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ACUTELY (EXTREMELY) <br /> HAZARDOUS MATERIALS <br /> REGISTRATION FORM <br /> Environmental Health Harvie., <br /> THIS FORM MUST BE COMPLETED BY THE OWNER OR OPERATOR OF EACH BUSINESS IN ANY <br /> COUNTY WHICH, AT ANY TIME HANDLES ACUTELY HAZARDOUS MATERIAL. SUBMIT THIS <br /> FORM TO ENVIRONMENTAL HEALTH SERVICES. <br /> Business Name: USA Petroleum Gasoline Station # 65 <br /> Business Address: 2500 LODI LODI CA. 96001 <br /> Business Mailing Address (if different) : 30101 AGOURA CT. <br /> SUITE 200 <br /> AGRORA HILL CA. 96001 <br /> Business Phone: 909 .622 .3424 <br /> ACUTELY HAZARDOUS MATERIALS HANDLED IN QUANTITIES EQUAL TO OR GREATER TAN THE <br /> LISTED TRESHOLD PLANNING QUANTITIES (TPQ'S) (SEE ATTACHED LIST) . (EACH MUST <br /> ALSO BE ENTERED ON A BUSINESS PLAN INVENTORY) <br /> CHEMICAL NAME MAXIMUM QUANTITY ON SITE <br /> AT ANY ONE TIME (in <br /> lbs. ) * <br /> Gasoline CAS# 8006.61 .9 12 , 000 gal <br /> Gasoline CAS# 8006 .61 .9 12 , 000 gal <br /> Gasoline CAS# 8006. 61 .9 12 , 000 gal <br /> D4:eae1 CAS# 6847{;34_a-6 8�09fr gni <br /> •ter mixture,, report only the AHX chemical portion of the mixt.re. <br /> I certify under penalty of law that the information on this form is true and <br /> accurately reflects the quantities of acutely hazardous materials handled by <br /> this business . <br /> this form must be signed by the owner or operator. <br /> Signature: Date <br /> Print or tVAe name: David Oldfield Title: Project Coordinator <br /> GENERAL DESCRIPTION OF HOW THE CHEMICAL IS USED OR PROCESSED AT YOUR BUSINESS <br /> AND THE PRINCIPAL EQUIPMENT USED IN THAT PROCESS (FOR THE CHEMICALS IN <br /> QUANTITIES GREATER THAN TPO'S ) NOTE: DO NOT INCLUDE TRADE SECRET <br /> INFORMATION. <br /> 14 <br />