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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS MATERIALS <br /> HAZARDOUS MATERIALS INVENTORY CHEMICAL DESCRIPTION <br /> one page per material per building 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 ❑ NO <br /> 1 <br /> FACILITY ID# MAP#(optlonal) 203 GRID#(opticnal) 204 <br /> II. CHEMICAL INFORMATION <br /> CHEMICAL NAME 205 TRADE SECRET ❑ Yes ® No 206 <br /> If Subject to EPCRA,refer to instructions <br /> COMMON NAME 207 208 <br /> Regular Unleaded Gasoline EHS" El Yes ❑ No <br /> CAS# 209 <br /> Mxaaos619 <br /> 'If EHS is"Yes",all amounts below must be in lbs. <br /> FIRE CODE HAZARD CLASSES(Completeifrequired byCUPA) 210 <br /> Flammable liquid <br /> HAZARDOUS MATERIAL 213 <br /> TYPE(Check one item only) ❑a.PURE ®b.MIXTURE E]c.WASTE 211 RADIOACTIVE CI Yes No 212 CURIES <br /> PHYSICAL STATE 215 <br /> (Check one item only) ❑a.SOLID N b. LIQUID ❑ c.GAS 214 LARGEST CONTAINER 10,000 <br /> FED HAZARD CATEGORIES 216 <br /> (Check afl that apply) M a. FIRE ❑b. REACTIVE ® c.PRESSURE RELEASE ®d. ACUTE HEALTH ® e. CHRONIC HEALTH <br /> AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 1 ANNUAL WASTE AMOUNT 215 STATE WASTE CODE 220 <br /> 5,000 10,000 <br /> UNITS" a.GALLONS Elb. CUBIC FEET 0c.POUNDS El d, <br /> DAYS ON SITE: 222 d.TONS 366 <br /> Check one item only) *If EHS,amount must be in pounds. <br /> STORAGE <br /> CONTAINER ❑a.ABOVE GROUND TANK ❑e.PLASTICINONMETALLIC DRUM ❑ i,FIBER DRUM ❑m.GLASS BOTTLE ❑ q.RAILCAR <br /> ®b.UNDERGROUND TANK ❑f.CAN E7 j.BAG ❑n. PLASTIC BOTTLE ❑ r.OTHER <br /> ❑c.TANK INSIDE BUILDING ❑g.CARBOY ❑ k.BOX 0 o. TOTE BIN <br /> ❑d. STEEL DRUM ❑h.SILO ❑ I. CYLINDER ❑P. TANK WAGON 223 <br /> STORAGE PRESSURE a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 <br /> STORAGE TEMPERATURE I$I a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑d. CRYOGENIC 225 <br /> %WT HAZARDOUS COMPONENT(For mixture or waste only) EHS CAS# <br /> 1 85-95 226 Petroleum Distillates 227 ❑Yes ❑ No 228 8006-61-9 229 <br /> 2 <4.9 239 Benzene 231 []Yes M No 232 100-14-1 233 <br /> 3 <11 234 Ethanol 235 ❑Yes ® NO 236 6756-1 237 <br /> 4 238 239 ❑Yes ❑ NO 240 <br /> 241 <br /> 5 242 243 ❑ Yes ❑ NO 240 <br /> 245 <br /> i1. <br /> If marea haza`ordous components are present at greater than 1%by weight If non-carcinogenic,or 0.1%by weight If carcinogenic,attach additional sheets of paper capturing the required <br /> r <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION 246 <br /> If EPCRA,Please Sign Here <br /> Li(1199) OES Form 2731 <br />