HomeMy WebLinkAboutHMBP4BID #:
Hazardous Materials
Disclosure Information Packet ver 3.0
Please Use Typewriter or Print Clearly
S+a or t -business and Adt ss Intorimation
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se Site Addres of a PO
Mailing Address mess (if different from above)
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Mail to the Attention of
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N City
State
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Zip
Mallinm Add roes (if erent tr9rn ro
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Owner's Name
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Business Phone
�e�c�ri`'�E4���e�orit triforrnatari
A) Supply the name, title, phone and available hours of the responsible person to contact During Business Hours:
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a 4,4, Jo
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SHIFT HOURS NAME / TTTLE PHONE NUMBER (extension)
.B) Supply the names, titles, phone numbers and available hours of up to three people to contact After Business Hours:
3 Ar o rr r
SHIFT HOURS NAME / TTrLE PHONE (with extension)
SHIFT HOURS NAME / TTrLE PHONE (with extension)
SHIFT HOURS NAME / TrrLE PHONE (with extension)
C) Supply the names, titles, phone numbers and available hours of two people to contact in case of an Emergency Haz Met Incident:
U -
SHIFT HOURS NAME / TTrLE PHONE (with extension)
U -
SHIFT HOURS NAME / TTiLE PHONE (with extension)
sectionIt: �► fienerat sad 8ui nQ r fornss o
Doing Business as (DBA) - if different than Business Name
City Business License N
l (-Y i
Give description of th main ope
Dun t& Brads�reeet (DriB) #r
'
your business
Employee Info - enter rlr of employees on site per shift hrs:
Shift Hours Number of Employees
Shift Hours
Shift Hours
Additional Business Info:
Standard Industrial Code (SIC)
Number of Employe"
Number of Employe"
Uniform Building/Occupancy Code (UBC)
6 100o i� I -3993
EPA ID #
YesL
Are you a non profit orpartmifa*
Lot Siz - Identify in sq.ft or acreage Number of floors Reporting Status (see Sec. IV)
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A No Chemicals are used in any way in our business operations
B Chemicals are used in our company, but we do NOT meet the
requirements for disclosure. We have no chemicals requiring disclosure
in any amounts.
C Chemicals are used in our business and we are reporting our Chemical
Inventory.
****SPECIAL NOTICE FOR DISCLOSURE PACKET UPDATES****
If any of the following occurs, you are required to notify our department within fifteen
(15) days to complete an updated Disclosure Forml
1. Change of Business Address
2. Change of Business Ownership
3. Change of Business Name
4. Cessation of Business Operation(s)
5. Change of Business Occupancy Class (UBC)
6. Reclassification of TRADE SECRET INFORMATION
7. Change of handling or use of previously undisclosed hazardous material, waste or combination thereof.
8. Storage or use of any new hazardous materials that would require you to comply with the disclosure laws.
9. A significant change in handling or inventory quantity (± 10%) of any hazardous material for which Disclosure
Information has already been made.
Saco »f`'► Sfratra
l certify, under the penalty of perjury, that the above information is true and correct to
the best of my knowledge.
E
J�) -A
Name and Title (please type or
nt)
?? e -
Please Return Form to:
Date
*******FOR OFFICIAL ADMINISTERING AGENCY USE ONLY********
/ ` 1i
Date Packet Returned
Reviewed / Inspected by
Date Packet Reviewed
If business is a target hazard, describe why
unwary cods
District Code
ire Mgt Zone
Notes:
Inspection M
(ling Category
HIVIM, Uate code
RIVIPP Date Required
HIVIPP se Qo—m—p
Total Hours Spent
Filing Status
Chemical Range
business Plan Flange
HAZMAT-SI CHEMICAL INVENTORY COVER PAGE
BUSINESS NAME:,
BUSINESS ADDRESS:
TOTAL NUMBER OF PAGES:
U.- 1
FOR
C leV t e r.5
S./ .
TOTAL NUMBER OF TRADE SECRET CHEMICALS REPORTED: J
TOTAL NUMBER OF NON -TRADE SECRET CHEMICALS REPORTED'
TOTAL NUMBER OF CHEMICALS REPORTED: /
ADMINISTERING AGENCY USE ONLY
INSPECTOR'S INITIALS: DATE:
DATA ENTRY: DATE:
NOTES:
SITE CHEMICAL INVENTORY FORM INSTRUCTIONS
PLEASE READ INSTRUCTIONS CAREFULLY BEFORE FILLING OUT INVENTORY FORMS
PRINT CLEARLY wmI INK OR USE TYPEWRITER ONLYI
The Chemical Inventory Disclosure form must be used for all reportable chemicals. Each form contains
space for two chemicals. If you do not have enough forms, please feel free to make as many copies
as necessary, or contact us and we will provide you with more.
You will note that two different forms have been supplied: one for regular chemicals and the other for
Trade Secret Chemicals. IMPORTANT: for your protection you must report all trade secret chemicals
on the Trade Secret Form ONLY. Your regular inventory should be reported on the forms NOT
designated as Trade Secret.
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
Trade Name Enter the trade name, if known. Leave this space blank if you
are reporting a pure chemical.
CAS# Enter CAS (Chemical Abstract Service) Number. Refer to your
MSDS sheet or shipping papers for this information. If you are
reporting a mixture, list its three main components.
Chemical Name Enter the true chemical name. If you are unsure of the true
name, use the common name, trade name or DOT shipping
name, if known. If you are reporting a mixture, list its three main
components.
% Enter '100%' for pure chemicals; enter the % for the three main
components of mixtures.
EPA 302 Circle the appropriate response if chemical is listed on the EPA
302 list of Extremely Hazardous Substances.
CARCINOGEN Circle the appropriate response if chemical is carcinogenic.
Misc Info Form & Type: Enter the appropriate codes from the Site
Chemical Inventory Code Tables 1 and 2, respectively.
DOT# Enter the four digit Department of Transportation number. Refer
Hazard Classes General: Enter up to three hazard classification codes from
Site Chemical Inventory Table 3.
Physical: Enter up to three EPA physical hazard codes
from Site Chemical Inventory Table 4.
Health: Enter one EPA health hazard code from Site
Chemical Inventory Table 5.
Waste Info EPA: Enter the four digit character/number EPA Waste
Numbers, if known.
State: Enter the three character/number State Waste Numbers,
if known.
Class: Enter Waste Class Code from Site Chemical Inventory
Table 6.
Min%: Enter the minimum % of waste the chemical will produce.
Max%: Enter the maximum % of waste the chemical will produce
(this number must be greater than the minumum %).
Rad: If radioactive, enter the number of microcuries.
11) NFPA Diamond Hazard Enter the one digit code (0-4) for each condition: Health, Fire
and Reactivity; and circle the applicable specific hazard:
Radioactive, Oxidizer, Water reactive, Corrosive, Poison and/or
Explosive.
12) Unit of Measure Identify the unit of measure used for this chemical (LBS, GA, CF,
etc.) from Site Chemical Inventory Code Table 7.
13) Max/Yr Estimate the maximum total amount of the chemical on -site (used
and handled in inventory) per year.
14) Max/Day Estimate the maximum amount of the chemical on -site any
given day (must be less than or equal to Max/Year).
15) Avg/Day Estimate the average amount of the chemical on -site any given
day (must be less than or equal to Max/Day).
16) Days on Site Enter the maximum number of days per year the chemical is on -
site.
17) Largest Container Identify by capacity the largest container on -site for storage of
this chemical.
18) Map Info Enter the page and grid reference number identifying the storage
location of this chemical from your site maps.
19) Codes Enter from Site Chemical Inventory Code Tables 8 - 11, the
Container Storage, Pressure Storage, Temperature Storage and
Disposal Treatment Codes.
20) Location Stored Give a brief description of the storage location of the chemical.
NOTE: If your Inventory of this chemical Is stored In several
locations, you must disclose each location separately.
21) How Used/ Misc Give a brief description of how the chemical is used and any
other information regarding the chemical you feel is importam
HazMat-71 CHEMICAL INVENTORY r-�RM ver 3.0
PrL.- clearly with INK or use typewriter ONLY
Please read attached Instructions carefully
Date: -�— 9 L BID: Page of
Acates code is required for input
TRADE NAME: I C rc-/)l u r c. I F/
MDrruRES (List the three most hazardous Ingredients):
CASE CHEMIC L NAME
•TC. rca (' /� ro e-4h,.,
MISC INFO HAZARD CLASSES
Form*: General*:_
Type*: Physical*•
DOT#: Health*:
WASTE INFO
EPA:
State:
Class*'
Min%:
Max%•
Rad:
EPA
% 302
CARCINOGEN
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
FIRE
HEALTH REAar
(Grew)
ROWCPE
Unit of
Measure! Max/Yr Max/Day: Avg/Day-
Days on Site' MAP INFO CODES
Page! Container Storage*! Temperature Storage-
-�est Container- Grid: Pressure Storage*: Disposal Treatment*:
LOCATION STORED'
How USED/MISC'
TRADE NAME:
MIXTURES (List the three most hazardous Ingredients): EPA
CAS# CHEMICAL NAME % 302 CARCINOGEN
Y/N Y/N
Y/N Y/N
- - - - - - - - - Y/N Y/N —
MISC INFO HAZARD CLASSES
Form*: General*:
Type*: Physical*: — —
DOT#E: Health*:
Unit of
Measure: Max/Yr:
Dp' on Site:
Largest Container:
LOCATION STORED:
How USED/MISC:
WASTE INFO
EPA:
State:
Class*:
Min%:
Max%:
Rad:
FIRE
HEALTH REACT
— 4 —
Croo)
ROWCPE
Max/Day: Avg/Day:
MAP INFO CODES
Page: Container Storage*: Temperature Storage*:
Grid: Pressure Storage*: Disposal Treatment*:
ate Chemical Inventory Code Ta. is
(in Alphabetic Description Sequence)
The following codes are used on the Site Chemical Inventory Form. The codes are sorted by description. For each
field that needs a code, look up the appropriate code and transfer it onto the inventory form.
M i ri� .... .. C±-Tds
(1) Chemical FORM Codes:
(2) Chemical TYPE Codes:
CODE
DESCRIPTION
CODE
DESCRIPTION
4
Crystals
M
Mixture
0
Formless
B
Mixture and Waste
2
Gas/Vapor
P
Pure
1
Liquid
W
Waste
5
Powder
Unknown/Undefined
3
Solid
(3) GENERAL Hazards:
CODE
DESCRIPTION
CODE
DESCRIPTION
31
Asphyxiant
28
Narcotic
1
Blasting agent
13
Non -Flammable Compressed Gas
2
Combustible Liquid
14
Organic Peroxide
3
Corrosive
15
ORM-A
30
Cryogenic
16
ORM-B
4
Etiologic Agent
17
ORM-C
5
Explosive A
18
ORM-D
6
Explosive B
19
ORM-E
7
Explosive C
20
Other Regulated Materials (ORM)
8
Flammable Compressed Gas
21
Oxidizer
9
Flammable Liquid
22
Poison Compressed Gas (Poison A)
10
Flammable Solid
23
Poison Liquid/Solid (Poison B)
32
Fuming Liquid
24
Pyrophoric or Spontaneously Combustible
27
Heat Sensitive
25
Radioactive
11
Hypergolic
29
Shock Sensitive
12
Irritant
26
Water Reactive
(4)-Er+, PHYSICAL
Ha=ards:
(5)anA WEe1
CODE
TH Hez=:ds:
DESCRIPTION
CODE
DESCRIPTION
1
Fire Hazard
2
Delayed
2
Reactive Hazard
1
Immediate (Acute)
3
Sudden Pressure Release
W POO!
(6) Waste Classification Codes:
CODE
DESCRIPTION
H
Acute Hazardous Waste
C
Corrosive
E
EP Toxic
I
Ignitable
R
Reactive
T
Toxic
Urft of Measur rtt
..............................
(7) Units of Measurement for Duanoty Information:
ABBREV DESCRIPTION
ABBREV
DESCRIPTION
CF Cubic Feet
ML
Milliliters
CM Cubic Meters
OZ
Ounces
CY Cubic Yards
PT
Pints
FO Fluid Ounce
LB
Pounds
GA Gallons
OT
Quarts
GR Grams
TL
Tons (Long)
KG Kilograms
TM
Tons (Metric)
LT Liter
TS
Tons (Standard)
MG Milligrams
PA3f1NI3#
(8) Storage CONTAINER Codes (C):
CODE
DESCRIPTION
A
Above Ground Tank
K
Bag
B
Below Ground Tank
L
Box
H
Can
I
Carboy
G
Fiber Drum
N
Fixed Pressurized Cylinder
O
Glass Bottle or Jug
D
Insulated Tank, including
Cryogenics
(9) Storage PRESSURE (P):
CODE DESCRIPTION
1 Ambient Pressure
2 Greater than Ambient Pressure
3 Less than Ambient Pressure
Unknown/Undefined
(10) Storage TEMPERATURE (T):
CODE
DESCRIPTION
4
Ambient Temperature
7
Cryogenic Conditions
S- -
- -Greater-than Ambient Temperature
6
Less than Ambient Temperature
Unknown/Undefined
(11) DISPOSAL Treatment (D):
CODE
DESCRIPTION
23
Air, Release During Process
5
Filtration
21
Ground Around Business
27
Hazardous Waste Landfill
3
Incineration
26
Injection Well
28
Land Application
4
Neutralization
29
Ocean Disposal
2
Recycle
CODE
DESCRIPTION
P
Plastic Bottle or Jug
F
Plastic or Non -Metallic Drum
M
Portable Pressurized Cylinder
S
Rail Car
J
Silo
E
Steel Drum
C
Tank Inside Building
R
Tank Wagon
a
Tote Bin
T
Other
CODE
DESCRIPTION
1
Sewer w/Clarifier or Treatment
20
Sewer w/o Clarifier or Treatment
6
Stabilization Pond
25
Storm Drain
30
Surface Impoundment
31
Transfer Station
22
Trash or Garbage
7
Treatment Pond
24
Waterway, except Ocean
Unknown/Undefined
qw. .
BID #:
Hazardous Materials
Business Plan Information Packetverao
Please Use Typewriter or Print Clearly
Seiction ` ' x BIISINES :TION
ziher_ S
Business Name
�/ l� 11,yeK-g ST,
Business Address (Not a PO )
l�
During Bus Hrs Contact NamefMe
Sec#ion i' Si�natur
(&,S) ,�-`gr,2,2-50
Phone
I certify, under penalty of perjury, that the proceeding information is true and correct
to 7best of my knowledge.
L 3 i i V2L
gigiiature Date
c) w "r ,
Name and Title (please type or print)
Pisa** Return Form to:
OUpN.
Enter #
County Sanitation District: Industrial Waste Water Discharge Permit:
County Underground Div: Public Works HazMat/Waste Permit:
County Health Dept: Hazardous Waste Control License:
State Health Dept: Hazardous Waste Control License:
State Health Dept: Radioactive Material License:
Carcinogen Registration Number:
Air Quality Management District Permit:
Other Government Agency Requiring Chemical Licenses (Agency, Uc#, Type):
U
AR 11411M.W. ams-3pr MAWNE law
HazMat Disposal Com• pany:
Name: —Ale
Address:
Phone:
Uc #:
J Y173j
Ernw9ency and Buairwwa Contacts of this Disposal Compmr.
Name / Trds Phone
Bus Hre:
After We:
00w Agencies Used for Emergency Ct"nup besides this Disposal Comparry.
Name, Uc# & Type -
Name, Lic# & Type:
Give the location and brief description of the following, if applicable:
1 ) Emergency Operation Plan:
2) Identification of nearby hazardous facilities and hazmat transportation routes:
3) Methods used for determining tt» occurrence of a release:
4) Methods / Procedures when responding to a release:
55) Emergency Notification Procedures:
6) Designation of community and facility coordinators:
%) Evacuation Plan:
8) Methods and schedules for exercising the evacuation plan:
9) Training Records, including implementation schedules:
Unll Hecoros:
11) Personnel Records:
12) MSDS Record Locations:
13) Identify your On -Site Fire Team:
14) Identify your On -She Clean -Up Personnel:
15) Identify your On -Site Medical Station (staff, training) OR your Medical Service* (agency name, address and phone):
16) Identify the type of Alarm System and special instructions:
Section YI - FIRE'VROTECTION & CONTROL
If your business has any of the following: 1) identify which site map page and
matrix coordinates the items are located; 2) In words, describe where the items
are located
) Absorbants:
2) Fire Hydrants:
3) Extinguishers:
4) Pumps:
J) Storm Drains:
6) Dikes: _
7) Sewers:
8) Supply Piping:
Seatlon VI IjConued} - FIRE PROTECTION & CONTROL
9) Stand Pipes:
10) Sprinklers/FDC:
11) Knox Box:
12) Emergency / Fire Exit:
13) Entrances and exits to the Properly and Building:
14) Entrances and exits to the Parking and Loading areas:
Shut-off Points:
15) Gas:
16) Water.
17) Power:
18) Electrical Panels: