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�- Non-Waste Hazardous Materials Inventory Statement <br /> Date: % For use by Unidocs Member Agencies or where approved by your Local Jurisdiction <br /> Business Name: , Type of Report on This Page: Page Of <br /> (Same as Facility Name) i'-v'� �' El Add; ❑Delete; evise g <br /> (One page per building or area) <br /> Chemical Location: EPCRA Confidential Location? ❑Yes; ❑No Facility ID# <br /> (BaBaiagistarage Area) Trade Secret Information? ❑Yes; ❑No (Agency Use or[).) ' <br /> 1. 2. 3. 4. 5. 6. 7. 8. 9. <br /> Map and Hazardous Components Type Quantities <br /> Grid or 3 Storage Codes <br /> (For mixtures only) and <br /> Haz. Location Chemical % Physical Max. Average Largest Storage Storage Hazard <br /> Class Code Common Name Name Wt. EHS CAS No. State Dail Dail Cont. Units Pressure Temp. Cate o <br /> isk <br /> ❑ ❑pure -allows ,ambient bieat •' <br /> ® ❑MixtureU pounds U>amb. U>amb. >L]: <br /> �� ❑ [�solid pries: Days On St ra e ❑�.feet ❑.amb. ❑.arab. ❑pressure release <br /> CAS No, ❑Egg itgtid (Ifadioactive) Lite'. Container:* ❑tons 13cryogenic Elacute health <br /> ® gas ❑chronic health <br /> ❑radioactive <br /> I <br /> ptite Mons bient ��'' ambient fire <br /> ❑ ❑Mixture ❑pounds ❑>arab. ❑>amb. @-. active <br /> ❑ Elsolid Coriv: flava On Sto e ❑un•�t ❑<amb. ❑.arab. ❑pressure release <br /> I <br /> CAS No. ❑EHS ® Q-r;�d (If radioactive) Lite: Contain. ❑tons ❑cryogenic F1 acute health <br /> ® p'❑'®'gas72.hrrmi.health <br /> ❑radioactive <br /> ❑ ❑pureallons ambient 0:arnbient ❑fire <br /> ❑ ❑Mixture ❑pounds ❑-ab. ❑>amb. �teactive <br /> � ❑ ❑solid Curies: Days On Storaee ❑or.feet ❑<amb. ❑<amb. ❑pressttrerelease <br /> El EHS (rfadi-cti e) Site: Container:* ❑tons <br /> CM No': ® mid ❑cryogenic acute health <br /> ® gas - <br /> [I chronic health <br /> 13radioaMive <br /> ® ❑pure .gatlons e�;ambieatsambient ❑fire <br /> ❑ ❑' �� <br /> 13poundsEl>amb. ❑>amb. eacfive <br /> �. <br /> �� ❑ ❑Solid Curies: Das On St. ounce ❑ca,fit ❑.arab. ❑.arab. ❑pressure e <br /> CAS No.: ❑EHS ® i4uid of adi.wi-) Site: Container.^ ❑tons 13 cryogenic Acute <br /> ❑ e❑— gas ❑chrome <br /> ❑redicacfive <br /> ❑ ❑pure Qagallons � mbientambient ❑fire <br /> ❑ ❑IfllxhwE t3pounds E]>amb. ❑>amb. 'reactive <br /> a. ❑ ❑solid Earles: Drava On Storaee ❑ feet ❑<mub. ❑<amb. `❑pressme release <br /> CAS No.: ❑EHS ® (4 J`cquld (Ifndi-ctirv.) Site: Container.* ❑tons ❑cryogenic � to health <br /> 6�❑gaschronic health <br /> � �®> ❑ ❑radioactive <br /> °7 ❑ pure allows biem •-ambient ❑fire <br /> ❑ ❑IDlxttire ❑pounds ❑>amb. ❑>amb.70 "reactive <br /> J ❑ ❑solidCarler: Drava On Storaee ❑ .feet ❑<amb. ❑<aub. pressure release <br /> AS No. ❑EHS ❑ quid (iraaioaaive) Site: Contetner.* ❑tows ❑7+tic ❑acute health' <br /> �• ❑chrome he Ith <br /> gas❑ -a.� : radraactrve <br /> # Code Storaee Twe Code Storage Type C e Storaee Tvoe Coe Storaee Twe Code Storage Tvoa ode Storaee Tvoe If EPCRA,sign below <br /> A Aboveground Tank D Steel Dram G Carboy J Bag M Glass Bottle or lug P Tank Wagon <br /> B Beloveground Tank E Plastic/Non-metallic Dttun H Silo K Box N Plastic Bottle or lug Q Rail Car <br /> C Tank Inside Building F Cev I Fiber Drum L Cylinder O Tote Bin R Other <br /> UN-020-7/17 www.unidoes.org Rev.07/24/06 <br />