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UNIFIED 900GRAM CONSOLIDATED FOM <br /> HAZARDOUS MATERIALS <br /> HAZARDOUS MATERIALS INVENTORY-CHEMICAL DESCRIPTION <br /> one a e er material get buildin or azea) <br /> ®ADD ❑DELETE ❑REVISE 200 Page 1 5 1 of 1 8 <br /> I. FACILITY INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA—Doing Business As) 3 <br /> Chevron Station#209167 <br /> CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 <br /> Car Wash Building ❑ YES ® NO <br /> 1 MAP#(optional) 203 GRID#(optional) 204 <br /> FACILITY ID# <br /> II. CHEMICAL INFORMATION <br /> CHEMICAL NAME 205 TRADE SECRET ❑ Yes ® No 206 <br /> ECOLAB: Blue Coral Velocity Clear Coat Protectant If Subject to EPCRA,refer to instructions <br /> COMMON NAME 207 208 <br /> Carwash Maintenance product EHS* ❑ Yes ® No <br /> CAS# 209 <br /> Mixture *If EHS is"Yes",all amounts below must be in lbs. <br /> FIRE CODE HAZARD CLASSES(Complete if required by CUPA) 210 <br /> N/A <br /> 213 <br /> HAZARDOUS MATERIAL 211 RADIOACTIVE ❑Yes ®No 212 CURIES <br /> TYPE(Check one item only) ❑a.PURE ®b.MIXTURE ❑c.WASTE <br /> PHYSICAL STATE 215 <br /> Check one item only) 214 LARGEST CONTAINER 15 <br /> ( y) ❑ a.SOLID ®b. LIQUID ❑ c.GAS <br /> FED HAZARD CATEGORIES 216 <br /> (Check all that apply) ® a. FIRE ❑b. REACTIVE ❑ c.PRESSURE RELEASE ®d. ACUTE HEALTH ❑ e. CHRONIC HEALTH <br /> AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 21a ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 <br /> 15 30 <br /> UNITS* ®a.GALLONS ❑b. CUBIC FEET El c. <br /> DAYS ON SITE: 222 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.PLASTICNONMETALLIC DRUM ❑ i.FIBER DRUM ❑m.GLASS BOTTLE ❑ q.RAILCAR <br /> ❑b.UNDERGROUND TANK ❑f CAN ❑ i.BAG ❑n. PLASTIC BOTTLE ❑ r.OTHER <br /> ❑c.TANK INSIDE BUILDING ❑g.CARBOY ❑ k.BOX ❑o. TOTE BIN <br /> ❑d. STEEL DRUM ❑It.SILO ❑ 1. CYLINDER ❑p. TANK WAGON 223 <br /> STORAGE PRESSURE ® a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 <br /> STORAGE TEMPERATURE S a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑d. CRYOGENIC 225 <br /> %WT HAZARDOUS COMPONENT(For mixture or waste only) EHS CAS# <br /> 1 4% 226 2-butoxyethanol 227 ❑Yes N No 228 111-76-2 229 <br /> 2 5-20% 23o distillates(petroleum),hydrotreated middle 231 ❑Yes ® No 232 64742-46-7 233 <br /> 3 5-20% 234 quaternary ammonium compounds,dicoco 235 <br /> alkyldimethyl,chlorides ❑Yes ® No 236 61789-77-3 237 <br /> 4 1-5% 238 amines,tallow alkyl,ethoxylated 239 ❑Yes ® No 24o 61791-28-2 241 <br /> 5 1-5% 242 proprietary 243 ❑Yes Z No 244 NJTSRN 245 <br /> If more hazardous 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 information. <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION 246 <br /> RFC Workbook Section 7-Emergency Response Page 2 of 4 Form#ER-1 Revision'Date: January 2007 <br />