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Ak <br />Ah <br />UN&M PROGRAM CONSO'LIDATrD FORM <br />HAZARDOUS MATERIALS <br />HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION <br />one page mr material r buildingor area <br />❑ADD [:]DELETE ®REVISE 200 Page 5 of 9 <br />I. FACILITY INFORMATION <br />BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) 3 <br />Chevron Station #94275 <br />CHEMICAL LOCATION 201 <br />CHEMICAL LOCATION CONFIDENTIAL 202 <br />EPCRA <br /> <br />❑ YES ® NO <br />�-1 <br />MAP# (optional) 203 <br />CrRID# (optional) 204 <br />FACILITY ID #® <br />0 <br />0 <br />O <br />® <br />® <br />® <br />® <br />O <br /> <br />II. CHEMICAL INFORMATION <br />CHEMICAL NAME 205 <br />TRADE SECRET ❑ Yes ® No 206 <br />Carbon Dioxide <br />If Subject to EPCRA, refer to instructions <br />COMMON NAME 207 <br />208 <br />EHS* Yes ®No <br />Carbon Dioxide CO2 <br />CAS# 209 <br />*If EHS is "Yes", all amounts below must be in lbs. <br />124-38-9 <br />FIRE CODE HAZARD CLASSES (Complete if required by CUPA) 210 <br />Compressed Gas Class 2.2 <br />HAZARDOUS MATERIAL <br />TYPE (Check one item only) ® a. PURE [Ib. MIXTURE ❑ c. WASTE 211 <br />RADIOACTIVE ❑Yes ®No 2t2 <br />213 <br />CURIES <br />PHYSICAL STATE <br />(Check one item only) ❑ a. SOLID ❑ b. LIQUID ® c. GAS 214 <br />215 <br />LARGEST CONTAINER 648 <br />FED HAZARD CATEGORIES 216 <br />(Check all that apply) ❑ a. FIRE ❑ b. REACTIVE Z c. PRESSURE RELEASE ® d. ACUTE HEALTH ❑ e. CHRONIC HEALTH <br />VERAGE DAILY AMOUNT 217 <br />MAXIMUM DAILY AMOUNT 218 <br />ANNUAL WASTE AMOUNT 219 <br />STATE WASTE CODE 220 <br />24 <br />648 <br />221 <br />DAYS ON SITE: 222 <br />UNITS* ❑ a. GALLONS ® b. CUBIC FEET [:1c. POUNDS ❑ d. TONS <br />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 />❑ b. UNDERGROUND TANK ❑ f. CAN ❑ j. BAG [In. PLASTIC BOTTLE ❑ r. OTHER <br />❑ c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k. BOX ❑ o. TOTE BIN <br />❑ d. STEEL DRUM ❑ h. SILO ® I. CYLINDER ❑ p. TANK WAGON 223 <br />STORAGE PRESSURE ❑ a. AMBIENT ® b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 <br />STORAGE TEMPERATURE ® a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 <br />%WT <br />HAZARDOUS COMPONENT (For mixture or waste only) <br />EHS <br />CAS # <br />1 100% 226 <br />Carbon Dioxide 227 <br />❑ Yes ® No 228 <br />124-38-9 229 <br />2 230 <br />231 <br />❑ Yes ❑ No 232 <br />233 <br />3 234 <br />235 <br />❑ Yes ❑ No 236 <br />237 <br />4 238 <br />239 <br />❑ Yes ❑ No 240 <br />241 <br />5 242 <br />243 <br />❑ Yes ❑ No 244 <br />245 <br />If more hazardous components 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 DOT#1013 246 <br />If EPCRA, Please Sign Here <br />UPCF (1/99) OES Form 2731 <br />