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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS MATERIALS <br /> HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION <br /> (one page per material per building or area) <br /> zoo. _ <br /> ❑ ADD ❑ DELETE ® REVISE Page If <br /> I. FACILITY INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3_ <br /> AUTO-CHLOR SYSTEM2oz. <br /> CHEMICAL LOCATION 2°I. CHEMICAL LOCATION CONFIDENTIAL <br /> EPCRA <br /> PRODUCTION SHOPIWAREHOUSE ❑ YES ® No <br /> 1- MAP# zo3. GRID# zoe. <br /> FACILITY ID# <br /> (Agency Use Only) C 13-16K/13-16,E 1 I-F <br /> II. CHEMICAL INFORMATION <br /> CHEMICAL NAME 205- TRADE SECRET Yes N No 2%. <br /> If Subject to EPCRA refer to instructions <br /> 20/. 208. <br /> COMMON NAME EHS* ❑ Yes ® No <br /> MACHINE DETERGENT#3 MD 3 <br /> oo. <br /> CAS# *IfEHS is"Yes,"all amounts below must be in lbs. <br /> 210 <br /> FIRE CODE HAZARD CLASSES(Complete if required by local agmq) <br /> 213. <br /> HAZARDOUS MATERIAL ❑a.PURE ®b.MIXTURE I]c.WASTE 211. RADIOACTIVE ❑Yes ®No 212. CURIES <br /> TYPE (Check one item only) <br /> 15. <br /> PHYSICAL STATE 214. LARGEST CONTAINER 1250 <br /> (Check one item only) ❑a.SOLID ®b.LIQUID ❑c.GAS <br /> 216. <br /> FED HAZARD CATEGORIES <br /> (Check all that apply) ❑a.FIRE ❑b.REACTIVE Ile.PRESSURE RELEASE ®d.ACUTE HEALTH ❑e.CHRONIC HEALTH <br /> AVERAGE DAILY AMOUNT 21'/. MAXBdT)M DAB,Y AMOUNT 219. ANNUAL WASTE AMOUNT Iq. STATE WASTE CODE zzo. <br /> 3750 -77077 cal. DAYS ON SITE 22x. <br /> UNITS- ®a.GALLONS ❑It.CUBIC FEET ❑c.POUNDS ❑d.TONS 365 <br /> Check one item only) a If EHS,amount muss be in pounds. <br /> STORAGE <br /> CONTAINER ❑a. ABOVEGROUND TANK [3c. PLASTICMONMETALLIC DRUM ❑i. FIBER DRUM ❑an. GLASS BOTTLE ❑q. RAILCAR <br /> ❑b. UNDERGROUND TANK [If CAN ❑j. BAG ®n. PLASTIC BOTTLE ❑r. OTHER <br /> ®c. TANK INSIDE BUILDING ❑g. CARBOY ❑k.BOX ❑o. TOTE BIN <br /> ❑d. STEEL DRUM ❑It SILO O 1. CYLINDER ❑P. TANK WAGON 2D. <br /> STORAGE PRESSURE ®a. AMBIENT ❑b. ABOVE AMBIENT ❑c. BELOW AMBIENT 2x4, <br /> STORAGE TEMPERATURE M a. AMBIENT ❑b. ABOVE AMBIENT ❑c. BELOW AMBIENT ❑d. CRYOGENIC 225. <br /> %WT HAZARDOUS COMPONENT(Formixture or waste only) EHS CAS# <br /> 1. 15-30 226. POTASSIUM HYDROXIDE 227. ❑Yes ® No 228. 1310-58-3 2M. <br /> 2. <br /> va. zn. El Yes ❑ No vx, 233. <br /> 3. <br /> 234. 235. ❑Yes ❑ No 236. 237. <br /> 4. <br /> 238. 239. ❑Yes ❑ No zoo. zu. <br /> 5. <br /> 242. 243. ❑Yes ❑ No 244. 245. <br /> furore haaardos; mm <br /> cupennare,eamt at grau i a <br /> ter N1%by weight oo<arcioogen c,or 0.I%by weight t ureipogenic,attach additional sheen of paper capturing the required information. <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION 2m. <br /> DOT Hazard Class: 8 <br /> If EPCRA,Please Sign Here. <br /> UPCF hwf2731(1/99)-1/2 http://w".unidocs.org Rev.04/17/00 <br />