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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS MATERIALS <br /> HAZARDOUS MATERIALS INVENTORY — CHEMICAL DESCRIPTION <br /> ane a e errrelenal er builtlin or area <br /> ❑ADD ❑DELETE ❑REVISE 200 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 201 CHEMICAL LOCATION CONFIDENTIAL 202 <br /> EPCRA <br /> ❑ YES E NO <br /> FACILITY ID# 1 MAP#(optional) 203 GRID#(optional) 204 <br /> 11. CHEMICAL INFORMATION <br /> CHEMICAL NAME 205 TRADE SECRET ❑ Yes E No 206 <br /> If Subject to EPCIRA,refer to instructions <br /> COMMON NAME 207 208 <br /> Premium Unleaded Gasoline EHS' El Yes E No <br /> CAS# 20s <br /> 'If EHS Is'Nes",all amounts below must be in lbs. <br /> MxBoossls <br /> FIRE CODE HAZARD CLASSES(Complete if required by CUPA) 210 <br /> Flammable liquid <br /> HAZARDOUS MATERIAL 213 <br /> TYPE(Check one item only) ❑a.PURE E b.MIXTURE ❑c.WASTE 211 RADIOACTIVE ❑Yes E No 212 CURIES <br /> PHYSICAL STATE 215 <br /> (Check one item only) ❑a.SOLID ®b. LIQUID ❑ c.GAS 214 LARGEST CONTAINER 10,000 <br /> FED HAZARD CATEGORIES 216 <br /> (Check all that apply) ® a. FIRE ❑b. REACTIVE 0 C.PRESSURE RELEASE E d. ACUTE HEALTH (9 e. CHRONIC HEALTH <br /> AVERAGE DAILY AMOUNT 217 1 MAXIMUM DAILY AMOUNT 216 1 ANNUAL WASTE AMOUNT 219 STATEWASTECODE 220 <br /> 5,000 10,000 <br /> 221 1 DAYS ON SITE: 222 <br /> UNITS* ®a.GALLONS ❑b. CUBIC FEET ❑ c.POUNDS ❑d.TONS 365 <br /> Check one item only) •If EHS,amount must be in pounds. <br /> STORAGE <br /> CONTAINER ❑a.ABOVE GROUND TANK ❑e.PLASTIC/NONMETALLIC DRUM ❑ L FIBER DRUM ❑In.GLASS BOTTLE ❑ q,RAILCAR <br /> 0 b.UNDERGROUND TANK ❑f.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. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑d. CRYOGENIC 225 <br /> °IoWT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS# <br /> 1 85-95 226 Petroleum Distillates 227 ❑Yes E NO 228 8006-61-9 229 <br /> 2 <4.9 230 Benzene 231 ❑Yes E No 232 100-14-1 233 <br /> 3 <11 234 Ethanol 235 ❑Yes E No 236 6756-1 237 <br /> 4 238 239 ❑Yes ❑ No 240 241 <br /> 5 242 243 ❑Yes ❑ NO 244 245 <br /> Ifnwre hazardous components are present at greater than i%by weight M non-carelnogenlc,or 0.1%by weight If carcinogenic,attach additional sheets of paper capturing the required <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION 246 <br /> If EPCRA,Please Sign Here <br /> UPCF(1/99) OES Fort)2731 <br />