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UNIFIED PROGRAM (UP) FORM <br /> EHAZA:RDOUSERIALS INVENTORY FORM—CHEMICAL DESCRIPTION <br /> waste(Do not combine material and waste on oneform) ❑ MATERIAL(NON-WASTE) <br /> ® WASTEone a e rmatedal builtlin or area❑AD ❑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 <br /> CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL 202 <br /> (EPCRA) ❑ YES ® NO <br /> <br /> ' MAP#(optional) 203 GRID#(optional) 204 <br /> FACILITY ID# � ..' 1of1 <br /> II. CHEMICAL INFORMATION <br /> CHEMICAL NAME <br /> 205 TRADE SECRET Yes No 206 <br /> WASTE FLAMMABLE LIQUID If Subject to EPCRA,refer to instructions <br /> COMMON NAME GAS-WATER MIXTURE 207 EHS' ❑ Yes ®No Zoe <br /> CAS#N/A 209 ;if EHS is-Yes-,all amounts below must be in lbs. <br /> 210 <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) [I a.PURE [11h.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 216 <br /> (Check all that apply) ®a. FIRE ❑b. REACTIVE ❑ c.PRESSURE RELEASE ®d. ACUTE HEALTH ®e. CHRONIC HEALTH <br /> AVERAGE DAILY AMOUNT 277 MAXIMUM DAILY AMOUNT 218 ANN UAL WASTE AMOUNT 219 STATEWASTECODE 220 <br /> 25 55 55 134 <br /> 221 DAYS ON SITE: 222 <br /> UNITS' Ms.GALLONS ❑b. CUBIC FEET ❑ c.POUNDS ❑d.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 ❑ L CAN ❑ j.BAG ❑n. PLASTIC BOTTLE ® r. OTHER <br /> ❑c.TANK INSIDE BUILDING ❑g.CARBOY ❑k.BOX ❑o. TOTE BIN <br /> Md. STEEL DRUM ❑h.SILO ❑I. CYLINDER ❑p. TANK WAGON 223 <br /> STORAGE PRESSURE Ea. 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 /> 89-90 225 MIXTURE OF GASOLINE&WATER OR 227 ❑Yes ® No 228 N/A, MIXTURE 229 <br /> OTHER CONTAMINATION IN GASOLINE <br /> 2 230 231 []Yes ❑No 232 233 <br /> 3 434 236 ❑Yes ❑NO 236 237 <br /> 4 P38 239 ❑Yes ❑ No 240 241 <br /> 5 P42 243 ❑Yes ONO 244 245 <br /> If more hazardous components are present at greater than 1%by weight If nomearelnogenic,or 0.1%by weight If carcinogenic,attach add ltlonal sheets of paper capturing the required <br /> Information. <br /> 246 <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION <br />