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UNEDOCS <br /> HAZARDOUS MATERIALS <br /> HAZARDOUS MATERIALS INVENTORY- CHEMICAL DESCRIPTION <br /> (One page per material per building or area) <br /> 200. <br /> ❑ ADD ❑ DELETE ❑ REVISE <br /> I. FACILITY INFORMATION <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> S-Mart #655 <br /> CHEMICAL LOCATION 201. CHEMICAL LOCATION CONFIDENTIAL EPCRA 202. <br /> Refrigeration and Air Conditioning System s-Th rouhout ❑ YES E NO <br /> FACILITY ID# 1 MAP#(Optional) 203. GRID#(Optional 204 <br /> (Agency Use Only) <br /> II. CHEMICAL INFORMATION <br /> CHEMICAL NAME 205. TRADE SECRET 206. <br /> Chlorod ifl uorom ethane IfsubjecnoEPCRA.refer toinstructime [:1 Yes ®No <br /> COMMON NAME 207. EHS- 208. <br /> Freon R22 El Yes E No <br /> CAS# 209. alf EHS is"Yes,"all amounts below must be in lbs. <br /> 75-45-6 <br /> FIRE CODE HAZARD CLASSES(Complete if required by CUPA) 210. <br /> HAZARDOUS MATERIAL 211. RADIOACTIVE 212. 1 CURIES _ 213. <br /> TYPE (Check one item only) E a.PURE ❑b.MIXTURE ❑c.WASTE ❑Yes E No <br /> PHYSICAL STATE 214. LARGEST CONTAINER 215_ <br /> (Check one item only) ❑a.SOLID ❑It.LIQUID E c.GAS 600 l bs <br /> FED HAZARD CATEGORIES 216. <br /> (Check all that apply) ❑a.FIRE ❑b.REACTIVE E c.PRESSURE RELEASE ❑d.ACUTE HEALTH ❑e.CHRONIC HEALTH <br /> AVERAGE DAILY AMOUNT 217. MAXIMUM DALLY AMOUNT 218. ANNUAL WASTE AMOUNT 219. STATE WASTE CODE 220. <br /> 1200 lbs 1200 lbs NA NA <br /> UNITS' ❑a.GALLONS ❑b.CUBIC FEET E c.POUNDS ❑d.TONS - 221. DAYS ON SITE 222. <br /> (Check one item only) a If EHS,amount most be in pounds. 365 <br /> STORAGE ❑a. ABOVEGROUND TANK ❑f CAN ❑k. BOX ❑p. TANK WAGON 223' <br /> CONTAINER ❑b. UNDERGROUND TANK ❑g. CARBOY Ell. CYLINDER ❑q. RAIL CAR <br /> ❑c. TANK INSIDE BUILDING ❑It. SILO ❑in. GLASS BOTTLE E r. OTHER <br /> ❑d. STEEL DRUM ❑i. FIBER DRUM ❑n. PLASTIC BOTTLE <br /> ❑e. PLASTICNONMECALLIC DRUM ❑j. BAG ❑o. TOTE BIN <br /> STORAGE PRESSURE [Ia. AMBIENT E b. ABOVE AMBIENT ❑c. BELOW AMBIENT 274. <br /> STORAGE TEMPERATURE ❑a. AMBIENT ❑b. ABOVE AMBIENT E c. BELOW AMBIENT ❑it. CRYOGENIC 225. <br /> %WT HAZARDOUS COMPONENT(For mixture or waste only) EHS CAS# <br /> 227. <br /> 1. 99.5 226. Chlorodifluoromethane ❑Yes E No 228' 75-45-6 229. <br /> 2, <br /> 230. 231. [1 Yes El Na 232. 233. <br /> 3, <br /> 234. 235. [1 Yes ED No 236. 237. <br /> 4, <br /> 238. 239. [1 Yes ❑ No 240. 241. <br /> If more haaar lous component 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. <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#655 Page 3 of 18 March 2011 <br />