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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS MATERIALS <br /> HAZARDOUS MATERIALS INVENTORY- CHEMICAL DESCRIPTION <br /> one page Let material get buildin m area <br /> []ADD []DELETE ®REVISE 200 Page 3 of 4 <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 Z NO <br /> � a MAP#(optional) 203 GRID#(optional) 204 <br /> FACILITY ID# ��, <br /> II. CHEMICAL INFORMATION <br /> CHEMICAL NAME SECRET ® Yes [INo 205 <br /> Petroleum Hydrocarbons If subject to EPCRA,refer to instructions <br /> COMMON NAME 207 208 <br /> Supreme Unleaded Gasoline 91 Octane) EHS* Yes ® No <br /> CAS# 209 <br /> *If EHS is"Yes",all amounts below must be in lbs. <br /> 86290-81-5 <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 FC <br /> URIES <br /> TYPE(Check one item only) ❑a.PURE Z b.MIXTURE ❑c.WASTE <br /> 215 <br /> PHYSICAL STATE <br /> (Check one item only) Ela.SOLID ®b. LIQUID El c.GAS 214 LARGEST CONTAINER 15,000 <br /> FED HAZARD CATEGORIES 215 <br /> (Check all that apply) Z a. FIRE ❑b. REACTIVE ❑ c.PRESSURE RELEASE ®d. ACUTE HEALTH Z e. CHRONIC HEALTH <br /> AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 <br /> 7,500 15,000 <br /> zzl DAYS ON SITE: 222 <br /> UNITS* Z a.GALLONS ❑b. CUBIC FEET ❑ c.POUNDS ❑d.TONS 365 <br /> Check one item only) *If EHS,amount must be in pounds. <br /> STORAGE <br /> CONTAINER ❑a.ABOVE GROUND TANK ❑e.PLASTICNONMETALLIC DRUM ❑ i.FIBER DRUM ❑m.GLASS BOTTLE ❑ q.RAILCAR <br /> ®b.UNDERGROUND TANK ❑f.CAN ❑ i.BAG ❑n. PLASTIC BOTTLE ❑ r.OTHER <br /> ❑c.TANK INSIDE BUILDING ❑g.CARBOY ❑ k.BOX ❑o. TOTE BIN <br /> ❑d. STEEL DRUM ❑It.SILO ❑ I. 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 /> <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION DOT HAZARD CLASS111203 245 <br /> If EPCRA,Please Sign Here <br /> UPCF Rev.(12/2007) <br />