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UNIFIED PROGRAM CONSOLIDATED fWRM <br /> HAZARDOUS MATERIALS <br /> HAZARDOUS MATERIALS INVENTORY- CHEMICAL DESCRIPTION <br /> one a r material ger buildin or area <br /> e <br /> ZADD ❑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 Z NO <br /> FACILITY ID# ` 1 MAP#(optional) 203 GRID#(optional) 204 <br /> II. CHEMICAL INFORMATION <br /> CHEMICAL NAME 205 TRADE SECRET ❑ Yes Z No 206 <br /> ECOLAB: MA-3 Shampoo If Subject to EPCRA,refer to instructions <br /> COMMON NAME 207 201 <br /> ❑ <br /> Carwash Cleaning Product EHS* Yes Z 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 /> HAZARDOUS MATERIAL 213 <br /> TYPE(Check one item only) Ela.PURE Z b.MIXTURE ❑c.WASTE 21 t RADIOACTIVE ❑Yes ®No 212 CURIES <br /> PHYSICAL STATE 215 <br /> (Check one item only) Ela.SOLID ®b. LIQUID [Ic.GAS 214 LARGEST CONTAINER 30 <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 211 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 <br /> 30 60 <br /> 221 DAYS ON SITE: 222 <br /> UNITS* ®a.GALLONS ❑b. CUBIC FEET ❑ c.POUNDS [Id.TONS 365 <br /> Check one item only) *If EHS,amount must be in pounds. <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 ❑ i.BAG ❑n. PLASTIC BOTTLE ❑ r.OTHER <br /> ❑c.TANK INSIDE BUILDING ❑g.CARBOY ❑ k.BOX ❑o. TOTE BIN <br /> ❑d. STEEL DRUM ❑h.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 14% 226 Sodium dodecylbenzene sulfonate 227 ❑Yes Z No 221 25155-30-0 229 <br /> 2 1-5% 230 Poly(oxy-1,2-ethanediyl), .alpha.-sulfo,omega.- 231 <br /> hydroxy-,c10-16-alkyl ethers,sodium salts ❑Yes ® No 23z 68439-46-3 233 <br /> 237 <br /> 241 <br /> 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 4 of 4 Form#ER-1 Revision Date: January 2007 <br />