PHONE No. No. of Employees FACILITYCONTACT Business ID Number 15-021- ,mow Section 1: Business Plan and Inventory Program ^ Routine Combined ^ Joint Agency ^hulti-Agency ^ Complaint ^ Re-inspection ~ ; V ~c=Compliance, OPERATION V=Violation J ^ ^ APPROPRIATE PERMIT ON HAND ^ ^ BUSINESS PLAN CONTACT INFORMATION ACCURATE ^ ^ VISIBLE ADDRESS ^ ^ CORRECT OCCUPANCY ^ ^ - VERIFICATION OF INVENTORY MATERIALS ^ ^ VERIFICATION OF QUANTITIES ^ ^ VERIFICATION OF LOCATION ^ ^ PROPER SEGREGATION OF MATERIAL ^ ^ VERIFICATION OF MSDS AVAILABILITYE ^ ^ VERIFICATION OF FIAT MAT TRAINING ^ ~ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES ^ ^ EMERGENCY PROCEDURES ADEQUATE ^ ^ CONTAINERS PROPERLY LABELED ^ ~ FIOUSEKEEPING ^ ,~ / ad FIRE PROTECTION ^ ^ SITE DIAGRAM ADEOUATE & ON HAND COMMENTS __ ~ ~ ~_. ---- Q~M,../~ c~cJ rr,ISP. _ _ ~.__._.._ - - ----- - --------- - _ ._... ..----- _.._.._. .-- __ ,. a.... _ ~~ ~,,z"4SE ?e,~~ n ©!c. SPru.s _f3Y ~~~~ ~'>~~p~aJ I~~~Y~-S~ -vt~~~/1'" ~nJ IdMKJ1,2 tom/ S! ANY HAZARDOUS WASTE ON SITE?: BYES ^ NO EXPLAIN: J'7C.~ U t ~- ~ .~C^lT-1 r!-r~,t~Zt= QUESTIONS REGARDING THIS INSPECTION? PLEASE CALL US AT ~F)G') ~ 3207-3979 _.---' Inspector (Please Print) Fire Prevention 1st-InlShift of Site -Business Site Respons' I arty (Please Print) N While -Environmental Services Yellow -Station Copy Pink -Business Copy ~ysl ~~ ~ CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES ~ •y UNIFIED PROGRAM INSPECTION CHECKLIST `k•E'~gti P 1715 Chester Ave., 3'd Floor, Bakersfield, CA 93301 FACILITY NAME ~~ 5~°~~ INSPECTION DATE l t / 2~ Section 4: Hazardous Waste Generator Program EPA ID # CA~ZOOD lg3698 ^ Routine ~ Combined ^ Joint Agency ^Muiti-Agency ^ Complaint ^ Re-inspection I OPERATION I C I V I COMMENTS I Hazardous waste determination has been made EPA ID Number Authorized for waste treatment and/or storage Reported release, fire, or explosion within 15 days of occurrence Established or maintains a contingency plan and training Hazardous waste accumulation time frames Containers in good condition and not leaking Containers are compatible with the hazardous waste Containers are kept closed when not in use Weekly inspection of storage area Ignitable/reactive waste located at least SO feet from property line Secondary containment provided Conducts daily inspection of tanks Used oil. not contaminated with other hazardous waste Proper management of lead acid batteries including labels Proper management of used oil filters Transports hazardous waste with completed manifest l Sends manifest copies to DTSC ,Retains manifests for 3 years - - Retains hazardous waste analysis for 3 years Retains copies of used oil receipts for 3 years Determines if waste is restricted from land disposal C=Compliance V=Violation Inspector: ~7`~R.3 Office of Environmental Services (bbl) 32b-3979 White -Env. Svcs. i 't"C-+~ S d i~ - Ihab "Bob" ~ ~ ~ ~ ~ o Abdelmalek, MBA ~ TM / Controller ~;' i; ' r~~ ~~ ©~ m ~ ~ . 661.861.1800 tel ~ - 661.861.1700 fax 661.861.1856 fax i ~ ~. ~, - i ~r--.~ ~ - 911 Oak Street I ,. '~ - - ~ • -pay retail again. Bakersfield, CA 93304 Business sponsible Party Pink -Business Copy. . ~_ B E R S F I 0 r/R~ ~ R rur r CITY' Ot~ l3:~tiERSt~lELD ,-~-«, OFFICE OF EN~'IRO~f~tE,~T.aL SERVICES 1715 Chester Ave., CA 93301 (66l) 326-3979 _' ~•±~ ~IEW ^ ADD ^ DELETE ^ REVISE HAZARDOUS MATERIALS INVENTORY ```~-~`~-~'' CHEMICAL DESCRIPTION - (one loan per matenal per bmloing or area+ 200 Pago _ of I. FACILITY INFORMATION 9USINESS NAME (Same as FACILITY NAME or OBA • Doing Bus+ness Asl y~t:~ t V Sd~PPC2 CHEMICAL LOCATION , ~ ~ ,~~ ~~~ ~ ~~t CL ~,c VJS -- FACILITY 10 # ; .., ~ - - ~ - : - ' ~ -r-- - - ~; MAP # (oPfionan 1 ~~ IS-;; I 11. C~-IEMICAL I,VFORMATIGN CHEMICAL NAME COMMON NAME --. -- ....... -. CAS # PHYSICAL STATE 20 t CHEMICAL LOCATION ^ y~ ^ No 202 CONFIDENTIAL (EPCRA) 203 GRID a (oPtiortal) - - -- 20-s 205- TRADE SECRET ^ y~ [] No 2C6 It Subject to EPCRA, refer to +nswaions 207 EHS' ^ Yes ^ No 208 209 'l(EHS is'Ya.' att attrouna below must be m ms. SES (Complete if reduested by local fire chief) ~ ~--- 2t0 PURE ^ MIXTURE ^ ~ CURIES 2t3 m w WA,~,-= R-.!~IOACTIVc ^ Ye5 ^ No 212 ^ s SOLID !~1LIOUID ^ g GAS 2t4 LARGEST CONTAINER ~~ 215 FED HAZARD CATEGORIES ^ t FIRE ^ 2 REACTIVE ^ 3 . RESS IRE .'EL ~.SE ~4 A ;U-E HEALTH ^ 5 CHRONIC HEALTH. 216 (Check all that apply) o c c ANNUAL WASTE AMOUNT STORAGE CONTAINER (Check alt that apply) STORAGE PRESSURE STORAGE TEMPERATURE 217 ;dAXIMI:bt 218 ~ AVERAGE 219 ~~ STATE WASTE CODE 220 D AILY AMOUNT DAILY AMOUNT UNITS' `~qa GAL ^ d CU FT ^ Ib - LBS ^ to TONS -- - -- 221 DAYS ON SITE 222 It EHS, amount must be in Ibs. ^ a ABOVEGROUND TANK ^ e PLASTIGNONMETALLIC DRUM ^ i FIBER DRUM ^ m GLASS BOTTLE ^ q RAIL CAR 223 ^ b UNDERGROUND TANK ^ t CAN v I BAG ^ n PLASTIC BOTTLE ^ r OTHER ^ c TANK INSIDE BUILDING ^ g CARBOY ^ k BOX ^ o TOTE BIN STEEL DRUM ^ h SILO ^ I CYLINDER ^ p TANK'NAGON AMBIENT ^ as ABOVE AMBIENT ^ ba BELOW AMBIENT 22a ~a AMBIENT ^ as ABOVE AMBIENT ^ b3 BELOW AMBIENT ^ c CRYOGENIC 225 %WT __-- -HA7.ARDOUS COMPONENT I EHS ' CAS # 7 226 ~ 227 ^ Yes ^ No 228 229 2 230 231 ^ Yes ^ No 232 233 3 234 235 ^ y~ ^ No 236 237 i a +. _ 238 ~.. - ..--- -_.. ...._ . _.._.._. - -... -- ~ -- - - -- 239 , .241 _ ~ Yes ^ No 240..._ i .._ 5 ~ 242 2a3 i ^ Yes ^ No 244 245 III. SIGNATURE ~~ ft~zS PRINT NAME & TITLE OF AUTHORIZED COMPANY REPRESENTATIVE ~ SIGNATURE ~~ ~ ~~ ~ ~ - ~~ ~~~~ DATE 246 PCF (7199) S:\CUPAFORMS10ES2731.TV4.wpd . ~_ B E R S F I O ~~Rt AIPTM T r..y i ~. A +..r~~ ` .OIEW CITI~' OI~ t3:~tiERS1~lELD OFFICE OF EN~'IROV~IE,~T.aL SER1~'iCES 171 Chester Ave., CA 93301 (661) 326-3979 HAZARDOUS MATERIALS INVENTORY CHEMICAL DESCRIPTION ~ A00 C DELETE ^ REVISE 20U I. FACILITY INFORMATION t3USINE§S NAME (Same as FACILIT`% NAME ar D6A • Doing Business As) ~T~ ~'F~i~PC-2 CHEMICAL LOCATION /~~~ ,...,y- ,. -_. _..-.i ._.-. FACILITY101<; ;~,+• ~ ~' -~~ - - t• MAPt<(optrona~ - ~ `t" 1 11. CiiEMICAL INFORMATION CHEMICAL NAME ~~' i T?~Z O t t~ COMMON NAME CAS # • ~N• "~ . "~!~ ~4~ (One lonn per matenal per buJtling or area i ' Page _ of 201 CHEMICAL LOCATION ^ y~ ^ No 202 CONFIDENTIAL (EPCRA) 203 GRID a (optional) -- 20•s 205 TRADE SECRET ~ y~ [] No 2C6 I! Subjed to EPCRA, refer to ~nstrucuons 207... - - -- --------- --- --- --- ---- EHS' ^ y~ ^ No 208 209 •If EHS is'Ya.' all amounts below must De m tbs. FIRE CODE HAZARD CLASSES (Complete if requested by local fire Chief) 2t0 TYPE /~P,URE m MIXTURE ^ w wA5`_ ^ R•,!`IOACTIV'c ^ Yes ^ No 2t2 CURIES 2t3 PHYSICAL STATE // ;. ^ s SOLID ~24.LLIOUIO ^ g GAS 214 LARGEST CONTAINER ~(~~ ~ 2'S FED HAZARD CATEGORIES fA~FIRE ^ 2 REACTIVE ^ 3 PRESSURE F~ELE:.SE _; 4 A ;U-E HEALTH ^ S CHRONIC HEALTH 2t6 (Check all that apply) ANNUAL WASTE 217 :dAXlMhbt 2t8 A.vERA^E -J„~Y1 219 STATE WASTE CODE 220 AMOUNT GAILY AMOUNT L~-+c./ ~ DAILY AMOUNT GS-LJ UNITS' ia.pa GAL ^ d CU FT ^ Ib LBS ^ to TONS 221 DAYS ON SITE 222 ' If EHS, amount must be in Ibs. STORAGE CONTAINER ABOVEGROUND TANK ^ e PLASTIGNONMETALLIC DRUM ^ i FIBER DRUM ^ m GLASS BOTTLE ^ q RAILCAR 223 (Check all that apply) ^ b UNDERGROUND TANK ^ f CAN V I BAG ^ n PLASTIC BOTTLE ^ r OTHER ^ c TANK INSIDE BUILDING ^ g CARBOY ^ k BOX ^ o TOTE BIN ^ d STEEL DRUM ^ h SILO ^ I CYLINDER ^ p TANK `NAGON STORAGE PRESSURE %~a AMBIENT ^ as ABOVE AMBIENT ^ ba dELOw AMBIENT 22a STORAGE TEMPERATURE ~J,•_ ~ptg(ENT ^ as ABOVE AMBIENT ^ b3 BELOW AMBIENT ^ c CRYOGENIC 225 %WT - '- _ HA7ARDOUS COMPONENT EHS CAS # 7 226 ~ 227 ^ Yes ^ No 228 229 2 230 237 ^ Yes ^ No 232 233 7 234 235 ^ Yes ^ No 236 237 I C- __ ._ _ _ _. _..... ~ - 239 , .247 . I ~ ~ - ~ Yes ^ Na ~ 240 ~~- i -.. ..: . 6 ~ 242 243 ^ Yes ^ No 244 245 III. SIGNATURE _ _ _ __ _ _ __ ~/~ ~ r',.I~ZS~e~ _ _____ _ _____ _ PRINT NAME & TITLE OF AUTHORIZED COMPANY REPRESENTATIVE ~ ~ ~ ~ ~ ~ SIGNATURE C~ ~ ~ DATE 246 JPCF 7/99 . ~ ) S:ICUPAFORMS10ES2731.TV4.wpd . ~_ 8 E R S F I 0 P/IP~ ABTM T wy v ~ A irr~- CITY' O1~ t3.-~1~ERS(~ IELD OFFICE OF EN~'IROV~IENT.aL SER~'[CES 1715 Chester Ave., CA 93301 (661) 326-3979 HAZARDOUS MATERIALS INVENTORY CHEMICAL DESCRIPTION "~J -.~ _ J (one form per matenal per Dwltling or area, ~lE-W ^ A00 Q DELETE ^ REVISE 200 ' ~ Page _ of __ 1. FACILITY INFORMATION _ ________ 9USINESS NAME (Same as FACILITY NAME or DBA - Dang Bus,ness Asl CHEMICAL LOCATION ` ~~ ~^, 20, CHEtAICAL LOCATION ~ PJ ~ ~ ~ ~ ~~t. Cl~c r `C~ C ~ b 2~ QA'~~ ST ~~~L" CONFIDENTIAL (EPCRA) ' ~ _... FACILITY 10 # ::,,. - ----- : ~ I ~ -.. .t~ MAP # (ophonaQ 203 GRID ++ (optionaQ ~ ---...- ---- I!. CiiEMICAL INFORMATION CHEMICAL NAME ~'L ~ ~.~ COMMON NAME I CAS # FIRE CODE HAZARD CLASSES (Complete if requested by local fire chief) 205 TRADE SECRET i Q es ^ No 2C6 If SuDjed to EPCRA. re/er to mstrua~ons 207...... ----------------- --- ----~--- EHS' ^ y~ ^ No 208 209 •If EHS is'Yes,' ~ amounts below must be in Lbs. 2t0 TYPE --- . --- -... -. .- . - PURE ^ m MIXTURE ^ w WAS-=_ ~ R-.!'IOACTIVc ^ No 2t2 CURIES ^Yes --- -- 2t3 PHYSICAL STATE ^ s SOLID ^I LIpUID ~ GAS 2t4 LARGEST CONTAINER Z>I"~ 2'S FED HAZARD CATEGORIES ^ t FIRE ^ 2 REACTIVE (~, CRESS JRE RELE:.SE _: 4 A ;U-E H `''~' EALTH ^ 5 CHRONIC HEALTH 2t 6 (Check all that apply) / ANNUAL WASTE 217 dGXIMUAt 218 ~S VCJ P.VERAGE 219 STATE WASTE CODE / 220 AMOUNT DAILY AMOUNT DAILY AMOUNT .> w UNITS' l _l ga GAL ~ CU FT ^ Ib LBS ^ to TONS 221 DAYS ON SITE 222 ' If EHS, amount must be in Ibs. STORAGE CONTAINER ^ a ABOVEGROUND TANK ^ e PLASTIGNONMETALLIC DRUM ^ i FIBER DRUM ^ m GLASS BOTTLE ^ q RAIL CAR 223 (Check all that apply) ^ b UNDERGROUND TANK ^ f CAN ~, I BAG ^ n PLASTIC BOTTLE ^ r OTHER ^ c TANK INSIDE BUILDING ^ g CARBOY k B OX ^ ^ o TOTE BIN ^ d STEEL DRUM ^ h SILO ~ '' ~// ~ d~CYLINDER ^ p TANK `NAGON STORAGE PRESSURE ^ a AMBIENT ~a ABOVE AMBIENT ^ ba dELOW AMBIENT 224 STORAGE TEMPERATURE Imo' a AMBIENT ^ as ABOVE AMBIENT ^ 03 BELOW AMBIENT ^ c CRYOGENIC 225 %WT HAZARDOUS COMPONENT EHS zzs zv ^ Yes ^ No 228 2 230 23t ^ Yes ^ No 232 3 234 235 ^ Yes ^ No 236 i i a ~. 238 .. '_'- - ......._ . _..-.... _ ~ ~ ~ ^ Yes ^ No 240..._ i 5 i 242 2.13 ^ Yes ^ No 244 -_. .....-_._ . _._ .. ..... I ---_ .-_. _._..._-. ..- -........ -.. - ... _...__. .... ._ ...-...._. I _.._ _.__ . _._ ._ .._ -...--- ---'--'---'---' III. SIGNATURE CAS # 229 233 237 _2At - 245 PRINT NAME & TITLE OF AUTHORIZED COMPANY REPRESENTATIVE SIGNATURE DATE 246 ^ Yes ^ No 202 --- - ° - ----- ~y - 1PCF (7/99) S:\CUPAFORMS\OES2731.TV4.wpd . ~_ 8 E R S F I b I~IR~ ARTM T -.y .M ~ . A ~~~• '~iEW C[Tl~' O1~ t3:~tiERS1~ IELD OFFICE OF EN~'IROV~[E~iT.aL SER~'[CES 1715 Chester Ave., CA 93301 (661) 326-3979 HAZARDOUS MATERIALS INVENTORY CHEMICAL DESCRIPTION O AOD G~ DELETE Q REVISE 20U I. FACILITY INFORMATION 9USINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) CHEMICAL LOCATION L J ~''`f`~ GC' SLR-/ICc ~~~''5 __ _ ..__. _...._i _..... -- I _ FACILIT`( 10 # : ~ .-. ~ ~ 1' MAP p (optiorra~ - II. CiiEMICAL ItVFORMATIGN CHEMICAL NAME lJ S ~~ a t Z. I COMMON NAME CAS p FIRE CODE HAZARD CLASSES (Complete it requested by local fire dried 2t0 TYPE ^ p PURE ^ m MIXTURE ~w WAS-_ ~ R•,OIOACTIVc ^ Yes ^ No 2t2 CURIES 2t3 PHYSICAL STATE ^ s SOLID '~LLIOUIO ^ g GAS 2ta LARGEST CONTAINER ~S 275 , FED HAZARD CATEGORIES ,fir I t FIRE ^ 2 REACTIVE ^ 3 PRESS JRE FELE.;SE .~ 4 A :U-E HEALTH ^ 5 CHRONIC HEALTH. . 2t 6 (Check all that apply) %~`= ANNUAL WASTE 217 d4XIMl;M 2t8 ~ ~ ~ - P.VERAGE // ~ 219 STATE WASTE CODE ( 220 AMOUNT GAILY AMOUNT j DAILY AMOUNT O UNITS' ,aa_ga GAL ^ d CU FT ^ Ib LBS ^ to TONS 221 DAYS ON SITE 222 ' If EHS, amount must be in Ibs. STORAGE CONTAINER ^ a ABOVEGROUND TANK ^ e PLASTIGNONMETALLIC DRUM ^ i F18ER DRUM ^ m GLASS BOTTLE ^ q RAIL CAR 223 (Check al! that apply) ^ b UNDERGROUND TANK ^ t CAN ~,) BAG ^ n PLASTIC BOTTLE ^ r OTHER ^ c TANK INSIDE BUILDING ^ g CARBOY ^ k BOX ^ o TOTE BIN - ~,Ii.STEEI DRUM ^ h SILO ^ I CYLINDER ^ p TANK `NAGON STORAGE PRESSURE .~ gMBIENT ^ as ABOVE AMBIENT ^ ba BELOW AMBIENT 224 STORAGE TEMPERATURE [AMBIENT ^ as ABOVE AMBIENT ^ b3 BELOW AMBIENT ^ c CRYOGENIC 225 %WT __ _ HA7AR000S COMPONENT EHS ~ CAS # 1 226 227 ^ Yes ^ No 228 229 2 230 237 ^ Yes ^ No 232 233 3 234 ~ 235 ^ Yes ^ No 236 237 a ......238 r.. --- -._......._.._....._. _.. -- - - - ---- ~ _ . 239 , _ 247 i ^ Yes ^ No 240..._ 5 , 242 233 I ^ Yes ^ No 244 245 JPCF (7/99) III. SIGNATURE __ _ ~~zS/d4 _ _____ _ ______ _ OIv1PANY REPRESENTATIVE ~ ~ SIGNATURE ~ ~ ~ DATE 246 r ~ `' .'~ .~ (one /arm pBr marginal per Owltlirtg or area: • Page _ of _ 201 CHEtAICAI LOCATION ^ y~ ^ No 202 CONFIDENTIAL (EPCRA) 203 GRID tl (ophonaq - _-- _- 20a 205 TRADE SECRET ^ yes ^ No 206 if Subject to EPCRA. reler to mstroarons 207 EHS' ^ y~ ^ No 208 209 •If EHS is'Ya,' >V amounts Eelow must be m ms. S:\CUPAFORMS\OES2731.TV4.wpd • ~ CIT~~ Ol~ l3:~tiERS1~ I~:LD B ~~~IP~ ' ° OFFICE OF EN~'iR0~1~lE~iT.aL SERti_ICES `~j~,, ABTM T 171 Chester Ave., CA 93301 (661) 326 3979 _' ~~ HAZARDOUS MATERIALS INVENTORY CHEMICAL DESCRIPTION (one lomr per malenal per Dwlding ~~ area i W ~ A00 Gi OELETE ^ REVISE 200 Page - of - I. FACILITY INFORMATION _ _ _____ _____ 9USINESS NAME (Same as FACILITY NAME or DBA - Ooing eus~ness Asl - ~ ~`~ s~,,p+n,~L. CHEMICAL LOCATION ~' ~_ /~~ C~ ~~tCc 17~1~5 ~ ~ CONF OENTIOAL~(EPCRA) ^ Yes ^ No 202 -- FACILITY ID # ; ;,%~ - - - - ' ~ ~ - t' MAP # (optiona0 203 GRlO a (optionaQ - -- - - --- 20-s - _,. I ~.. . IL CiiEMiCAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ^ Yes ^ No 2C6 C.1 S'~~ /\n f "r'I (~~-1["L~~ K Subject ;o EPCRA. reler to ~nstruaions ---- --°-- .... - - 207... - ---- -------- -- --- --- ------ -- COMMON NAME EHS' ^ Yes ^ No 208 CAS # 209 •I[ EHS ii Yes,' ~ amwnts below must be m tbs FIRE CODE HAZARD CLASSES (Complete it requested by local fire chief) 2t0 TYPE -- -_._....------- -- - -- -----.- fem. -._...._ _ ^NO 2t2 CURIES 2t3 ^ pPURE ^ m MIXTURE w WAS-= ~ R-,UtOAC ~ Nc ^ Yes PHYSICAL STATE ^ s SOLIO I~-I LIQUID ^ g GAS 27a LARGEST CONTAINER S-~ 215 FED HAZARD CATEGORIES ^ t FIRE ^ 2 REACTIVE ^ 3 PRESSURE F.ELE:.SE - ~4 A ;U'E HEALTH ^ S CHRONIC HEALTH 2t 6 (Check all that apply) ANNUAL WASTE 217 :v1gXIMUAt 218 P.VERAGE ,'3 219 STATE WASTE CODE 220 AMOUNT OAILY AMOUNT S S DAILY AMOUNT UNITS' ~-9a GAL ^ d CU FT ^ Ih LBS ^ to TONS 221 GAYS ON SITE 222 ' If EyHgS, amount must be in Ibs. STORAGE CONTAINER ^ a ABOVEGROUND TANK ,~I E PLASTIGNONMETALLIC DRUM ^ i FIBER DRUM ^ m GLASS BOTTLE ^ q RAIL CAR 223 (Check all that apply) ^ b UNDERGROUND TANK ^ f CAN v 1 BAG ^ n PLASTIC BOTTLE ^ r OTHER ^ c TANK INSIDE BUILDING ^ 9 CARBOY ^ k BOX ^ o TOTE BIN ^ d STEEL DRUM ^ h SILO ^ I CYLINDER ^ p TANK WAGON STORAGE PRESSURE a AMBIENT ^ as ABOVE AMBIENT ^ ba BELOW AMBIENT 224 STORAGE TEMPERATURE ~L a AMBIENT ^ as ABOVE AMBIENT L~. b3 BELOW AMBIENT ^ c CRYOGENIC 225 %WT J~ HA7_ARDOUS COMPONENT EHS CAS # t 226 i 227 ^ Yes ^ No 228 229 2 230 23t ^ Yes ^ No 232 233 3 234 235 ^ Yes ^ No 236 237 i i a ~.. 238 ~_ _-._ .__......-.. _,.-. _. ....._..._..---.-..---._. .. .. _. 239 , -24t - i I ^ Yes ^ No 240..._ ..... ~.-----~_._.- 4 _.. _. . - _. . 5 ~ 242 2J3 ~ 245 ^ Yes ^ No 244 III. SIGNATURE ~}-~-GJ f /~24w4 PRINT NAME S TITLE OF AUTHORIZED COMPANY REPRESENTATIVE ~ ~ ~ SIGNATURE DATE 246 1PCF (7/99) S:\CUPAFORMS\OES2731.TV4.wpd