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i <br /> UNIFIE PROGRAM CONSOLIDATE FORM <br /> HAZARDOUS MATERIALS <br /> HAZARDOUS MATERIALS INVENTORY- CHEMICAL DESCRIPTION <br /> one paie Eer materialLet u ng or area <br /> [-]ADD ❑DELETE ®REVISE 200 Page 1 2 1 of 4 <br /> I. FACILITY INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA—Doing Business As) 3 <br /> Chevron Station#96171 <br /> CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 <br /> ❑ YES Z NO <br /> FACILITY ID# MAP#(optional) 7UR—�ptional) 204 <br /> �� <br /> 1 <br /> II. CHEMICAL INFORMATION <br /> CHEMICAL NAME 205 TRADE SECRET ® Yes ❑ No 206 <br /> Petroleum Hydrocarbons If subject to EPCRA,refer to instructions <br /> COMMON NAME 207 los <br /> EHS* El Yes ® No <br /> Regular Unleaded Gasoline 87 Octane <br /> CAS# 209 <br /> *If EHS is"Yes",all amounts below must be in lbs. <br /> 86290-81-5 <br /> FIRE CODE HAZARD CLASSES(Complete if required by CUPA) 210 <br /> Flammable Liquids Class 3 <br /> 213 <br /> HAZARDOUS MATERIAL 211 RADIOACTIVE ElYes ®No 212 FCURIES <br /> TYPE(Check one item only) ❑a.PURE Z b.MIXTURE ❑c.WASTE <br /> 215 <br /> PHYSICAL STATE 214 LARGEST CONTAINER 20,000 <br /> (Check one item only) ❑ a.SOLID Z 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 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 <br /> 10,000 20,000 <br /> 221 DAYS ON SITE: 222 <br /> UNITS* ®a.GALLONS ❑b. CUBIC FEET El 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.PLASTIC/NONMETALLIC DRUM ❑ i.FIBER DRUM ❑In.GLASS BOTTLE ❑ q.RAILCAR <br /> ®b.UNDERGROUND TANK ❑f CAN ❑ j.BAG [In. 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 Z a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 <br /> STORAGE TEMPERATURE Z a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑d. CRYOGENIC 225 <br /> %WT HAZARDOUS COMPONENT(For mixture or waste only) EHS CAS# <br /> 1 100% 226 Gasoline 227 ❑Yes Z No 228 86290-81-5 229 <br /> 2 .1-4.9% 230 Benzene 231 ❑Yes Z No 232 71-43-2 233 <br /> 3 .1-3% 234 Ethyl Benzene 235 ❑Yes Z No 236 100-41-4 237 <br /> 4 .1-2% 238 Naphthalene 239 ❑Yes Z No 240 91-20-3 241 <br /> 5 0-10% 242 Ethanol 243 ❑Yes Z No 244 64-17-5 245 <br /> 6 0-15% 246 Methyl Tert Butyl Ether(MTBE) 247 ❑Yes Z No 248 1634-04-4 249 <br /> 7 0-17% 250 Tertiary Amyl Methyl Ether(TAME) 251 ❑Yes Z No 252 994-05-8 253 <br /> 8 0-18% 254 Ethyl Tert-Butyl Ether(ETBE) 255 ❑Yes Z No 256 637-92-3 257 <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 DOT HAZARD CLASS#1203 246 <br /> If EPCRA,Please Sign Here <br /> UPCF Rev.(12/2007) <br />