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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS MATERIALS <br /> HAZARDOUS MATERIALS INVENTORY- CHEMICAL DESCRIPTION <br /> • one a e get material Eer building or area <br /> ❑ADD ❑DELETE ®REVISE 200 Page 1 4 1 of <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 /> Inside Store ❑ YES ® NO <br /> MAP#(optional) 203 GRID#(optional) 204 <br /> FACILITY ID# � <br /> II. CHEMICAL INFORMATION <br /> CHEMICAL NAME 205 TRADE SECRET ❑ Yes ® No 206 <br /> Carbon Dioxide If Subject to EPCRA,refer to instructions <br /> COMMON NAME 207 208 <br /> EHS* ❑ Yes ® No <br /> Carbon Dioxide CO2 <br /> CAS# 209 <br /> *If EHS is"Yes",all amounts below must be in lbs. <br /> 124-38-9 <br /> FIRE CODE HAZARD CLASSES(Complete if required by CUPA) 210 <br /> Compressed Gas Class 2.2 <br /> 213 <br /> HAZARDOUS MATERIAL 211 RADIOACTIVE ElYes ®No 2127 CURIES <br /> TYPE(Check one item only) ®a.PURE ❑b.MIXTURE ❑c.WASTE <br /> 215 <br /> PHYSICAL STATE 214 LARGEST CONTAINER 2429 <br /> (Check one item only) ❑ 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 1 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 <br /> 1215 2429 <br /> 221 DAYS ON SITE: 222 <br /> UNITS* Ela.GALLONS ®b. CUBIC FEET El c.POUNDS El 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 ❑m.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 ❑ 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 /> 1 100% 226 Carbon Dioxide 227 ❑Yes ® No 228 124-38-9 229 <br /> 2 230 e 231 ❑Yes ❑ NO 232 233 <br /> 3 234 235 ❑Yes ❑ No 236 237 <br /> 4 238 239 ❑Yes ❑ NO 240 241 <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 DOT HAZARD CLASS#1013 246 <br /> If EPCRA,Please Sign Here <br /> UPCF Rev.(12/2007) <br />