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Non -Waste Hazardous Materials Inventory Statement <br />Date: For use by Unidocs Member Agencies or where approved by your Local Jurisdiction <br />A Aboveground Tank D Steel Drum G Carboy t Bag <br />B Belowground Tank E PlsstidNon-metallic Drum H Silo K Box <br />C Tank Imide Building F Can 1 Fiber Drum L Cylinder <br />M Olm Bottle or Jug P Tank Welton <br />N Pbwic Bonk or Jug Q Rail Car <br />O Tote Bin R Other <br />UN -020 www.unidoes.org 7/18 - Rev. 12/14/10 <br />It EFUKA, sign below: <br />Business Name: <br />(Same as Facilit) Name) <br />Chemical Location: EPCRA Confidential Location? ❑ Yes; ❑ No Facility ID # <br />(Buildtng/Stonge Area) Trade Secret Information?❑Yes; No (Ag—y Use Only) <br />❑ <br />Type of Report on This Page: <br />❑ Add; ❑ Delete; ❑ Revise <br />— - <br />Page of <br />(One page per heading or area) <br />1. <br />Haz <br />Class <br />2. <br />Map and <br />Grid or <br />Location <br />Code <br />3. <br />Common Name <br />4. <br />Hazardous Components <br />(For mixtures only) <br />Chemical % <br />Name Wt. o. <br />5. <br />Type <br />and <br />ical <br />State <br />❑ paw <br />❑ Inixttue <br />6. <br />Quantities <br />Max. Average Largest <br />Daily Daily Cont. <br />7. <br />Units <br />gallonsambkm <br />❑ P.— <br />❑ ea Fat <br />❑ toro <br />8. <br />Storage Codes <br />Storage Storage <br />Pressure Temp. <br />ambient6rc <br />❑ > arab. ❑ > amb. <br />❑ crash. ❑ (arab. <br />❑ ayogenr <br />9. <br />Hazard <br />Categories <br />❑ teaarve <br />❑ P.n rekme <br />❑acute hnhh <br />❑ chmnie health <br />❑ radioae&v <br />0-1 ❑ <br />❑ <br />❑ <br />❑ solid <br />Ss: <br />Days Ota <br />$jtr: <br />Storage <br />�4Lt>E�:' <br />CAS No•: 0.(tfredioective) <br />❑ <br />mllchtre <br />saw. <br />❑ W. -J, <br />❑ eta feet <br />❑ tom <br />11 ambient <br />❑ > amb. <br />❑ -amb <br />El ambient <br />❑ -.b <br />❑ <amb <br />❑ eryog. <br />0 fine <br />❑ ,active <br />❑ pressure release <br />❑ acute health <br />[Ichronic health <br />❑ radioactive <br />❑ <br />❑ solid <br />li uid <br />cadt3t <br />(Ifraio eta.) <br />DIY, On <br />Sj(g: <br />StoraLe <br />Contain s:• <br />No: ❑ ENS <br />❑ <br />❑p� <br />g.Uom <br />❑ pour& <br />❑ ca feet <br />❑ toro <br />ambo ra <br />❑ > amb. <br />❑ lamb <br />ambientfan <br />❑ lamb <br />❑ < emb. <br />❑ ayog— <br />❑ Mai- <br />❑ prmaae relesse <br />❑ aane health <br />❑ cluonic health <br />❑ radioactive <br />El <br />❑ <br />❑ solid <br />❑ liquid <br />❑ gas <br />Carla: <br />ltfnsiowve) <br />D� <br />Silt: <br />St( <br />Covtaluer: • <br />S No.: <br />CA ❑ EHS <br />❑ <br />❑ <br />01 <br />11 Pure,gaUoro <br />❑ mixture <br />❑ Potmds <br />cu. feta <br />❑ tom <br />ambient <br />❑ > amb. <br />[I (arab. <br />ambietu <br />❑ > amb. <br />❑ (arab. <br />❑ ..g. <br />fire <br />❑ ra Vi <br />11presmemkme <br />❑ anus health <br />El chore beukh <br />❑ radioactive <br />❑ <br />❑ <br />❑solid <br />[I liquid <br />Ps <br />sLd�� <br />Ofrtdkati.e) <br />Da" On <br />Sk4: <br />Storrme❑ <br />Contafaer:• <br />CAS No.: ❑EHS <br />El <br />El❑ <br />01 <br />P <br />❑ ruixttae <br />gaUom <br />❑ poured <br />❑ w.lea <br />❑ tom <br />arab. <br />❑ > amb <br />❑ <amb. <br />ambient <br />❑ > amb <br />❑ <amb. <br />❑ ayogenic <br />fire <br />❑ raaivc <br />❑ prenvure relm,e <br />❑acute health <br />❑ chronic bale <br />❑ ret h tr e <br />❑ <br />❑ <br />❑ solid <br />❑ liquid <br />❑ » <br />f-Rda: <br />(Ifraboanive) <br />Days On <br />Sid: <br />Stouts <br />Contain er:• <br />CAS No•: ❑ EHS <br />❑ <br />❑ <br />[Z!C_MT�No,: <br />C <br />* Storage, <br />13 Pure <br />❑ mixture <br />gallon <br />❑ pounds <br />❑ a. feet <br />❑ tom <br />ambiaa <br />❑ > amb. <br />❑ < amb. <br />ambirmt <br />❑ > amb. <br />❑ < amb. <br />❑ cTyogenic <br />D fire <br />❑ reactive <br />❑ pressure rekase <br />❑ aarte heath <br />❑ choreic heath <br />❑ radioactive <br />❑ <br />[I solid <br />❑ liquid <br />❑ S. <br />Co <br />(tfmbac°ve) <br />Days On <br />C°ntatnV:• <br />❑ ENS <br />�oQt Sfonn'IW°e <br />❑ <br />❑ <br />Code S[onae TV- r...t. c- <br />A Aboveground Tank D Steel Drum G Carboy t Bag <br />B Belowground Tank E PlsstidNon-metallic Drum H Silo K Box <br />C Tank Imide Building F Can 1 Fiber Drum L Cylinder <br />M Olm Bottle or Jug P Tank Welton <br />N Pbwic Bonk or Jug Q Rail Car <br />O Tote Bin R Other <br />UN -020 www.unidoes.org 7/18 - Rev. 12/14/10 <br />It EFUKA, sign below: <br />