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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS MATERIALS AUG B 6 2011 <br /> HAZARDOUS MATERIALS INVENTORY- CHEMICAL DESCRIP ��N <br /> (One page per material per building or area) n QUIN COUN <br /> <br /> <br /> <br /> <br /> <br /> ❑ YES ® NO <br /> FACILITY ID# _ I MAP#(Option.!) z0z. GRID#(Optiormq zoo. <br /> (Apocy Use Only) <br /> II. CHEMICAL INFORMATION <br /> CHEMICAL NAME 205. TRADE SECRET 206. <br /> Petroleum H drocarbon mixture Ifsubjed(oMM,bRrminslmcfiuns ❑Yes ONO <br /> COMMONNAME 207 EHS- los. <br /> Used Fuel Filters with Gasoline Residue ❑Yes ONO <br /> CAS# 209 *If EHS is"Yes,"all amounts below must be in lbs. <br /> 8006-61-9 <br /> FIRE CODE HAZARD CLASSES(Complete fmquimd by COPA) 210 <br /> HAZARDOUS MATERIAL 211. RADIOACTIVE 2¢. <br /> CURIES 213. <br /> TYPE (Check ane item only) ❑a.PURE ❑b.MD(TURE ®c.WASTE <br /> ❑Yes ON. <br /> PHYSICAL STATE 214. LARGEST CONTAINER z1s. <br /> (Check one item only) ®a.SOLID ❑b.LIQUID ❑c.GAS 200 pound drum <br /> FED HAZARD CATEGORIES (55-gallon) 216. <br /> (Check all that apply) ®a.FIRE ❑b.REACTIVE ❑c.PRESSURE RELEASE ®d.ACUTE HEALTH ❑e.CHRONIC HEALTH <br /> AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT zls. ANNUAL WASTE AMOUNT 219. STATE WASTE CODE 220 <br /> 3 5 45 213 <br /> UNITS' ❑a.GALLONS ❑b.CUBIC FEET Z c.POUNDS221' 222' <br /> ❑d.TONS DAYS ON <br /> (Check core item only) •If EHS,amount must be in pounds. 365 <br /> STORAGE ❑a. ABOVEGROUND TANK ❑f CAN ❑k. BOX ❑p. TANK WAGON 2z3. <br /> CONTAINER ❑b. UNDERGROUND TANK ❑g. CARBOY ❑I. CYLINDER ❑q. RAIL CAR <br /> ❑c. TANK INSIDE BUILDING ❑h. SILO ❑m. GLASS BOTTLE ❑r. OTHER <br /> ®d. STEEL DRUM ❑i. FIBER DRUM ❑n. PLASTIC BOTTLE <br /> ❑e. PLASTIC/NONMETALLIC DRUM ❑j. BAG ❑o. TOTE BIN <br /> STORAGE PRESSURE ®a. AMBIENT ❑b. ABOVE AMBIENT224' <br /> ❑c. BELOW AMBIENT <br /> STORAGE TEMPERATURE ®a. AMBIENT ❑b. ABOVE AMBIENT ❑c. BELOW AMBIENT ❑d. CRYOGENIC 225' <br /> %WT HAZARDOUS COMPONENT(For mixture or waste only) EHS CAS# <br /> 226. 227. 228. 229. <br /> l 5% Gasoline 11 Yes ® Na 8006-61-9 <br /> 230. .231 232. 233. <br /> 2. 95% Inert Fuel Filter media 11 Yes ® Nn <br /> n4. 23s. 236. 237. <br /> 3. E]Yes [:] No <br /> ns. 239. 240. 241. <br /> 4. ❑Yes ❑ No <br /> u2. 243. 244, 245. <br /> 5. ❑Yes El No <br /> Ifmarc hmrdeur mmponmb arc present at irr+ter than 1%by weizht if non-nrcinozeni4 or 0.1%by weight if<anioa8miq ottaeb oddifiaml rheets of peper npwrine the requirtd infarmstion. <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION 246. <br /> DOT Hazard Class: <br /> If EPCRA,Please Sign Here. <br /> UPCFRev. (12/2007)-5/2 www.unidocs.org <br />