Laserfiche WebLink
a Aft <br /> UNIFIM PROGRAM CONSOLIDATE FORM <br /> HAZARDOUS MATERIALS <br /> HAZARDOUS MATERIALS INVENTORY- CHEMICAL DESCRIPTION <br /> one page Eer material building or area <br /> ❑ADD ❑DELETE ®REVISE 200 Pagel 2 1 of <br /> I. FACILITY INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA—Doing Business As) 3 <br /> Chevron Station#208118 <br /> CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 <br /> ❑ YES ® NO <br /> NyMAP#(optional) 203 GRID#(optional) 204 <br /> FACILITY ID# <br /> II. CHEMICAL INFORMATION <br /> CHEMICAL NAME 205 TRADE SECRET ® Yes ❑ No 206 <br /> Petroleum Hydrocarbons If Subject to EPCRA,refer to instructions <br /> COMMON NAME 207 208 <br /> Regular Unleaded Gasoline 87 Octane EHS* ❑ Yes ® No <br /> CAS# 209 <br /> 86290-81-5 *If EHS is"Yes",all amounts below must be in lbs. <br /> FIRE CODE HAZARD CLASSES(Complete if required by CUPA) 210 <br /> Flammable Liquids Class 3 <br /> 213 <br /> HAZARDOUS MATERIAL 211 RADIOACTIVE ❑Yes Z No 212 CURIES <br /> TYPE(Check one item only) ❑a.PURE Z b.MIXTURE ❑c.WASTE <br /> 215 <br /> PHYSICAL STATE <br /> (Check one item only) ❑ a.SOLID Z b. LIQUID ❑ c.GAS 214 LARGEST CONTAINER 2®,®®® <br /> FED HAZARD CATEGORIES 215 <br /> (Check all that apply) Z a. FIRE ❑b. REACTIVE ❑ c.PRESSURE RELEASE Z d. ACUTE HEALTH Z e. CHRONIC HEALTH <br /> AVERAGE DAILY AMOUNT 21 7 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 <br /> 7,500 20,000 <br /> 221 DAYS ON SITE: 222' <br /> UNITS* Z a.GALLONS ❑b. CUBIC FEET El c.POUNDS El d.TONS 365 <br /> Check one item only) *If EHS,amount must be in pounds. <br /> STORAGE <br /> CONTAINER ❑a.ABOVE GROUND TANK ❑e.PLASTIC/NONMETALLIC DRUM ❑ i.FIBER DRUM ❑m.GLASS BOTTLE ❑ q.RAILCAR <br /> Z b.UNDERGROUND TANK ❑f.CAN ❑ j.BAG ❑n. PLASTIC BOTTLE ❑ r.OTHER <br /> ❑c.TANK INSIDE BUILDING ❑g.CARBOY ❑ k.BOX ❑o. TOTE BIN <br /> ❑d. STEEL DRUM ❑It.SILO ❑ 1. CYLINDER ❑p_ TANK WAGON 223 <br /> STORAGE PRESSURE Z a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 <br /> STORAGE TEMPERATURE Z a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑d. CRYOGENIC 225 <br /> %WT HAZARDOUS COMPONENT(For mixture or waste only) EHS CAS# <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> If more hazardous components are present at greater than 1%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 DOT HAZARD CLASS#1203 246 <br /> If EPCRA,Please Sign Here <br /> UPCF Rev.(12/2007) <br />