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UNIFIED PROGRAM CONSOLIDATED FORM HAZARDOUS MATERIALS <br /> HAZARDOUS MATERIALS INVENTORY _ CHEMICAL DESCRIPTION <br /> rial er buildin or area, <br /> []ADD ❑DELETE ❑REVISE zoo Page of <br /> I. FACILITY INFORMATION 3 <br /> BUSINESS NAME(Same as FACILITY NAME or DEA—Doing Business As) <br /> Beacon Station#3492 201 CHEMICAL LOCATION CONFIDENTIAL 202 <br /> CHEMICAL LOCATION EPCRA <br /> ❑ YES ® NO zoo <br /> 1 MAP#(optional) 203 GRID#(optional) <br /> FACILITY ID# <br /> II. CHEMICAL INFORMATION - 206 <br /> 205 TRADE SECRET ❑ Yes ® No <br /> CHEMICAL NAME <br /> If Subject to EPCRA.refer to instructions <br /> Carbon Dioxide 207 208 <br /> COMMON NAME EHS' ❑ Yes ® No <br /> CO2 <br /> CAS# 209 'If EHS is"Yes",all amounts below must be in lbs. <br /> 124-38-9 210 <br /> FIRE CODE HAZARD CLASSES(Complete if required by CUPA) <br /> 2-NFLG/121 213 <br /> HAZARDOUS MATERIAL 211 RADIOACTIVE ❑Yes ®No 212 CURIES <br /> TYPE(Check one item only) ®a.PURE ❑b.MIXTURE ❑c.WASTE 215 <br /> PHYSICAL STATE 214 LARGEST CONTAINER <br /> (Check one item only) ❑a.SOLID ❑It. LIQUID ® c.GAS 216 <br /> FED HAZARD CATEGORIES <br /> (Check all that apply) ❑ a. FIRE ❑b. REACTIVE ® c.PRESSURE RELEASE ❑d. ACUTE HEALTH ❑ e. CHRONIC HEALTH <br /> AVERAGE DAILY AMOUNT 217 MAXIMUM GAILY AMOUNT <br /> 219 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 <br /> 221 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 cunds. <br /> STORAGE <br /> CONTAINER [I a.ABOVE GROUND TANK ❑e.PLASTIC/NONMETALLIC DRUM ❑ t.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 223 <br /> ❑d. STEEL DRUM ❑h.SILO ® I. CYLINDER ❑p. TANK WAGON <br /> 229 <br /> STORAGE PRESSURE ❑ a. AMBIENT ® b. ABOVEAMBIENT [Ic. BELOWAMBIENT <br /> STORAGE TEMPERATURE ®a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑d. CRYOGENIC <br /> 225 <br /> o/aWT HAZARDOUS COMPONENT(For miMure or waste only) <br /> EHS CAS# <br /> 100 226 Carbon Dioxide 227 ❑Yes ® No 229 124-38-9 229 <br /> t <br /> 231 [1Yes [INo 232 233 <br /> Z 230 <br /> 235 C1Yes ElNo 236 237 <br /> 3 234 <br /> 239 [1Yes ElNo 240 241 <br /> 4 239 <br /> 243 ❑Yes [INo 244 245 <br /> 5 242 <br /> H more hazardous components are present at greater than 1°h by weight It non<arcinogenic,ar 0.1 b by weight if carcinogenic,attach additional sheets of paper capturing Ne requiretl <br /> 246 <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION <br /> For Soda Fountain Sales <br /> If EPCRA, Please Sign Here <br /> OCS FoiIn 273. <br /> UPCF(1199) <br />