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UNIFIED GRAM CONSOLIDATED FWRM <br /> HAZARDOUS MATERIALS <br /> HAZARDOUS MATERIALS INVENTORY- CHEMICAL DESCRWTION <br /> one pge er material Let bu=or area <br /> ®ADD ❑DELETE ❑REVISE 200 Page ( 1 of 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 Buildin ❑ YES ® NO <br /> MAP#(optional) _ 203 GRID#(optional) 204 <br /> FACILITY ID# <br /> [11M 1 <br /> II. CHEMICAL INFORMATION <br /> CHEMICAL NAME 205 TRADE SECRET ❑ Yes ® No 206 <br /> Westle s SS Foam Brush Soap Triple Conditioner—Blue—Red-Yellow If Subject toEPCFA,refer to instructions <br /> COMMON NAME 207 208 <br /> Carwash Cleaning 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 /> 215 <br /> PHYSICAL STATE <br /> (Check one item only) ❑ a.SOLID ®b. LIQUID El c.GAS 214 LARGEST CONTAINER 30 <br /> FED HAZARD CATEGORIES 216 <br /> (Check all that apply) S a. FIRE ❑b. REACTIVE ❑ c.PRESSURE RELEASE 10 d. ACUTE HEALTH ❑ e. CHRONIC HEALTH <br /> AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 <br /> 30 60 <br /> 221 DAYS ON SITE: 222 <br /> UNITS` ®a.GALLONS ❑b. CUBIC FEET El c.POUNDS ❑d.TONS DA <br /> Check one item only) •If EHS,amount must be in pounds. 365 <br /> STORAGE <br /> CONTAINER ❑a.ABOVE GROUND TANK ®e.PLASTIC/NONMETALLIC DRUM ❑ i.FIBER DRUM ❑m.GLASS BOTTLE ❑ q.RAILCAR <br /> ❑b.UNDERGROUND TANK ❑f CAN ❑ j.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 ®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 ® No 228 111-76-2 229 <br /> 2 5-20% 230 Sulfonic acids,c14-16-alkane hydroxyl and c14-16- 231 ❑Yes ® No 232 68439-57-6 233 <br /> alkene, sodium salts <br /> 3 1-5% 234 Imidazoliumcompounds,l-[2-(2-carboxyethoxy)ethyll-1(or3)-(2- 235 68604-71-7 <br /> carboxyethyl)-4,5-dihydro-2-norcoco alkyl,hydroxides,disodium salts Yes ® No 236 237 <br /> 4 1-5% 238 d-glucopyranose,oligomeric,c10-16-alkyl 239 <br /> ❑Yes ® No zao 110615-47-9 241 <br /> glycosides <br /> 5 242 243 ❑Yes ❑ No 244 245 <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 /> If EPCRA,Please Sign Here <br /> RFC Workbook Section 7-Emergency Response Page 3 of 4 Form#ER-1 Revision Date: January 2007 <br />