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Non-Waste Hazardous Materials Inventory Statement <br /> Date: <br /> For use by Unidocs Member Agencies or where approved by your Local Jurisdiction ti <br /> Business Name: Typeof Report on This Page: � <br /> g ` <br /> (Same as Facility Name) Pae�., ^ ❑Add; ❑Delete;Devise s- Of <br /> (One page per building or area) <br /> Chemical Location: EPCRA Confidential Location? ❑Yes; —]No Facility ID# <br /> (latiamglsmrageArsa) Trade Secret Information? El ❑No (Ag-q,Use On179 <br /> 1. 2. 3. 4. 5. 6. 7. 8. 9. <br /> Map and Hazardous Components Type Quantities Storage Codes <br /> Grid or or mixtures <br /> Haz. Location Chemical only) <br /> Physical Max. Average Largest Storage Storage Haz <br /> awL <br /> Class Code Common Name Name Wt. EHS CAS No. State Dail Dail Cont. Units Pressure Tem . Cate <br /> ® ❑ <br /> pure > ons ambient ,,r'+��nbient <br /> I �.- e ❑ ❑mixt 'e U pounds u>amb. t_1>amb. U reactive <br /> t solid ❑ ❑ stab. <amb. sure release <br /> CAS / D1ir ❑ ❑ Cartes: Daus On Storage co feet < ❑ ❑P� <br /> 1 --NO-^ ❑EuS ® =paid ��d108Ca°e) Sfte: Container.* ❑loos ❑cryogenic {❑{�,raac�utehealth <br /> ® gast,et-etirovic health <br /> 1 ••� radioactive <br /> ❑ ❑Puff ❑gallons ambient ❑ambient ❑Bre <br /> ❑ ❑miAtln'e. ❑pounds ❑>amb. ❑>stab. E]reactive <br /> ❑ ❑solid Curies: D s n Stora¢e ❑co.� ❑<amb. ❑<omb. ❑pressure release <br /> CASNo.: (Ifradi—fi") Site: Container.* toys <br /> ❑EHS ® ❑liquid ❑ ❑cryogenic ❑acute health <br /> ! ❑gas - ❑chronic health <br /> i ❑ <br /> ❑ ❑ ❑radioactivern <br /> Y-"' ❑gallons ❑ambiem ❑ambient ❑fire <br /> i ❑ ❑mixtur ❑poaads ❑>amb. ❑>amb. ❑reactive <br /> ❑ solid Curies: Days On Storage ❑ fcut ❑<amb. <amb. <br /> CAS No.; ❑Egg (Ir,ad;°aake) Site: Container:* ❑ ❑��release <br /> ® ❑Liquid — ❑tons ❑cryogenic ❑scale health <br /> ® ❑gas Elchronic health <br /> ❑tadioactive <br /> ® <br /> ❑1 ❑gallons ❑ambient ❑ambietn ❑fire <br /> ❑ ❑rnix� ❑po®ds ❑>amb. ❑>amb. ❑reactiv <br /> ❑ ❑solid Codes: a O Storage ❑cu.feet ❑<.b. ❑<.b, ❑ e <br /> CAS No.: ❑FHS ® ❑flgaid (Itraaivaeti.e) Site: Container.* ❑tons ❑cryogenic ❑acu <br /> ® ❑gas ❑chronic health <br /> i ❑radioactive <br /> ❑ ❑gallons ❑ambient ❑mnbient ❑fire <br /> ❑ ❑mlxttue ❑pounds ❑>amb. ❑>amb. ❑reactive <br /> i ❑ Curies: D On Stora a cu.feet <amb. <amb. <br /> ❑solid av$_ _g- ❑ ❑ ❑ ❑pressure miease <br /> CAS No.: ❑EHS ® ❑liquid (Irraataacrrn:) Site: Container:* ❑tons ❑cryogenic ❑acute health <br /> ® ❑gas ❑chronic health <br /> ❑tadioactive <br /> ❑Pure gallons ambi. ❑ambient ❑fire <br /> ❑ ❑ID>RtilT¢ ❑pou:rds ❑>amb. ❑>amb. ❑reactive <br /> ❑ Carl Days On Stara e ❑cu.feet ❑<amb. <amb. <br /> solid _p_ ❑ ❑pressure release <br /> CAS No.: ❑EHS ❑ ❑liquid ptraa;°acd.e) Site: Container:* ❑tons s❑cryogenic ❑scute health <br /> El ❑gas t radioactive <br /> ❑t--7I ebn5nfc health <br /> * Code Storage Tvoe ode Storage Trve C e Storage Tune Code Storaee Yvoe Code Storage use Code Storage Type <br /> A Aboveground Tank D Steel Dry G Carboy a Ba IfEPCRA,sign beiosv <br /> tJ <br /> Bag M Glass Bottle or Jug P Tank Wagon ,,. <br /> B BelowgtovadTook E Plastic/Non-metallic Drum H Silo g Box <br /> N Plastic Bottle or Jug Q Rai]Car <br /> C Tank Inside Building F Can I Fiber Drum L Cylinder O Tote HixR Other <br /> UN-020-7/17 www.unidoes.org Rev.07/24/06 <br /> w� <br />