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HomeMy WebLinkAbout2700 M STREET _HMBP 2.20.09USINES J Y . N ER/O PIER LTOR ID ENT _ Z nTION k Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) 13akersfield, CA 93301 FACILITY INFORMATION (661) 862 -8700 Fax (661) 862 -8701 •. Page I of I 1. IDENTIFICATION FACILI'T'Y ID# I BEGINNING DATE loo 101 . FA0003356 1 15- 0 1 0- 0 0 4 4 5 3 02/20/2009 ENDING DATE- 02/20/2010 BUSINESS NAME(SameasFACILITYNAMEorDBA - DoingBusinessAs) 3 BUSINESS PHONE 102 KERN MEDICAL CENTER 661 326 -2468 BUSINESS SITE ADDRESS 103 BUSINESS FAX IO2a 1700 MT VERNON AVE BUSINESS CI "fY 104 ZIP, CODE 105 COUNTY 108 BAKERSFIELD CA 93305 Kern County DUN & BRADSTREET 106 PRIMARY SIC 107, PRIMARY NAICS Iola 8062 None specified BUSINESS MAILING ADDRESS Io8a 1700 MT VERNON AVE BUSINESS MAILING CrrY 108e ZIP CODE I08d alWbSTATT BAKERSFIELD CA 93306 BUSINESS OPERATOR NAME 109 BUSINESS OPERA "rOR PHONE 110 CHARLES CLAYTON 11. BUSINESS OWNER OWNER NAME 111 OWNER PHONE 112 KERN COUNTY MEDICAL CENTER O _ OWNER MAILING ADDRESS 113 1700 MT VERNON AVE OWNER MAILING CITY 14 STAI•E 115 ZIP CODE Ile BAKERSFIELD CA 93306 111. ENVIRONMENTAL CONTACT CONTACT NAME_ 117 CON "rACT PHONE 118 CHARLES CLAYTON (661) 326 -24.68 CONTACT• MAILING ADDRESS, 119 CONTACT EMAIL 1193 1700 MT VERNON AVE claytonc @kernmedctr.com CITY 120 STATE 121 ZIP CODE 122 BAKERSFIELD CA 93306 1 - PRIMARY- IV. EMERGENCY CONTACTS - SECONDARY - NAME 123 'NAME 128 LEANN VICTORY CHARLES CLAYTON TITLE 124 rITLE 129 ENGINEERING LABORATORY MANAGER BUSINESS PHONE 125 BUSINESS PHONE 130 (661) 326 -2483 (661) 326 -2468 24- 1-IOUIZ PHONE 126 24 -HOUR PHONE 131 . (661) 326 -2000 (661) 326 -2000 PAGEIZ # i27 PAGER # 132 ADDI'T'IONAL LOCALLY COLLECTED INFORMATION: 133 APN: 12802003 Certification: Based on my inquiry of those individuals responsible for obtaining the information, I certify under penalty of law that I have personally examined and am familiar with the information submitted and believe the information is true, accurate, and complete. SIGNA'T'URE OF OWNER /OPERATOR OR DESIGNATED REPRESENTATIVE DATE 134 NAME OF DOCUMEN 'r PREPARER 135 ad'. �ru 03/06/2009 1 NAME OF SIGNER (print) 136 TITLE OF SIGNER 137 CHARLES CLAYTON HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield, CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661) 862 -8701 (one page per material per building or are4 ❑ ADD ❑ DELETE ❑ REVISE 200 Page I of 5 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 LABORATORY ❑ Yes ❑ No HAZ -MAT STORAGE FACILITY ID # I MAP# (optional) 203 GRID #(optional) 204 FA0003356 1 5- 0 1 0- 0 0 4 4 5 3 11. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes 0 No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes ❑x No 208 ISOPROPYL ALCOHOL *If EFIS is "Yes ", all amounts below must be in Ibs CAS# 209 FIRE CODE HAZARD CLASSES(Not currently requiresby KCEHSD) 210 HAZARDOUS MATERIAL RADIOACTIVE 212 CURIES 213 TYPE Check one item onl a. PURE ❑ b. MIXTURE ❑ c. WASTE ❑ Yes No 0.00 PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) Q a. SOLID ❑ b. LIQUID ❑ c. GAS 1.00 FED HAZARD CATEGORIES 216 apply) a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE ❑ d. ACUTE HEALTH e. CHRONIC HEALTH (Check all that a I ❑ AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT '- -18 ANNUAL WAS "fE AMOUNT ' -19 STATE WASTE CODE 22 -0 15.00 20.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) ❑X a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. 365 STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK ❑ e. PLASTICINONMETALLIC DRUM ❑ i. FIBER DRUM m. GLASS BOTTLE ❑ q. RAIL CAR ❑ b. UNDERGROUND TANK ❑ f. CAN ❑ j. BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER ❑ c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k. BOX ❑ o. TOTE BIN ❑ d. STEEL DRUM ❑ h. SILO ❑ 1. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE 19 a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE ❑X a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 I 1 ❑ Yes ❑ No 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑ Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 243 244 245 5 ❑ Yes ❑ No If more hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street. Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield. CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661) 862 -8701 (one page per material per building or are4 ❑ ADD ❑ DELETE ❑ REVISE 200 Page 2 of 5 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 LABORA'T'ORY ❑ Yes 0 No HAZ -MA "1' STORAGE FACILITY ID # MAP# (optional) 203 GRID# (optional) 2 04 FA0003356 1 5- 0 1 0- 0 0 4 4 5 3. 11. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes ❑x No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes ❑x No 208 XYLENE *If EHS is "Yes ", all amounts below must be in Ibs CAS# 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item only) ❑ a. PURE ❑ b. MIXTURE ❑ c. WASTE ❑ Yes No 0.00 PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) ❑ a. SOLID ❑ b. LIQUID [:1 c. GAS 1.00 FED HAZARD CATEGORIES 216 (Check all that apply) a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE ❑ d. ACUTE HEALTH ❑x e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 5.00 12.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) ❑X a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. 365 STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK ❑ e. PLASTICINONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAIL CAR ❑ b. UNDERGROUND TANK ❑ f. CAN ❑ j. BAG ❑x n. PLASTIC BOTTLE ❑ r. OTHER ❑ c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k. BOX ❑ o. TOTE BIN ❑ d. STEEL DRUM ❑ h. SILO ❑ 1. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE Q a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 0.00 ❑ Yes ❑x No 230 231 232 233 2 0.00 ❑ Yes ❑x No 234 235 236 237 3 0.00 ❑ Yes ❑x No 238 239 240 241 4 0.00 ❑ Yes ❑x No 242 243 244 245 5 0.00 1 ❑ Yes ❑ No If more hazardous components are present at greater than 1% by weight if non- carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield, CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661) 862 -8701 (one page per material per building or are4 ❑ ADD ❑ DELETE ❑ REVISE 200 Page 3 of 5 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 LABORATORY C] Yes [g -No LAB TREATMENT UNIT FACILITY ID # MAP# (optional) 203 GRID #(optional) 204 FA0003356 1 5- 0 1 0- 0 0 4 4 5 3 11. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes 0 No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EFIS* ❑ Yes ❑x No 208 FORMALDEHYDE WASTE *If EHS is "Yes ", all amounts below must be in Ibs CAS# 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item only) ❑ a. PURE ❑ b. MIXTURE 0 c. WASTE [] Yes 0 No 0.00 PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) Q a. SOLID ❑ b. LIQUID ❑ c. GAS 40.00 FED HAZARD CATEGORIES 216 (Check all that apply) a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE d. ACUTE HEALTH >< e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT ' -19 STATE WASTE CODE 220 7.00 20.00 . UNI "fS *. 221 DAYS ON SITE: 222 (Check one item only) Q a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. 365 STORAGE CONTAINER 223 ❑ a. ABOVEGROUND TANK ❑ e. PLASTICINONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAILCAR ❑ b. UNDERGROUND "TANK ❑ f. CAN ❑ j. BAG ❑x 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 WAGON STORAGE PRESSURE ❑X a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE [R] a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 0.00 ❑ Yes ❑x No 230 231 232 233 2 0.00 ❑ Yes ❑x No 234 235 236 237 3 0.00 ❑ Yes ❑x No 238 239 240 241 4 0,00 ❑ Yes ❑x No 242 243 244 245 5 0.00 ❑ Yes ❑x No If more hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield, CA 93301 HAZARDOUS MATERIALS (661 ) 862 -8700 Fax (661 ) 862 -8701 (one page per material per building or are41 ❑ ADD ❑ DELETE ❑ REVISE 200 Page 4 of 5 L FACILITY INFORMATION. BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 LABORATORY ❑ Yes ❑ No LAB TREATMENT UNIT FACILITY ID # MAP# (optional) 203 GRID# (optional) 204 FA0003356 I S- 0 1 0 ll. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes No Zoe If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes ❑x No 208 WASTE XYLENE *If EHS is "Yes ", all amounts below must be in lbs. CAS# 209 F RE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item only) ❑ a. PURE ❑ b. MIXTURE c. WASTE C] Yes ❑x No 0,00 PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) © a. SOLID ❑ b. LIQUID ❑ c. GAS 1.00 FED HAZARD CATEGORIES 216 (Check all that apply) Ig a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE ❑x d. ACUTE HEALTH ❑x e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 58.00 58.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) ❑ a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. 365 STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK ❑ e. PLASTICINONMETALLIC DRUM ❑ i. FIBER DRUM ❑x m. GLASS BOTTLE ❑ q. RAIL CAR ❑ b. UNDERGROUND TANK ❑ f. CAN ❑ j. 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 WAGON STORAGE PRESSURE a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE Q a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 ❑ Yes ❑ No 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑ Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 243 244 245 5 ❑ Yes ❑ No If more hazardous components are present at greater than 11% by weight if non - carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield, CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661) 862 -8701 (one page per material per building or are4 ❑ ADD ❑ DELETE ❑ REVISE 200 Page 5 of 5 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 LABORATORY ❑ Yes 0 No HISTOLOGY FACILITY ID # MAP# (optional) 203 GRID# (optional) 204 FA0003356 1 1 5- 0 1 1 0- 0 0 1 4 4 5 131 1 I1. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes ❑x No 208 FORMALIN 10% *If EHS is "Yes ", all amounts below must be in Ibs CAS# 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 9 r HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item only) ❑ a. PURE ❑ b. MIXTURE Q c. WASTE ❑ Yes (] No Q,QQ PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) (] a. SOLID ❑ b. LIQUID ❑ c. GAS FED HAZARD CATEGORIES 216 (Check all that apply) a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE ❑ d. ACUTE HEALTH ❑ e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 1 STATE WASTE CODE 220 UNITS* 221 DAYS ON SITE: 222 (Check one item only) ❑x a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK ❑ e. PLASTICNONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAILCAR ❑ b. UNDERGROUND TANK ❑ f. CAN ❑ j. BAG 0 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 WAGON STORAGE PRESSURE ❑ a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE ❑ a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 10.00 FORMALDEHYDE ❑ Yes i] No 230 231 232 233 2 0.00 ❑ Yes x❑ No 234 235 236 237 3 0.00 ❑ Yes I] No 238 239 240 241 4 0.00 ❑ Yes g No 242 243 244 245 5 0.00 ❑ Yes Zx No If more hazardous components are present at greater than I% by weight if non - carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246' If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield, CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661 862 -8701 (one page per material per building or are4 ❑ ADD ❑ DELETE ❑ REVISE 200 Page I oft 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 LAUNDRY 1 ❑ Yes ❑ No LAUNDRY AREA CHCEMICAL STORAGE FACILITY ID # l MAP# (optional) 203 GRID# (optional) 204 FA0003356 1 5- 0 1 0 11. CHEMICAL INFORMATION CHEMICAL NAME-- 205 TRADE SECRET ❑ Yes ❑x No 206 If subject to EPCRA, refer to instructions COMMON NAME .207 EHS* ❑ Yes ❑x No 208 SUPER IMPEDE STAIN REMOVER *If EHS is "Yes ", all amounts below must be in Ibs S#-- 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSO) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item only) ❑ a. PURE ❑x b. MIXTURE ❑ c. WASTE ❑ Yes [E No Q,QQ PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) ❑Q a. SOLID ❑ b. LIQUID ❑ c. GAS 15,00 FED I4AZARD CATEGORIES 216 (Check all that apply) ❑ a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE ❑x . d. ACUTE HEALTH ❑ e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 30.00 45.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) ❑x a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. 365 STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK e. PLASTICINONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAIL CAR ❑ b. UNDERGROUND TANK ❑ f. CAN ❑ j. 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 WAGON STORAGE PRESSURE Q a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE Q a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 ❑ Yes ❑ No 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑ Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 243, 244 245 5 Yes ❑ No If more hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1 % by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health.Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield, CA 93301 HAZARDOUS MATERIALS (661 ) 862 -8700 Fax (661 ) 862 -8701 (one page per material per building or area) ❑ ADD ❑ DELETE ❑ REVISE 200 Page 2 of 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 LAUNDRY ❑ Yes No LAUNDRY CHEMICAL STORAGE AREA FACILITY ID # I MAP# (optional) 203 GRID #(optional) 204 FA0003356 1 5- 0 1 0- 0 0 4 4 5 3 II. CHEMICAL INFORMATION CHEMICAL NAM — 205 TRADE SECRET ❑ Yes Z No 206 If subject to EPCRA, refer to instructions C MON NAME 207 EH S* ❑ Yes No 208 LIQUID DWERALK IC *If EHS is "Yes ", all amounts below must be in lbs S# 209 FIRE CO *I�tD CCA9S_ S (Not currently requires by KCE .,SD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 I'YI'E Check one item only) ❑ a. PURE ❑x b. MIXTURE ❑ c. WASTE ❑ Yes Zx No 0.00 PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) ❑Q a. SOLID ❑ b. LIQUID ❑' c. GAS 15,00 FED HAZARD CATEGORIES 216 (Check all that apply) ❑ a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE ❑x d. ACUTE HEALTH ❑x e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 30.00 45.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. 365 STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK Zx e. PLASTICINONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAIL CAR ❑ b. UNDERGROUND TANK ❑ f CAN ❑ j. BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER ❑ c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k. BOX ❑ o. TOTE BIN ❑ d. STEEL DRUM ❑ h. SILO ❑ 1. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE ❑K a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 0.00 ❑ Yes Zx No 230 231 232 233 2 0.00 ❑ Yes Zx No 234 235 236 237 3 0.00 ❑ Yes Zx No 238 239 240 241 4 0.00 ❑ Yes Zx No 242 243 244 245 5 0.00 ❑ Yes Zx No If more hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street. Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield, CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661) 862 -8701 (one page per material per building or are4 ❑ ADD ❑ DELETE ❑ REVISE 200 Page I of 35 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION ❑ Yes ❑ No B- BASEMENT AND MAINTENANCE DEPT FACILITY ID # 1 MAP# (optional) 203 GRID #(optional) 204 FA0003356 1 5- 0 1 0- 0 0 4 4 5 3 11. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes 0 No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes Q No 208 FREON 11. *If EHS is "Yes ", all amounts below must be in lbs CAS# 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item only) 0 a. PURE ❑ b. MIXTURE ❑ c. WASTE [j Yes Z No 0,00 PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) ❑ a. SOLID ❑ b. LIQUID g c. GAS 50.00 FED HAZARD CATEGORIES 216 (Check all that apply) ❑ a. FIRE ❑ b. REACTIVE I@ c. PRESSURE_ RELEASE (] d. ACUTE HEALTH ❑x e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 A TIE AMOUNT 219 STATE WASTE CODE 220 200. 200.00 UNITS* 221 DAYS ON SITE: 222 (Check one item onl 1:1 a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. 365 STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK ❑- e...PI�AS+I 01V1Cf TALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAILCAR ❑ b. UNDERGROUND TANK ❑ f. CAN ❑ j. 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 WAGON STORAGE PRESSURE ❑ a. AMBIENT b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE 0 a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %w,r HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 ❑ Yes Z No 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑ Yes Z No 238 239 240 241 4 ❑ Yes ❑ No 242 243 244 245 5 ❑ Yes ❑ No If more hazardous components are present at greater than 1% by weight if non - carcinogenic, m-0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield, CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661) 862 -8701 (one page per material per building or areal ❑ ADD ❑ DELETE ❑ REVISE 200 Page 2 of 35 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION ❑ Yes ❑ No MAINTENANCE DEPT FACILITY ID # MAP# (optional) 203 GRID# (optional) 2 04 FA0003356 1 5- 0 1 0- 0 0 4 4 5 3 11. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes [0 No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes No 208 FREON 12 *If EHS is "Yes ", all amounts below must be in lbs. CAS# 2 -09 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item only Z a. PURE E] b. MIXTURE ❑ c. WASTE ❑ Yes Z No 0,00 PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) ❑ a. SOLID ❑ b. LIQUID ❑x c. GAS 0,00 FED HAZARD CATEGORIES 216 (Check all that apply) ❑ a. FIRE ❑ b. REACTIVE ❑x c. PRESSURE RELEASE ❑x d. ACUTE HEALTH ❑x e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 iv1AXIMUM- DAILY AX400IgT`-M ANNUAL - -WASTE AMOUNT 219 STATE WASTE CODE 220 0.00 f��- -' M 200.00 UNITS'" 221 YS ON SITE: 222 (Check one item only) a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. STORAGE CONTAI R 223 ❑ a. ABOVE GROU K�❑_e. PLASS TALLIC DRUM ❑ i. FIBER DRUj� �ASSBOTTLE ❑ q. RAIL CAR b. UNDERGROUND TANK ❑ f. CAN —.4= j"B ❑ n. PLOTTLE ❑ r: OTHER ❑ c. TANK INSIDE BUILDING ❑ g. CARBOY •.•- --- °^ ❑ k. BOX ❑ o. TOTE BIN ❑ d. STEEL DRUM ❑ h. SILO ❑x I. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE ❑ a. AMBIENT b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 ❑ Yes ❑ No 230 - 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑ Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 243 - 244 245 $ ❑ Yes [3 No If more hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield, CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661 ) 862 -8701 (one page per material per building or areO ❑ ADD ❑ DELETE ❑ REVISE 200 Page 3 of 35 I. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION ❑ Yes ❑ No MAINTENANCE DEPT FACILITY ID # I MAP# (optional) 203 GRID# (optional) 204 FA0003356 1 5- 0 1 0- 0 0 4 4 5 3 H. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes Z No 206 if subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes Q No 208 FREON 22 *If EHS is "Yes ", all amounts below must be in lbs. CAS# 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item only) a. PURE ❑ b. MIXTURE ❑ c. WASTE ❑ Yes Z No 0.00 PHYSICAL STATE 214 ❑ a. SOLID ❑ b. LIQUID [E c. GAS LARGEST CONTAINER 219 50.00 (Check one item only) FED HAZARD CATEGORIES ❑ 216 (Check all that apply) a. FIRE ❑ b. REACTIVE [M c. PRESSURE RELEASE d. ACUTE.HEALTH e. CHRONIC HEALTH AVERAGE DAILY AMOUNT A'X1 - M DAILY AMOUNT WASTE AMOUNT 219 STATE WASTE CODE 220 200.00 200.00 UNITS* ' 221 DAYS ON SITE: 222 (Check one itet only) ❑ a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TON * If EHS, amount must be in pounds. 365 STORAGE CONTAIN 223 ❑ a. ABOVE GROUND TANK ❑ e. PLASTIC(NONME ,ALL -Ie UM ❑ i. FIBER DRUM ❑ M. GLASS BOTTLE ❑ q. RAILCAR ❑ b. UNDERGROUND TANK L. ❑ j. 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 WAGON STORAGE PRESSURE ❑ a. AMBIENT b. ABOVE AMBIENT ❑ C. BELOW AMBIENT 224 STORAGE TEMPERATURE a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 ❑ Yes ❑ No 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑ Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 243 244 245 5 ❑ Yes ❑ No If more hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department Unified Program Consolidated Form (UPCF) 2700 M Street, Suite 300 Bakersfield, CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661 ) 862 -8701 (one page per material per building or are4 ❑ ADD ❑ DELETE ❑ REVISE 200 Page 4 of35 I. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION ❑ Yes ❑ No MAINTENANCE DEPT FACILITY ID # I MAP# (optional) 203 GRID# (optional) 204 FA0003356 10- b 0 4 4 5 3 II. CHEMICAL INFORMATION CHEMICAL E 205 TRADE SECRET ❑ Yes No 206 If subject to EPCRA, refer to instructions CO ON NAME 207 EHS* ❑ Yes ❑ No 208 HYDROCARBON OIL *If EHS is "Yes ", all amounts below must be in Ibs CA 209 Fl RE CODE � AR S (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE (Check one item only) ❑x a. PURE ❑ b. MIXTURE ❑ c. WASTE ❑ Yes ❑x No 0,00 PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) ❑x a. SOLID ❑ b. LIQUID ❑ c. GAS 55.00 FED HAZARD CATEGORIES 216 (Check all that apply) I] a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE ❑x d. ACUTE HEALTH e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 55.00 55:00 UNITS* - 221 DAYS ON SITE: 222 (Check one item only) ❑x a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. 365 STORAGE CONTAINER ( 223 ❑ a. ABOVE GROUND TANK ❑ e. PLASTICNONMETALLIC DRUM ❑ i. FIBER DRUM ❑ M. GLASS BOTTLE ❑ q. RAILCAR ❑ b. UNDERGROUND TANK ❑x f CAN ❑ j. 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 WAGON STORAGE PRESSURE ❑x a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ C. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 ❑ Yes ❑ No 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑ Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 243 244 245 j ❑ Yes ❑ No If more hazardous components are present at greater than I% by weight if non - carcinogenic, or 0.1 % by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield, CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661) 862 -8701 (one page per material per building or are4 ❑ ADD ❑ DELETE ❑ REVISE 200 Page 5 of 35 I. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION ❑ Yes ❑ No OPERATING ROOM FACILITY ID # I MAP# (optional) 203 GRID #(optional) 204 FA0003356 1 5- 0 1 0- 0 4 5 3 II. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes 0 No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes 0 No 208 CARBON DIOXIDE *If EHS is "Yes ", all amounts below must be in lbs CAS# 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item onl a. PURE ❑ b. MIXTURE C] c. WASTE C] Yes 2 No 0,00 PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) ❑ a. SOLID ❑ b. LIQUID 0 c. GAS 0.00 FED HAZARD CATEGORIES 216 (Check all that apply) ❑ a. FIRE ❑ b. REACTIVE ❑x c. PRESSURE RELEASE ❑x d. ACUTE HEALTH ❑ e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 CODE 220 0.00 1,200.00 UNITS* 1 ON SITE: 222 (Check one item only) ❑ a. GALLONS ❑X b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS �7 * If EHS, amount most be in pounds. STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK ❑ e. PLASTICINONMETALLIC DRUM ❑ i. FIBER DRUM ❑ GL S �BOTTLq..RAIL CAR b. UNDERGROUND TANK ❑ f. CAN ❑ j. BAG ❑ n. ER ❑ c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k. BOX ❑ o. TOTE BIN ❑ d. STEEL DRUM ❑ h. SILO ❑x I. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE ❑ a. AMBIENT b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %wT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 I ❑ Yes ❑ No 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑ Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 243 244 245 $ ❑ Yes ❑ No If more hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield. CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661) 862 -8701 (one page per material per building or are4 ❑ ADD ❑ DELETE ❑ REVISE 200 Page 6 of 35 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION ❑ Yes ❑ No MAINTENANCE DEPT FACILITY ID # MA P# (optional) 203 GRID# (optional) 204 FA0003356 1.- 0 0 4 4 5 3 11. CHEMICAL INFORMATION CHEMICAL NAM' 205 TRADE SECRET ❑ Yes No 206 If subject to EPCRA, refer to instructions C MMON NAME 207 EHS* ❑ Yes No 208 PAINT *If EHS is "Yes ", all amounts below must be in Ibs CA 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item only ❑x a. PURE ❑ b. MIXTURE ❑ c. WASTE ❑ Yes ❑ No 0.00 PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) Q a. SOLID ❑ b. LIQUID ❑ c. GAS 5.00 FED HAZARD CATEGORIES 216 (Check all that apply) ❑x a. FIRE ❑ b. REACTIVE ❑x c. PRESSURE RELEASE ❑x d. ACUTE HEALTH ❑x e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 400.00 400.00 1 UNITS* 221 DAYS ON SITE: 222 (Check one item only) ❑x a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. 365 STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK ❑ e. PLASTICINON METALLIC DRUM 1 ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAILCAR ❑ b. UNDERGROUND TANK f. CAN ❑ j. 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 WAGON STORAGE PRESSURE a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE ❑x a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 I ❑ Yes ❑ No 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑ Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 243 244 245 5 ❑ Yes ❑ No If more hazardous components are present at greater than, 1 % by weight if non - carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department . Unified Program Consolidated Form (UPCF) 2700 M Street. Suite 300 Bakersfield. CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661) 862 -8701' (one page per material per building or are4 ❑ ADD ❑ DELETE ❑ REVISE 200 Page 7 of 35 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION ❑ Yes ❑ No MAINTENANCE DEPT FACILITY ID # I MAP# (optional) 203. GRID# (optional) 204 FA0003356 1 5- 0 1 0 11. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes Q No 206 If subject to EPCPA, refer to instructions COMMON NAME 207 EHS* ❑ Yes No 208 ACETYLENE *If EHS is "Yes ", all amounts below must be in Ibs CAS# 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item only) (] a. PURE ❑ b. MIXTURE ❑ c. WASTE ❑ Yes Z No 0.00 PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) ❑ a. SOLID ❑ b. LIQUID ❑x c. GAS 0.00 FED HAZARD CATEGORIES 216 (Check all that apply) Q a. FIRE ❑x b. REACTIVE 0 c. PRESSURE RELEASE ❑x d. ACUTE HEALTH ❑ e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 S CODE 220 0.00 600.00 --° UNITS* DAYS ON SITE: 222 (Check one item only) ❑ a. GALLONS 0 b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK ❑ e. PLASTIC(NONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. L�BOTTLEq IL CAR b. UNDE RGROUND TANK ❑ f CAN ❑ j. BAG ❑ n. PLHER ❑ c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k. BOX ❑ o. TOTE BIN ❑ d. STEEL DRUM ❑ h. SILO ❑x I. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE ❑ a. AMBIENT b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 ❑ Yes ❑ No 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑ Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 243 244 245 5 ❑ Yes ❑ No If more hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1 % by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield. CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 FAX (661 862 -8701 (one page per material per building or areal ❑ ADD ❑ DELETE ❑ REVISE 200 Page 8 of 35 I. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION ❑ Yes ❑ No RESERVE TANK WEST OF E.R. ENTRANCE FACILI'T'Y ID # MAP# (optional) 203 GRID #(optional) 204 FA0003356 1 5- 0 1 0- 0 0 4 4 5 3 1 11. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes Q No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes 0 No 208 OXYGEN LIQUIFIED *If EHS is "Yes ", all amounts below must be in Ibs CAS# 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Clteck one item only) (] a. PURE ❑ b. MIXTURE C] c. WASTE ❑ Yes 0 No Q,QQ PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) (] a. SOLID ❑ b. LIQUID ❑ c. GAS 172,500.00 FED HAZARD CATEGORIES 216 (Check all that apply) a. FIRE ❑ b. REACTIVE 0 c. PRESSURE RELEASE 0 d. ACUTE HEALTH ❑ e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 172,500.00 172,500.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) ❑ a. GALLONS b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. 365 STORAGE CONTAINER 223 a. ABOVE GROUND TANK ❑ e. PLASTICNONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAILCAR ❑ b. UNDERGROUND TANK ❑ f. CAN ❑ j. 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 WAGON STORAGE PRESSURE a. AMBIENT b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE ❑ a. AMIBIENT ❑ b. ABOVE AMBIENT 0 c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 ❑ Yes ❑ No 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑ Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 243 244 245 5 ❑ Yes ❑ No If more hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department Unified Program Consolidated Form (UPCF) 2700 M Street. Suite 300 Bakersfield, CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661) 862 -8701 (one page per material per building or are4 ❑ ADD ❑ DELETE ❑ REVISE 200 Page 9 of 35 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION ❑ Yes ❑ No F -WARD & GAS STORAGE AREA WEST OF E.R. E FACILITY ID # 1 MAP# (optional) 203 GRID #(optional) 204 FA0003356 1 5- 0 1 0- 0 0 4 4 513 11. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes 0 No 206 If subject to EPCRA, refer to instructions COMMO NAME,---- . 207 EHS* ❑ Yes 0 No 208 /•I'TROUS OXIDE - K BOTTL *If EHS is "Yes ", all amounts below must be in Ibs CAM, 209 FIRE CO ,AZA&Q CLASS of currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Clteck one item only) a. PURE ❑ b. MIXTURE ❑ c. WASTE ❑ Yes No Q,QQ PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) ❑ a. SOLID ❑ b. LIQUID ❑ c. GAS 56$.00 FED HAZARD CATEGORIES 216 (Check all that apply) ❑ a. FIRE ❑ b. REACTIVE ❑x c. PRESSURE RELEASE ❑x d. ACUTE HEALTH ❑x e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 18,069.00 18,096.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) ❑ a. GALLONS b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. 365 STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK ❑ e. PLASTIGNONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAILCAR ❑ b. UNDERGROUND TANK ❑ f. CAN ❑ j. BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER ❑ c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k. BOX ❑ o. TOTE BIN ❑ d. STEEL DRUM ❑ h. SILO ❑x I. CYLINDER ❑ p. TANK WAGON S'T'ORAGE PRESSURE ❑ a. AMBIENT b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 ❑ Yes ❑ No 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑ Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 243 244 245 5 ❑ Yes ❑ No If more hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield, CA 93301 HAZARDOUS MATERIALS (661 ) 862 -8700 Fax (661) 862 -8701 (one page per material per building or are4 ❑ ADD ❑ DELETE ❑ REVISE 200 Page 10 of 35 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION ❑ Yes ❑ No MAIN BLDG & GAS STORAGE AREA WEST OF E.R FACILITY ID # I MAP# (optional) 203 GRID #(optional) 204 FA0003356 1 5- 0 1 0- 0 0 4 4 5 3 11. CHEMICAL INFORMATION CHEMICAL ME 205 TRADE SECRET ❑ Yes 0 No 206 If subject to EPCRA, refer to instructions CO ON NAME 207 EHS* ❑ Yes 0 No 208 r0c - H BOTTLES *If EHS is "Yes ", all amounts below must be in Ibs CAS# 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item only) a. PURE ❑ b. MIXTURE ❑ c. WASTE ❑ Yes Zx No 0.00 PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) ❑ a. SOLID ❑ b. LIQUID ❑x C. GAS 250.00 FED HAZARD CATEGORIES 216 (Check all that apply) I] a. FIRE ❑ b. REACTIVE 9 C. PRESSURE RELEASE ❑ d. ACUTE HEALTH ❑ e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 TE AMOU NT 219 STATE WASTE CODE 220 12,000.00 12,000.00 7U� UNITS* 221 DAYS ON SITE: 222 (Check one item only) ❑ a. GALLONS [g] b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS " If EHS, amount must be in pounds. 365 STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK ❑ e. PLASTIC/NONMETALLIC DRUM ❑ i. FIBER DRUM. ❑ M. GLASS BOTTLE ❑ q. RAILCAR ❑ b. UNDERGROUND TANK ❑ f CAN Z j. BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER ❑ c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k. BOX ❑ o. TOTE BIN ❑ d. STEEL DRUM ❑ h. SILO ❑x I. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE ❑ a. AMBIENT b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 ❑ Yes ❑ No 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 Z Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 243 244 245 5 ❑ Yes ❑ No If more hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1 % by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 ff EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield. CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661) 862 -8701 (one page per material per building or areal ❑ ADD ❑ DELETE ❑. REVISE 200 Page I I of 35 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION ❑ Yes ❑ No MAIN BLDG & GAS STORAGE AREA WEST OF E.R FACILITY ID # 1 MAP# (optional) 203 GRID #(optional) 204 FA0003356 1 5- 0 1 0- 0 0 4 4 5 3 H. CHEMICAL INFORMATION CHEMICAL N 205 TRADE SECRET ❑ Yes [g No 206 If subject to EPCRA, refer to instructions CO 207 EHS* ❑ Yes 0 No 208 MONNAME 2 - E BOTTLES *If EHS is "Yes "., all amounts below must be in Ibs y� # 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item only) 0 a. PURE ❑ b. MIXTURE ❑ c. WASTE ❑ Yes 0 No 0,00 PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) ❑ a. SOLID ❑. b. LIQUID 0 c. GAS 23.00 FED HAZARD CATEGORIES 216 (Check all that apply) a. FIRE ❑ b. REACTIVE 0 c. PRESSURE RELEASE ❑ d. ACUTE HEALTH ❑ e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 966.00 966.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) ❑ a. GALLONS ❑X b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. 365 STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK ❑ e. PLASTICINONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAILCAR ❑ b. UNDERGROUND TANK ❑ f. CAN ❑ j. BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER ❑ c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k.. BOX ❑ o. TOTE BIN ❑ d. STEEL DRUM ❑ h. SILO ❑x I. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE ❑ a. AMBIENT b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ C. BELOW.AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # t 226 227 228 229 1 ❑ Yes ❑ No 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑ Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 243 244 245 5 ❑ Yes ❑ No If more hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1 % by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield. CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661) 862 -8701 (one page per material per building or are r) ❑ ADD ❑ DELETE, ❑ REVISE 200 Page 12 of 35 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION ❑ Yes ❑ No O.R. & GAS STORAGE AREA WEST OF E.R. ENT FACILITY ID # MAP# (optional) . 203 GRID# (optional) 204 FA0003356 1 5- 0 1 0- 0 0 4 415 3 11. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes 0 No 206 If subject to EPCRA,,refer to instructions COMMON NAME 207 EHS* ❑ Yes 0 No 208 NITROGEN *If EHS is "Yes ", all amounts below must be in lbs CAS# 209 FIRE CODE HAZARD CLASSES(Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item only) a. PURE' ❑ b. MIXTURE ❑ c. WASTE ❑ Yes Z No 0.00 PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) ❑ a. SOLID ❑ b. LIQUID I] c. GAS 258.00 FED HAZARD CATEGORIES 216 (Check all that apply) ❑ a. FIRE ❑ b. REACTIVE l@ c. PRESSURE RELEASE [E d. ACUTE HEALTH ❑ e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 5,676.00 5,676.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) ❑ a. GALLONS Z b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount trust be in pounds. 365 STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK ❑ e. PLASTICYNONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAILCAR ❑ b. UNDERGROUND TANK ❑ f. CAN ❑ j. BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER ❑ c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k. BOX ❑ o. TOTE BIN ❑ d. STEEL DRUM ❑ .h. SILO ❑x 1. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE ❑ a. AMBIENT ❑x b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 ❑ Yes ❑ No 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑ Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 243 244 245 5 ❑ Yes ❑ No If more hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1 % by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield, CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661)'862 -8701 (one page per material per building or are4 ❑ ADD [I DELETE El REVISE 200 Page 13 of 35 L FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION ❑ Yes E] No AUXILLARY FACILITY ID # I MAP# (optional) 203 GRID #(optional) 204 FA0003356 1 1 5- O 1 0- 0 1014 4 11. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes 0 No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes No 208 HELIUM *If EHS is "Yes ", all amounts below must be in Ibs CAS# 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item only) a. PURE ❑ b. MIXTURE ❑ c. WASTE ❑ Yes Z No Q,QQ PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) ❑ a. SOLID ❑ b. LIQUID c. GAS Q.QQ FED HAZARD CATEGORIES 216 (Check all that apply) ❑ a. FIRE ❑ b. REACTIVE I@ c. PRESSURE RELEASE d. ACUTE HEALTH ❑ e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 0.00 1,200.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) ❑ a. GALLONS ❑x b. CUBIC FEET ❑ c. POUNDS ❑ A. TONS * If EHS, amount must be in pounds. STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK ❑ e. PLASTICINONMETALLIC DRUM ❑ i. FIBER DRUM [j m. GLASS BOTTLE ❑ q. RAIL CAR ❑ b. UNDERGROUND TANK ❑ f CAN ❑ j. BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER ❑ c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k. BOX ❑ o. TOTE BIN ❑ d. STEEL DRUM ❑ h. SILO ❑x 1. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE ❑ a. AMBIENT ❑x b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE ❑ a. AMIBIENT ❑ b. ABOVE AMBIENT c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 ❑ Yes ❑ No 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑ Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 243 244 245 5 ❑ Yes ❑ No If more hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 30.0 Unified Program Consolidated Form (UPCF) Bakersfield, CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661) 862 -8701 (one page per material per building or are4 ❑ ADD ❑ DELETE ❑ REVISE 200 Page 14 of 35 I. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION El Yes El No BOILER ROOM FACILITY ID # I MAP# (optional) 203 GRID# (optional) 204 FA0003356 1 5- 0 1 0 11. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes Q No 208 SODIUM BISULFITE *If EHS is "Yes ", all amounts below must be in Ibs CAS# 209 FIRE CODE HAZARD CLASS ES(Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 I'YI'E Clleck one item only) ❑ a. PURE b. MIXTURE ❑ c. WASTE ❑ Yes ❑x N0 0,00 PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) Q a. SOLID ❑ b. LIQUID ❑ c. GAS 55.00 FED HAZARD CATEGORIES 216 (Check all that apply) ❑ a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE ❑x d. ACUTE HEALTH ❑x e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ,ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 55.00 55.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) ❑X a. GALLONS ❑ b. CUBIC FEE"I' ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. 365 STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK ❑ e. PLASTICNONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAIL CAR ❑ b. UNDERGROUND TANK ❑x f CAN ❑ j. 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 WAGON STORAGE PRESSURE ❑X a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE ❑X a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 ❑ Yes ❑ No .230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑ Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 243 244 245 5 F ❑ Yes ❑ No If more hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield, CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661 ) 862 -8701 (one page per material per building or are4 ❑ ADD ❑ DELETE ❑ REVISE 200 Page 15 of 35 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION ❑ Yes ❑ No BOILER ROOM FACILITY ID # 1 MAP# (optional) 203 GRID# (optional) 204 FA0003356 1 5- 0 1 0- 0 0 4 4 5 3 11. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes ❑x No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes ❑x No 208 SODIUM ACRYLATE RESIN *If EHS is "Yes ", all amounts below must be in lbs CAS# 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 21.1 RADIOACTIVE 212 CURIES 213 TYPE Check one item onl ❑ a. PURE ❑x b. MIXTURE ❑ c. WASTE E] Yes ❑ No Q,QQ PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) ❑Q a. SOLID ❑ b. LIQUID ❑ c. GAS 55,00 FED HAZARD CATEGORIES 216 (Check all that apply) ❑ a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE ❑x d. ACUTE HEALTH ❑x e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 55.00 55.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) ❑X a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. 365 STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK ❑ e. PLASTICNONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAILCAR ❑ b. UNDERGROUND TANK ❑x f. CAN ❑ j. 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 WAGON STORAGE PRESSURE a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE ❑X a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) ENS CAS # 226 227 228 229 1 ❑ Yes ❑ No 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑ Yes ❑ No 238 239 240 241 4 ❑ Ycs ❑ No 242 243 244 245 5 ❑ Yes ❑ No If more hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield, CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661) 862,8701 (one page per material per building or are4 ❑ ADD ❑ DELETE ❑ REVISE 200 Page 16 of 35 1. FACILITY. INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION ❑ Yes ❑ No BOILER ROOM FACILITY ID # 1 MAP# (optional) 203 GRID# (optional) 204 FA0003356 1 5- 0 1 0- 0 0 4 4 5 3 II. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes Z No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* Z Yes ❑ No 208 . CYCLOHEXYLAMINE *If EHS is "Yes ", all amounts below must be in Ibs CAS# 2 °9 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item only) ❑ a. PURE b. MIXTURE ❑ c. WASTE ❑ Yes Q No Q,QQ PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) Q a. SOLID ❑ b. LIQUID ❑ c. GAS 0.00 FED HAZARD CATEGORIES 216 (Check all that apply) Q a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE ❑x d. ACUTE HEALTH ❑x e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 . ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 0.00 400.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) Q a. GALLONS ❑ b. CUBIC FEET ❑ c'. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK ❑ e. PLASTIC/NONMETALLIC DRUM ❑ i. FIBER DRUM ❑ M. GLASS BOTTLE ❑ q. RAILCAR ❑ b. UNDERGROUND TANK (] f. CAN ❑ j. 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 WAGON STORAGE PRESSURE a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE Q a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ C. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 ❑ Yes ❑ No 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑ Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 243 244 245 5 ❑ Yes ❑ No If more hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield, CA 93301 HAZARDOUS MATERIALS (661 ) 862 -8700 Fax (661) 862 -8701 (one page per material per building or areal ❑ ADD ❑ DELETE Z REVISE 200 Page 17 of 35 I. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION ❑ Yes ❑ No S OF MAINT SHOP AREA FACILITY ID # 1 MAP# (optional) 203 GRID# (optional) 204 FA0003356 1 5- 0 1 0- 0 0 4 4 5 3 11. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes 0 No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes Q No 208 DIESEL - SOUTH TANK - UST *If EHS is "Yes ", all amounts below must be in Ibs CAS# 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 213 TYPE Check one item only) Z a. PURE ❑ b. MIXTURE ❑ c. WASTE ICURIES E] Yes [E No 0.00 PHYSICAL STATE 214 Z a. SOLID ❑ b. LIQUID ❑ c. GAS LARGEST CONTAINER 215 10,000.00 (Check one item only) FED HAZARD CATEGORIES 216 (Check all that apply) [R] a. I =IRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE ❑x d. ACUTE HEALTH ❑x e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 8,000.00 10,000.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) Z a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. 365 STORAGE CONTAINER 223 ❑ a. ABOVE GROUND "TANK ❑ e. PLASTICfNONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAILCAR ❑x b. UNDERGROUND TANK ❑ f CAN ❑ j. 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 WAGON STORAGE PRESSURE a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE ❑x a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (Formixture or waste only) EHS CAS # 226 227 228 229 1 ❑ Yes ❑ No 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑ Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 243 244 245 5 ❑ Yes ❑ No If more hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield, CA 93301 HAZARDOUS MATERIALS (661 ) 862 -8700 Fax (661) 862 -8701 (one page per material per building or areal ❑ ADD ❑ DELETE ❑ 'REVISE 200 Page 18 of 35 I. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION El Yes ❑ No MAINTENANCE DEPT FACILITY ID # I MAP# (optional) 203 GRID #(optional) 204 FA0003356 1 5- 0 1 0- 0 0 4 4 5 3 I1. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes ❑x No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes ❑x No 208 CHEVRON 350 *If EHS is "Yes ", all amounts below must be in lbs. CAS# 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item only) ❑Q a. PURE ❑ b. MIXTURE ❑ c. WASTE [] Yes ❑ No 0.00 PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) a. SOLID ❑ b. LIQUID ❑ c. GAS 0.00 FED HAZARD CATEGORIES 216 (Check all that apply) a. FIRE [I b. REACTIVE ❑ c. PRESSURE RELEASE ❑x d. ACUTE HEALTH ❑x e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 0.00 55.00 1 UNITS* 221 DAYS ON SITE: 222 (Check one item only) a. GALLONS ❑ I b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK ❑ e. PLASTICNONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAIL CAR ❑ b. UNDERGROUND TANK ❑x f. CAN ❑ j. BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER ❑ c. TANK INSIDE BUILDING ❑.g. CARBOY ❑ k. BOX ❑ o. TOTE BIN ❑ d. STEEL DRUM ❑, h. SILO ❑ 1. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE n a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 I ❑ Yes ❑ No 230 - 231 232 233 2 ❑ Yes ❑ No 234 - 235 236 237 3 ❑ Yes ❑ No 238 239 - 240 241 4 ❑ Yes ❑ No 242 243 244 245 5 ❑ Yes ❑ No If more hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield. CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661) 862 -8701 (one page per material per building or are4 ❑ ADD ❑ DELETE ❑ REVISE 200 Page 19 of 35 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION ❑ Yes ❑ No MAIN TANK WEST OF E.R. ENTRANCE FACILITY ID # I MAP# (optional) 203 GRID #(optional) 204 FA0003356 1 5- 0 1 0- 0 0 4 4 5 3 11. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes 0 No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes ❑x No 208 OXYGEN LIQUIFIED . *If EHS is "Yes ", all amounts below must be in Ibs CAS# 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item only) Z a. PURE [:].b. MIXTURE ❑ c. WASTE ❑ Yes Z No 0.00 PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) Z a. SOLID ❑ b. LIQUID ❑ c. GAS 632,500.00 FED HAZARD CATEGORIES 216 (Check all that apply) a. FIRE ❑ b. REACTIVE c. PRESSURE RELEASE d. ACUTE HEALTH e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 632,500.00 632,500.00 1 UNITS* 221 DAYS ON SITE: 222 (Check one item only) ❑ a. GALLONS [g b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * if EHS, amount must be in pounds. 365 STORAGE CONTAINER 223 a. ABOVE GROUND TANK ❑ e. PLASTIC(NONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAILCAR ❑ b. UNDERGROUND TANK ❑ f. CAN ❑ j. BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER ❑ c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k. BOX ❑ o. TOTE BIN ❑ d. STEEL DRUM ❑ h. SILO ❑ 1. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE ❑ a. AMBIENT b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE ❑ a. AMIBIENT ❑ b. ABOVE AMBIENT ❑x c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 ❑ Yes ❑ No 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑ Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 243 244 245 5 ❑ Yes ❑ No If more hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield. CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661) 862 -8701 (one page per material per building or are4 . ❑ ADD ❑ DELETE ❑ REVISE 200 Page 20 of 35 ' 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION ❑ Yes ❑ No IN HOSPITAL & GAS STORAGE AREA WEST OF E FACILITY ID # 1 MAP# (optional) 203 GRID #(optional) 204 FA0003356 1 5 - 0 1 0- 0 0 4 4 5 3 11. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes ❑X No 208 NITROUS OXIDE - E BOTTLES *If EHS is "Yes ", all amounts below must be in Ibs CAS# 209 FIRE CODE' HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item onl a. PURE E] b. MIXTURE E] c. WASTE [] Yes No 0.00 PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) ❑ a. SOLID ❑ b. LIQUID 0 c. GAS 78.00 FED HAZARD CATEGORIES 216 (Check all that apply) ❑ a. FIRE ❑ b. REACTIVE 0 c. PRESSURE RELEASE 0 d. ACUTE HEALTH e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 702.00 702.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) ❑ a. GALLONS 0 b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. 365 STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK ❑ e. PLASTIC/NONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAILCAR ❑ b. UNDERGROUND TANK ❑ f CAN ❑ j. BAG ❑ 'n. PLASTIC BOTTLE ❑ r. OTHER ❑ c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k. BOX ❑ o. TOTE BIN ❑ d. STEEL DRUM ❑ h. SILO ❑x I. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE ❑ a. AMBIENT ❑x b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE ❑x a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 ❑ Yes ❑ No 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑ Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 243 244 245 5 ❑ Yes ❑ No 1 If more hazardous components are present at greater than 1% by weight if non- carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCI -) Bakersfield, CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661 ) 862 -8701 (one page per material per building or areal ❑ ADD ❑ DELETE ❑ REVISE 200 Page 21 of35 I. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION ❑ Yes ❑ No AST NORTH OF ENGINEERING SOUTH OF CORONE FACILITY ID # I onal) MAP# (opti 20; GRID# (optional) 204 FA0003356 1 5- 0 1 0- 0 0 4 4 5 3 11. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes ❑x No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes ❑x No 208 DIESEL - OR/ER - AST *If EHS is "Yes", all amounts below must be in Ibs CAS# 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item only) a. PURE [] b. MIXTURE ❑ c. WASTE C] Yes CE No O.00 PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) a. SOLID ❑ b. LIQUID ❑ c. GAS 1,500.00 FED HAZARD CATEGORIES 216 (Check all that apply) ❑x a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE_ RELEASE ❑x d. ACUTE HEALTH e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 1,500.00 1,500.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) ❑Q a. GALLONS [] b. CUBIC FEET [] c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. 365 STORAGE CONTAINER 223 ❑x a. ABOVE GROUND TANK ❑ e. PLASTICINONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAILCAR ❑ b. UNDERGROUND TANK ❑ f. CAN ❑ j. BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER ❑ c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k. BOX ❑ o. TOTE BIN ❑ d. STEEL DRUM ❑ h. SILO ❑ 1. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE ❑x a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC. 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # ' 226 227 228 229 1 ❑ Yes ❑ No 230 231 232 233 2 ❑ Yes. ❑ No 234 235 236 237 3 ❑ Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 243 244 245 5 ❑ Yes ❑ No If more hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield, CA 93301 HAZARDOUS MATERIALS (661 ) 862-8700 Fax (661) 862 -8701 (one page per material per building or are4 ❑ ADD ❑ DELETE ❑ REVISE 200 Page 22 of 35 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION C] Yes C] No AST NORTH OF ENGINEERING SOUTH OF CORONE FACILITY ID # I MAP# (optional) 203 GRID# (optional) zoo FA0003356 T15 - 0 1 0- 0 0 4. 4 5 3 11. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes 0 No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes No 208 DIESEL - ECC - AST *If EHS is "Yes ", all amounts below must be in Ibs CAS# 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item only) a. PURE ❑ b. MIXTURE ❑ c. WASTE ❑ Yes ❑x No Q,QQ PHYSICAL STATE 214 LARGEST CONTAINER 219 (Check one item only) Q a. SOLID ❑ b. LIQUID ❑ c. GAS 1,000.00 FED HAZARD CATEGORIES 216 (Check all that apply) a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE d. ACUTE HEALTH 0 e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 1,000.00 1,000.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) Q a. GALLONS ❑ b. CUBIC FEET ❑ C. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. 365 STORAGE CONTAINER 223 a. ABOVE GROUND TANK ❑ e. PLASTICNONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAILCAR ❑ b. UNDERGROUND TANK ❑ f CAN ❑ j. 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 WAGON STORAGE PRESSURE a. AMBIENT ❑ b. ABOVE AMBIENT ❑ C. BELOW AMBIENT 224 STORAGE TEMPERATURE a. AIv1IBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 ❑ Yes ❑ No 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑ Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 243 244 245 5 ❑ Yes ❑ No If more hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1 % by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL' DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield. CA 93301 HAZARDOUS MATERIALS (661 ) 862 -8700 Fax (661) 862-8701 (one page per material per building or area ❑ ADD ❑ DELETE ❑ REVISE 200 Page 23 ol'35 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION ❑ Yes ❑ No BIO HAZARD STORAGE AREA FACILITY ID # 1 MAP# (optional) 203 GRID #(optional) 204 FA0003356 1 5- 0 1 0- 0 0 4 4 5 3' IL CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes ❑x No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes No 208 RED BAG WASTE *If "EHS is "Yes ", all amounts below must be in lbs. CAS# 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Clteck one item onl ❑ a. PURE [] b. MIXTURE c. WASTE C] Yes No Q,QQ PHYSICAL STATE 214 ❑ a. SOLID b. LIQUID ❑ c. GAS LARGEST CONTAINER 215 55.00 (Check one item only) FED HAZARD CATEGORIES 216 (Check all that apply) a. FIRE ❑ b. REACTIVE ❑ e. PRESSURE RELEASE d. ACUTE HEALTH 0' e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 500.00 750.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) ❑ a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. 365 STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK ❑ e. PLASTICNONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAIL CAR ❑ b. UNDERGROUND TANK ❑ f CAN ❑ j. BAG Zx n. PLASTIC BOTTLE Z r. OTHER ❑ c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k. BOX Z o. TOTE BIN ❑ d. STEEL DRUM ❑ h. SILO ❑ 1. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE 0 a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 ❑ Yes ❑ No 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑ Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 .243 244 245 5 ❑ Yes ❑ No If more hazardous components are present at greater than 11% by weight if non - carcinogenic, or 0.1 % by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDI'T'IONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield, CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661 ) 862 -8701 (one page per material per building or are4 ❑ ADD ❑ DELETE ❑ REVISE 200 Page 24 of 35 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION ❑ Yes ❑ No NORTH SIDE OF MAINT OFFICE BUILDING FACILITY ID # I MAP# (optional) 203 GRID# (optional) 204 FA0003356 1 5- 0 1 0- 0 0 4 4 5 3 1 Ill. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes 0 No 208 WASTE OIL *If EHS is "Yes ", all amounts below must be in Ibs CAS# 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item onl ❑ a. PURE ❑ b. MIXTURE Q c. WASTE ❑ Yes No Q,QQ PHYSICAL STATE 214 (] a. SOLID ❑ b. LIQUID ❑ c. GAS LARGEST CONTAINER 215 55.00 (Check one item only) FED HAZARD CATEGORIES 216 (Check all that apply) Q a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE [0 d. ACUTE HEALTH ❑ e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 300.00 300.00 221 UNITS* 221 DAYS ON SITE: 222 (Check one item only) a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. 365 STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK I] e. PLASTICtNONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAILCAR ❑ b. UNDERGROUND TANK ❑ f CAN ❑ j. 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 WAGON STORAGE PRESSURE a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 ❑ Yes ❑ No 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑ . Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 243 244 245 5 ❑ Yes ❑ No If more hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street. Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield, CA 93301 HAZARDOUS MATERIALS (661 ) 862 -8700 Fax (661) 862 -8701 (one page per material per building or areal ❑ ADD ❑ DELETE ❑ REVISE 200 Page 25 of 35 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION ❑ Yes ❑ No NORTH SIDE OF MAINT BUILDING FACILITY ID # MAP# (optional) 203 GRID# (optional) 204 FA0003356 1 5- 0 1 0- . 0 0 4 4 5 3 H. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes 0 No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes No 208 DIESEL - BOILER DAY TANK - AST *If EHS is "Yes ", all amounts below must be in Ibs CAS# 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item only) ❑ a. PURE Z b. MIXTURE ❑ c. WASTE ❑ Yes Z No 0,00 PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one iletn only) (] a. SOLID ❑ b. LIQUID ❑ c. GAS 448.00 FED HAZARD CATEGORIES 216 (Check all that apply) D a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE Q d. ACUTE HEALTH e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 448.00 448.00 UNITS* 221 DAYS ON SITE. 222 (Check one item only) 0 a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. 365 STORAGE CONTAINER .223 ❑x a. ABOVE GROUND TANK ❑ e. PLASTICINONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAILCAR ❑ b. UNDERGROUND TANK ❑ f CAN ❑ j. BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER ❑ c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k. BOX ❑ o. TOTE BIN ❑ d. STEEL DRUM ❑ h. SILO ❑ 1. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE a. AMIBIENT ❑ 6. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 ❑ Yes ❑ No 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 _ 237 3 ❑ Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 243 244 - 245 5 ❑ Yes ❑ No If more hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield, CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661) 862 -8701 (one page per material per building or are4 ❑ ADD ❑ DELETE ❑ REVISE 200 Page 26 of 35 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION ❑ Yes ❑ No . BOILERS NEXT TO ER FACILITY ID # MAP# (optional) 203 GRID# (optional) 204 FA0003356 1 5- 0 1 0- 0 0 4 4 5 3 II. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes Z No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes ❑X No 208 DIESEL - DAY TANK - ER BOILERS *If EHS is "Yes ", all amounts below must be in lbs. CAS# 209 FI RE CODE HAZARD CLASSES (Not currently requires by KCEHSn) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Clteck one item onl ❑ a. PURE b. MIXTURE ❑ c. WASTE ❑ Yes No Q,QQ PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) (] a. SOLID ❑ b. LIQUID ❑ c. GAS 50.00 FED HAZARD CATEGORIES❑ 216 (Check all that apply) a. FIRE ❑ b: REACTIVE ❑ c. PRESSURE RELEASE d. ACUTE HEALTH e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 50.00 50.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) ❑x a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. 365 STORAGE CONTAINER 223 a. ABOVE GROUND TANK ❑ e. PLASTIGNONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAILCAR ❑ b. UNDERGROUND TANK ❑ f CAN ❑ j. 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 WAGON STORAGE PRESSURE ❑x a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE ❑x a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 ❑ Yes ❑ No 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑ Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 243 244 245 5 ❑ Yes ❑ No If more hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield, CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661) 862 -8701 (one page per material per building or are4 ❑ ADD ❑ DELETE ❑ REVISE 200 Page 27 of 35 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION ❑ Yes ❑x No FACILITY ID # 1 MAP# (optional) 203 GRID# (opti onal) 204 FA0003356 1 5- 0 1 10� - 0 Il. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes [E No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes ❑x No 208 CHLOROISOTHIAZOLIN *If EHS is "Yes ", all amounts below must be in Ibs CAS# 209 FIRI: CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item only) ❑ a. PURE Q b. MIXTURE ❑ c. WASTE ❑ Yes Zx No 1 0,00 PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) (] a. SOLID ❑ b. LIQUID ❑ c. GAS 30.00 FED HAZARD CATEGORIES 216 (Check all that apply) ❑ a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE ❑ d. ACUTE HEALTH ❑ e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 2.00 4.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) Q a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. STORAGE CONTAINER 223 Q a. ABOVE GROUND TANK ❑ e. PLASTICINONMETALLIC DRUM ❑ J. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAILCAR ❑ b. UNDERGROUND TANK ❑ f. CAN ❑ j. BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER ❑ c. TANK INSIDE BUILDING ❑ g. CARBOY Z k. BOX ❑ o. TOTE BIN ❑ d. STEEL DRUM ❑ h. SILO ❑ 1. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE ❑ a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE ❑ a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229. 1 0.00 ❑ Yes ❑x No 230 231 232 233 2 0.00 ❑ Yes ❑x No 234 235 236 237 3 0.00 ❑ Yes Zx No 238 239 240 241 4 0.00 ❑ Yes Zx No 242 243 .244 245 5 0.00 ❑ Yes [E No If more hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield, CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661) 862 -8701 (one page per material per building or =4 ❑ ADD ❑ DELETE ❑ REVISE 200 Page 28 of 35 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION ❑ Yes 0 No FACILITY ID # I MAP# (optional) 203 GRID# (optional) 204 FA0003356 1 5- 0 1 0- 0 11. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes [g No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes ❑X No 208 SODIUM HYPOCHLORATE *If EHS is "Yes ", all amounts below must be in Ibs CAS# 209 FIRE CODE HAZARD CLASSES(Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE❑ 212 CURIES 213 TYPE Check one item onl ❑ a. PURE ❑x b. MIXTURE ❑ c. WASTE Yes Q No 0 00 PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) 0 a. SOLID ❑ b. LIQUID ❑ c. GAS 30.00 FED HAZARD CATEGORIES 216 (Check all that apply) ❑ a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE ❑ d. ACUTE HEALTH ❑ e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 1.50 2.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) ❑X a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. STORAGE CONTAINER 223 ❑x a. ABOVE GROUND TANK ❑ e. PLASTICINONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAIL CAR ❑ b. UNDERGROUND TANK ❑ f. CAN ❑ j. BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER ❑ c.'TANK INSIDE BUILDING ❑ g. CARBOY ❑ k. BOX ❑ o. TOTE BIN ❑ d. STEEL DRUM ❑ h. SILO ❑ 1. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE ❑ a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE ❑ a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c..BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 0.00 ❑ Yes ❑x No 230 231 - 232 233 2 0.00 ❑ Yes ❑x No 234 235 236 237 3 0.00 ❑ Yes ❑x No 238 239 240 241 4 0.00 ❑ Yes ❑x No 242 243 244 245 5 0.00 ❑ Yes ❑x No If more hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield, CA 93301 HAZARDOUS MATERIALS (661 ) 862 -8700 Fax (661) 862 -8701 (one page per material per building or are4 ❑ ADD ❑ DELETE ❑ REVISE 200 Page 29 of 35 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION ❑ Yes No FACILITY ID #. 1 MAP# (optional) 203 GRID #(optional) 204 FA0003356 1 5- 0 1 0- 0 11. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes ❑x No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes ❑x No 208 SODIUM BROMIDE *If EHS is "Yes ", all amounts below must be in Ibs CAS# 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item onl ❑ a. PURE b. MIXTURE ❑ c. WASTE ❑ Yes ❑x No Q,QQ PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) a. SOLID ❑ b. LIQUID ❑ c. GAS 30.00 FED HAZARD CATEGORIES 216 (Check'all that apply) ❑ a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE ❑ d. ACUTE HEALTH ❑ e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 1.50 2.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) ❑x a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. STORAGE CONTAINER 223 ❑x a. ABOVE GROUND TANK ❑ e. PLASTICINONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAILCAR ❑ b. UNDERGROUND TANK ❑ f CAN ❑ j. 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 WAGON STORAGE PRESSURE ❑ a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE ❑ a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 0.00 ❑ Yes ❑x No 230 231 232 233 2 0.00 ❑ Yes ❑x No 234 235 236 237 3 0.00 ❑ Yes No 238 239 240 241 4 0.00 ❑ Yes ❑x No 242 243 244 245 5 0.00 ❑ Yes ❑x No If more hazardous components are present at greater than 11% by weight if non - carcinogenic, or 0.1 % by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY. - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield, CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661) 862 -8701 (one page per material per building or are4 [:1 ADD E] DELETE ❑ REVISE 200 Page 30 of 35 I. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION ❑ Yes [g No FACILITY ID # I MAP# (optional) 203 GRID# (optional) 204 FA0003356 1 5- 0 1 0- 0 0 4 4 5 3 11. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes [E No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes ❑x No 208 BROMINE *If EHS is "Yes ", all amounts below must be in Ibs CAS# 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item only) ❑ a. PURE ❑x b. MIXTURE ❑ c. WASTE ❑ Yes Zx No 0,00 PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) ❑ a. SOLID ❑x b. LIQUID ❑ c. GAS 50.00 FED HAZARD CATEGORIES 216 (Check all that apply) ❑ a FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE ❑ d. ACUTE HEALTH ❑ e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 1.00 2.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) ❑ a. GALLONS ❑' b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK Z e. PLASTICINONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAIL CAR ❑ b. UNDERGROUND TANK x❑ f. CAN ❑ j. 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 WAGON STORAGE PRESSURE ❑ a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE ❑ a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) 'EHS CAS # 226 227 228 - 229 1 0.00 ❑ Yes Zx No 230 231 232 233 2 0.00 Z Yes Zx No 234 235 236 237 3 0.00 ❑ Yes Zx No 238 239 240 241 4 0.00 ❑ Yes Zx No 242 243 244 245 5 0.00 ❑ Yes Zx No If more hazardous components are present at greater than 1 % by weight if non - carcinogenic, or 0.1 % by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield, CA 93301 HAZARDOUS MATERIALS (661 ) 862 -8700 Fax (661) 862 -8701 (one page per material per building or area) ❑ ADD ❑ DELETE ❑ REVISE 200 Page 31 of 35 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION ❑ Yes No FACILITY ID # 1 MAP# (optional) 203 GRID# (optional) 2 04 FA0003356 1 5- 0 1 0- 0 0 4 513 II. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes Q No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes No 208 REFRIGERANT 408 *If EHS is "Yes ", all amounts below must be in lbs. CAS# 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item only) Q a. PURE ❑ b. MIXTURE ❑ c. WASTE ❑ Yes Q No Q,QQ PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) ❑ a. SOLID ❑ b. LIQUID ❑x c. GAS 25.00 FED HAZARD CATEGORIES 216 (Check all that apply) ❑ a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE ❑ d. ACUTE HEALTH ❑ e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 1.00 5.00 UNITS* 221 DAYS ON SITE: 222 (Check one ilem only) ❑ a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK ❑ e. PLASTIC/NONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAILCAR ❑ b. UNDERGROUND TANK ❑x f. CAN ❑ j. BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER ❑ C. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k. BOX ❑ o. TOTE BIN ❑ d. STEEL DRUM ❑ h. SILO ❑ 1. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE ❑ a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE ❑ a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 0.00 ❑ Yes ❑x No 230 231 232 233 2 0.00 ❑ Yes ❑x No 234 235 236 237 3 0.00 ❑ Yes ❑x No 238 239 240 241 4 0.00 ❑ Yes ❑x No 242 243 \244 . 245 5 0.00 ❑ Yes ❑x No If more hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street. Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield. CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661) 862 -8701 (one page per material per building or area) ❑ ADD ❑ DELETE ❑ REVISE 200 Page 32 of 35 I. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION ❑ Yes No FACILITY ID # I MAP# (optional) 203 GRID #(optional) 204 FA0003356 I S- 0 1 0- 0 II. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes ❑x No 208 REFRIGERANT 409 *If EHS is "Yes ", all amounts below must be in lbs CAS# 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 21 1 RADIOACTIVE 212 CURIES 213 TYPE Check one item only) ❑x a. PURE . ❑ b. MIXTURE ❑ c. WASTE ❑ Yes ❑ No 0,00 PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) ❑ a. SOLID ❑ b. LIQUID ❑x c. GAS 25.00 FED HAZARD CATEGORIES 216 (Check all that apply) ❑ a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE ❑ d. ACUTE HEALTH ❑ e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 1.00 5.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) Cl a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK ❑ e. PLASTIC/NONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAIL CAR ❑ b. UNDERGROUND TANK ❑x f. CAN ❑ j. BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER ❑ c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k. BOX ❑ o. TOTE BIN ❑ d. STEEL DRUM ❑ h. SILO ❑ 1. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE ❑ a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE ❑ a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 0.00 ❑ Yes ❑x No 230 231 232 233 2 0.00 ❑ Yes ❑x No 234 235 236 237 3 0.00 ❑ Yes ❑x No 238 239 240 241 4 0.00 Yes [] ❑ No 242 243 244 245 5 0.00 ❑ Yes ❑x No If more hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1 % by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street. Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield, CA 93301 HAZARDOUS MATERIALS (661 ) 862 -8700 Fax (661) 862 -8701 (one page per material per building or are4 ❑ ADD ❑ DELETE ❑ REVISE 200 Page 33 of 35 I. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION ❑ Yes [0 No FACILITY ID # I MAP# (optional) 203 GRID #(optional) 204 FA0003356 1 5- 0 1 0- 0 I1. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes [E No Zoe If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes Q No 208 SODIUM HYROXIDE *If EHS is "Yes ", all amounts below must be in Ibs CAS# 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item only) ❑ a. PURE b. MIXTURE ❑ c. WASTE ❑ Yes No Q.QQ PHYSICAL STATE - 214 LARGEST CONTAINER 219 (Check one item only) a. SOLID ❑ b. LIQUID [3 c. GAS 75.00 FED HAZARD CATEGORIES 216 (Check all that apply) ❑ a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE ❑ d. ACUTE HEALTH ❑ e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 7.00 10.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) ❑x a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. STORAGE CONTAINER 223 ❑x a. ABOVE GROUND TANK ❑ e. PLASTIC/NONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAILCAR ❑ b. UNDERGROUND TANK ❑ f CAN ❑ j. BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER ❑ c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k. BOX ❑ o. TOTE BIN ❑ d. STEEL DRUM ❑ h. SILO ❑ 1. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE ❑ a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE ❑ a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS. CAS # 226 227 228 229 1 0.00 ❑ Yes ❑x No 230 231 232 233 2 0.00 ❑ Yes ❑x No 234 235 236 237 3 0.00 ❑ Yes ❑x No 238 239 240 241 4 0.00 ❑ Yes ❑x No 242 243 244 245 5 0.00 Yes No ❑ � If more hazardous components are present at greater than 1 % by weight if non - carcinogenic, or 0.1 % by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield, CA 93301 HAZARDOUS MATERIALS (661 ) 862 -8700 Fax (661) 862 -8701 (one page per material per building or are4 ❑ ADD ❑ DELETE' ❑ REVISE 200 Page 34 of 35 L FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION ❑ Yes Z No FACILITY 1D # I MAP# (optional) 203 GRID# (optional) 204 FA0003356 1 5- 0 1 0- 0 11. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes Q No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes 0 No 208 GASOLINE *If EHS is "Yes ", all amounts below must be in Ibs CAS# 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 213 TYPE Check one item only a. PURE ❑ b. MIXTURE ' ❑ c. WASTE ❑ Yes [E No rajE�00 PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) a. SOLID ❑ b. LIQUID ❑ c. GAS 5,00 FED HAZARD CATEGORIES 216 (Check all that apply) ❑ a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE ❑ d. ACUTE HEALTH ❑ e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 1.00 2.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) ❑X a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK ❑ e. PLASTICINONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAILCAR ❑ b. UNDERGROUND TANK ❑x f CAN ❑ j. BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER ❑ c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k. BOX ❑ o. TOTE BIN ❑ d. STEEL DRUM ❑ h. SILO ❑ 1. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE ❑ a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE ❑ a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 0.00 ❑ Yes x❑ No 230 231 232 233 2 0.00 ❑ Yes No 234 235 236 237 3 0.00 ❑ Yes ❑x No 238 239 240 241 4 0.00 ❑ Yes ❑x No 242 243 244 245 5 0.00 Yes No ❑ ❑x If more hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department Unified Program Consolidated Form (UPCF) 2700 M Street. Suite 300 Bakersfield, CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661) 862 -8701 (one page per material per building or arc4 ❑ ADD ❑ DELETE ❑ REVISE 200 Page 35 of 35 I. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL, LOCATION CONFIDENTIAL EPCRA 202 MAINTENANCE DIVISION ❑ Yes 0 No FACILITY ID # I MAP# (optional) 203 GRID# (optional) 204 FA0003356 1 5- 0 1 0- 0 0 4 4 5 3 11. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes ❑x No. 208 REFRIGERANT 134 *If EHS is "Yes ", all amounts below must be in Ibs CAS# 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 213 TYPE Check one item onl a. PURE ❑ b. MIXTURE ❑ c. WASTE ❑ Yes No 7R� ,QQ PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) ❑ a. SOLID ❑ b. LIQUID Zx c. GAS 25.00 FED HAZARD CATEGORIES 216 (Check all that apply) ❑ a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE ❑ d. ACUTE HEALTH ❑ e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 1.00 5.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) ❑ a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK ❑ e. PLASTICNONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAILCAR ❑ b. UNDERGROUND TANK ❑x f. CAN ❑ j. BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER ❑ c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k. BOX ❑ o. TOTE BIN ❑ d. STEEL DRUM ❑ h. SILO ❑ 1. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE ❑ a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE ❑ a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227. 228 229 1 0.00 ❑ Yes ❑x No 230 231 232 233 2 0.00 ❑ Yes ❑x No 234 235 236 237 3 0.00 ❑ Yes ❑x No 238 239 240 241 4 0.00. ❑ Yes ❑x No 242 243 244 245 5 0.00 ❑ Yes ❑x No If more hazardous components are present at greater than I% by weight if non - carcinogenic, or 0.1 % by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here 'HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield. CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661) 862 -8701 (one page per material per building or are4 ❑ ADD ❑ DELETE ❑ REVISE 200 Page I of 8 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 NUCLEAR MED /RADIOLOGY ❑ Yes ❑ No 4TH FLOOR A WING RM A -437 & RM B423 FACILITY ID # I MAP# (optional) 203 GRID# (optional) 204 FA0003356 1 5- 0 1 0- 0 0 4 4 5 3 11. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes Q No 208 IODINE 123 *If EHS is "Yes ", all amounts below must be in Ibs CAS# 209 FIRE CODE HAZARD CLASSES(Not currently requires by KCEnSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item only) ❑ a. PURE 0 b. MIXTURE ❑ c. WASTE ❑ Yes ❑ No 0.99 PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) ❑X a. SOLID ❑ b. LIQUID ❑ c. GAS 99.00 FED HAZARD CATEGORIES 216 (Check all that apply) ❑ a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE Q d. ACUTE HEALTH (] e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 99.00 99.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) ❑ a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. 365 STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK ❑ e. PLASTIC(NONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAILCAR ❑ b. UNDERGROUND "TANK ❑x f CAN ❑ j. BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER ❑ e. TANK INSIDE BUILDING ❑ g. CARBOY ❑ .k. BOX ❑ o. TOTE BIN ❑ d. STEEL DRUM ❑ h. SILO ❑ 1. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE a. AMBIENT ❑ b. ABOVE-AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 ❑ Yes ❑ No 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑ Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 243 244 245 5 ❑ Yes ❑ No If more hazardous components are present at greater than 1 % by weight if non - carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services_ Department Unified Program Consolidated Form (UPCF) 2700 M Street, Suite 300 Bakersfield, CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661) 862 -8701 (one page per material per building or are4 ❑ ADD ❑ DELETE ❑ REVISE 200 Page 2 of 8 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 NUCLEAR MED /RADIOLOGY ❑ Yes ❑ No 4TH FLOOR A WING RM A -437 & RM B -423 FACILITY ID # 1 . MAP# (optional) 203 GRID# (optional) 204 FA0003356 1 5- 0 1 0- 0 0 4 4 5 3 11. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes 0 No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes Q No 208 CESIUM -133 *If EHS is "Yes ", all amounts below must be in Ibs CAS# 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item onl ❑ a. PURE ❑x b. MIXTURE ❑ c. WASTE ❑x Yes .❑ No 0,99 PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) a. SOLID ❑ b. LIQUID ❑ c. GAS 99.00 FED HAZARD CATEGORIES 216 (Check all that apply) ❑ a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE d. ACUTE HEALTH e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 99.00 99.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) ❑ a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount most be in pounds. 365 STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK ❑ c. PLASTIC/NONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAILCAR ❑ b. UNDERGROUND TANK ❑x f CAN ❑ j. BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER ❑ c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k. BOX ❑ o. TOTE BIN ❑ d. STEEL DRUM ❑ h. SILO ❑ 1. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE a. AMIBIENI' ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 ❑ Yes ❑ No 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑ Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 243 244 245 5 ❑ Yes ❑ No If more hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield, CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661) 862 -8701 (one page per material per building or are4 ❑ ADD ❑ DELETE ❑ REVISE 200 Page 3 of 8 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 NUCLEAR MED /RADIOLOGY ❑ Yes E] No NUCLEAR MEDICINE GENERATOR FACILITY ID # I MAP# (optional) 203 GRID# (optional) 204 FA0003356 1 5- 0 1 0- 0 0 4 4 5 3 11. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes 0 No 206 • If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes 0 No 208 TECHNESIUM *If EHS is "Yes ", all amounts below must be in Ibs CAS# 209 FIRE CODE HAZARD CLASSES(Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 21 1 RADIOACTIVE 212 CURIES 213 TYPE Clueck one iteun only) a. PURE ❑ b. MIXTURE ❑ c. WASTE Z Yes ❑ No 1,50 PHYSICAL STATE 214 LARGEST CONTAINER 219 (Check one item only) ❑ a. SOLID b. LIQUID ❑ c. GAS 2.00 FED HAZARD CATEGORIES 216 (Check all that apply) ❑ a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE ❑x d. ACUTE HEALTH e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 2.00 2.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) ❑ a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. 365 STORAGE CON'T'AINER 223 ❑ a. ABOVE GROUND TANK ❑ e. PLASTIC/NONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAILCAR ❑ b. UNDERGROUND TANK ❑ f CAN ❑ j. BAG ❑ n. PLASTIC BOTTLE ❑x r. OTHER ❑ c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k. BOX ❑ o. TOTE BIN ❑ d. STEEL DRUM ❑ h. SILO ❑ I. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE ❑X a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 ❑ Yes ❑ No 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑ Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 243 244 245 5 ❑ Yes ❑ No If more hazardous components are present at greater than I% by weight if non - carcinogenic, or 0.1 % by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield, CA 93301 HAZARDOUS MATERIALS (661 ) 862 -8700 Fax (661) 862 -8701 (one page per material per building or areal ❑ ADD ❑ DELETE ❑ REVISE 200 Page 4 of 8 I. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 NUCLEAR MED /RADIOLOGY ❑ Yes ❑ No NUCLEAR MEDICINE STORAGE AREA FACILITY ID # 1 MAP# (optional) 203 GRID# (optional) 204 FA0003356 1 0 4 4 5 3 11. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes No' 208 IODINE 131 *If EHS is "Yes ", all amounts below must be in Ibs CAS# 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item only) (] a. PURE ❑ b. MIXTURE ❑ c. WASTE ❑ Yes Z No 0.00 PHYSICAL STATE 214 LARGEST CONTAINER 215 . (Check one item only) ❑ a. SOLID ❑x b. LIQUID ❑ c. GAS 99.00 FED HAZARD CATEGORIES 216 (Check all that apply) ❑ a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE ❑ d. ACUTE HEALTH e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 99.00 99.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) ❑ a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS " If EHS, amount must be in pounds. 365 STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK ❑ e. PLASTICINONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAIL CAR ❑ b. UNDERGROUND TANK' ❑x f CAN ❑ j. 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 WAGON STORAGE PRESSURE a> AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE ❑x a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 ❑ Yes ❑ No 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑ Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 243 244 245 5 ❑ Yes ❑ No If more hazardous components are present at greater than 1% by weight if non - carcinogenic, or 0.1 % by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - ..CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield, CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661) 862 -8701 (one page per material per building or are4 ❑ ADD ❑ DELETE ❑ REVISE 200 Page 5 of 8 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY.NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 NUCLEAR MED /RADIOLOGY ❑ Yes ❑ No BASEMENT STORAGE AREA UNDER NUCLEAR MEDI FACILITY ID # 1 MAP# (optional) 203 GRID# (optional) 204 FA0003356 1 5- 0 1 0- 0 0 4 4 5 3 11. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes [E No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes 0 No 208 RADIOACTIVE WASTES *If EHS is "Yes ", all amounts below must be in Ibs CAS# 209 F RE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item only) E] a. PURE [] b. MIXTURE Z c. WASTE Z Yes El No 1,50 PHYSICAL STATE 214 ❑ a. SOLID Zx b. LIQUID ❑ c. GAS LARGEST CONTAINER 215 350.00 (Check one item only) FED HAZARD CATEGORIES 216 (Check all that apply) [] a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE. d. ACUTE HEALTH e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 55.00 75.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) ❑ a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. 365 STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK Z e. PLASTIC/NONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAIL CAR ❑ b. UNDERGROUND TANK ❑ f CAN ❑ j. BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER ❑ c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k. BOX ❑ o. TOTE BIN d. STEEL DRUM ❑ h. SILO ❑ 1. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE ❑x a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 ❑ Yes ❑ No 230 231 232 _ 233 2 Z Yes Z No 234 235 236 237 3 ❑ Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 243 244 245 5 ❑ Yes ❑ No If more hazardous components are present at greater than 1 % by weight if non - carcinogenic, or 0.1 % by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department 2700 M Street, Suite 300 Unified Program Consolidated Form (UPCF) Bakersfield, CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661) 862 -8701 (one page per material per building or areal ❑ ADD ❑ DELETE ❑ REVISE 200 Page 6 of 8 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 NUCLEAR MED /RADIOLOGY ❑ Yes ❑ No RADIOLOGY, ER DEPT AND OTHER AREAS THAT FACILITY ID # I MAP# (optional) 203 GRID #(optional) 204 FA0003356 1 5- 0 1 0- 0 0 4 415 3 11. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes No 206 If subject to EPCRA, refer to instructions - COMMON NAME 207 EHS* ❑ Yes 0 No 208 X -RAY FIXER SOLUTION PART A *If EHS is "Yes ", all amounts below must be in Ibs CAS# 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item only) ❑ a. PURE b. MIXTURE ❑ c. WASTE ❑ Yes Q No 0.00 PHYSICAL STATE 214 LARGEST CONTAINER 215 (Clieck one item only) Z a. SOLID ❑ b. LIQUID ❑ c. GAS 5.00 FED HAZARD CATEGORIES 216 (Check all that apply) a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE d. ACUTE HEALTH e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 150.00 200.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) ❑X a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. 365 STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK Z e. PLASTICINONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAIL CAR ❑ b. UNDERGROUND TANK ❑ f. CAN ❑ j. BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER ❑ c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k. BOX ❑ o. TOTE BIN ❑ d. STEEL DRUM ❑ h. SILO ❑ 1. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE a. AMIBIENT , ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 - 229 1 ❑ Yes ❑ No 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑ Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 243 244 245 5 ❑ Yes ❑ No If more hazardous components are present at greater than 11% by weight if non - carcinogenic, or 0.1 % by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department Unified Program Consolidated Form (UPCF) 2700 M Street, Suite 300 Bakersfield, CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661) 862 -8701 (one page per material per building or are4 ❑ ADD ❑ DELETE ❑ REVISE 200 Page 7 of 8 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 NUCLEAR MED /RADIOLOGY ❑ Yes ❑ No RADIOLOGY, ER AND OTHER PLACES IN FACILI FACILITY ID # 1 MAP# (optional) 203 GRID# (optional) 204 FA0003356 1 5- 0 1 0- 0 0 4 4 5 3 II. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes No 208 X -RAY FIXER SOLUTION PART B *If EHS is "Yes ", all amounts below must be in Ibs CAS# 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 'TYPE Check one item only) ❑ a. PURE Z b. MIXTURE ❑ c. WASTE ❑ Yes Q No 0,00 PHYSICAL STATE 214 Z a. SOLID ❑ b. LIQUID ❑ c. GAS LARGEST CONTAINER 215 5.00 (Check one item only) FED HAZARD CATEGORIES 216 (Check all that apply) ❑ a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE d. ACUTE HEALTH e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 100.00 200.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) Q a. GALLONS ❑ b. CUBIC FEET. ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in pounds. 365 STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK 0 e. PLASTICINON METALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAILCAR ❑ b. UNDERGROUND TANK ❑ f. CAN ❑ j. BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER ❑ c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k. BOX ❑ o. TOTE BIN ❑ d. STEEL DRUM ❑ h. SILO ❑ 1. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE ❑x a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC .225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 ❑ Yes ❑ No 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑ Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 243 244 245 $ Yes No (] ❑ If more hazardous components are present at greater than I% by weight if non - carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION Kern County Environmental Health Services Department Unified Program Consolidated Form (UPCF) 2700 M Street. Suite 300 Bakersfield, CA 93301 HAZARDOUS MATERIALS (661) 862 -8700 Fax (661 ) 862 -8701 (one page per material per building or area) ❑ ADD ❑ DELETE ❑� REVISE 200 Page 8 of 8 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 KERN MEDICAL CENTER CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 NUCLEAR MED /RADIOLOGY ❑ Yes ❑ No RADIOLOGY AND OTHER AREAS THAT HAVE X -RA FACILITY ID # 1 MAP# (optional) 203 GRID# (optional) 204 FA0003356 1 5- 0 1 0- 0 0 4 4 5 3 1 I1. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes ❑x No 206 If subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑ Yes Q No 208 X -RAY DEVELOPER WASTE *If EHS is "Yes ", all amounts below must be in Ibs CAS# 209 FIRE CODE HAZARD CLASSES (Not currently requires by KCEHSD) 210 HAZARDOUS MATERIAL 211 RADIOACTIVE 212 CURIES 213 TYPE Check one item only) ❑ a. PURE ❑ b: MIXTURE ❑ c. WASTE ❑ Yes No Q,QQ PHYSICAL STATE 214 a. SOLID ❑ b. LIQUID ❑ c. GAS LARGEST CONTAINER 215 10.00 (Check one item only) FED HAZARD CATEGORIES 216 (Check all that apply) ❑x a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE ❑x d. ACUTE HEALTH ❑x e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 100.00 100.00 UNITS* 221 DAYS ON SITE: 222 (Check one item only) ❑X a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS * If EHS, amount must be in Pounds. 365 STORAGE CONTAINER 223 ❑ a. ABOVE GROUND TANK ❑x e. PLASTICINONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. RAILCAR ❑ b. UNDERGROUND TANK ❑ f. CAN ❑ j. 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 WAGON STORAGE PRESSURE ❑X a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE ❑x a. AMIBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # X226 227 228 229 1 ❑ Yes ❑ No 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑ Yes ❑ No 238 239 240 241 4 ❑ Yes ❑ No 242 243 244 - 245 $ ❑ Yes ❑ No If more hazardous components are present at greater than I% by weight if non - carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA, Please Sign Here