HomeMy WebLinkAboutSLOUNIFLOW_FS1 Admin iRC3926i Color_0175_001_Redacted.ge,
FORM S - SAN OBISFO COUNTY CERTIFIED AGENCY
BUSINESS OWNER/OPERATOR IDENTIFICATION (trw dBtcr
1 I. IDENTIFICATION
FACILITY ID#I 100BEGINNING DATE
January 2009
ENDING DATE
January 2010
101
BUSINESS NAME (Sme as TACILITY NAME or DBA - Doing Business As)
United Parcel Service
3 to2BUSINESS PHONE
(8Os) s44-7r84
BUSINESS SITE ADDRESS
3601 Sacramento Drive
103
104CITY
San Luis CA
ZIP CODE 105
93401
DUN & BRADSTREET
oo-686-5927
106 t0'tSIC CODE (4 disit #)
4789
COUNTY
San Luis Obispo
108
109
Mark Schilling
BUSINESS OPERATOR NAME 110BUSINESS OPERATOR PHONE
(80s) s44-7t84
tr. BUSINESS OWNER
OWNER NAME
United Parcel Service
lll l12OWNER PHONE
(2t3) 6t2-t890
OWNER MAILING ADDRESS
lzE West Olympic Blvd
n4
Los Angeles
CITY 115STATE
CA
116ZIP CODE
90015
M. ENVIRONMENTAL CONTACT
tI7
Hamilton
CONTACT NAME 118CONTACT PHONE
(2r3) 6r2-t890
ll9
1201 West Olympic Blvd
CONTACT MAILING ADDRESS
Los Angeles
CITY 120 t2tSTATE
CA
122ZIP CODE
9001s
IV. EMERGENCY CONTACTS -SECONDARy--PRIMARY-
Mark schilling
NAME t23
Randy Hughlett
t28NAME
Center Manager
124TITLE 129TITLE
Supervisor
BUSINESS PHONE
(80s) s44-7r84
125 BUSINESS PHONE
(818) 947-4831
130
z4-HOUR PHONE
P
N/A
CELL PHONE #
13124-HOUR PHONE
N/A
#
ADDITIONAL LOCALLY COLLECTED INFORMATION:133
Certification: Based on my inquiry of those individuals responsible for obtaining the information, I certit, under penalty of law that I have personally eiaminea .and
informaln submitted and believe the information is true, accurate, and completeam familiar with the
TURE OFOWNER/OPMATOR
hrunn.'
OR DESIGNATED REPRESENTATIVESIGNA 134DATE
02t24t2009
135NAME OF DOCUMENT PREPARER
Klotonva Hamilton
NAME
S,IGNER
(nrint)
Nick Moldovan
136
District Plant Engineering Manager
TITLE OF SIGNER 137
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Chemical
InventorJ)
Forms
San Luis obispo County l)"u.oo,r, *"rJl"ffi;ntory Form lrr".ni.ul Description Page
(1)l-lnoo floelere X Revtse PAGE (2)oF (3)
United Parcel ServiceBUSINESS NAME:
cHEMTCAL LOCATTON (4)
MAP # (5)GRrD # (6)
CHEMICAL LOCATION IS CONFIDENTIAL AND NOT SUBJECT TO PUBLIC DISCLOSURE
1
CHEMICAL NAME (7)
coMMoN NAME (8)
cAs # (e)
TYPE (12)
PHYSTCAL STATE (13)
HAZARD CATEGORIES (16)
STATE WASTE CODE (17)
DAYS ON SITE (18)
LARGEST CONTAINER (19)
SToRAGE CONTATNER (24)
STORAGE PRESSURE (25)
SToRAGE TEMPERATU RE (26)
ZT
50
%wT
ETHYLENE GLYCOL + OTHER GLYCOLS TRADE SECRET (10)
EHS (11)
N/A
N/AWASTE ANTIFREEZE
10721'l
l-lpune l-lurxrune Xwnsre
Esolro Xltouto ncns
UNrTS (20)
365 lf EHS amounts must be in lb.
55 oal
RADTOACTTVE (14)(1 5)
FIRE REACTIVE PRESSURE RELEASE HEALTH EcHnorutc HEALTH
l-lv Xr.r
MAX DA|LY AMT (21)
AVG DAILY AMT (22)
ANNUAL WASTE AMT (23)
IF EHS BOX IS "Y'
ALL AMOUNTS MUST BE IN LBS
pCURIES
55 qal
20
55
BIENT AMBIENT BELOW AMBIENT
AMBIENT AMBIENT LOW AMBIENT NIC
1
2
3
4
5
S COMPONENT
ETHYLENE GLYCOL
EHS
llv Xll
l-lv ll r.t
Ev Et't
llv nrl
Ev nru
CAS NUMBER3U
107211
CU FT
TONS
GROUND TANK WAGON
BELOW GROUND TANK ncvlrxoen
ncmss BorrLE
flnnt cnn
[rnrux rNsrDE BUTLDTNG
Xsreel onuv nneen onuNi BOTTLE
PLASTIC/NONMETALLIC DRUM BIN
(31) ADDITIONAL LOCALLY COLLECTED INFORMATION
q .,-ru--
Adapted frorn OES Fonn 2730 02/24109 O :\document!poel\forms\wastanti.doc
-) FORMI _ .)
San Luis Obispo County ,..izardous Material Inventory Form - .,hemical Description Page
(1)Enoo loelere Xnevtse PAGE (2)oF (3)
BUSINESS NAME:
cHEMTCAL LOCATION (4)
MAP # (5)
United Parcel Service
GRrD # (6)K11
CHEMICAL LOCATION IS CONFIDENTIAL AND NOT SUBJECT TO PUBLIC DISCLOSURE .,/
1
cHEMICAL NAME (7)
COMMON NAME (B)
cAS # (e)
TYPE (12)
PHYSTCAL STATE (13)
HMARD CATEGORIES (16)
STATE WASTE CODE (17)
DAYS ON S|TE (18)
LARGEST CONTAINER (19)
SToMGE CONTAINER (24)
SToRAGE PRESSURE (25)
SToRAGE TEMPERATURE (26)
PETROLEUM HYDROCARBON
DIESEL FUEL
68476-34-6
f-lsolro Xlrouro l-lcns
TRADE SECRET (10)
EHS (11)
nv Xx
N
RADTOACTTVE (14)(15)
RE RE RELEASE HEALTH RONIC HEALTH
uNrrs (20)
Xcnl ncu rr
llr-as lroNs
365 lf EHS amounts must be in lb.
'12000
IENT AMBIENT ELOW AMBIENT
NT AMBIENT BELOW AMBIENT
llv XN
MAX DAILY AMT (21)
AVG DA|LY AMT (22)
ANNUAL WASTE AMT (23)
IF EHS BOX IS "Y"
ALLAMOUNTS MUST BE IN LBS
pCURIES
I 0800
550
N/A
o/oWIZT
99.5%
05%
1
2
J
4
5
S COMPONENT
DIESEL FUEL
NAPHTHALENE
PETROLEUM DISTILLATES
EHSzv
NY XN
nv Xru
l-lv Xrl
l-lY l-lr.t
!v Ett
CAS NUMBER
GROUND TANK WAGON
Xeelow cRouND TANK
f]rnrux TNSTDE BUILDTNG
nsrEel oRuu
ncnneov INDER L CAR
!stlo
!rraeR onuM
ncmss BorrLE
BOTTLE
PLASTIC/NONMETALLIC DRU M BIN
68476.34-6
91-20-3
NONE
(31) ADDITIONAL LOCALLY COLLECTED INFORMATION
rd
Adapted flom OES Fonn 2730 02/24/09 O :\docurnent\jpoel\forms\diesel.doc
.') FORMI -1
San Luis Obispo County uizardous Material Inventory Form - vhemical Description Page
(1)DELETE REVISE PAGE (2)oF (3)
BUSINESS NAME: United Parcel Service
cHEMTCAL LOCATION (4
MAP # (5)GR|D # (6)t5
CHEMICAL LOCATION IS CONF IDENTIAL AND NOT SUBJECT TO PUBLIC DISCLOSURE
cHEMICAL NAME (7)
coMMoN NAME (B)
cAS # (9)
TYPE (12)
PHYSICAL STATE (13)
HAZARD CATEGORIES (16)
STATE WASTE CODE (17)
DAYS ON SITE (18)
LARGEST CONTAINER (19)
STORAGE CONTAINER (24)
SToRAGE PRESSURE (25)
SToRAGE TEMPERATURE (26)
PETROLEUM HYDROCARBON TRADE SECRET (10)
EHS (11)
N/A
N/AWASTE OIL/OIL FILTERS
N/A
PURE
l-lsolro Xlrouro l-lcns RADTOACTTVE (14)
Xonr- ncu rr
l-lms llrorus MAX DA|LY AMT (21)
AVG DA|LY AMr Q2)
ANNUAL WASTE AMT (23)
IF EHS BOX IS "Y"
ALL AMOUNTS MUST BE IN LBS
pCURIES
110
55
1 500
EY Xlt (1 5)
rng nRERcrve RELEAsE XncurE HEALTH CHRONIC HEALTH
221
365
110
uNrrs (20)
lf EHS amounts must be in lb.
NT AMBIENT AMBIENT
NT AMBIENT AMBIENT RYOGENIC
1
2
3
4
5
HAZARDOUS
PETROLEUM HYDROCARBON
EHSZY
l-lY Xru
nv !u
l-lv [-lt't
nY !N
Iv nru
CAS NUMBER
GROUND TANK CAN WAGON
nerlow GRoUND TANK
Ernur TNSTDE BUTLDTNG
ncnnsov
nsto
R Ennt cnn
BOTTLE
L DRUM DRUM npusrtc BorrLE
METALLIC DRUM BIN
100
(31) ADDTTIONAL LOCALLY COLLECTED INFORMATION
w\7 4q
ST
Adapted frorn OES Form2730 02124/09 O:\document\poel\fonns\wastanti.doc
BUSINESSOWNER/OPERAT0RIDENTIFICATION
AGENCY
APR 27 2iit,4
FORMS_SANLUIS COT]NTY CERTIFIED UNIFIED
I. IDENTIFICATION
101ENDING DATE
2005
100BEGINNING DATE
J 2004FACILITY ID#
fflt<>
544-7r84(8
3
(Sme s FACILITY NAME or DBA - Doing Businss As)
United Parcel Service 103
3601 Sacramento Drive
SITE
CA
7-IP CODE
93401
San Luis
CITY
SIC CODE (4 digit #)
4789
106
00-686-5927
DLTN &
COUNTY
San Luis BUSINESS OPERATOR
$os) s44-7184
110
Neil McClelland
S OPERATORNAME
II. BUSINESS OWNER
I 612-1890
OWNERPHONElll
OWNER NAME
United Parcel Service
Blvd
ADDRESSOWNER
1201West
90015
ZIPll5ST
CA
il4
Los
IU. ENVIRONMENTAL CONTACT
490-3065
Gabriel A. Peredo
NAME
1l
Blvd1201West
ACT
90015
NPSTATE
CALos
EMERGENCY CONTACTS -SECONDARY--PRIMARY-IV
NAME123
Neil McClelland
NAME
TITLE
Center
544-7184s44-7184
BUSINESS
24.HOURPHONE126
PHONE
N/A
132
N/A
# I CELL
ADDITIONAL LOCALLY COLLECTED INFORMATION:
that I havepenalty of andcertifuobtainingonlnqurrymyandcomplete.ls accurate,fiue,informationbelieveandthesubmittedthewithinformationfamiliaram 135OF
Gabriel A. Peredo
t34TE
04122104
District Plant
OF
NickMoldovan
OF (print)
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E* *l/Page--i- of-11-
1 FORMS-SAN LUr.-COT]NTY CERTIF'IED TINIF'IED -AGENCY
O'1/BUSINESS OWNERiOPERATOR IDENTIFICATION FEB 1 8 200b
L,/ LtaPage I Of_ /_
U?Dnr€ or$LIDENTIFICATIONI
100BEGINNING DATE
Janrary 2004
l0rENDING DATE
J 2005
FACILITY ID#4glo
102BUSINESS PHONE
(805) 544-7184
BUSINESS NAME (Sme m nACILITY NAME or DBA - Doing Business As)
United Parcel Service
3
BUSINESS SITE ADDRESS
3601 Sacramento Drive
103
CA
t05ZIP CODE
93401San Luis Obispo
104CITY
107SIC CODE (4 digit #)
4789
DUN & BRADSTREET
00-686-s927
106
San Luis Obispo
r08COUNTY
il0BUSINESS OPERATOR PHONE
(80s) s44-7r84
BUSINESS OPERATOR NAME
Neil McClelland
109
il. BUSINESS OWNER
r12OWNER PHONE
(2r3) 612-1890
OWNER NAME
United Parcel Service
lll
OWNER MAILING ADDRESS
1201 West Olympic
113
Blvd
115STATE
CA
I l6ZIP CODE
90015
114
Los Angeles
CITY
ilI. EIWIRONMENTAL CONTACT
118CONTACT PHONE
(2r3) 612-1890
CONTACT NAME
Klotonya Hamilton
1t'?
119
1201 West Olympic Blvd
CONTACT MAILING ADDRESS
t2lSTATE
CA
122ZIP CODE
90015Los Angeles
CITY
IV. EMERGENCY CONTACTS -SECONDARY--PRIMARY-
128NAME
Gary HutchingsNeil McClelland
r23NAME
t29TITLE
SupervisorCenter Manager
124TITLE
BUSINESS PHONE
(80s) 544-7r84
130
BUSINESS PHONE
(80s) s44-7r84
t25
13124-HOUR PHONE
N/A
t32PAGER#
24-HOU
PAGER # /
N/A
t27
133
ADDITIONAL LOCALLY COLLECTED INFORMATION
Certification: Based on my inquiry ofthose individuals responsible for obtaining the information, I certify under penalty of law that I have personally examined and
am familiar with the information submitted and believe the information is true, accurate, and complete
DATE
02/t7 t2005
134 r35NAME OF DOCUMENT PREPARER
Barbara Boliver
ATIVETOR OR DESIGNA
TITLE OF SIGNER
District Plant Engineering Manager
131*fe OF SIGNER (prinO
Nick Moldovan
t36
loi
lc)
FORMS-SANLUII COUNTY CERTIFIED UNIFIED P,o
BUSINESS OWNER/OPERATOR IDENTIFICATION F[I] ? A ?i.flfi
1
ztttb Llltcti+4 otIDENTIFICATIONI.
FACILITY ID#I 100BEGINNING DATE
January 2005
l0lENDING DATE
January 2006
BUSINESS NAME (Same as raCuTY NAME or DBA - Doing Business As)
United Parcel Service
3 BUSINESS PHONE
(80s) s44-7184
t02
BUSINESS SITE ADDRESS
3601 Sacramento Drive
103
San Luis Obispo
104CITY
CA
t05ZTP CODE
93401
DTJN & BRADSTREET
00-686-5927
106 107SIC CODE (4 digit #)
4789
COUNTY
San Luis Obispo
108
BUSINESS OPERATOR NAME
Neil McClelland
109 lt0BUSINESS OPERATOR PHONE
(80s) s44-7184
I BUSINESS OWNER
OWNERNAME
United Parcel Service
lil 112OWNER PHONE
(2t3) 6t2-r890
OWNER MAILING ADDRESS
1201 West Olympic Blvd
ll3
lr4
Los Angeles
CITY il5STATE
CA
ll6ZIP CODE
90015
III. ENVIRONMENTAL CONTACT
CONTACTNAME
Klotonya Hamilton
117 lt8CONTACT PHONE
(213) 612-1843
CONTACT MAILING ADDRESS
1201 West Olympic Blvd
lt9
Los Angeles
t20CITY 121STATE
CA
t22ZIP CODE
90015
IV. EMERGENCY CONTACTS .SECONDARY--PRIMARY-
Neil McClelland
123NAME
Mike King
128NAME
Center Manager
t24TITLE 129TITLE
Supervisor
BUSINESS PHONE
(805) s44-7184
BUSINESS PHONE
(80s) s44-7184
130
24.HOUR PHONE t26 l3l
N/A
12'7 PAGER#/CELLPHONE#
N/A
132
ADDITIONAL LOCALLY COLLECTED INFORMATION
Based on my inquiry ofthose individuals responsible for obtaining the information, I certify under penalty of law that I
am familiar with the information submitted and believe the information is true, accurate, and complete.
02/22/2006
TED REPRESENT TIVE
NAME OF SICil,IER(print)
Nick Moldovan
136
District Plant Engineering Manager
137TITLE OF SIGNER
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IdAN / I ZULI/I. IDENTIFICATION
100BEGINNING DATE
January 2007
101ENDING DATE
January 2008
FA(ILITY ID#FA /tV to
t02BUSINESS PHONE
(80s) s44-7184
BU@TY NAMEoT DBA - Doing BusinessAs)
United Parcel Service
3
BUSINESS SITE ADDRESS
3601 Sacramento Drive
103
105ZIP CODE
93401San Luis Obispo
104CITY CA
107SIC CODE (4 disit #)
4789
DUN & BRADSTREET
00-686-s927
106
rc CorEz
COUNTY
109ol
San Luis
BUSINESS OPERATOR NAME
{.{ei$ffibffand
BUSINESS OPERATOR PHONE
(805) s44-7t84
il,. v BUsINEss owNER
t2OWNER PHONE
(2t3) 6t2-r890
OWNER NAME
United Parcel Service
1ll
OWNER MAILING ADDRESS
1201 West Olympic Blvd
ll3
115STATE
CA
116ZIP CODE
90015Los Angeles
ll4CITY
il. ENVIRONMENTAL CONTACT
ll8CONTACT NAME
ll9
t3 6t2-t843
CONTACT PHONE
Hamilton
CONTACT MAILING ADDRESS
Blvd1201 West
t2tSTATE
CA
t22ZIP CODE
90015Los Angeles
120CITY
IV. EMERGBNCY CONTACTS -SECONDARy--PRIMARY-
Mike Kins
128NAMENAME
-ltuilAacCHfand
t23
r29TITLE
SupervisorRi "hq!"d C,o
t24TITLE
Center
BUSINESS PHONE
(80s) s44-7184
t30BUSINESS PHONE
(80s) s44-7t84
t25
24-HOUR PHONE
N/A
24.HOUR PHONE
N/A
PAGER
133ADDITIONAL LOCALLY COLLECTED INFORMATION
individuals responsible for obtaining the information, I certify u'nder penalty of law that I have personally examined and
,r *.am familiar with the information submitted and believe the information is true, accurate, and complete.
Certification: Based on my inquiry of those
DATE
02t2U2007
t34 135NAME OF DOCUMENT PREPARER
Klotonva Hamilton
SIGNATURE-OF oynERIOTETETOR OR DESIGNATED REPRESENTATIVEffiVttt-'
TITLE OF SIGNER
District Plant Engineering Area Manager
t3'7NAME OPS16NER (prin0
Nick Moldovan
136
F D SiOL FORMS_SANLL.-COUNTY CERTIFIED UNIFIED }.AGENCY F lLe,,
BUSINESS OWNER/OPERATOR IDENTIFICATION,IaThdI urca*z
?
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Page- of-
FOR.M I
San Luis Obispo County' -)zardous Material Inventory Form - hemical Description Page
(1)nnnp norlrrE nnevrse PAGE (2)tu oF (3)
j4-'t{
-United..P..a.rs..el. -s-erv-r,c-eBUSINESS NAME:
cHEMtCAL LOCATTON (4)
MAP # (s)GR|D # (6)
CHFMI CAL LOCATION IS CONFIDENTIAL AND NOT SUBJECT TO PUBLI C DISCLOSIJRE
1
cHEMTCAL NAME (7)
coMMoN NAME (B)
cAS # (e)
TYPE (12)
PHYSICAL STATE (1s)
HAZARD CATEGORTES (16)
STATE WASTE CODE (17)
DAYS ON SrTE (18)
LARGEST CONTAINER (19)
SToRAGE CONTAINER (24)
SToRAGE PRESSURE (25)
SToRAGE TEMPERATURE (26)
Z( I "lo
99.5%
0.5%
PETROLEUM HYDROCARBON
FUEL
68476"34-6
lpunE fiuxrune nwesre
SOLID
365 lf EHS amounts must be in lb.
TRADD SECRtrT (10)nv XN
EHS (11)nY XN
IF EHS BOX IS "Y"
ALLAMOUNTS MUST BE IN LBS
RADTOACTTVE (14)[]v XN (1s)
Xntnr lnencrve flpnessuRE RELEAsE Xecure HEALTH Xcnnourc HEALTH
UNrTS (20)MAX DATLYAMT (21)
AVG DATLYAMT (22)
ANNUAL WASTE AMT (23)
pCURIES
1 0800
550
N/A12000
1
2
?
4
5
XRNrereNr []lRsove AMBIENT l-lsrlow AMBTENT
IENT AMBIENT BELOW AMBIENT CRYOGENIC
HAZARDOUS COMPONENT
DIESEL FUEL
NAPHTHALENE
PETROLEUM DISTILLATES
GAL
LBS
FT
nroNs
GROUND TANK BOX TANK WAGON
RAIL CARGROUNDTANKflcnnaov
nsro
f]rrseR onuilr
!cvlrruorn
ANK INSIDE BUILDING GLASS BOTTLE
PLASTIC BOTTLE
TOTE BIN
DRUM
ALLIC DRUM
NY XN
f-lv X t't
nv Xru
flv [tt
[lY l-]ru
68476-346
91-20-3
NONE
(31 ) ADDTTTONAL LOCALLY COLLECTED TNFORMATTON
Adapted from OES Form 2730 0_2/.14/0354124D&
O:\document\jpoel\,forms\diesel. doc
FORM I
San Luis Obispo County I' \rdous Material Inventory Form - ' )mical Description Page
DELETE REVISE PAGE (2)oF (3)tC-tt
(1)il
United Parcel ServiceBUSINESS NAME:
cHEMICAL LOCATION (4)
MAP # (s)GR|D # (6)
HEMICAL LOCATION IS CONFIDENTIAL AND NOT SUBJECT TO PUBLIC DISCLOSURE
IJ
CHEMICAL NAME (7)
coMMoN NAME (B)
cAS # (e)
TYPE (12)
PHYSICAL STATE (13)
HAZARD CATEGORIES (16)
STATEWASTE CODE (17)
DAYS ON SITE (18)
LARGEST CONTAINER (19)
STORAGE CONTAINER (24)
SToRAGE PRESSURE (2s)
sroRAGE TEMPERATURE (26)
o,6WT
NE GLYCOL + OTHER GLYCOLS TRADE SECRET (10)
EHS (11)
N/A
WASTE ANTIF
PURE
LIOUID RADTOACTTVE (14)l-lv Xtt (15)
MAX DAILY AMT (21)
AVG DAILY AMT (22)
ANNUAL WASTE AMT (23)
N/A
IF EHS BOX IS'Y"
ALL AMOUNTS MUST BE IN LBS
pCURIES
55
55 qal
FIRE RELEASE HEALTH HEALTH
uNrrs (20)
Xcnr- [curr
Elss Drons
365 lf EHS amounts musl be in lb'
55 oal
BIENT BOVE AMBIENT BELOW AMBIENT
BIENT AMBIENT BELOW AMBIENT RYOGENIC
tt
501
2
3
4
5
HAZARDOUS COM ENT
ETHYLENE GLYCOL
EHS
I_IY XN
flv fltt
I-lv [-]t't
[]v nu
Dv f]tt
CAS NUM
107211
1
GROUND TANK ANK WAGON
flee low cnouNDrANK
[rnrux TNStDE BUILDING
Xsrcrl oRurrl
flcnneov
Istt-o
flcvltruoen
[cr-Rss oonle
flnnu cRn
DRUM PLASTIC BOTTLE
TOTE BINPLASTIC/NONMETALLIC DRUM
(31) ADDITIONAL LOCALLY COLLECTED INFORMATION
Adapted from OES Form 2730 02114/03 O:\document\ poe 1\forms\wastanli doc
(1)DD DELETE REVISE
FORM I
San Luis Obispo County' -)zardous Material Inventory Form - - "'lemical Description Page
PAGE (2)IZ f4oF (3)
United Parcel ServiceBUSINESS NAME:
cHEMTCAL LOCATION (4)
MAP # (5)t5
CHEMICAL LOCATION IS CONFIDENTIAL NOT SUBJECTTO PUBLIC
GRID # (6)
DISCLOSURE
1
cHEMICAL NAME (7)
coMMoN NAME (8)
cAS # (e)
TYPE (12)
PHYSICAL STATE (13)
HAZARD CATEGORIES (16)
STATE WASTE CODE (17)
DAYS ON SITE (18)
LARGEST CONTAINER (19)
SToRAGE CONTAINER (24)
SToRAGE PRESSURE (25)
SToRAGE TEMPERATURE (26)
ETHYLENE GLYCOL + OTHER GLYCOLS TRADE SECRET (10)l*l v X t't
NT
-21-1
l-lpunr Xuxrune nwnsrr
SOLID ID GAS RADIOACTIVE (14)[-lv Xtt
MAX DATLYAMT (21)
AVG DArLY AMT (22)
ANNUAL WASTE AMT (23)
zvl Er
I]Y XN
l-lv X t't
[v Xtt
nv Xru
l-lv Xtt
EHS (11)[]v X r.r
IF EHS BOX IS "Y"
ALL AMOUNTS MUST BE IN LBS
uCURIES
60 oal
35 qal
CAS N
107-21-1
1 1 1.46-6
PROPRIETARY
7758-114
(15)
E REACTIVE PRESSURE RELEASE HEALTH HEALTH
uNrrs (20)
Xcar ncurr
l-lues l-lroNs
365 lf EHS amounts must be in lb.
55 oal
BIENT AMBIENT ELOW AMBIENT
ENT AMBIENT BELOW AMBIENT ENIC
zl I "hvu
94o/o
1olo
3o/o
2lo
1
2
3
4
5
HAZARDOUS NT
ETHYLENE GLYCOL
DIETHYLENE GLYCOL
ADDITlVES
DIPOTASSIUM PHOSPHATE
GROUND TANK BOX
CYLINDER
TANK WAGON
RAIL CARBELOW GROUND TANK Icnnaov
!sno
f]Rern oRunr
flrnr'rx rNsrDE BUtLDtNG
Xsrrel oRurvt
lclnss BorrLE
BOTTLE
ALLIC DRUM BAG BIN
(31) ADDTTIONAL LOCALLY COLLECTED INFORMATION
D:\DATA\Paul\Enviromental\Buiseness Plans\san Luis\ANTFREEZ.doc 14-Feb-03
FORM I
San Luis Obispo County I- -lardous Material Inventory Form - r-'emical Description Page
DD LETE REVISE PAGE (2)oF (3)/*
(l )
$
United Parcel ServiceBUSINESS NAME:
cHEMICAL LOCATION (4)
MAP # (5)GR|D # (6)t5
IS CONFIDENTIAL AND NOT SUBJECT TO PUBLIC DISCLOSURECHEMICAL LOCATION
CHEMICAL NAME (7)
coMMoN NAME (B)
cAs # (9)
TYPE (12)
PHYSICAL STATE (13)
HAZARD CATEGORIES (16)
STATE WASTE CODE (17)
DAYS ON SITE (18)
LARGEST CONTAINER (19)
SToRAGE CONTAINER (24)
STORAGE PRESSURE (25)
STORAGE TEMPERATURE (26)
WAS SOLVENT
WASTE SOLVENT
N/A
TRADE SECRBT (10)
(15)
MAX DAILY AMT (21)
AVG DAILY AMT (22)
ANNUAL WASTE AMT (23)
N/A
EHS (11)N/A
IF EHS BOX IS "Y"
ALL AMOUNTS MUST BE IN LBS
pCURIES
12
30
SOLID LIOUID RADTOACTIVE (14)
1
2
?
4
E
REACTIVE PRESSURE RELEASE HEALTH HEALTH
213 uNrrs (20)
365 lf EHS amounls must be in lb.
30
ENT BOVE AMBIENT BELOW AMBIENT
IENT AMBIENT AMBIENT CRYOGENIC
coM
l-lv Xtt
Iv Xtt
|-lv flx
nv []tl
EY [N
NUMBER
N/A
N/A
(31) ADDITIONAL LOCALLY COLLECTED INFORMATION
FTXcr
flLes
GROUND TANK CAN WAGON
[eelow cRoUNDTANK
flrnnx lNslDE BUtLDtNG
Xsrerl oRurvt
Ecaneov
Istt-o
flcvr-rNoen
[cmss BorrLE
f]pusrc BorrLE
CAR
DRUM
PLASTIC/NONMETALLIC DRUM TOTE BIN
90
10 NM
D:\DATA\Paul\Enviromental\Buiseness Plans\san Luis\wASTESOL.doc 14-Feb-03
FORM I
san Luis obispo County 1'.\prdous Material Inventory Form - r\pmical Description Page
DD DELETE REVISE PAGE (2)oF (3)f1 &(!
(1)
United Parcel ServiceBUSINESS NAME:
CHEMICAL LOCATION (4)
MAP # (5)GR|D # (6)t5
1
CONFIDENTIAL AN D NOT SUBJ ECT TO PUBLIC DISCLOSURECHEMICAL LOCATION IS
CHEMICAL NAME (7)
COMMON NAME (B)
cAs # (e)
TYPE (12)
PHYSICAL STATE (13)
HAZARD CATEGORIES (16)
STATE WASTE CODE (17)
DAYS ON SITE (18)
LARGEST CONTAINER (19)
sroRAGE CONTAINER (24)
SToRAGE PRESSURE (25)
STORAGE TEMPERATURE (26)
TRADE SECRET (10)
EHS (11)
N/A
N/AWASTEFILTERS
N/A
flpune MIXTURE
LIOUID GAS RADIOACTIVE (14)[-lv Xn (1s)
MAX DAILY AMT (21)
AVG DAILY AMT (22)
ANNUAL WASTE AMT (23)
IF EHS BOX IS "Y"
ALL AMOUNTS MUST BE IN LBS
pcURlES
110
1500
FIRE RELEASE HEALTH HEALTH
221
365
110
US
uNrTs (20)
FT
LBS
lf EHS amounts must be in lb.
IENT AMBIENT LOWAMBIENT
IENT ABOVE AMBIENT BELOW AMBIENT CRYOGENIC
o,6WT
100
ENT
(31) ADDITIONAL LOCALLY COLLECTED INFORMATION
CASZJTET
l-lv Xtt
nv ilru
flv f]tt
nv lru
lv Dn
S
1
2
3
4
5
GROUND TANK CAN TANK WAGON
RAIL CARf]aelow cRoUNDTANK
f]rnNr trustoe BUILDING
Xsrrel onuna
flcrneov
flstt-o
ncvunorR
flcuss BorrLE
[rrerR onuut PLASTIC BOTTLE
DRUM BAG BIN
M
Adapted from OES Form 2730 A2114103
O :\document\poel\,forms\wastanti' doc
Fegc _ of
-
or
CERTIFIED
(cuPAGENCYA)RAMPROGT,rNIr,EDCOUNTTOBISPOSANL{rtsIFORM YRINVENTOcALCIIENTI metcrial
N
D REVISE
FACILffY INFORMATIONI.t
e>I)(':-^\S LT':e-L
As)BusincssDBADotngorNAMEFACILITYas(SamcNAMEBUSINESS r'0 lc-v'*OL C LIVt+,&U
A2
NO
CONFIDENTIALCHEMICALLOCATION
EPCRA
ml
LOCATION
GRID!fl (ado{rd)MAP# (oPdon:t)I
FACILITY ID f
CITEMICAL II{FORMATIONtr.206Ycs
(o
TRADE SECRET
refer to instructious
No
Tf
85
NAME
E Y"s El NoEIIS*
@MMON NAME
*If EHS ls tYes", all amounts below must be in lbs'
cAS.{
(Cotrplctc if rcquitrd bY CUPA)cr-ASSESHAZARDFIREClCDE
CURIES
RADTOACTIVE Evcs ElNo
EI A. PURE E b. MIKfURE O C' WASTEMATERI^L TYPEHAZARDOUS
it.morE only)(Ch.ct
LARGEST CoNTAINER 2-
215
E a. SOUD [] b. LIQUID E C. GASATESTPttYSlc L
iemorE only)(Chc*
.1 24
7
E d. ToNs
E e. GALIONS
c.POUNDStrFEETCUBICb.EI Itrbcoustlroslt.If
((!.*@ ilcrtr
rrNlTS.
ACBTYLBNE
2
3
1
212
5
wasteor ontY)mixturc(ForCOMPONENTHAZARDOUS%wr
EHS
El No
EINo
fl No
DNo
fl tto
fl Y.*
O Y..
fl Yo
fl Yo
fl Y".
I 100
fED HAZARD.CATECoRIES 8t a. FIRE E b. REACTTVE 8I C. PRESSURE RELEASE Et d. ACUTE HEALTH E C. CHRONIC HEALTH
((!cctr[ eat"PPIY)
DAYS ON SITE:->6
t.PI.ASTIC BOTTLE
TOTEBIN
TANKWA@N
r. OTITER
q. MILCAR
E.
IL
o.
p-
trtrt-C.
f. c.tN
&C RBOY
h. slto
J. BAG
k Box
@NTAINER
STORAGE PRESSURE fl r AMBIENT Et t. rtsovE AusrEr'rr E C. BEIOWAMBIENT
STOMGETEMPERATURE 8l r AMBIEIIT E u. rtgovE.tMBENr E c. BEI-OWAMBIENT
taat @9co&n gactaa r{ g6ad a!&ly T
b. T,NDERGROUND TANK
c. TANK INSIDE BUII-DING
d. STEELDRUM
tlt]tr CYLINDER
Eo. cnYocsltlc
74862
.hc{r o( PlFr agturlot
CAS #
ADDtTlONAL T,oCAI,LY COLI^ECTED INFORMATION
(0.rat*!
C:\examPle\ACEWLN .OOO 22'Feb40
FORM T - SAN LUIS OBISPO COI.'NIY CERTIFIED T'NTETED PROGRAM AGENCY (CI,PA)
CHEMICAL NVtrNTORY lraterid or
Page
-
of-
EADD u DELETE
FACILffY INFORMATIONI.
jbo
I ac-Lu <^'^a-^k D",, 5 t-As)BusincssDBADolng
BUSINESS (-P-<,e,.v'{)
EPCRA
NO
ml
GRID# (oPtioo:t)2fi
VAP# (oPtionrl)2n3I
FACILITY ID 'f
CIIEMICAL INFORMATIONII.206
If to EPCRA, refer to instructions
TRADE SECRET NoYes205
CTIEMICAL NAME
fl vo Elrlo
208
EHS+
NAME
*If EHS is (Yes', all amounts below must be in lbs'
cAS#
(Cooptc(c if rcquircd bY CUPA)CLASSESHAZARDFIRECODE 2t3
CURIES
RADI.ASTIyE Eves EINo
El a. PuRE E t. uxtune E c' WASTE
TIAZARDOUS MATERIAL TYPE
(Chcckorc ianonlY)
r.ARGEsrclcMAINER -z8j
E a. souD E b. uQUID 8I c' GAS
PT{YSTCALSTATE
(CtcctolE ircmoolY)E C. CHRONIC HEALTHE d. ACI.NE HEALTH
El a. FIRE Eb. REACTTVE ElC. PRESSURERELEASECATECOzuESHAZARDFED
dutdt 4plv)(Ctcc&
TE
zz->2a7 217
2ZL
DAYS ON SIfE:'7Q)Ed.TONS
E r- GALIONSUNITSE
ncfi
c. POUNDSFEETCUBICb.a IlbcEsst,rnogrt.r lll.
IL
o.
p.
i.
c.T
trtr1
@ITTATNER
trtlu
trtrtr
r. OTHER
q. RAILCARJ. BAG
k Box
LCTUIIDER
f. CAN
g. CARBOY
h- slto
b. T,'NDERGROUNDTANK
c. TANK INSTDEBUILDING
d. STEEL DRUM
Pl,rtSTIC BOITLE
TOTEBIN
TANKWAGON
I c BELOWAMBTENT8lu. lgoweMBlEbrrE T" AMBTENTSTORAGE PRESSURE Ea.cnYocewrcE c. BELOWAMBIET'ITE b. ABoVEAMBIENTE r. AMBIES{TSTORAGETEMPEMTURE cAs #rlrtDwasteoronty)mixturc(ForCOMPONENTHAZARDOUS%wr 778u47EIYcs EINO
OXYGBNI 100
ElYo ENo
2 EY"r ENo
3 Elvo ElNo
I EYc. ENo
5
Lrrll
tb.PTP€T
q btrdrud gskrrt.! lfa6fc€&ln ?(saaa
COLLBCTtsD INFORMATTONADDMONALrccAltY
A:\OXYGEN'OOC I 1'Fetr00
FORMS-SANLUII-COI'NTY CERTIFIED fINIFIED 'AGENCY
BUSINESS OWNER/OPERATOR IDENTIFICATION FFH 1 B ?Oi)3
I. IDENTIF'ICATION
1 100BEGINNING DATE
Januarv 2003
t0lENDING DATE
Januarv 2004
FACTLTTYID#r I I t I
"?tt>/ 4V ro / rl'I A-j l':illiiil
102BUSINESS PHONE
(805\ 544-7184
BUSINESS T.;/EVTC 1S*" "'y'ACILITY
NAME OT DBA _ DOiNg BUSiNESS AS)
United Parcel Service
3
BUSINESS SITE ADDRESS
3601 Sacramento Drive
103
CA
105ZIP CODE
9340rSan Luis Obispo
104CITY
107SIC CODE (4 digit #)
4789
DUN & BRADSTREET
00-686-5927
106
COUNTY
San Luis Obispo
108
110BUSINESS OPERATOR PHONE
(805) 544-7184
BUSINESS OPERATOR NAME
Neil McClelland
109
il. BUSINESS OWNER
tt2OWNER PHONE
(2t3\ 6t2-t890
OWNER NAME
United Parcel Service
1ll
OWNER MAILING ADDRESS
1201 West Olympic Blvd
113
115STATE
CA
lr6ZIP CODE
9001s
tt4
Los Angeles
CITY
UI. EIWIRONMENTAL CONTACT
118CONTACT PHONE
(80s) 490-306s
CONTACT NAME
Barbara Boliver
tt'I
CONTACT MAILING ADDRESS
1201 West Olympic Blvd
119
t2tSTATE
CA
r22ZIP CODE
90015Los Anseles
t20CITY
IV. EMERGENCY CONTACTS -SECONDARy-.PRIMARY.
Gary Hutchings
128NAMENAME
Neil McClelland
t23
129TITLE
SupervisorCenter Manager
124TITLE
BUSINESS PHONE
(80r 544-7184
130BUSINESS PHONE
(80s) s44-7r84
125
24.HOUR PHONE 126 'o'131
pRc or,LLPHoNE#
N/A
t32PAGER# I CELL PHONE#
N/A
127
ADDITIONAL LOCALLY COLLECTED INFORMATION
Certification: Based on my inquiry of those individuals responsible for obtaining the information, I certify under penalty of law that I have personally examined and
am familiar with dre information submitted and believe the information is tme, accurate, and complete.
TOR OR DESIGNATED REPRESENTATIVE
02n4t03
134DATE NAME OF DOCUMENT PREPARER
Barbara Boliver
135
NAt6tOF SIGNER (prinr)t Ni"k Moldovan
136
District Plant Engineering Manager
TITLE OF SIGNER 131
2
t/
a/'LP,
D:\DATA\Paul\Enviromental\Buiseness Plans\San Luis\FRM-S.do cO2nalB ./
EL+ l/
e"s" I ot l/'
-l FORM I -)
San Luis Obispo County Hi.-drdous Material Inventory Form - C,^emical Description Page
(1)l-lnoo IoElrre ERevtse PAGE (2)oF (3)IF0I
-United..P..ar.s_e_[._S_er-v_1-c3BUSINESS NAME:
cHEMTCAL LOCATTON (4)
MAP # (5)GR|D # (6)110
CHEMICAL LOCATION IS CONFIDENTIAL AND NOT SUBJECT TO PUBLIC DISCLOSURE
1
cHEMICAL NAME (7)
coMMoN NAME (8)
cAS # (e)
TYPE (12)
PHYSTCAL STATE (13)
HAZARD CATEGORTES (16)
srATE WASTE CODE (17)
DAYS ON S|TE (18)
LARGEST CONTATNER (19)
STORAGE CONTAINER (24)
STORAGE PRESSURE (25)
SToRAGE TEMPERATURE (26)
PETROLEUM HYDROCARBON
DIESEL FUEL
68476-34-6
EpunE Xvtxrune nwnsre
l-lsolro Xlrouro llcns
TRADE SECRET(10)
EHS (1 1)
nv Xru
RADTOACTTVE (14)(15)
Xnrnr nnencrve !pnessunE RELEAsE Xncurr HEALTH Xcnnouc HEALTH
UNrTS (20)
Xonr- ncunr
nlas nrorus
365 lf EHS amounts must be in lb.
1 2000
XnMgteNr Eneove AMBIENT Eaelow AMBTENT
XRMSrgNrr nReove AMBTENT neeLow AMBTENT ncRvoceuc
HAZARDOUS COMPONENT EHS
l-lY Xrl
MAX DATLY AMT (21)
AVG DArLY AMT (22)
ANNUAL WASTE AMT (23)
l-l v X r.t
IF EHS BOX IS'Y"
ALL AMOUNTS MUST BE IN LBS
pCURIES
1 0800
ssd
N/A
CAS NUMBER
1
2
3
4
5
flneove cRouND rANK
XElaer-ow cRouND rANK
nrRxxrtrstoe BUILDTNG
lsrrel onuvt
n pnsrrcnoNMETALLrc DRUM
Ecnru
ncnneov
nsrr-o
[f eox
ncvuruoen
nouss BorrLE
nrnrux wAGoN
nnnt cnn
FIBER DRUM
BAG
PLASTIC BOTTLE
TOTE BIN
99.5%
0.504
DIESEL FUEL
NAPHTHALENE
PETROLEUM DISTILLATES
NY XN
[]Y X t't
l-lv Xrl
l-lv l-]ru
l-lv l-ltrt
68476-34S
91-20-3
NONE
(31) ADDITIONAL LOCALLY COLLECTED INFORMATION
Adapted from OES Form 2730 02/..1_4l03$4lgl9&
O:\document\jpoel\forms\diesel. doc
san Luis obispo county n']l.uou, *"r"ll"ffr:ntory Form - L^)*i.ul Description Page
(1)nnoo Eoelrt flnevtse PAGE (2)oF (3)t4tl
United Parcel ServiceBUSINESS NAME:
cHEMTCAL LOCATION (4)
MAP # (s)t5
CHEMICAL LOCATION IS CONFIDENTIAL
cRrD # (6)
NOT SUBJECT TO PUBLIC DISCLOSURE
1
cHEMTCAL NAME (7)
coMMoN NAME (8)
cAs # (9)
TYPE (12)
PHYSICAL STATE (13)
HAZARD CATEGORTES (16)
STATE WASTE CODE (17)
DAYS ON S|TE (18)
LARGEST CONTAINER (19)
STORAGE CONTAINER (24)
SToRAGE PRESSURE (25)
STORAGE TEMPERATURE (26)
Zl ) "loVU
50
+ OTHER GLYCOLS
WASTE ANTIFREEZE
107211
PURE
nsouo Xuouto norc
uNrTs (20)
365 lf EHS amounts musl be in lb.
55 qal
RADTOACTTVE (14)(15)
FIRE REACTIVE PRESSURE RELEASE HEALTH CHRONIC HEALTH
TRADE SECRST (10)
nv Xn
MAX DATLYAMT (21)
AVG DA|LY AMT (22)
ANNUAL WASTE AMT (23)
N/A
EHS (11)N/A
IF EHS BOX IS'Y'
ALL AMOUNTS MUST BE IN LBS
pCURIES
55 oal
20 qal
55 oal
1
2
3
4
5
IENT AMBIENT BELOW AMBIENT
IENT NABOVE AMBIENT BELOW AMBIENT CRYOGENIC
HAZARDOUS COMPONENT EHS
ETHYLENE GLYCOL
CAS NUMBER
107211
FT
TONS
GROUND TANK BOX TANK WAGON
!eeLow cRoUNDTANK
nrmx rNsrDE BUTLDTNG
Xsreel oRuv
Iclnaov
nsuo
!cvlruoen
lomss BorrLE
[emsrrc BorrLE
nnnt cnn
laeeR onuM
IC DRUM BAG BIN
[ ]Y Xtl
nv nn
nv Elt
llv l-lt't
nv nu
Adapted from OES Form 2730 02/14/03
(31) ADDTTTONAL LOCALLY COLLECTED INFORMATION
O: \document\poel\forms\wastanti. doc
(1)Enoo noelerE Enevtse
,_) FORM I '-")
San Luis Obispo County Hi.rardous Material Inventory Form - L^.emical Description Page
PAGE (2)l7 or rurFTl
[Jnited Parcel ServiceBUSINESS NAME:
cHEM|CAL LOCATION (4)
MAP # (s)GR|D # (6)t5
CHEMI CAL LOCATION IS CONFIDENTIAL AND NOT SUBJECT TO PUBLIC DISCLOSURE
1
cHEMTCAL NAME (7)
coMMoN NAME (8)
cAS # (e)
TYPE (12)
PHYSICAL STATE (13)
HAZARD CATEGORIES (16)
STATE WASTE CODE (17)
DAYS ON S|TE (18)
LARGEST CONTATNER (19)
SToRAGE CONTAINER (24)
STORAGE PRESSURE (25)
STORAGE TEMPERATURE (26)
ZT
94o/o
1olo
3olo
2%
O6WT
ETHYLENE GLYCOL + OTHER GLYCOLS
ANTIFREEZE/COOLANT
-,|
lllpune XvrxruRe nwnsre
l-lsouo Xlrouro l-lcns
uNrTs (20)
365 lf EHS amounts must be in lb.
55 qal
RADTOACTIVE (14)(15)
FIRE REACTIVE PRESSURE RELEASE ACUTE HEALTH HEALTH
TRADE sEcRE"r (10)
l-lv Xr.t
MAX DATLYAMT (21)
AVG DAILY AMT (22)
ANNUAL WASTE AMT (23)
N
EHS (11)nv Xru
IF EHS BOX IS "Y'
ALL AMOUNTS MUST BE IN LBS
pCURIES
60 qal
35 oal
0 qal
1
2
3
4
5
BIENT AMBIENT BELOW AMBIENT
BIENT AMBIENT BELOW AMBIENT CRYOGENIC
HAZARDOUS COM EHS
ETHYLENE GLYCOL
DIETHYLENE GLYCOL
ADDITIVES
DIPOTASSIUM PHOSPHATE
CAS NUMBER
107-2't-1
11146-6
PROPRIETARY
7758-114
FT
TONS
GROUND TANK BOX TANK WAGON
narLow GRoUNDTANK
nrnrux TNSTDE BUTLDTNG
Xsrrel onuv
Icnneov
flsro
nrreEn onuNr
flcvuruoen
f]onss BorrLE
npmsrrc BorrLE
flnnt cnn
DRUM BAG TOTE BIN
flY XN
l-lv X N
l-lv Xtl
nv XN
llv Xtt
(31) ADDTT|ONAL LOCALLY COLLECTED INFORMATION
D:\DATA\Paul\Enviromental\Buiseness Plans\San Luis\ANTFREEZ.doc 14-Feb-03
--) FORM r ''-)- San Luis Obispo County Hr.zardous Material Inventory Form - L^remical Description Page
(1)lnoo Xoelere n nevtse PAGE (2)oF (3)/(o
United Parcel ServiceBUSINESS NAME:
cHEMTCAL LOCATION (4)
MAP # (5)GR|D # (6)t5
CHEMICAL LOCATION IS CONFIDENTIAL D NOT SUBJECT TO PUBLIC DISCLOSURE
1
CHEMICAL NAME (7)
coMMoN NAME (8)
cAs # (s)
TYPE (12)
PHYSTCAL STATE (13)
HAZARD CATEGORTES (16)
STATEWASTE CODE (17)
DAYS ON S|TE (18)
LARGEST CONTAINER (19)
STORAGE CONTAINER (24)
SToRAGE PRESSURE (25)
SToRAGE TEMPERATURE (26)
O6WT
SOLVENT
WASTE SOLVENT
N/A
PURE
nsouo Xuouto nons
TRADE SECRET (10)
nY Xru
MAX DAILYAMT (21)
AVG DAILYAMT (22)
ANNUAL WASTE AMT (23)
N/A
EHS (1 1)N/A
IF EHS BOX IS'Y'
ALL AMOUNTS MUST BE IN LBS
pCURIES
30
12
30
1
2
3
4
5
RADTOACTTVE (14)(1 s)
Xrrne PRESSURE RELEASE HEALTH HEALTH
213 UNrTS (20)
365 lf EHS amounts must be in lb.
30
IENT AMBIENT BELOW AMBIENT
IENT AMBIENT BELOW AMBIENT CRYOGENIC
HAZARDOUS COM
WASTE SOLVENT
PETROLEUM HYDROCARBON
CAS NUMBER
N/A
N/A
FT
GROUND TANK CAN BOX TANK WAGON
RAIL CARnaelow cRoUNDTANK
!rnrur rrusroe BUTLoTNG
!cnneov
nsuo
nrreeR onuM
!cnrruoen
DRUM
GLASS BOTTLE
PLASTIC BOTTLE
TOTE BINDRUM
90
t0
nv Xru
l-lv R ru
nY nru
l-lY l-ltt
nv nru
(31) ADDTTTONAL LOCALLY COLLECTED INFORMATION
D:\DATA\Paul\Enviromental\Buiseness Plans\San Luis\WASTESOL.doc 14-Feb-03
' San Luis obispo County n).oou, *","11"ffJ.ntory Form - c.)-i.ul Description Page
(1)nnoo noelere X nevtse PAGE (2)oF (3)/4 w
United Parcel ServiceBUSINESS NAME:
cHEMTCAL LOCATTON (4)
MAP # (s)GR|D # (6)
CHEMICAL LOCATION IS CONFIDENTIAL AND NOT SUBJECT TO PUBLIC DISCLOSURE
1 l5
cHEMTCAL NAME (7)
coMMoN NAME (8)
cAs # (e)
TYPE (12)
PHYSTCAL STATE (13)
HAZARD CATEGORIES (16)
STATE WASTE CODE (17)
DAYS ON S|TE (18)
LARGEST CONTATNER (19)
SToRAGE CONTAINER (24)
STORAGE PRESSURE (25)
STORAGE TEMPERATURE (26)
ZT
100
O6WT
PETROLEUM
WASTE OIUOIL FILTERS
N/A
lpunr Xurxrune flwnsre
l-lsolro Xlrouto lcRs
UNrTS (20)
TRADE SECRET (10)
nv Xru
MAX DAILYAMT (21)
AVG DArLY AMT (22)
ANNUAL WASTE AMT (23)
N/A
EHS (11)N/A
IF EHS BOX IS'Y"
ALL AMOUNTS MUST BE IN LBS
pCURIES
110
55
1 500
RADTOACTTVE (14)(1 s)
FIRE REACTIVE PRESSURE RELEASE HEALTH HEALTH
221
365 lf EHS amounts must be in lb.
110
IENT AMBIENT BELOW AMBIENT
IENT OVE AMBIENT BELOW AMBIENT RYOGENIC
S COMPONENT EHS CAS N
I
2
3
4
5
PETROLEUM HYDROCARBON
FT
ABOVE GROUND TANK BOX TANK WAGON
Eerlow GRoUND TANK
nrarur rNsrDE BUILDING
Xsreel oRuw
ncnneoY
flstt-o
!cvlrruoen lnnt cnn
!rreen onuna
GLASS BOTTLE
PLASTIC BOTTLE
TOTE BINDRUMBAG
!Y Xru
nv nru
nY nru
l-lY Ett
l-lY llru
Adaped from OES Form 2730 02114/03
(31) ADDTTTONAL LOCALLY COLLECTED INFORMATION
O :\document!poelVorms\wastanti. doc
FORM I - SAN LUIS OBISPO COTJNTY CERTIFIED UNIflED PROG
CIMMICAL INVENTORY or
RAM AGENCY (CI.IPA)
nlaterid
P18c_of_zp
Eopt-srE D REVISE
I. FACILITY INFORMATION
I
?^n
As)BusincssDBAorNAMEDoingFACILITY1SNAME(SamcBUSTNESS LD)O l'D J(/'c^n^-o-4'1*9,t-c3bt)(<-a_->1.e-\+lttL o&u 2n2LOCATIONCONFIDENTI,ALCHEMICAL
EPCRA
NOYES
LOCATION
GRID# (optiocdlMAP# (opriona)m3I
FACILITY IDf
tr. CIMMICAL INFORMATION
26
to EPCRA,refer to instmctions
NoYesTRADE SECRET
IfCHEMICAL NAME
2o5
flvo ElNoEIIS*
208
CTCMMON NAME
*If EHS ls 'Yes", all amounts below must be in lbs'
2t0
CLASSES (crtrplctc if rcquircd bv CUPA)TIAZARDFIRECODE
CURIES
212
MDIOACTTVE EYCS EINO
HAZARDOUS MATERI,A L TYPE El a. PURE E b. MIXTURE E C' WASTE
(Chcck orc itcm only)
INRGEST CONTAINER
2t5
PHYSICALSTATE
(Ctrcct orr ftcm only)
E A. SOLID [f b. LIQUID EI C' GAS
8I a. FIRE E b. REACTTVE EI C. PRESSURE RELEASE Ed.ACUTEHEALTH f]C.CHRONICHEALTH
FED HAZARD CATEOORIES
(Chcct dl lhat rPPIY)219w2l
A AMOUNT
22+
E d. roNs
E e. GALI,ONS E b. CUBIC FEE'r E c' POUNDS
(Ctff&qr tarnonlY)emount must be hrrNlTS.
EHS
I{AZARDOUS COMPONENT (For mixture or waste onty)%wr
Elvcs EINo
ACETYLENEr 100
Dvo nNo
2
Evcs DNo231
3
E Y"s D llo
4
Elvcs flNo
21121t
212
5
OONTAINER
STORAGE PRESSURE
STORAGETEMPEMTURE
G @9oc!GE
a.
b. UNDERGROTJNDTANK
c. TANK INSIDE BUILDING
d. STEEL DRUM
pr€.d il ga(a l* by
c.f-c N
g.A{RBOY
h. SILO
i.
j. BAG
k- BOX
trtrtr
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al.
n. PIISTIC BOTTLE
o. TOTEBIN
p. TANKWAGON
cAs #
o( prptr th.
trn r. OTHER
q. MILC.AR
CYLINDER
E r- AMBIENT El t. esovE '/tuslENr
E C. BEIOWAMBIENT
El E. AMBIENT E t. ASOVEEUBIENT E c. BELTWAMBTENT E a. cRYoceNrc
74862
211
I
ADDMONAL IOCALLY COLLECTED TNFORMATION
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ibo I
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a.*ct'",-.r,,p--ho Dt, -, S L O
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As)BusincssorNAMEDBAFACILMYDoingas(SamcNAMEBUSINESS (-e-(,.<4.v't)LIn?*nI,L CHEMTCAL
EPCRA
NO
CONFIDENTTAL
YES
CHEMICAL t.ocATloN
GRID# (optionrl)204YdPf loptiond)
203I
FACILMY ID #
II. CIMNtrCAL INFORMATION
26
to EPCRA'refer to instructions
NoYesTRADE SECRET
IfCI{EMICAL NAME
205
flvo KnoEHS*
2N
@MMONNAME
+If EHS is 'Yes", all amounts below must be in lbs'N
cAs#
7 210
FIRE CIDE IIAZARD CLASSES (Corplcc if rcquircd bv CUPA)
CURIES
212
RADIOACTTVE E YCS EI NO
HAZARDOUS MATERI.AL TYPE
(Chcck orr itcm onlY)
E a. PURE E b. MDCTURE EC. WASTE
I.ARGEST CINTAINER 27'>2t5
PTTYSTOILSTATE
(Chcctorc iamonlY)EI a. SOLID E b. LIQUID El C. GAS
Ea.FIRE Et. NT,ECTTVE EC. PRESSURERELEASE Ed.ACLTTEHEALTH EC.CHRONICHEALTH
FED ITAZARD CATEC,ozuES
(Ch.cl.tl dut aPPIY)TE CODE219
zz->MAXIMUM-287AMOUNT
DAYS ON SITE:
'9Q2El d. ToNs
E a. GALIINS
*lf EHS,emoult msst bc hUNITS'
o(E hcmodly)
EIb.CUBICFEET EC.POUNDS
22t
m.i.c.a.trtr@}TTANER
rltlutltltr
r. OTHER
q. RAILCARn. PLASTICBOTTLE
o. TOTEBIN
p.TANKWAGON
j. BAG
k BOX
L CYLNDER
f. CAN
g. C"{RBOY
h. slto
b. UNDERGROUNDTANK
c. TANK TNSIDE BUILDING
d. STEELDRUM
E C. BEI,OW AMBIENT
STORACE PRESSURE [f I AMBIENT EI b. ABOVEAMBIENT
E a. cnYocexrcE c. BEL,oW AMBIENT
STORAGE TEMPERATURE 8 E. AMBIENT E b. ABOVEAMBIENT
cAs #BHS
IIAZARDOUS COMPONENT (For mixturc or waste only)%wr
778U47EYcs ElNo
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Evo ENo
231
2
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ADDMONAL I'CALLY C1OLLECTBD INFORMATION
A:\OXYGEN.DOC 1 1'Fetr00
FORMS-SANL\
I
)onrspo coLrNTy cERTTFIED UNIFIE.Eocnlvt lcBNcv
BUSINESS OWNER/OPERATOR IDENTIFICATION
of
I. IDENTIFICATION
FACILITYID# . ..
6 R 4$\U
BEGINNING DATEjAx zooo
100 ENDING DATEDgc- ?-ooo
l0l
BUSINESS NAME (Sme u TACILITY NAME or DBA - Doing Business As)
UNTTED PARceu sEavlcE
5 BUSINESS PHONE(80-rl 5{tr- -t le'\
102
BUSINESS SITE ADDRESS 103
3eor sficfrAme,vro brlv
CITY S OB)S PO
104
SNnJ Lur CA
zIP coDE q zq o t
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DUN & BRADSTREET"^Uo^:'686- 5c) zf 106 SIC CODE (4 dieit #)107tr eg
COUNTY 6 108CISA^, Lvts OBISPO
BUSINESS OPERATOR NAME
rvl AR,K schi llll.ve 109 BUSINESS OPERATOR PHONE( 8oS) Sqq-1,8Y
110
II. BUSINESS OWNER
owNER*ott u$/ ll*FD P RRcer sgfa{tcE OWNERPHONE(zt3) 6lZ-lB?o
tt2
OWNER MAILING ADDRESS I
r zol w " oL) rnnL
113glvP * P\nuT €vGl^/ee-Yq Itvc $€pr
CITY l14
L,Os A'VS €LES STATE 115
CA ztPcoDh oo I s ll6
In. ETWIRONMENTAL CONTACT
CONTACT NAME FR ED c-A \tri llo lt7 CONTACT PHONE(Bos) 3-7S-l8ll
118
CONTACT MAILING ADDRESS
rSO I RAr\rc$o Corfglo P\ nnrT EvGrN ee.t<ivc
u9
6 uvA
cIrY NEwBrJay PNAK
STATE l2l
CA ZIP CODEQrszo t1a
.PRIMARY.IV. EMERGENCY CONTACTS -SECONDARY-
NAME fh NAK scHitti",re 123 NAME Sgooice r<i icht-f 128
TITLE 124C[:^/TER Ym Ad A Ce R
TITLE tzg
SV PEAVISOR.
BUSINESS PHONE,'U'r\DJr'""'L"gos) 51q *7t 81
t25 BUSINESS PHONE 130
( BoS) 59Y -l tBq
24-HOUR PHONE 126 24-HOUR tll
PAGER #127
tu/a PAGER #132v/a
133
ADDITIONAL LOCALLY COLLECTED INFORMATION:
Certification: Based on my inquirY of those individuals responsible for obtaining the information,I certify under penalty of law that I have personally examined and
am familiar with the information submitted and believe the information is true, accurate, and complete.t*ru"tfiffiffi OR REPRESENTATIVE DATE 1343"8-a)NAME OF DOCUMENT PREPARER 135tr-AED cAstr llo
NAME OF SIGNER-(print)
M I KE BOST
136 TITLE OF SIGNER
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2.-7P *o\A:\Frm-s.DOC 1 4-Feb-00
FORM I - SAN LIIIS OBtsPO COUNTY CERTIFIED UNIHED PROG^<AM AGENCY (CUPA)
CHEMICAL INVENTORY
or area)material
Page ofLflenoEnel.srs Bnsvlss 2W
I. FACILITY INT'ORMATION
BUSINESS NAME (Same as FACILITY NAME or DBA - Doin-g
VNItED ?PaceL sE rrv I cE
Business As)
TIONCHEMICAL CIIEMICAL LOCATION CONFIDENTIAL
EPCRA
YES
2UGRID# (optional)tr-5MAP# (optional)
IFACILITY ID #
tr. CIIEMICAL INFORMATION
to EPCRA, refer to instructions
206
If
TRADE SECRET Yes No205
YCOLS
CHEMICAL NAME
GLYCOL +
I Yes ElNoEHS+
208
#
COMMON NAME
*If EHS is "Yes", all amounts below must be in lbs.
209cAs#
FIRE CODE HAZARD CLASSES (completc if required bv CUPA)
i
213
CURIESRADIOACTIVE El Yes E NoHAZARDOUS MATERIAL TYPE
(Check one item onlY)EI A. PURE E b, MIXTURE Ex C. WASTE
211
LARGEST CONTAINER
215S5PHYSICAL STATE
(Check one item only)E a. SOLID EI U. I-IQUIO E C. GAS
214
FED HAZARD CATEGORIES
(Check all that aPPIY)[f a. FIRE E b. REACTTVE El c. PRESSURE RELEASE E d. ACUTE HEALTH EI e' CHRONIC HEALTH
2t6
STATE WASTEztq
220ANNUALW5sAMOUNTAMOUNTMAXIMUM
55
217
a5
AMOUNT
DAYS ON SITE:
3C"SUNITS'
(Check one item
E u. cusrc rsEr [f c. POUNDS
rlf EHS, amormt must be in Pounds.
E a. roNsE a. GALLONS
E b. UNDERGROUND TANK
EI c. TANK INSIDE BUILDING
EId. STEEL DRUM
f. CAN
g. CARBOY
h. sILo
trtrtr
j. BAG
K. BOX
I. CYLINDER
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m. GLASS BOTTLE
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p. TANKWAGON
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CONTAINER
,
a.GROUND TANK r. OTHER
q. RAIL CAR
8 A. AMBIENT E U. ESOVE EN,ISIENT E c. BELOW AMBIENTSTORAGE PRESSURE
224
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CAS #EHSHAZARDOUS COMPONENT (For mixture or waste only)%wr
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! Yes EIuoET}IYLENE GLYCOLq,
233
flves "E No
232
2
fI Yes flNo
236235
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240239
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fl ves Ll No
244243
5
the rquiredshels of papcror 0.1% byby wekht lfIf morc brardoc coDpoueots re pwtrt lt greater erchoge[ic'
A:\WASTANTI.DOC 1 1-Feb-OQ
flapo !peLBrB EIREVISE
200 ofPage
I. FACILITY INT'ORMATION
BUSINESS NAME (Same as FACILITY NAME or DBA - Doing
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FACILITY ID #
Eves ElNoE c. WASTE
202
TIONCHEMICAL
II.
206No
208
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*If
I
211211
CURIES
s
205 TRADE SECRET
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MAP# loptionall
YES NO
CIIEMICAL INT'ORMATION
IfCHEMICAL NAME
COMMON NAME
PETROLEUM
ttYestt, all amounts below must be in lbs.
refer to instructions
cAs#
64
HAZARDOUS MATERTAL TYPE
(Check one item only)E a. PURE 8 b.
CIIEMICAL LOCATION CONFIDENTIAL
EPCRA
! ves Eluo
LARGESTCoNTAINER lzO
215
PHYSICAL STATE
(Check one item only)E a. solrD I b. LIQUID
FED HAZARD CATEGORIES
(Check all that aPPIY)
RELEASE EI d. ACUTE HEALTH E E. CHRONIC HEALTH
216
El a. FIRE Eb. REACTIVE E C.
t//s
STATE WASTE CODE 2202r9ANNUAL WASTE AMOUNT
noMgAVERAGE DAILY AMOUNT
6o ILO
MAXIMUM DAILY
E A. GALLONS fI b. CUBIC FEET
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UNITST IIf EHS,
E n. PLASTIC BOTTLE
fl o. TorE BIN
[] p. TANK wAGoN
223
E r. OTHER
E q. RAIL CAR
i. FIBER m.ALLIC
FSILO
EJ. BAG
k. Box
I. CYLINDER
b. UNDERGROUND TANK
c. TANK INSIDE BUILDING
d. STEEL DRUM
flre.a. ABOVE GROUNDSTORAGE
CONTAINER
E c. BELOWE b. ABOVE AMBIENTEl a. AMBIENTSTORAGE PRESSURE
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225
STORAGETEMPERATURE EA.
CAS #(For mixture or waste only)%wr
64742-65-0
u9
EYes XNo "HYDROCARBON
2n226I 100
233
lves Euo230
,,
23't
[Yes lxo214
J
241
fl Yes flNo4
t
E Yes flNo5
242
cmlptreuG are prent rt gruts lbrtr 1% bY
p8p€r epturlog thesttrch rdditioultfrcusrcbogedc' or 0.%DOre
FORM I - SAN LI.[S OBISPO COTINTY CERTIFMD UNIFIED PROGRAM AGENCY (CI]PA)
CIMMICAL II{VENTORY
material or
A:\PETOIL.DOC 1 1-Feb-00
FORM I - SAN LUIS OBISPO COT]NTY CERTIFIED I.INIFIED PROGRAM AGENCY (C{JPA)
CIIEMICAL II{VENTORY
material or
of200Page
Eaoo
I. FACILITY INFORMATION
f]DELETE
BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business 3As)
UM ITED P NtZCe.l sg ,?-v{ c e.
CHEMICAL LOCATION
EPCRA
l-l ves trlNo
202CONFIDENTIALCHEMICAL LOCATION 201
2MGRID# (optional)
-T-5
203MAP# (optional)
ItffilFACILITY ID #
tr. CIIEMICAL INFORMATION
TRADESECRET U
ect to EPCRA, refer to instructions
206NoYeslzs
If Subj
CHEMICAL NAME
W AsTg h4cT0.r< ei L
205
2.47q
I
rmoToR o\LCOMMON NAME
USE
*If EHS is "Yes", all qmounts below must be in lbscAs#
N/
EHS*
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Lt cl.u r oFIRE CODE HAZARD CLASSES (complete
COM fs\.tst\ble
flYes X No
213
CURIES
212
RADIOACTIVE EYCS ENOHAZARDOUS MATERIAL TYPE
(Check one item oDiy)E a. PURE 8 b. MIXTURE E C. WASTE
21r
2t5
LARGEST CONTAINER lzoPHYSICAL STATE
(Check one item onlY)E a. soLID El L t-tQuto E c. GAs
214
FED HAZARD CATECORIES
(Check all that apply)El a. FIRE fl b. REAC-IM El c. PRESSURE RELEASE I d. ACUTE HEALTH E e' CHRONIC HEALTH
216
220STATE WASTE CODE
221-ANNUAL
WASTE AMOUNT
't bo
2192r8MAXIMUM DAILY AMOUNT
tzoAVERAGE DAILY AMOUNT
60
21't
DAYS ON SITE:
36.5UNITS*
(Check one item only)
E b. CUBIC FEET EI C. POUNDS
*If EIIS' amornt must be in Pounds.
E d. ToNsI a. GALLONS
221
tr
Etr
b. UNDERGROUND TANK
c. TANK INSIDE BUILDING
d. STEEL DRUM
trtrtr
f. CAN
g. CARBOY
h. stl.o
trtrtr
J. BAG
K. BOX
I. CYLINDER
223
El r. orHER
E q. RAIL CAR
El p. TANKWAGoN
aai
PLASTIC/NONMETALLIC DRUMfl a. ABOVE GROUND T m. GTASSANK Ee.E i. FIBER DRUMSTORAGE
CONTAINER n. PLASTIC BOTTLE
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STORAGETEMPERATURE, EA. AMBIENT Eb.ABOVEAMBIENT ft c. BELOWAMBIENT Eld. cRYocENIC
CAS #EHSHAZARDOUS COMPONENT (For mixture or waste only)%wT
6't?t \8s1 229
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224
10
226
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. o.
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2n
233
r,// gEYes ENoD ele aG€^/T \ ryh)brtogs
231
t5
230
7
23'l236
I Yes E llo
235234
J
241240
[Yes [No
239238
4
2452M
! Yes flNo242
5
243
psp€r epturiDg lheor 0.1% by1% by weight tfcomponents m prent rt gstcr shetsmltrogedc,DOrc
ADDITIONAL LOCALLY COLLECTED INFORMATION
7
A:\WASTOIL.DOC 1 1-Feb-00'
FORM I - SAN LI.]IS OBISPO COI]NTY CERTIFIED I]NINED PROGRAM AGENCY (CT]PA)
CIMMICAL II\IVENTORY
ormaterial
of2Nflaop
I. FACILITY INFORMATION
BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As)
UT'f ITED PA rlC€L SE 12 V ICE
CHEMICAL LOCATION 202
NO
CONFIDENTIAL
EPCRA
201
2MGRID# (optional)
K- 5-
203MAP# (optional)IFACILITY ID #
tr. CIMMICAL INT'ORMATION
to EPCRA, refer to instructions
TRADE SECRET 206
If
Yes NoCHEMICAL NAME
flYes X No
208
EHS*COMMON NAME
*If EHS is "Yes", all amounts below must be in lbs.cAs#
N/A
2@
FIRE CODE IIAZARD CLASSES (complete if rcquired bv cuPA)
210
zt3
CURIES
212
MDIOACTIVE EYCS ENOHAZARDOUS MATERIAL TYPE
(Check one item only)EI a. PURE El b. MXTURE E C. WASTE
2tt
I-ARGEST CONTAINER
2t5
55PHYSICAL STATE
(Check one item only)E a. SOLID EI b. LIQUID E C. GAS
214
FED HAZARD CATEGORIES
(Check all that aPPIY)
E a. FrRE E b. REACTIVE E c. pRESSURE RELEASE EI d. ACUTE HEALTH El e. CHRONIC HEALTH
2t6
ATE WASTE CODE
221
220AMOUNTANNUAL55Y AMOUNT 218
52t7DAILY5
222DAYS ON SITE:
36,5Eb. CUBICFEET E C. POUNDS
rlf EHS' amount must be in Poulds'
n d. ToNsEl a. GALLONS
(Check one item
UNNS*
f. CAN
g. CARBOY
h. SILO
trutr
j. BAG
k. Box
I. CYLINDER
utrtr
n. PLASTIC BOTTLE
o. TOTE BIN
p. TANK WAGON
223
r. OTHER
q. RAILCAR
FIBER DRUMCROUND TANK DRUMe.a.trtr
,tr
BI
f] b. UNDERGROUND TANK
m.BOlTLE
STORAGE
CONTAINER
c. TANK INSIDE BUILDING
d. STEEL DRUM
E A. AMBIENT EI b. ABOVE AMBIENT E C. BELOW AMBIENTSTORAGE PRESSURE
224
STORAGE TEMPEMTURE , E A. AMBIENT E b. ABOVE AMBIENT El d. cRYocENIcE c. BELOW AMBIENT
n5
cAs #EHSHAZARDOUS COMPONENT (For mixture or waste only)VoWT
! Yes ElNoPETROLEUM HYDROCARBONI 100
flYes fl No
114
.,
237
[Yes ENo3
lYes ENo4
[Yes nuo5
by velght lf by mtgbtcompoBenls re Pmt rt SHIFIf Eore
lnforution.rttsch p8p€ror
AIWASTOIL.DOC 1 1-Feb-00
ofPageileopEoeLeru
2m
I. FACILITY INT'ORMATION
BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business
LlffrTr=> pAr2.(,€\ SE,aVIcE
As)
CHEMICAL LOCATION CONFIDENTIAL
EPCRA
202
YES
CHEMICAL LOCATION 0
GRID# (optional)K-toMAP# (optional)203
FACILITY ID #
II. CEE]VIICAL INFORMATION
to EPCRA, refer to instructions
206
If
TRADE SECRET Yes No
D i sseu FU ELCHEMICAL NAME 205
flYes K No
208
EHS*COMMON NAME b t es ert-
*If EHS is "Yes", all arnounts below must be in lbs.( rva'r XfU{-€)CAS#
NIAFIRE CODE HAZARD CLASSES (complste if required by CUPA)
2t3
CURIES
212
RADToACTIvE fl Yes I NoHAZARDOUS MATERIAL TYPE
(Check one item only)fI a. PURE 8 b. MXTURE E C. WASTE
r.,{RGEsTcoNTAINER I Z OO O
2t5
PHYSICAL.STATE
(Check one ilem only)E a. SOLID EI b. LIQUID E C. GAS
FED HAZARD CATEGORIES
(Check all ftat aPPIY)Ela. FIRE Eb. REACTM Ec. PRESSURERELEASE Ed.ACUTEHEALTH Ee. GHRONICHEALTH
216
ATE WASTE
N/A
220WASTE
N/aDAILY
IOBOO
21217DAILY
5500 a)aDAYS ON SITE:365fl d. roNsEI a. GALLONS
(Check one item
221
UNITS*rlf EHS, anount must be in
E b. CUBIC FEET E C. POUNDS
E
Etr
b. UNDERGROUND TANK
c. TANK INSIDE BUILDING
d. STEEL DRUM
rlutr
L
j.
k.
l.
CONTAINER
BOTTLEDRUMm.trtrtrtr
I CYLINDER
trtr
BAG
BOX
fl h. srl'o
E n. PLASTIC BOTTLEe.a. ABOVE GROUND r. OTHER
q. RAIL CARo. TOTE BIN
p. TANKWAGON
f. CAN
g. CARBOY
8I A. AMBIENT E b. ABOVE AMBIENT EI C. BELOW AMBIENTSTORAGE PRESSURE
224
STORAGETEMPERATURE 8 A. AMBIENT E b. ABOVEAMBIENT EI C. BELOWAMBIENT E d' CRYOGENIC
CAS #EHSI{AZARDOUS COMPONENT (For mixture or waste only)%wr
6 8.1rr- z1- e
279
EYes ElNo, FUEL D f esEL szL " 91"1u
'N/A
233
flYes E No'
AD D \Trves C c"ur-i- PuST)
231
I
/37
flYes Xl No
241
Ll ves I No
EIYes EI No
5
or 0.1% byIf @rc tf rttrch of pap€r sptuitrg the required
coElErcnls re pKtrt rt gHter thsu l% by reighr tf
ADDITIONAL LOCALLY COLLECTED INFORMATION
FORM I - SAN LTIIS OBISPO COLTNTY CERTIFIED I.]NIFIED PROGRAM AGENCY (CUPA)
CIIEMICAL II{VENTORY
material or
AiPETGAS.DOC 1 1-Feb-00
FORM I . SAN LUIS OB.} COUNTY CERTIFIED UNIFIED PRC
\L.M
AGENCY (CI'PA)
CHEMICAL II.IVENTORY
or area)material
ofPageflaooflosrsrr
I. FACILITY INFORMATION
ulvr TFD ?xruceL s€Yzvrc€
3
BUSINESS NAME (SAMC AS FACILITY NAME OT DBA -Doing Business As)
CIIEMICAL LOCATION CONFIDENTIAL
EPCRA
202
YES NO
201
CHEMICAL LOCATION
204GRID# (optional)
-T-S
MAP# (opriona.l)
LFACILITY ID #
tr. CHEI\,TICAL INT'ORMATION
to EPCRA, refer to ilstructions
2M
If
TRADE SECRET Yes No.HEMI.AL **u ETI{ y LEve GLY CO L
205
flYes .F *o
208
EHS*COMMON NAME
+N/T\ FAE "-e *If EHS is "Yes", all amounts below must be in lbsN/+cAs#
210
FIRE CODE HAZARD CLASSES (cotrPlee if rcquircd bv CUPA)
CUzuES
2r2
RADIOACTIVE E Yes ^K NOHAZARDOUS MATERTAL TYPE
(Check one iem only)L-] A. PURE EI b. MIXTURE
2ll
Ec.
LARCEST CONTAINER 55PHYSICAL STATE
(Check one i€m only)E a. SOLrD E[ u. t-tQuto D c. GAS
214
FED HAZARD CATEGOzuES
(Check all fiat apply)fi a. FrRE n b. REACilvE LI c. PRESSURE RELEASE El d. AcurE HEALTH El e. GHRONIC HEALTH
STATE W
r//4
CODEANNUAL WASTE AMOUNT Lt9
b55
AMOUNT
2S
AVERAGE
22DAYS ON SITE:365E d. T0NS$ a. GALL0NS
(Check one item only)
22l
UNMST rlf EHS, amout must be in
G b. CUBIC FEET EI C. POUNDS
E f. cAN
E g. CARBOY
E h. sILo
trtr
G
l.
j.
k.
l.
223
r. OTHER
q. RAIL CAR
BOTTLEDRUMm.ALLIC un
CYLINDER
tru
BAG
BOX
a. ABOVE GROUND E n. PTASTIC BOTTLE
&d. srEEL DRUM
STORAGE
CONTAINER o. TOTE BIN
p. TANK WAGON
b. UNDERGROUND TANK
c. TANK INSIDE BUILDING
El a. AMBIENT [f b. ABovE AMBIENT E C. BELOW AMBIENTSTORAGE PRESSURE
224
sToRAcETEMPERATURq s a. AMBIENT El b. ABOVEAMBIENT EI C. BELOW AMBIENT E d. CRYOGENIC
CAS #EHSHAZARDOUS COMPONENT (For mixture or waste only)%wr '10-)-z\- \zu
f] Yes E[No- ETHvt€
^J
a 6 Lic.' L
t:]u6
I q5
232
flYes flNo230
',
23t
E6
flvo ENoE4
3
241
I Yes fl No
2&
238
4
244
EIv.s Eluo
243242
5
psp€r qptuirg lhcUmrshcGorreight@opoerG E pEBt aa gmtcr then l% by
ADDITIONAL LOCALLY COLLECTED INFORMATION 1+: :{
..t. -1 t .1 . ,\a- '.
AtoxYGEN.DOC 1 1-Feb-00
Page _ of_
Eeno f]REVISE
I. FACILMY INFORMATION
Dr-VM
BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As)
CHEMICAL LOCATION 2n2CONFIDENTIAL
EPCRA
YES
2nt
CHEMICAL LOCATION
GRID# (optiona)I MAP# (optional)2n3
FACILITY ID #
tr. CHEMICAL INT'ORMATION
TRADE SECRET
If Subject to EPCRA, refer to instructions
206YesNo
CHEMICAL NAME
flYes flNo
208
EHS*COMMON NAME
2n'l
*If EHS is "Yes", all amounts below must be in lbs'209
cAs#
4862
FIRE CODE HAZARD CLASSES (complete if rcquirtd bv CUPA)
2t3
CURIESRADIOACTTVE EI YES 8 NOHAZARDOUS MATERTAL TYPE
(Check one item only)El a. PURE E u. t'{lxruns fl c. WASTE
2tl
DLARGEST CONTAINER
215
PHYSICAL STATE
(Check one item onIY)
fl a. SoLID E b. LIQUID Et c. ces
FED HAZARD CATEGORIES
(Check alt ttnt aPPIY)
El a. FrRE fl b. REACTM El c. PRESSURE RELEASE I d. AcuTE HEALTH E e' GHRONIC HEALTH
STATE W CODEWASTEDAILY
3*+
2t8
VERAGE DAILY AMOUNT ^L?y
217
DAYS ON SITE:E d. roNsE a. GALLONS
(Cbeck one it€m only)
221
UNITS+*If amount must be in
El u. custc FEer EI c. POUNDS
E] b. UNDERGROUND TANK
E c. TANK INSIDE BUILDING
f] d. STEEL DRUM
223
r. OTHER
q. RAIL CAR
i. FIBERGROUND TANK j. BAG
k. BOX
"pJ. cvltunen
m.DRUMa.
CONTAINER trn trtrff h. srl-o
E n. PI,ASTIC BOfiLEe.
o. TOTE BIN
p. TANKWAGON
f. CAN
g. CARBOY
E A. AMBIENT EI b. ABOVE AMBIENT E C. BELOW AMBIENT
STOMGE PRESSURE
STOMGE TEMPEMTURE EI A. AMBIENT E b. ABOVE AMBIENT EC. BELOWAMBIENT E d. CRYOCENIC
CAS #EHSHAZARDOUS COMPONENT (For mixture or waste only)%wr 729
74862
2U
[Yes EINoACETYLENE
226I 100 233232
E Yes ! t'lo2n
t
237
flYes E No
236235
3 241240
E Yes flNo
239
4 245244
fl ves fl no
243
242
5
or 0.1% bylfffi
rcquircdqrcimgcnlc, rttrch rdditbul sbccc of prper
c@poeoG lrc PW[t ll grua4r thl! l% by
ADDITIONAL I,OCALLY COLLECTED INFORMATION
FORM I - SAN LTIIS OBISPO COI.INTY CERTIFIED I.INIFIED PROGRAM AGENCY (CTJPA)
CHEMICAL ITWENTORY
material or
C:\example\ACETYLN.DO C 22-F eb-0O
FORM I - SAN LUIS OBISPO COI.INTY CERTIFIED T]NIFIED PROGRAM AGENCY (CTJPA)
CIIEMICAL IT\TVENTORY
material or
Page _ of_
fl,cDo flou-Ern Ensvlse 2N
I. FACILITY INFORMATION
BUSINESS NAME (Same as FACILITY NAME or DBA - Doing
ot fiHffinn@Jro 'Dc-v
JBusiness As)
{,{.?. s
CHEMICAL LOCATION CONFIDENTIAL
EPCRAll vBs El No
202
CHEMICAL LOCATION 201
GRID# (optionat) 2uMAP# loptional;203
ffil.*FACILITY ID #
II. CMMICAL INFORMATION
rnamsecner flY". I No
If Subject to EPCRA' refer to
206
instructions
CHEMICAL NAME
OXYGEN
205
flves E NoEHS*
2!8
COMMON NAME ,0'l
cAs#
7
*If EHS is '(Yes", all amounts below must be in lbs.
2to
FIRE CODE HAZARD CLASSES (complete if rcquircd by CUPA)
2t3
CURIES
2t2
PaDIoACTIVE EYes EnoHAZARDOUS MATERIAL TYPE
(Check one item only)El a, PURE E b. MIXTURE E C. WASTE
211
LARGEST CONTAINER
zt5
9t83PHYSICAL STATE
(Check one item only)E A, SOLID E b. LIQUID 8 C. GAS
214
FED HAZARD CATEGORIES
(check all that apply)I a. FrRE EI b. REACTTVE EI c. PRESSURE RELEASE E d. ACUTE HEALTH E e. GHRONIC HEALTH
216
STATEWASTECODE 22o2t9WASTE AMOUNTztEDAILY AMOUNT
>B+
AVERAGE DAILY AMOUNT 2t7
L@11
DAYS ON SITE:E d. roNsD a. GALLONS
(Check one item onIY)
i. RBER
j. BAGCONTAINERk. Box
EI I. CYLINDER
222221
UNITS*
m.DRUMe.un
*r amount must be in Pounds.
E h. sILo
a. ABOVE GROUND TANK
b. UNDERGROUND TANK
c. TANK INSIDE BUILDING
d. STEEL DRUM
223
r. OTHER
q. RAIL CAR
En. PLASTICBOTTLE F
El o. TorE BIN tr
E p. TANKwAGoN
f. CAN
g. CARBOY
8 b. CUBIC FEET E C. POUNDS
STORJ{GETEMPERATURE El a. AMBIENT D b. ABOVEAMBIENT E c' BELOW AMBIENT E d. cRYocENIc
CAS #
224
VoWT HAZARDOUS COMPONENT (For mixture or waste only)EHS
STOMGE PRESSURE E a. AMBIENT E b. esovgeMstgNr E c. BELOWAMBIENT
7782M7
229
[Yes XNo
2Uall
OXYGEN
226I 100
233
EYes lNo
2322312N
2
231
lYes ENo
236235234
3
241
Eves ilNo
240219238
4
244
lYes Eno
243242
5
p8p€r qptuirg therddiiioul 6heasor 0.1% by lf orclnogenic'cmporenG rre pIwd rt gster tbrn l% by weight ifIf mrc
ADDITIONAL LOCALLY COLLECTED INFORMATION
A:\OXYGEN.DOC 1 1-Feb-00
Huzardous Materiuls Business Plan - List of Chemicals
PermitNo: 60-0118 Facility: U.P.S.
Address: 3601 SACRAMENTO D& SAN LIJIS OBISPO
Maximum Physical Largest
Units Grid No
24 CU FT Gas 24ACETYLENE DICHLORIDT
GAL Liquid MALIPHATIC HYDROCARBONS
GAL Liquid 5555ANTI FREEZE
GAL Liquid 1ffiBENZENE AND TOLUENE 1m
GAL Liquid 55ETHYLENE GLYCOL LIQUID 52
m CU FT Gas NOXYGEN
GAL Liquid 55PETROLEUM DISTILLATES m
Tuesday, Septemher 28, 1999 Page I of I
BID #:
Hazardous Materials
Disclosure lnformation Pa
Please Use Typewriter or Print Cl
s0cti6-n,i.l;;,,Bu$Jriog;:and,;$ddtas$i.,.lhf-offiau6n
0
\\1
\rU\
'.JMTTCD PARcgL E-ra-Vr
Business Namo
3601 sACeomEilTo orr-ive 0 sls P() cA q3qol
g
S A.v Uu'rs ,
Businoss Sile Addresg (Noi a PO Box)Suile/Bldg #City Stato Zip
I A TNE AS A*flVtr-
Mailing Address Businesa Namo (il difforent from above)
FRED crrsTi\lo .- PlsrvT EN 6tN€€n-wq DepT
Mail to lhe Attention of
t 5-0 t RAn/c r-r o conJ EJCI e\vd .l-\}i-,Ru rzy Pr+ra<<-A all32et
Mailing Address (if ditlerent lrom above)Crty Stato Zip
U MIteD p ARcE.L s€P-vrLE-
Onner's Name
5el q- '7t gq
A) Supply tha name, title, phona and availabta hours ol he rasponsible peson to contact Durinq Business Hours:
r6o5\
Business Phone
6 Arq-'.6 fln.
sHtrr nEqRS
\\Bl Supply the nbmes,
too*- 6 P^
C4)
MAAK 3c\rrlliruq / wtArvprGge
NAME / TITLE PHoNE NUMBEB (extension)
lides, phone numbors and available lours ol up to three people to contacl Atter Business Hglrrs:
{h A€.R*cl+r\\rrrJe/ nn trrVAGEe
SHIFT HOURS
tt gpr- I ft'\
SHIFT HOURS
b0u*- b.*n
MME / TTTLE
teu oJw&LD / sv PEprrrso B
oxtension)
NAME / TTLE
^Jt
L sv pr l50R
SHIFT HOURS NAME / TTTLE (whh extension)
Cl Supply tha names, tides, phone numbers and auailable hours of two poople to con. ,ct in case o/ an Emerqenw Haz Mal lncident:
bAtq - hqrvl K. ge.h r) lrru G / W Br/r+Ct=R,lnpe
SHIFT HOURS NAME / TITLE PHONE (with extension)
bpu*bw
SHIFT HOURS
Jeaa, Alqrxa-/ Sr pv
rueuE I rnt-e PHONE (with extension)
)
****SPECIAL NOTICE FOR DISCLOSURE PACKET UPDATES****lf any of the following occurs, you are required to notify our department within fifteen(15) days to.complete an updated Disclosure Form!
Change ol Buciness Addrosa
Change of Businoss Otnorship
Chango ol Businoss Namo
Cessation of Businesg Oporation(s)
Change ol Busines! Occupanry Class (UBC)
Roclassilication of TMDE SECRET INFORMATION
chango ol handling or use.of proviously undisclosod hazardous material, waste or combination theroof.
florage-.or uso of any new hazardour matorialc that would roquire you to comply with tha digclosuro laws,A significant change in handling.or inventory quantity (t ro*) oi"ny rr"zuroous material lor which Disclosurolnlormation har alroady beon made,
SF,gtf p"n#iffilgn;etur€-
I certify, under
the best of my
the penalty of perjury, that the ab,ove information is true and correct to
Signature
3 r 6 r_g__0_
Date
FN cAs.ln I [o - O\ par-r €ri/ GtV{ertru
Nam e and Title (please type or print)
Plearc Relurn Form lo:
1.
2.
3.
4.
5.
6.
7.
8.
9.
SAN LUIS OBISPO FIRE DEPT.
748 PIS|\IO STREET SAN LUIS OEISPO. CA 93J01
Ssctldn :i,l! l..:,i,.,ican sfa! .,..and,,,SUnd{n0i {nfdrmatlon
4
U Nl te>?\\ 6 e,r:-Vtce,
Doing Eusinoss as.than Eusiness Name
00 -686* 51 Z"l
Dun & Eradsireet (D&B) #
DE L\YE r?.y
cAD 18r uq 0zz
EPA ID #
Arac€-L
'l .r
Shitt Hours
Give description ol tho main operation ol your businoss
Employae lnfo - enter # ol amployaas on slta par shift hrs:
..0O Oyn _ nl3gR"^z5
Number of Employoos
Numbor ol Employoea
Number ol Employeea
B
Unilorm Building/Occupancy Codo (UBC)
1
Number ol lloora
lt1
Shift Hou rt
Shitt Houre
Adaitlona Business lnlo:
1
Standard lndustrial Code (SlC)
t-lL Gt\ s. {f
Yes
Aro yar a non'prcfl o,ganbdod?
C
Lot Foporting Status (seo Soc. tV)
our company, but we do NOT meet the
e. We have no chemicals requiring disclosure
used in any way in our business operations
-,.,,*B Chemicals are used inWt* 1h4;Anon'tfiiil}sctosur
in any amounts,
C Chemicals are used in our business and we are reporting our Chemical
h,'t$.,.. 1,,n .,-,lnv€ntqfy,,1_\':'*r#il1
bi*', '.1'.. ' -.,;i i-:;1..,#*iffi
HazM" )l Cnf utcAL tNVENToRY .
-)nru
ver 3.0
Print clearly with INK or use typewriter ONLy
Please read attached instructions carefully
Date:
'cate3 code is roquirod lor input
3/d? B BID:Page I of 3
THt! FORT TO REPORT
Secar-r CHerlcels ONLYI
EPA
302
y/G
y/G)
YiN
Cnmruoca
Y/tl
Y/N
Y/N
Mrsc lxro
Form*: I
Type*; M
oor*: lZ0b
Hlzlno Cutsses
General*:z
I
Physical*: I
Heatth*: L
Wasre lxro
EPA:
State:
-
Class*:
Min%:
Mdxo6
Rad:
Coors
Container Storage*
Pressure Storage*:
HEetTI
-L
55rocl
Flercr
Frne
3
0
(CiElc)
owc PERUnit of
Measure Gpttoars M l2Ooo Ma{Day: t 2O00
Days on Site' 3b5
'oest Conta lzooo I Temperature Storage*: {
Disposal Treatment*:
Map lruro
Page: -lGrid: |-'l
Lr--nTtoN Sfoneo
How Useo/Mrs FVe.u Ka V€Wtc-\ gS
Tnaoe Naue:0tL
EPA
302
Y /61
Y/N
Y/N
Cemruocat
Y/@
Y/@
Y/N
Mrsc lHro
Form*: I'
Type*:
DOT#:
Unit of
Measure:
th---+-
tqq3
HAZARD Cuqsses
General*: Z
Physical*: I
Wasre lHro
EPA:
State:
Class*:
Mino/":
Maxo6:
FtRE
It
{Circle}
Health*:Rad:
A.ltorfs Max/yr:MaVDay: Zb O
z
He,cLTH
I
Bucr
G Avg/Day:
ROWCPE
I30
Davs en $i1s; 3 Mlp luro CooesPage: I Container_storage*: I Temperature Storage*: IGrid: E- pressure Storage*: , oi"pb""i ii""ir"nF, --r-Lcu vcst container:
Locanon SroReo:
How Useo/Mrsc:
Gs
z$o
zBo
{TOR} . JRM ver 3.0
Prlnt clearly with INK or use typewriter ONLy
Please read attached instructions carefully
3 I BtD:Page 2 ot 3Date:
.ticateg codo is roquirod for inpr.d
EPA
302
Y/@
Y/N
Y/N
Cemrcoa.
Yie
Y/N
Y/N
Mrsc lnro
Form*: I
Type*: M
DOT#: -
Hazeno CuassEs
General*:z
Physical*: I z
-Health*:z
Wasre lxro
EPA:
State:
Class*:
Min",6:
ub*t
Rad:
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Avg/Day 3o
FtRE
t
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(Circlo)
RE^cr
ROWCPE
Unit of 6att orvs
Days on gits' ts6lf
--gst Gonta 55
Locenox Sron
5S Max/D qr
Map lxro Cooes
Page: I =- Container Storage*: I Temperature Storage*: I
Grid: FY Pressure Storage*: I Disposal Treatment*:
How Useo/Mls o ^/T \+
o//o
EPA
302
Y/N
Y,, N
Y/N
CercNoce't
Y/N
Y/N
Y/N
Mrsc lNro
Form*:
Type*:
DOT#:
w
qrgq
Hazeno Cusses
General*: Z
Physical*: 1 2* _
Heahh*: L
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EPA: lvotv RCAA MinTo:FrRe
State: rC O I
Class*: I1-
HEAITH
tu
Avg/Day: 3o
Ma;36:
I
0 RE cr
Rad
Unit of
Measure:
D>"^ on Site: 365
r-afgest container: 55
(Glrclc)
ROWCPE
GU.tlorrS Max/f1;-5 MaVDay: 55-
Map lxro CooesPage:_l Container Storage*: I Temperature Storage*: I
GriO: T]f- Pressure Storage*: . Disposal Treatmentl:
-
How Useo/Mrsc:
Locanox Sroneo
Hazlr. Sl CHEMICAL INVENTOR, ORM ver 3.0
Prlnt clearly with INK or use typewriter ONLy
Please read attached instructions carefully
?8 BID:Page 3 of 3Date:
ricatos cods ic requirod lor inpr.rt
TR.qoe Nnue:t)seil fi{ota P O \L
Mrrunes (Llst the three most hazardous lngredlents):CAS# CHeurcru Neue EPA
302
Y t6)
Y/N
Y/N
o//o Cemlrcce
Y/o
Y/N
Y/tl
Mrsc viruro
Form*: I
Type*: \N
oor*: ol \ 8Q
Hazano CLcssEs
General*: Z
Physical
Healthi:
Wasre lxro
EpA: Noil Y<crz4 Min%:
State: \Ol Ubxt"
Class*: I'T Rad:
HEllrx
z-
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\
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REAqr
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Unit of
Measure: Gr.\llon) Max//\LO lzo
ROWCPE
6c)Avg/D
Days on Site Bas
--gst Conta lZo
Cooes
Container Storage*: ) Temperature Storage*: I
Pressure Storage*: I Disposal Treatment*:
Map lNro.
Page: I
Grid: F 7
Locanox
How Usro/Mrsc
Tnqoe Naue:
MtrruRes (Llst the three most hazardous lngredlents):CAS# CxEurcAr Nnue o//o
EPA
302
Y/N
Y/N
Y/N
Camruocery
YiN
Y/N
Y/N
Mrsc lxro
Form*:
Type*:
DOT#:
Unit of
Measure:
Dr"- on Site:
urQ€st Container:
Hazano CLqsses
General*:
Physical*:
Health*:
Wasre lxro
EPA:
State: i)
Cl"ar*,-
Min%:
Ma;3A:
Rad:
Herrx
FrFEt
(Clrc,c)
Rgcgr
ROWCPE
Udx/Day AvglDay
Map lxro CooesPage: Container Storage*: Temperature Storage*:
Grid:
-
Pressure Storagl*: Disposal Treatment*:
-Locanox SroReo:
How Useo/Mrsc
Max/Yr:
I
)
BID #:
.1
'r'r{Hazardous aterials
3pz
t-Disclosure Information Packet ver 3.0
Please Use Typewriter or Print Clearly
q
UNTTED PARCEL SERVTCE
Business Nams
Sile Address (Not a PO Suite/Bldg #State Zip
qAMEl I s aElnvF
Maiiing Address Businesg Narne (il ditferent from above)
FRED CASTILLO
Mail to tho Attention ol
SAME AS ABOVE
Mailing Address (if different from above)City State Zip
TINTTET)PAREEL SERVTCE
Orner's Namo
544-7r84
A) Supply the name, tide, phone and auailable hours of the responsible person to contact Durino BusineQs Hours:
0600-1.BOO KEITH HUGHES,/MANAGER reF
SHIFT HOUBS NAME / TITLE PHONE NUMBER (extension)
.B) Supply the names, tides, phone numbers and availabte hours of up lo hree people to conhct Afler Business Hoursl
0600-1BOO KEITH HUGHES,/MANAGER q - ozne
/8O5 \\-/
Business Phone
SHIFT HOURS
lBOO-0600
SHIFT HOUBS MME / TITLE
OSOO-15OO GARY HUTCHTNGS,/SUPERVTSOR
exiension)MME / TITLE
DAN KURISU/EOORDTNATOR
SHIFT HOURS NAME / TITLE
Cl Supply the names, tides, phona numbers and amilable hours of two people to contact in case of an Emeroenw Haz Mai lncident:
0600-1800 irERRy zvP?.tl./supERvrsoR
PHONE (with exiension)SHIFT HOURS
lBOO-0600
NAME / TITLE
irANrcE KrrCHLr,/SUPERVTSOR
SHIFT HOURS NAME / TITLE PHONE (with extension)
't
****SPECIAL NOTICE FOR DISCLOSURE PACKET UPDATES****lf any of the following occurs, you are required to notify our department within fifteen(15) days to complete an updated Disclosure Form!1. Change ol Busine3! Address2, Change ol Business Orvnership3. Change of Business Name4, Cessation ol Busine$ Operaiion(s)5. Chango of Busines! Occupancy Ciass (UBC)6. Beclassification ol TMDE SECBET trufORUAftOru?-' 9.h*st of handling ot use.ol previously undisclosed hazardoug material, wasie or combination thereof.9' Storage-or use of any new hazardous malerials that would r"quit" youio comply with the disclosure laws.9' A-significant change in handling.or inventory quarndy (.r- 1096) ol any hazardous material for which Disclosureln{ormation har already been made.
I certify, under the penatty of perjury, that the abgve information is true and correct tothe best of my knowtedge. '
Signature -Ll_7
I e4
Date
DAN KURTSU MATERTAI COORDTNATOR
Name and Title (please type or print)
Plearc Fo{urn Form to:
SAN LUIS OBISPO FIRE DEPI.
748 PISIIO.STREET SAN LUIS OEISPO, CA 93101
HazMaI-P\CHEMICAL INVENTORY FdlM ver 3.0
Print clearly with INK or use typewriter ONLy
Please read attached instructions carefully
Date: 9-B-94 BID:Page 1 of 3
:icaies code is required {or inpld
CamNooal
EPA
302
Yi N
Y/N
o N
/@
/@
Y
Y
Mrsc lxro
Form*:-l-
Type*: M
9919;1203
Unit of GALLONSMeasu
Days on S 36s
Hlzlno Cuasses
General*: I
Physical*: I
Heatth*: 2
Wesre lxro
EPA:
State:
Class*: X
FrnE
Min%:
Rad:
HEALTH
1
5soo
3
*
Fscr
ROWCPE
L2000 L2000
--est I 2000
Map lxro -
3??:+
Cooes
Container Storaget: Temperature Storage*:
Pressure Storager: Disposal Treatment*: _
Loclnox
How Useo/Mlsc FUEL FOR PACKAGE CARS
Cemrcoel
Y /6D
EPA
302
Y/N
Y/N
Y/N
Y
Y/N
Mrsc lxro
Form*: I
Type*: M
DOT#: t gg3
Hnzlno Cuesses
General*: 2
Physical*: 1
Heahh*: 2
Wlsre lxro
EPA:
State:
Class*:
Min%:
Ma<o,6:
1
0 BEAcTHsqlrH
I
Frne
Rad:
Unit of
Measure: GALLONS
Da..^ on Site: 365
Ldrgest Container: 2BO
Mep lxro Cooes
Page: 1 Container Storage*:
CriO: E7- Pressure Storage*:
-
(Cilclol
ROWCPE
Avg/Day: L 3O
Temperature Storage*:
Disposal Treatment*:
-
MaVDay: 2BO
How Useo/Mrsc: L
Max/Yr: 28O
LocAnoN StoReo:
HazMat
e-B-e4 BID:Page z of 3
-P\CHEMICAL |NVENTORY FC-]M ver 3.0
Print clearly with INK or use typewriter ONLy
Please read attached instructions carefully
icates code is required for
Date:
inprn
TH} TOil TO BEPORT
SE€Fr CHerE ls OilLn
CemNoos'l
EPA
302
Y/N
Y/N
Y/N
Y (D)
Y/N
Y/ N
Mrsc lxro
Form*: 1
Type*: M
DOT#: -
Hnzlno CLqsses
Generai*: a
Physicaf*: i L
-Heatth*: L
55
Wasre lxro
EPA:
State:
Class*:
M
Mino6:
Rad:
Helt-n
30
Rarcr
Frne
I
c
{Circl.)
2
Unit of
Measure. GALLONS
Days on S ha. 365
'oest 55
ROWCPE
55
MAP INFo. CooesPage: r Container Storage*: - Temperature Storage*:Grid: B-7 pressure
Lr-,nTlON
How
TRADE NAME: WASTE ANTT-FREEZE
Mrrrunes (Llst the three moet hazardoue lngredlents):CAS# Cxeurcel Nrue EPA% g0Z CArcNoGs.l
Y/N Y/N
Y/N Y/N
YiN Y/N
Mtsc lxro
Form*: I
Type*: W
DOT#: 9t89
Unit of
Measure: GALLONS
Davs on Site: 365
HazaRo CLqsses
General*: :L
Wasre lxro
EPA: NoN-RcRA Min%:
State: ool M*,-
FtFE
1I
{Cll9l"}
Physical*: r 2
Heahh*: L Class*: :i -f Rad:
Max/Yr: 55 MaVDay: 55
Mlp lnro Cooes
Avg/Day: 30
Temperature Storage*:
Disposal Treatment*:
HEALTH
2
Balct
ROWCPE
Ld,vest conrainer: ss cALLoNs __-ffi?:=ts F,"#?:t::?$t":;'
@ERT' -:j- vrvrq!
LocATtoN Stoneo:
How useo/Mrsc:
HazMat-'ICHEM|CAL INVENTORY Fr -)M
ver 3.0
Prlnt clearly with INK or use typewriter ONLy
Please read attached instructions carefully
Date: 9-8-94 BID:Page g of 3
.ricales oodo ic required for inpr,i
Tmoe NlMe:
Mocnlnes (Llst the three most hazardous lngredlents):CAS# Cxeurcer Nnue a/o
EPA
302
Y/N
Y/N
Y/N
Cnrolpae
Y/N
Y/N
Y/N
Mrsc lxro
Form*:-L-
Type*: hr
DOT#.9189
Haz,a,no Cuasses
General: fu
Physical *.
Wlsre lxro
EPA: NON-RCRA Min%:
Sr"rq oOl
Class*: d
HEALTT-I REAcT
ROWCPE
Avg/Day:--@---
Temperature Storage*:
Disposal Treatment*: _
Frne
1
*
2Health*: L Rad:
Unit of
M
Days on S 65
Maxfrr:---129--- M 1?o
ira. 3
'.est contai 20
Map lHro CooesPage: 1 Container Storager:
Grid: E-7 Pressure Storager
Locanox S
How Useo/M
TRloe Naue:
Mxrunes (Llst the three most hazardous lngredlents):CAS# CHEurcer NeuE o/o
EPA
302
Y/N
Y/N
Y/N
Camrpcal
YiN
Y/N
Y/N
Mrsc lxro
Form*:
Type*:
DOT#:
Unit of
Measure:
Da"- on Site:
urgest container:
Hazlno Cusses
Generali:
PhysicaF:
Health*:
Wasre lxro
EPA:
State: _
Class*:
Max/Day:
Map lxro
Page:
Grid:
-
Min%:
MalfA:
Rad:
Avg/Day:
Cooes
Container Storager:
Pressure Storage*:
HEATTH RgAcr
(Clrrlcl
FOWCPE
Temperature Storage*:
Disposal Treatment*:
-
Frne
0
Locanox SroReo:
How Useo/Mlsc:
MaxA/r: