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UNIFIED PROGRAM (UP) FORM <br /> HAZARDOUS MATERIALS INVENTORY FORM—CHEMICAL DESCRIPTION <br /> Indicate material OR waste(Do not combine material and waste on oneform) ❑ MATE RIAL(NO N-WASTE) <br /> ® WASTE <br /> one gale per material per building or area <br /> []ADD []DELETE ®REVISE REPORTING YEAR 2006 200 Page of <br /> I. FACILITY INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA—Doing Business As) 3 <br /> 7-Eleven#14117-2725 County Club, Stockton <br /> CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL 202 <br /> (EPCRA) ❑ YES ® NO <br /> <br /> i MAP#(optional) 203 GRID#(optional) 204 <br /> FACILITY I D# m rE I;' <br /> 17 <br /> 1 of 1 <br /> 11. CHEMICAL INFORMATION <br /> CHEMICAL NAME 205 TRADE SECRET ❑Yes 0 No los <br /> WASTE ABSORBENT&DISPENSER FUEL FILTER If Subject to EPCRA,refer to instructions <br /> COMMON NAME WASTE ABSORBENT&DISPENSER FUEL FILTER 207 EHS' ❑ Yes ®No Zoe <br /> CAS#N/A 209 "If EHS is"Yes",all amounts below must be in lbs. <br /> ztn <br /> FIRE CODE HAZARD CLASSES(Complete if required by COPA) <br /> 213 <br /> HAZARDOUS MATERIAL 211 RADIOACTIVE []Yes ®No 212 CURIES <br /> TYPE(Check one item only) ❑a.PURE ❑b.MIXTURE ®c.WASTE <br /> 215 <br /> PHYSICAL STATE 214 LARGEST CONTAINER 55 <br /> (Check one item only) ® a.SOLID ❑b. LIQUID ❑c.GAS <br /> FED HAZARD CATEGORIES 21s <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 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 <br /> 25 55 55 352 <br /> 221 DAYS ON SITE: 222 <br /> UNITS' ®a.GALLONS ❑b. CUBIC FEET 11c.POUNDS [Id.TONS 365 <br /> Check one item only) 'If EHS,amount must be In unds. <br /> STORAGE <br /> CONTAINER ❑a.ABOVE GROUND TANK ❑e.PLASTIC/NONMETALLIC DRUM ❑ I.FIBER DRUM ❑m. GLASS BOTTLE ❑ q.RAIL CAR <br /> ❑b.UNDERGROUND TANK ❑ f.CAN ❑ ).BAG ❑n. PLASTIC BOTTLE ❑ r. OTHER <br /> ❑c.TANK INSIDE BUILDING ❑g.CARBOY ❑k.BOX ❑o. TOTE BIN <br /> Md. STEEL DRUM ❑h.SILO Ell. 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 HAZARDOUS COMPONENT(For mixture or waste only) EHS CAS# <br /> 1 89-90 226 MIXTURE OF SILCATE &HYDROCARBONS 227 ❑Yes ® No 228 N/A, MIXTURE 229 <br /> &SPENT FUEL FILTERS <br /> 2 230 231 []Yes ❑NO 232 233 <br /> 3 434 235 ❑Yes ❑No 236 237 <br /> 4 238 239 []Yes ❑ No 240 241 <br /> 5 242 243 []Yes []NO 244 245 <br /> ff more hazardous components are present at greater than 1%by welghl g noncarclnogenle,or 0.1%by welght H carcinogenic,attach additional sheets of paper capturing the required <br /> Information. <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION z4s <br />