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RECEIVED <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS MATERIALS O L T 13 20 t, <br /> ,�. HAZARDOUS MATERIALS INVENTORY- CHEMICAL DESCRIPTION 3A <br /> 10/14/2009-05:13:25 PM N COUNTY <br /> Page_ fEOgEa ENCVSERVICES <br /> I. FACILITY INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 <br /> ARCH ARCO AM/PM <br /> <br /> ❑X YES❑NO <br /> FACILITY 1D# 1 <br /> <br /> <br /> CHEMICAL INFORMATION <br /> CHEMICAL NAME 205 TRADE SECRET(11) OYES 0 N 206 <br /> CARBON OXIDE If Subject to EPCRA.refer to insuuaione <br /> COMMON NAME 207 208 <br /> CO2 TANK EHS* ❑YES ®NO <br /> CAS# 209 <br /> *If EHS is "Yes",all amounts must be in lbs. <br /> N/A <br /> FIRE CODE HAZARD CLASSES(Complete if required by CUPA) 210 <br /> LEAVE BLANK <br /> HAZARDOUS MATERIAL ®a.PURE I7 b.MIXTURE D e.WASTE 211 RADIOACTIVE D YES ONO 212 CURIES 0 213 <br /> TYPE(Check one item only) <br /> PHYSICAL STATE 215 <br /> 214 <br /> (Check one item only) O SOLID O LIQUID H GAS LARGEST CONTAINER 400 <br /> FED HAZARD CATEGORIES 216 <br /> FIRE REACTIVE ®PRESSURE RELEASE ❑ACUTE HEALTH ❑CHROMC HEALTH <br /> (Check all that apply) <br /> AVERAGE DAILY AMOUNT 2l7 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 2t9 STATE WASTE CODE 220 <br /> 125 250 N/A N/A <br /> 221 DAYS ON SITE 222 <br /> UMTS* D GAL D CU FT 0 LBS D TONS 365 <br /> (Check an item only *If EHS,amount must be in pounds. <br /> STORAGE D ABOVE GROUND TANK D CARBOY D GLASS BOTTLE D Other... <br /> CONTAINER D UNDER GROUND TANK D SILO D PLASTIC BOTTLE <br /> D TANK INSIDE BUILDING D FIBER DRUM D TOTE BIN <br /> D STEEL DRUM D BAG D TANK WAGON <br /> D PLASTICINONMETALLIC DRUM D BOX D RAIL CAR <br /> D CAN ®CYLINDER ❑OTHER 223 <br /> STORAGE PRESSURE DAMBIENT NABOVEAMBIENT OBELOWAMBIENT 224 <br /> STORAGE TEMPERATURE DAMBIENT DABOVEAMBIENT OBELOWAMBIENT 0CRYOGENIC 225 <br /> %WT 1HAZARDOUS COMPONENT(For mixture or waste out EHS CAS# <br /> N/A 226 227 ❑YES ❑NO 228 229 <br /> 230 231 ❑YES O NO 232 233 <br /> 234 235 ❑YES D NO 236 237 <br /> 238 239 ❑YES ❑NO 240 241 <br /> 242 243 OYES u NO 244 245 <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION: 1013 246 <br /> (33)UNITED NATIONS ID#(DOT) <br /> (34)WHAT IS MATERIAL <br /> USED FOR? FOR SODA FOUNTAIN DRINKS MACHINE <br /> If EPCRA,Please Sign Herc <br /> UPCF(Rev.12/2007) <br />