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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS MATERIALS <br /> HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION <br /> ane page ger material nor buildin QZea <br /> ❑ADD ❑DELETE ❑REVISE 200 <br /> Page_of <br /> I. FACILITY INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA—Doing Business As) - 3 <br /> 7-Eleven Store# 14117 <br /> CHEMICAL LOCATION tet CHEMICAL LOCATION CONFIDENTIAL 202 <br /> EPCRA <br /> ❑ YES ® NO <br /> FACILITY ID# 1 MAP#(optional) 203 GRID#(optional) 204 <br /> IL CHEMICAL INFORMATION <br /> CHEMICAL NAME 205 TRADE SECRET <br /> ❑ Yes ® No zos <br /> Carbon Dioxide If Subject to EPCRA,refer to instructions <br /> COMMON NAME 207 Zoe <br /> EHS" ❑ Yes ® No <br /> CAS# los <br /> 124-38-9 <br /> "If EHS is"Yes",all amounts below must be in Itis. <br /> FIRE CODE HAZARD CLASSES(Complete if required by CUPA) 210 <br /> HAZARDOUS MATERIAL 213 <br /> TYPE(Check one item only) ®a.PURE ❑b.MIXTURE ❑C.WASTE 211 RADIOACTIVE ❑Yes ®No 212 CURIES <br /> PHYSICAL STATE 214 LARGEST CONTAINER 300 215 <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 217 1 MAXIMUM DAILY AMOUNT 21e 1 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 <br /> 150 300 <br /> DI <br /> UNITS' ❑a.GALLONS ®b. CUBIC FEET [Iz21 ON 222 c.POUNDS ❑d.TONS DAYS <br /> OS <br /> 355 <br /> Check one item only) 'If EHS,amount must be in pounds. <br /> STORAGE <br /> CONTAINER [Ia.ABOVE GROUND TANK ❑e.PLASTIC/NONMETALLIC DRUM ❑ I.FIBER DRUM ❑m.GLASS BOTTLE ❑ q.RAILCAR <br /> ❑b.UNDERGROUND TANK ❑I.CAN ❑ j.BAG ❑n. PLASTIC BOTTLE ❑ r.OTHER <br /> ❑c.TANK INSIDE BUILDING ❑g.CARBOY ❑ k.BOX ❑o. TOTE BIN <br /> ❑d. STEEL DRUM ❑h.SILO ® I. CYLINDER ❑p. TANK WAGON 223 <br /> STORAGE PRESSURE ❑ a. AMBIENT ® b. ABOVEAMBIENT ❑ c. BELOWAMBIENT 224 <br /> STORAGE TEMPERATURE ®a. AMBIENT ❑ b. A80VE AMBIENT ❑ c. BELOW AMBIENT ❑d. CRYOGENIC 225 <br /> %gWT HAZARDOUS COMPONENT(For mixture or waste only) EHS CAS# <br /> 226 227 ❑Yes ❑ NO 229 229 <br /> 2 230 231 ❑Yes ❑ NO 232 233 <br /> 3 234 235 ❑Yes ❑ No 236 <br /> 237 <br /> 4 239 239 ❑Yes ❑ NO 240 241 <br /> 5 242 243 ❑Yes ❑ No 244 <br /> zos <br /> If more hammicus components are present at greater than 1%by weight If non carcinogenic,or g.-1%by weight If carcinogenic,attach additional sheets of paper capturing the required <br /> Informal <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION 246 <br /> If EPCRA,Please Sign Here <br /> UPCF(1199) OES Form 2731 <br />