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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) ® MATERIAL(NON-WASTE) <br /> ❑ WASTE <br /> one page per material er buildin or area <br /> []ADD ❑DELETE ®REVISE REPORTING YEAR 2005 200 1 Page of <br /> I. FACILITY INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA—Doing Business As) 3 <br /> 7-Eleven#14117 201 CHEMICAL LOCATION CONFIDENTIAL 202 <br /> CHEMICAL LOCATION <br /> (EPCRA) ❑ YES ® NO <br /> 204 <br /> MAP#(optional) 203 GRID#(optional) <br /> FACILITY ID# ,j 1 Of 1 <br /> II. CHEMICAL INFORMATION <br /> CHEMICAL NAME 205 TRADE SECRET Yes ®No 206 <br /> CARBON DIOXIDE If Subject to EPCRA,refer to lnstmd,ons <br /> COMMON NAME CARBON DIOXIDE 207 EHS' El Yes ®No zoe <br /> CAS#124-38-9 209 'if EHS is'Yes',all amounts below must be in lbs. <br /> 210 <br /> FIRE CODE HAZARD CLASSES(Complete if required by CUPA) <br /> 213 <br /> HAZARDOUS MATERIAL 211 RADIOACTIVE ❑Yes ON 212 CURIES <br /> TYPE(Check one item only) E a.PURE ❑b.MIXTURE ❑c.WASTE <br /> 215 <br /> PHYSICAL STATE 214 LARGEST CONTAINER 400 <br /> (Check one Item only) ❑ a.SOLID Ob. LIQUID Elc.GAS <br /> FED HAZARD CATEGORIES 216 <br /> (Check all that apply) ❑a. FIRE ❑b. REACTIVE E c.PRESSURE RELEASE E d. ACUTE HEALTH ❑e. CHRONIC HEALTH <br /> AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 216 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 <br /> 200 400 NIA NIA <br /> 221 DAYS ON SITE: 222 <br /> UNITS' Oa.GALLONS ❑b. CUBIC FEET E c.POUNDS ❑d.TONS 365 <br /> Check one item only) 'If EHS.amount must be in ounds. <br /> STORAGE <br /> CONTAINER ❑a.ABOVE GROUND TANK ❑e.PLASTICINONMETALLIC DRUM ❑ i,FIBER DRUM ❑m. GLASS BOTTLE ❑ q.RAIL CAR <br /> ❑b.UNDERGROUND TANK ❑ I.CAN ❑ j.BAG [In. PLASTIC BOTTLE ❑ r. OTHER <br /> ❑c.TANK INSIDE BUILDING ❑9.CARBOY ❑k.BOX ❑o. TOTE BIN <br /> ❑d. STEEL DRUM ❑h.SILO E I. CYLINDER ❑p. TANK WAGON 223 <br /> STORAGE PRESSURE [Ia. AMBIENT E b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 <br /> STORAGE TEMPERATURE ❑a. AMBIENT ❑b. ABOVE AMBIENT ❑ c. BELOW AMBIENT Ed. CRYOGENIC 226 <br /> %WT HAZARDOUS COMPONENT(For mixture or waste only) EHS CAS# <br /> 1 100 226 CARBON DIOXIDE 227 ❑Yes E No 228 124-38-9 229 <br /> 2 230 231 []Yes ❑No 232 233 <br /> 3 23a 235 ❑Yes ❑No 236 237 <br /> 4 238 239 []Yes ❑ No 240 241 <br /> 5 242 243 []Yes []NO 244 245 <br /> If more harardoua components are present at greater unwin 1%by weight if non•earclrwgenle,or 0.1%by weight H carcinogenic,attach addllional sheets of paper capturing the required <br /> Information. <br /> 246 <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION <br />