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RECEIVE® <br /> UNIFIED PROGRAM CONSOLIDATED FORM 17 2009 <br /> HAZARDOUS MATERIALS <br /> SA <br /> HAZARDOUS MATERIALS INVENTORY- cmmicALVU U�Nnp <br /> one a erm 11 H or area <br /> ❑ADD ❑DELETE ®REVISE. 2ao Page 1 5 Of1 5 <br /> I. FACILITY INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA—Doing Business As) 3 <br /> Chevron Station#307709 <br /> CHEMICAL <br /> ❑ YES ® NO <br /> FACILITY ID# MA P#(opdonen 203 GRID#(optional) 204 <br /> EEKIIJUITT71 <br /> II. CHEMICAL INFORMATION <br /> CHEMICAL NAME 205 TRADE SECRET <br /> ❑ Yes ® No 206 <br /> Carbon Dioxide <br /> If gubjea w FPCRA,refer to irutmgiov <br /> COMMON NAME 207 208 <br /> Carbon Dioxide CO2 EHS* ❑ Yes ® No <br /> CAS# 209 <br /> 124-38-9 I``//jJ <br /> *#, 5}s s",Hall amounts below must be in lbs. <br /> �� <br /> FIRE CODE HAZARD CLASSES(Complete if required by CUPA) 210 <br /> Compressed Gas Class 2.2 <br /> HAZARDOUS MATERIAL 213 <br /> TYPE(Check one item only) ®a.PURE ❑b.MIXTURE ❑c.WASTE 211 IO TIVE ❑Yes ®No 212 CURIES <br /> PHYSICAL STATE 215 <br /> (Check one item only) ❑ a.SOLID ❑b. LIQUID ® c.GAS ARGEST CONTAINER 2429 <br /> FED HAZARD CATEGORIES 216 <br /> (Check all that apply) ❑ a. FIRE ❑b. REACTIVE ®c.PRESSURE RELE Md. ACUTE HEALTH ❑ e. CHRONIC HEALTH <br /> AVERAGE DAILY AMOUNT 217 1 MAXIMUM DAIL UNT 21g ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 <br /> 1215 2429 <br /> 221 222 <br /> UNITS- ❑a.GALLONS ®b. CUBIC FEE c.POUNDS [IDAYS ON SITE: <br /> d.TONS 365 <br /> Check one item only) •IfEHS mm <br /> aot must is owds. <br /> STORAGE n/r <br /> CONTAINER ❑a.ABOVE GROUND T dAt.ASTIC ONMETALLIC DRUM ❑ i.FIBER DRUM ❑m.GLASS BOTTLE ❑ q.RAILCAR <br /> ❑b.UNDERGROUND TANK AN ❑ j.BAG [In. PLASTIC BOTTLE ❑ r.OTHER <br /> ❑c.TANK INSIDE BUILDING g.C OY ❑ k.BOX ❑o. TOTE BIN <br /> ❑d. STEEL DRUM h. 0 ® I. CYLINDER ❑p. TANK WAGON 223 <br /> STORAGE PRESSURE ❑ a. AMBIENT b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 <br /> STORAGE TEMPERATURE ®a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑d. CRYOGENIC 225 <br /> %WT HAZARDO COMPONENT(For mixture or waste only) EHS CAS# <br /> I 100% 226 Carbon Di ide 227 ❑Yes ® No 229 124-38-9 229 <br /> 2 230 231 ❑Yes ❑ No 232 <br /> 233 <br /> 3 234 235 ❑Yes ❑ No 236 237 <br /> 4 ng 239 ❑Yes ❑ No No <br /> zal <br /> 5 242 243 ❑Yes ❑ No 244 <br /> 245 <br /> ff more haeaedom compovub ere preeem at greater than IR by weight Jvov<aruvogenie,or 0.1%by weight ifureinoguiq atheh additioval aheeb of paper capturing the required fvformation. <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION DOT HAZARD CLASS#1013 246 <br /> If EPCRA,Please Sign Here <br /> UPCF Rev.(12/2007) <br />