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HomeMy WebLinkAboutHMBP3U1vIFIED PROGRAM CONSOLIDATED FORivi HAZARDOUS MATERIALS HAZARDOUS MATERIALS INVENTORY — CHEMICAL DESCRIPTION ate Paw off matenal per building or area ❑ADD ❑DELETE ❑REVISE 21 I. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA — Doing Business As) 3 PAUL'S DRY CLEANERS CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 of Building. ❑ YES 1 FACILITY ID # 1 F A 0 0 0 5 1 0 3 MAI'# (optional) 203 GRID# (optional) 204 01 B2 II. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET LJ Yes 206 ,Waste Hydrocarbon Solvent If Subject to EPCRA, referto instructions COMMON NAME 207 208 Waste Hydrocarbon Solvent EHS* ❑ Yes CAS# 209 If EHS is "Yes", all amounts below must be in lbs. FIRE CODE HAZARD CLASSES (Complete if required by CUPA) 210 Combustible Liquid, Class II (1.1 II) HAZARDOUS MATERIAL TYPE (Check one item only) Oa. PURE Ob. MIXTURE Oc. WASTE 211 213 RADIOACTIVE []Yes 212 TCURIES PHYSICAL S 1'A 1 E 213 (Check one item only) O a. SOLID Ob LIQUID O c. GAS 214 LARGEST CONTAINER 55.0 FED HAZARD CATEGORIES - PHYSICAL 9FLAMMABLE GAS UNDER PRESSURE EXPLOSIVE SELF HEATING (check all that apply) ❑ PYROPHORIC ❑OXIDIZER []ORGANIC PEROXIDE ❑ SELF REACTIVE ❑ PYROHORIC GAS []CORROSIVE TO METAL ❑ CONTACT WATER EMITS FLAMMABLE GAS ❑ COMBUSTA13LE TO DUST ❑X HAZARD NOT OTHERWISE CLASSIFIED FED HAZARD CATEGORIES -HEALTH: ❑ CARCIGONECITY ❑ ACUTE TOXICITY ❑REPRODUCTIVE TOXICITY [_]SKIN CORROSION OR IRRITATION (check all that apply) ❑ RESPIRATIORY OR SKIN SENSITIZATION ❑ SERIOUS EYE DAMAGE OR EYE IRRIATIION ❑ SPECIFIC TAGET ORGAN TOXICITY ❑ ASPIRATION HAZARD ❑ GERM CELL MUTAGENICITY ❑ SIMPLE ASPHYXIANT Ej] HAZARD NOT OTHERWISE CLASSIFIED AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 55.0 1 55.0 1 55.0 1 UNITS* Qa. GALLONS O b. CUBIC FEET O C. POUNDS Od. TONS 221 1 DAYS ON SITE: 222 Chcck one item only) • If 1:11S, amount must be in pounds. 365.0 STORAGE CONTAINER ❑a. ABOVE GROUND TANK ❑e. PLASTIC/NONMETALLIC DRUM[] i. FIBER DRUM ❑m. GLASS BOTTLE ❑q. RAIL CAR ❑b. UNDERGROUND TANK ❑ f. CAN ❑). BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER ❑c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k BOX ❑ o. TOTE BIN Rld. STEEL DRUM ❑ It. SILO ❑ I. CYLINDER ❑ p. TANK WAGON 223 STORAGE PRESSURE O a. AMBIENT O b. ABOVE AMBIENT O c BELOW AMBIENT 224 STORAGE TEMPERATURE O a. AMBIENT O b. ABOVE AMBIENT O c. BELOW AMBIENT Od. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 Waste Hydrocarbon Solvent 227 ❑Yes 228 229 F5.O230 Dirt, Debris 231 ❑Yes 232 233 3 234 235 1:1 236 237 4 236 239 ❑Yes 240 241 5 242 243 ❑Yes 244 245 If more haxarttou• components are present at greater than 1% by weight if non -carcinogenic, or 0.1 % by weight ircarcinogenir, attach additional sheets of paper cepluring the required information. DDITIONAL LOCALLY COLLECTED INFORMATION 244 dFIED PROGRAM CONSOLIDATED FC FACILITY INFORMATION BUSINESS ACTIVITIES Page 1 of I. FACILITY IDENTIFICATION FACILITY ID # IFIAIOIOI015111 0 3 t EPA ID # (Hazardous Waste Only) 2 (Agency Use Only) CAD981666464 BUSINESS NAME (Same as Facility Name ofDBA-Doing Business As) DRY QLEANERS3 BUSINESS SITE ADDRESS 214 HIGUERA ST 10) BUSINESS SITE CITY SAN LUIS OBISPO 10A CA ZIPCODE 93401 los II. ACTIVITIES DECLARATION NOTE: If you check YES to any part of this list, lease submit the Business Owner/Operator Identification page. Does your faciIit y... If Yes, please com lete these pages of the UPCF.... A. HAZARDOUS MATERIALS Have on site (for any purpose) at any one time, hazardous materials at or above HAZARDOUS MATERIALS 55 gallons for liquids, 500 pounds for solids, or 200 cubic feet for compressed ❑x YES INVENTORY —CHEMICAL gases (include liquids in ASTs and USTs); or the applicable Federal threshold DESCRIPTION quantity for an extremely hazardous substance specified in 40 CFR Part 355, Appendix A or B; or handle radiological materials in quantities for which an ernergency plan is required pursuant to 10 CFR Parts 30 40 or 70? B. REGULATED SUBSTANCES Have Regulated Substances stored onsite in quantities greater than the threshold quantities established by the California Accidental Release ❑ YES Coordinate with your local agency prevention Program (CalARP)? responsible for CaIARP. C. UNDERGROUND STORAGE TANKS (USTs) UST FACILITY (Formerly SWRCB Form A) Own or operate underground storage tanks? ❑ YES UST TANK (one page per tank) (Formerly Form B) D. ABOVE GROUND PETROLEUM STORAGE Own or operate ASTs above these thresholds: Store greater than 1,320 gallons of petroleum products (new or used) in ❑ YES NO FORM REQUIRED TO CUPAs aboveground tanks or containers. E. HAZARDOUS WASTE Generate hazardous waste? Q YES EPA ID NUMBER — provide at the top of this page Recycle more than 100 kg/month of excluded or exempted recyclable materials (per HSC 25143.2)? ❑ YES RECYCLABLE MATERIALS REPORT (one per recycler) Treat hazardous waste on -site? ❑ YES ON -SITE HAZARDOUS WASTE TREATMENT — FACILITY ON -SITE HAZARDOUS WASTE TREATMENT — UNIT (one page per unit) Treatment subject to financial assurance requirements (for Permit by Rule and Conditional Authorization)? ❑ YES CERTIFICATION OF FINANCIAL ASSURANCE Consolidate hazardous waste generated at a remote site? ❑ YES REMOTE WASTE / CONSOLIDATION SITE ANNUAL NOTIFICATION Need to report the closure/removal of a tank that was classified as ❑ YES HAZARDOUS WASTE TANK hazardous waste and cleaned on -site? CLOSURE CERTIFICATION Generate in any single calendar month 1,000 kilograms (kg) (2,200 pounds) or Obtain federal EPA ID Number, file more of federal RCRA hazardous waste, or generate in any single calendar ❑ YES Biennial Report (EPA Form 8700- month, or accumulate at any time, 1 kg (2.2 pounds) of RCRA acute hazardous 13A/B), and satisfy requirements for waste; or generate or accumulate at any time more than 100 kg (220 pounds) of RCRA Large Quantity Generator. spill cleanup materials contaminated with RCRA acute hazardous waste. Household Hazardous Waste (HHW) Collection site? ❑ YES See CUPA for required forms. F. LOCAL REQUIREMENTS 15 (You may also be required to provide additional infonnation by your CUPA or local agency.) UPCF Rev. (12/2007) FORM S — SAN LUIS OBISPO COUNTY CERTIFIED UNIFIED PROGRAM AGENCY BUSINESS OWNER/OPERATOR IDENTIFICATION I. IDENTIFICATION BUSINESS NAME (Same as FACILITY NAME or DBA — Doing Business As) BUSINESS PHONE PAUL'S DRY CLEANERS 8055432250 BUSINESS SITE ADDRESS 214 HIGUERA ST CITY SAN LUIS OBISPO CA ZIP CODE 93401 COUNTY San Luis Obispo IUS SS ERATOR NAME raltm o BUSINESS OPERATOR PHONE 8055432250 II. BUSINESS OWNER OWNER NAME OWNER PHONE MORABITO, JAMES 8055432250 OWNER MAILING ADDRESS 214 HIGUERA CITY STATE ZIP CODE SAN LUIS OBISPO CA 193401 III. ENVIRONMENTAL CONTACT CONTACT NAME CONTACT PHONE Jim Morabito 8055432250 CONTACT MAILING ADDRESS 214 Higuera Street CITY STATE ZIP CODE San Luis Obispo CA 193401 -PRIMARY- IV. EMERGENCY CONTACTS -SECONDARY- NAME NAME MORABITO, ROD MORABITO, JIM TITLE TITLE MANAGER Owner BUSINESS PHONE BUSINESS PHONE 8055432250 8055432250 24-HOT IR Punrrg 24-HOUR PHONE PAGER # / CELL PHONE # PAGER # / CELL PHONE # 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. SIGNATURE OF OWNER/OPERATOR OR DESIGNATED REPRESENTATIVE DATE NAME OF DOCUMENT PREPARER Submitted via Public Portal 11 /02/2012 Rod Morabito NAME OF SIGNER (print) TITLE OF SIGNER Jim Morabito Manager FORM I — SAN LUIS OBISPO COUNTY CERTIFIED UNIFIED PROGRAM AGENCY (CUPA) CHEMICAL INVENTORY one arc cr malcrial mr building or area) ❑ADD ❑DELETE ❑REVISE I. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA — Doing Business As) PAU L'S DRY CLEANERS CHEMICAL LOCATION - aIlding. CHEMICAL LOCATION CONFIDENTIAL EPCRA ❑ YES ❑ NO FACILITY ID # FA0005103 MAP# 0 1 GRID# L^ (Agency use only) H. CHEMICAL INFORMATION CHEMICAL NAME Hydrocarbon Based Solvent TRADE SECRET ❑ Yes [I No IfSubject to EPCRA, refer to instructions COMMONNAME Hydrocarbon Dry Cleaning Solvent EHS* ❑Yes ❑ No CAS# *If EHS is "Yes", all amounts below must be in lbs. FIRE CODE HAZARD CLASSES (Completeirrequired by CUPA) Combustible Liquid, Class II (1.1 II) HAZARDOUS MATERIAL TYPE 0(Check one item only) a. PURE ❑ b. MIXTURE [Ic. WASTE RADIOACTIVE ❑Yes [INo CURIES PHYSICAL STATE ❑ a. SOLID ❑x b. LIQUID ❑ c. GAS LARGEST CONTAINER 150.0 (Check one item only) FED HAZARD CATEGORIES x a. FIRE ❑ b. REACTIVE c, PRESSURE RELEASE (Check all that apply) ❑ ❑ ❑ d. ACUTE HEALTH 0 e. CHRONIC HEALTH AVERAGE DAILY AMOUNT MAXIMUM DAILY AMOUNT ANNUAL WASTE AMOUNT STATE WASTE CODE 150.0 1 150.0 UNITS* ❑X a. GALLONS ❑ b, CUBIC FEET ❑ c. POUNDS ❑ d. TONS DAYS ON SITE: 365.0 (Check one item only) *If EHS, amount must be in pounds. STORAGE ❑x a. ABOVE GROUND TANK ❑ e. PLASTIC/NONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE CONTAINER ❑ b. UNDERGROUND TANK ❑ f CAN ❑ j. BAG ❑ n. PLASTIC BOTTLE ❑ q. RAIL CAR ❑ c. TANK INSIDE BUILDING ❑ g. CARBOY 0 k. BOX Q o. TOTE BIN ❑ r. OTHER ❑ d. STEEL DRUM [3 It. SILO (3 I. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE ❑x a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT STORAGE TEMPERATURE ❑x a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 1 ❑ Yes ❑ No 2 ❑ Yes ❑ No 3 ❑ Yes ❑ No 4 ❑ Yes ❑ No 5 ❑ Yes ❑ No If more hazardous components are present at greater than 1 % by weight if non -carcinogenic, or 0.1 % by weight if enrcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION If FPC'RA Plca.se Sign Here FORM I — SAN LUIS OBISPO COUNTY CERTIFIED UNIFIED PROGRAM AGENCY (CUPA) CHEMICAL INVENTORY one a material 1t•r buildim, or:urt•al ❑ADD ❑DELETE REVISE I. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA — Doing Business As) PAU L'S DRY CLEANERS CHEMICAL LOCATION CHEMICAL LOCATION CONFIDENTIAL EPCRA ❑ YES ❑ NO FACILITY ID # FA0005103 MAP# O GRID# ^ (Agency use only) L H. CHEMICAL INFORMATION CHEMICAL NAME Perch I o roethyl e n e TRADE SECRET 0 Yes No instructions If Subject to EPCRA, refer to COMMONNAME PERC EHS* ❑Yes ❑ No CAS# *If EHS is "Yes", all amounts below must be in lbs. FIRE CODE HAZARD CLASSES (Complete if required by CUPA) Toxic (Tox) HAZARDOUS MATERIAL TYPE x a. PURE [I b. ❑ b. MIXTURE ❑ c, WASTE RADIOACTIVE Yes []No TC7ES (Check one item only) PHYSICAL STATE ❑ a. SOLID ❑x b. LIQUID ❑ c. GAS LARGEST CONTAINER 180.0 (Check one item only) FED HAZARD CATEGORIES ❑ a. FIRE [Ib. REACTIVE ❑ c, PRESSURE RELEASE ❑x d. ACUTE HEALTH ❑x e. CHRONIC HEALTH (Check all that apply) AVERAGE DAILY AMOUNT MAXIMUM DAILY AMOUNT ANNUAL WASTE AMOUNT STATE WASTE CODE 180.0 180.0 UNITS* ❑X a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS DAYS ON SITE: 365.0 (Check one item only) *If EHS, amount must be in pounds. STORAGE ❑x a. ABOVE GROUND TANK ❑ e. PLASTIC/NONMETALLIC DRUM ❑ i. FIBER DRUM 0 m. GLASS BOTTLE CONTAINER ❑ b. UNDERGROUND TANK Q f. CAN ❑ j. BAG ❑ n. PLASTIC BOTTLE 13 q. RAIL CAR ❑ c. TANK INSIDE BUILDING 0 g. CARBOY Q k. BOX ❑ o. TOTE BIN 0 r. OTHER ❑ d. STEEL DRUM ❑ h. SILO Q 1. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE ❑x a. AMBIENT ❑ b ABOVE AMBIENT ❑ c, BELOW AMBIENT STORAGE TEMPERATURE ❑x a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c, BELOW AMBIENT ❑ d. CRYOGENIC %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 1 ❑ Yes ❑ No 2 ❑ Yes ❑ No 3 ❑ Yes ❑ No 4 ❑ Yes ❑ No 5 ❑ Yes ❑ No 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. ADDITIONAL LOCALLY COLLECTED INFORMATION If EPCRA, Please Sign Here FORM I — SAN LUIS OBISPO COUNTY CERTIFIED UNIFIED PROGRAM AGENCY (CUPA) CHEMICAL INVENTORY one page per material per building or area ❑ADD ❑DELETE ❑REVISE L FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA — Doing Business As) PAU L'S DRY CLEANERS CHEMICAL LOCATION " ' CHEMICAL LOCATION CONFIDENTIAL EPCRA ❑ YES ❑ NO FACILITY ID # FA0005103 MAP# GRID# (Agency use only) II. CHEMICAL INFORMATION CHEMICAL NAME Waste Filters w/P E RC TRADE SECRET ❑ Yes []No If Subject to EPCRA, refer to instructions COMMONNAME Waste PERC Filters EHS* ❑Yes ❑ No CAS# *If EHS is "Yes", all amounts below must be in lbs. FIRE CODE HAZARD CLASSES (Complete if required by CUPA) Toxic (Tox) HAZARDOUS MATERIAL TYPE ❑ a. PURE 0 b. MIXTURE ❑ c. WASTE (Check one item only) RADIOACTIVE ❑ Yes ❑ No CURIES PHYSICAL STATE x a. SOLID ❑ ❑ b, LIQUID ❑ c, GAS LARGEST CONTAINER 5 5.0 (Check one item only) FED HAZARD CATEGORIES ❑ a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE ❑ d ACUTE HEALTH 0 e. CHRONIC HEALTH (Check all that apply) AVERAGE DAILY AMOUNT MAXIMUM DAILY AMOUNT ANNUAL WASTE AMOUNT STATE WASTE CODE 55.0 110.0 200.0 UNITS* ❑X a, GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS DAYS ON SITE: 365.0 (Check one item only) *If EHS, amount must be in pounds. STORAGE ❑ a. ABOVE GROUND TANK e. PLASTIC/NONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE CONTAINER ❑ b. UNDERGROUND TANK ❑ f. CAN ❑ j. BAG ❑ n. PLASTIC BOTTLE ❑ q. RAIL CAR ❑ c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k. BOX ❑ o TOTE BIN ❑ r. OTHER m d. STEEL DRUM ❑ h. SILO [11. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE ❑x a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT STORAGE TEMPERATURE ❑x a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # I 75.0 Aluminum Housing ❑ Yes ❑ No z 20.0 Fiber Filter Material ❑ Yes ❑ No 3 5.0 Perch loroethlyene Residue ❑ Yes ❑ No a ❑ Yes ❑ No 5 ❑ Yes ❑ No If mare 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. ADDITIONAL LOCALLY COLLECTED INFORMATION If EPCRA. Please Sign Here FORM I — SAN LUIS OBISPO COUNTY CERTIFIED UNIFIED PROGRAM AGENCY (CUPA) CHEMICAL INVENTORY one page per material per building or area [:]ADD ❑DELETE ❑REVISE I. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA —Doing Business As) PAU L'S DRY CLEANERS CHEMICAL LOCATION ding CHEMICAL LOCATION CONFIDENTIAL EPCRA ❑ YES ❑ NO FACILITY ID # FA0005103 MAP# O GRID# ^ use only) L(Agency II. CHEMICAL INFORMATION CHEMICAL NAME Waste Hydrocarbon Filters TRADE SECRET El Yes ❑ No instructions If Subject to EPCRA, refer to COMMON NAME Waste Hydrocarbon Filters EHS* ❑Yes ❑ No CAS# *If EHS is "Yes", all amounts below must be in lbs. FIRE CODE HAZARD CLASSES (Complete i£required by CUPA) Combustible Liquid, Class II (1.1 II) HAZARDOUS MATERIAL TYPE (Check one item only) ❑ a PURE ❑ b. MIXTURE ❑x c. WASTE RADIOACTIVE ❑ Yes [I No CURIES PHYSICAL STATE ❑x a. SOLID ❑ b. LIQUID ❑ c. GAS LARGEST CONTAINER 55 (Check one item only) . FED HAZARD CATEGORIES 0 a FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE ❑ d. ACUTE HEALTH e. CHRONIC HEALTH (Check all that apply) AVERAGE DAILY AMOUNT MAXIMUM DAILY AMOUNT ANNUAL WASTE AMOUNT STATE WASTE CODE 55.0 1 55.0 1 55.0 UNITS* ❑X a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS DAYS ON SITE: ^ O (Check one item only) *If EHS, amount must be in pounds. b . STORAGE ❑ a. ABOVE GROUND TANK e. PLASTIC/NONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE CONTAINER ❑ b. UNDERGROUND TANK ❑ f. CAN ❑ j BAG ❑ n. PLASTIC BOTTLE ❑ q RAIL CAR ❑ c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k- BOX ❑ o. TOTE BIN ❑ r. OTHER ❑x d. STEEL DRUM ❑ h SILO [11. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE 0 a AMBIENT ❑ b ABOVE AMBIENT ❑ c. BELOW AMBIENT STORAGE TEMPERATURE ❑x a AMBIENT ❑ b. ABOVE AMBIENT ❑ c BELOW AMBIENT ❑ d. CRYOGENIC %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # I 75.0 Aluminum Housing ❑ Yes ❑ No z 20.0 Fiber Filter ❑ Yes ❑ No 3 5.0 Hydrocarbon Residue ❑ Yes ❑ No 4 ❑ Yes ❑ No 5 _T❑ Yes ❑ No If more hazardous components are present at greater than 1 % by weight if non-cnrcinogenic, or 0.1 % by weight if carcinogenic, attach ndditionnl sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION If EPCRA. Please Sign Here FORM I — SAN LUIS OBISPO COUNTY CERTIFIED UNIFIED PROGRAM AGENCY (CUPA) CHEMICAL INVENTORY one a �c cr material ,cr huildin or urea) ❑ADD ❑DELETE ❑REVISE I. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) PAU L'S DRY CLEANERS CHEMICAL LOCATION - — - Jing CHEMICAL LOCATION CONFIDENTIAL EPCRA ❑ YES ❑ NO FACILITY ID # FA0005103 MAP# 0 / II GRID# ^ (Agency use only) L II. CHEMICAL INFORMATION CHEMICAL NAME Waste Hydrocarbon Solvent TRADE SECRET Yes No If Subject to EPCRA, refer to instructions COMMONNAME Waste Hydrocarbon Solvent EHS* ❑Yes ❑ No CAS# *If EHS is "Yes", all amounts below must be in lbs. FIRE CODE HAZARD CLASSES (Complete if required by CUPA) Combustible Liquid, Class II (1.1 II) HAZARDOUS MATERIAL TYPE ❑ a. PURE ❑ b. MIXTURE ❑x c. WASTE (Check one item only) RADIOACTIVE ❑ Yes ❑ No CURIES PHYSICAL STATE ❑ a. SOLID 0 b. LIQUID ❑ c. GAS LARGEST CONTAINER 55.0 (Check one item only) FED HAZARD CATEGORIES ❑x (Check all that apply) a. FIRE ❑ b. REACTIVE ❑ c, PRESSURE RELEASE ❑ d. ACUTE HEALTH ❑X e. CHRONIC HEALTH AVERAGE DAILY AMOUNT MAXIMUM DAILY AMOUNT ANNUAL WASTE AMOUNT STATE WASTE CODE 55.0 1 55.0 1 55.0 UNITS* ❑X a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS DAYS ON SITE: ^ ^ 3 (vim 0 (Check one item only) *IEHS, amount must be in pounds. Vhf . STORAGE ❑ a. ABOVE GROUND TANK ❑ e. PLASTIC/NONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE CONTAINER ❑ b. UNDERGROUND TANK ❑ f. CAN ❑ j. BAG ❑ n. PLASTIC BOTTLE ❑ q. RAIL CAR Q c. TANK INSIDE BUILDING Q g, CARBOY Q k. BOX i' o. TOTE BIN ❑ r. OTHER M d. STEEL DRUM 0 h. SILO 13 1. CYLINDER [3 p. TANK WAGON STORAGE PRESSURE ❑x a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c BELOW AMBIENT STORAGE TEMPERATURE ❑x a. AMBIENT ❑ b, ABOVE AMBIENT ❑ c, BELOW AMBIENT ❑ d CRYOGENIC %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # I 95.0 Waste Hydrocarbon Solvent ❑ Yes ❑ No z 5.0 Dirt, Debris ❑ Yes ❑ No 3 ❑ Yes ❑ No 4 ❑ Yes ❑ No 5 ❑ Yes ❑ No 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. ADDITIONAL LOCALLY COLLECTED INFORMATION If EPCRA Please Silln Here FORM I — SAN LUIS OBISPO COUNTY CERTIFIED UNIFIED PROGRAM AGENCY (CUPA) CHEMICAL INVENTORY (one iiai,,c tivr material per huddin, or m cal ❑ADD ❑DELETE ❑REVISE I. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA — Doing Business As) PAU L'S DRY CLEANERS CHEMICAL LOCATION _ _ _ Y :g CHEMICAL LOCATION CONFIDENTIAL EPCRA ❑ YES NO FACILITY ID # FA0005103 MAP# 0 GRID# ^ (Agency use only) L H. CHEMICAL INFORMATION CHEMICAL NAME Waste Perch loroethylene TRADE SECRET ❑ Yes []No instructions If Subject to EPCRA, refer to COMMONNAME Waste PERC EHS* ❑Yes ❑ No CAS# *If EHS is "Yes", all amounts below must be in Ibs. FIRE CODE HAZARD CLASSES (Complete if required by CUPA) Toxic (Tox) HAZARDOUS MATERIAL TYPE (Check one item only) ❑ a, PURE ❑ b. MIXTURE ❑x c. WASTE RADIOACTIVE ❑Yes ❑ No CURIES PHYSICAL STATE ❑ a. SOLID ❑ b. LIQUID 0 c. GAS LARGEST CONTAINER 55 (Check one item only) . FED HAZARD CATEGORIES ❑ a. FIRE ❑ b, REACTIVE ❑ c. PRESSURE RELEASE ❑x d. ACUTE HEALTH ❑x e. CHRONIC HEALTH (Check all that apply) AVERAGE DAILY AMOUNT MAXIMUM DAILY AMOUNT ANNUAL WASTE AMOUNT STATE WASTE CODE 110.0 1 110.0 1 370.0 UNITS* 0 a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d_ TONS DAYS ON SITE: ^ 5 (Check one item only) *If EHS, amount must be in pounds. b .O STORAGE a. ABOVE GROUND TANK ❑ e. PLASTIC/NONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m, GLASS BOTTLE CONTAINER ❑ b. UNDERGROUND TANK ❑ f. CAN ❑ j. BAG ❑ n. PLASTIC BOTTLE ❑ q. RAIL CAR ❑ c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k BOX ❑ o. TOTE BIN ❑ r. OTHER ❑ d. STEEL DRUM ❑ It. SILO ❑ I. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE ❑x a AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT STORAGE TEMPERATURE ❑x a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 1 97.0 Perch loroethylene ❑ Yes ❑ No 2 3.0 Solids, Debris ❑ Yes ❑ No 3 ❑ Yes ❑ No 4 ❑ Yes ❑ No 5 ❑ Yes ❑ No 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. ADDITIONAL LOCALLY COLLECTED INFORMATION If EPCRA, Please Sign Here n c � rD C CD y a r o � � c C O N C IC, Z O � c c � C o O Zz— • o ti yOy c.,'� �,q Owe O � O -� cn cD C � a � a o c O .. � o eD M FORM I — SAN LUIS OBISPO COUNTY CERTIFIED UNIFIED PROGRAM AGENCY (CUPA) CHEMICAL INVENTORY (one page per material per building or area) ❑ADD ❑DELETE ❑REVISE 200 Page & of/ I. FACILITY INFORMATION BUSIN S NA E (S me as FACILITY NAME or DBA - Doing Business As) 3 CHEMICAL L CA ION 201 CHEMICAL LOCATION CONFIDENTIAL 202 �� EPCRA V e W YES 0 -kj FACILITY ID 1 MAP# (optional) 203 -#-2-3 GRID# (optional) 204 II. CHEMICAL INFORMATION CHE CAL N 205 TRADE SECRET El Yes No 206 7E ] {ci/1 / /'('y k n 2. If Subject to EPCRA, refer to instructions COM N NAME 207 208 EHS* Yes ❑ No CASH 209 *If EHS is "Yes", all amounts below must be in lbs. FIRE CODE HAZARD CLASSES. (Complete if required by CUPA) 210 HAZARDOUS MATERIAL TYPE tut( PURE ❑ b. MIXTURE ❑ c. WASTE 211 RADIOACTIVE El Yes Wo 212 CURIES 213 (Check one item only) , - PHYSICAL STATE 214 ❑ a. SOLID Xb. LIQUID ❑ c. GAS 3 -- L1"' 215 LARGEST CONTAINER 'y I,,f (Check one item only) H f ,�jQO qo,0 APA/4 216 FED HAZARD CATEGORIES ' ❑ a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE ❑ d. ACUTE HEALTH'e. CHRONIC HEALTH (Check all that apply) AVERAGE DAILY AMOUNT / 217 MAXIMUM DAILY AMOUNT z1s ANNUAL WASTE AMPUNT 219 STATE WASTE CODE 220 60 Gyll>IS ; h cN.'r•� , �4 /pH-S UNITS* Xa. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS 221 DAYS ON SITE: 222 �3 (Check one item only) *If EHS, amount must be in pounds. (D STORAGE ❑ a. ABOVE GROUND TANK ❑ e. PLASTICM METALLI, ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE 223 , T 5 CONTAINER ❑ b. UNDERGROUND TANK [If. CAN U$v t 1" ❑ j. BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER BUILDING ❑ CARBOY ! ' ❑ k. BOX ❑ TOTE BIN ❑ RAIL CAR ❑ TANK INSIDE g. o. q. ' ❑ I. CYLINDER ❑ TANK WAGON d. STEEL DRUM ❑ It. SILO p. s ` STORAGE PRESSURE j$a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE C' a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 L / 227 PrC��O�l El Yes ❑ No 226 ©®©1 n7 /g- q 229 . roe P ,L. 230 2 231 232 ❑ Yes El No 233 234 3 235 236 ❑ Yes ❑ No 237 238 4 239 240 ❑ Yes ❑ No 241 242 5 243 244 ❑ Yes ❑ No 245 H 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. ADDITIONAL LOCALLY COLLECTED INFORMATION i t4-, S 2 6 r ++ � ex 1� If EPCRA. Please Slat lfOd A:1Chemical Inventory Business Plan.DOC 14-Feb-00