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UNIDOCS <br /> HAZARDOUS MATERIALS <br /> HAZARDOUS MATERIALS INVENTORY- CHEMICAL DESCRIPTION <br /> (One page per material per building or area) <br /> ❑ ADD ❑ DELETE ❑ REVISE 2w_ <br /> I. FACILITY INFORMATION <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> S-Mart#209 <br /> CHEMICAL LOCATION 201 1 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202_ <br /> Refrigeration and Air Conditioning Systems-throughout the store ❑ YES ® NO <br /> FACILITY ID# 1. MAP#(Opnonal) 203- -GRID#(optional) 2� <br /> (Agency Use # - - <br /> II. CHEMICAL INFORMATION <br /> CHEMICAL NAME 205. TRADE SECRET 206 <br /> Chlorodifluoromethane R22 Ifwbject to EPCRq refer to inmmdbns ❑Yes ®No <br /> COMMON NAME 207_ EHS* 208. <br /> Freon R22 ❑Yes ®No <br /> CAS# 209 *If EHS is"Yes,"all amounts below must be in lbs. <br /> 75-45-6 <br /> FIRE CODE HAZARD CLASSES(Complete ifregvired by COPA) 210. <br /> HAZARDOUS MATERIAL 211. RADIOACTIVE 212- CURIES 213, <br /> TYPE (Check one item only) ®a.PURE ❑b.MIXTURE [3 c.WASTE [I Yes ®No N/A <br /> PHYSICAL STATE 214. LARGEST CONTAINER 215_ <br /> (Check one item only) ❑a.SOLID ❑b.LIQUID ®c.GAS 3200 <br /> FED HAZARD CATEGORIES 216. <br /> (Check all that apply) ❑a.FIRE ❑b.REACTIVE ®C.PRESSURE RELEASE ❑it.ACUTE HEALTH ❑e.CHRONIC HEALTH <br /> AVERAGE DAILY AMOUNT 217_ MAXIMUM DAILY AMOUNT 218 1 ANNUAL WASTE AMOUNT 219- STATE WASTE CODE 220. <br /> 3325 3325 N/A N/A <br /> UNITS* ❑a.GALLONS ❑b.CUBIC FEET ®c.POUNDS ❑d.TONS 221- DAYS ON SITE 222. <br /> (Check ane item only) *If EHS,amount most be in pounds. 365 <br /> STORAGE ❑a. ABOVEGROUND TANK ❑f CAN ❑k. BOX ❑p. TANK WAGON 223. <br /> CONTAINER ❑It. UNDERGROUND TANK ❑g. CARBOY ❑1. CYLINDER ❑q. RAILCAR <br /> ❑C. TANK INSIDE BUILDING ❑h. SILO ❑In. GLASS BOTTLE ®r. OTHER <br /> ❑d. STEEL DRUM ❑i. FIBER DRUM ❑n. PLASTIC BOTTLE <br /> ❑e. PLASTIC/NONMETALLIC DRUM ❑j. BAG ❑o. TOTE BIN <br /> STORAGE PRESSURE [Ia. AMBIENT ®b. ABOVE AMBIENT ❑a BELOW AMBIENT 224. <br /> STORAGE TEMPERATURE ❑a. AMBIENT ❑It. ABOVE AMBIENT ®c. BELOW AMBIENT ❑d. CRYOGENIC 225. <br /> %WT HAZARDOUS COMPONENT(For mixture or waste only) EHS CAS# <br /> 226 227. 228. 229. <br /> 1. ❑Yes ❑ No <br /> 230. 231. 232. 233. <br /> 2. ❑Yes ❑ No <br /> 234. 235. 236. 237. <br /> 3. ❑Yes ❑ No <br /> 239. 239. 240, 241. <br /> 4. [1Yes ❑ No <br /> 24z. z43. za4. 245. <br /> 5. ❑Yes ❑ No <br /> If more hmardoua antawneon an present at greater than I%by weight if non-cammogenic,or 0.1%by weight if carcinogenic aaach additional Aeen of paper capturing the required information. <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION 246. <br /> DOT Hazard Class: <br /> If EPCRA,Please Sign Here. <br /> If this facility is subject to Federal Emergency Planning and Community Right to Know Act(EPCRA)reporting requirements,a signature is required at the <br /> bottom of the form if the page lists an Extremely Hazardous Substance(EHS) handled at or above its Federal Threshold Planning Quantity (TPQ)or 500 <br /> pounds,whichever is less. <br /> S-Mart#209 Page 6 of 20 July 2012 <br />