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UNIFIED PROGRAM CONSOLIDATED FORM

By Carolyn Scott,2014-04-15 03:12
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UNIFIED PROGRAM CONSOLIDATED FORM

    UNIFIED PROGRAM CONSOLIDATED FORM

     HAZARDOUS MATERIALS

    HAZARDOUS MATERIALS INVENTORY CHEMICAL DESCRIPTION

    200. Page ___ of ___ ADD DELETE REVISE

    I. FACILITY INFORMATION

     3. BUSINESS NAME (Same as FACILITY NAME or DBA)

     201. 202. MATERIAL LOCATION(s)-(e.g. NW corner warehouse), **not facility address** CHEMICAL LOCATION CONFIDENTIAL EPCRA YES NO 1. 203. 204. MAP # GRID #(s) FACILITY ID# (Agency Use Only)

     II. CHEMICAL INFORMATION 205. 206. CHEMICAL NAME TRADE SECRET Yes No

     If Subject to EPCRA, refer to instructions Petroleum Distillates 207. 208. COMMON NAME EHS*(extremely haz. substance) Yes No Waste Oil

    209. CAS# *If EHS is “Yes,” all amounts below must be in lbs. 210. FIRE CODE HAZARD CLASSES Required Combustible Liquid II/IIA/IIIB Combustible Dust Combustible Fiber Irritant Pyrophoric (gas/solid/liq) Explosive Organic Peroxide UD I/II/III/IV/V Flammable Gas(gas/liq) Flammable Solid Corrosive Flammable Liquid IA/IB/IC Radioactive Unstable Reactive 1/2/3N/3D/4D Oxidizer 1/2/3/4 Oxidizing Gas(gas/liq) Carcinogen Water Reactive 1/2/3 Toxic(highly) Cryogenic (Flammable/Oxidizing) Sensitizer Other Health Hazards

    LIST ALL THAT APPLY: Combustible liquid III, Irritant 213. HAZARDOUS MATERIAL a. PURE b.MIXTURE c. WASTE 211. RADIOACTIVE Yes No 212. CURIES NA TYPE (Check one item) o 215. nPHYSICAL STATE 214. LARGEST CONTAINER l(Check one item only) a. SOLID b. LIQUID c. GAS y216. ) FED HAZARD CATEGORIES (Check all that apply) a. FIRE b. REACTIVE c. PRESSURE RELEASE d. ACUTE HEALTH e. CHRONIC HEALTH

    217. 218. 219. 220. AVERAGE DAILY AMOUNT(on site) MAXIMUM QUANTITYSTORED ANNUAL WASTE AMOUNT STATE WASTE CODE

     221 221. 222. DAYS ON SITE(if not all year list months on site) UNITS* a. GALLONS b. CUBIC FEET c. POUNDS d. TONS (Check one item only) * If EHS, amount must be in pounds. STORAGE CONTAINER a.ABOVEGROUND TANK e.PLASTIC/NONMETALLIC DRUM i.FIBER DRUM m.GLASS BOTTLE q.RAIL CAR b.UNDERGROUND TANK f.CAN j.BAG n.PLASTIC BOTTLE r.OTHER

     c.TANK INSIDE BUILDING g.CARBOY k.BOX o.TOTE BIN

     d.STEEL DRUM h.SILO l.CYLINDER p.TANK WAGON 223. STORAGE PRESSURE a. AMBIENT b. ABOVE AMBIENT c. BELOW AMBIENT 224. STORAGE TEMPERATURE a. AMBIENT b. ABOVE AMBIENT c. BELOW AMBIENT d. CRYOGENIC 225.

    % WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS #

    226. 227. 228. 229. Yes No 1. 90 Petroleum bases lubricating oils 2.230. 231. 232. 233. Yes No 3. 234. 235. 236. 237. Yes No

    4. 238. 239. 240. 241. Yes No 5. 242. 243. 244. 245. 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. 246. ADDITIONAL LOCALLY COLLECTED INFORMATION If EPCRA, Please Sign Here:_________________________ NFPA Ratings: Health-1,Fire-1,Reactivity-0,Special Hazards- .

     MAKE ADDITIONAL COPIES OF THIS PAGE AS NEEDED

You must complete a separate inventory page for each individual hazardous material and hazardous waste that you handle at your facility in an aggregate quantity subject to Hazardous Materials Business Plan reporting requirements (please refer to the Hazardous Materials Business Plan Information Sheet). The completed inventory must reflect all hazardous materials at your facility, reported separately for each building or outside storage area, with separate pages for unique occurrences of physical state, storage temperature, or storage pressure. Where the aggregate quantities of some hazardous materials are below the Business Plan threshold reporting quantity, report the general hazard class of the materials (e.g. "Misc. Flammable Liquids"), rather than the Common Name, and the aggregate quantity of all hazardous Hazardous Materials Inventory - Chemical Description Page (OES Form 2731) Instructions materials having this hazard class which individually are below the threshold reporting quantity. (Note: Numbering of these instructions follows the UPCF data element numbers on the Inventory page.) 1. FACILITY ID NUMBER - This number is for agency use only. Leave this space blank. 3. BUSINESS NAME - Enter the complete Facility Name. 200. ADD/DELETE/REVISE - Indicate whether the material is being added to the inventory, deleted from the inventory, or if information previously submitted is being revised. (Note: You may leave this blank if you resubmit your entire inventory annually.) 201. CHEMICAL LOCATION - Enter the building or outside area where the hazardous material is handled. A chemical stored at the same pressure and temperature in multiple locations in one building may be reported on a single page. 202. CHEMICAL LOCATION CONFIDENTIAL - EPCRA - You must check "Yes" to keep chemical location information confidential. If you do not wish to keep chemical location information confidential check "No." 203. MAP NUMBER - Enter the page number of the Business Plan Storage Map where the location of the hazardous material is shown. 204. GRID NUMBER - Enter the grid coordinates from your Business Plan Storage Map that correspond to the location of the hazardous material. If applicable, multiple grid coordinates can be listed. 205. CHEMICAL NAME - Enter the proper chemical name of the hazardous material. If the chemical is a mixture or waste, do not complete this field; complete the "Common Name" field instead. 206. TRADE SECRET - Check "Yes" if the information in this section is declared a trade secret, "No" if it is not. If "Yes," and the business is subject to EPCRA, disclosure of designated Trade Secret information is bound by 40 CFR and the business must submit a "Substantiation to Accompany Claims of Trade Secrecy" form to the United States Environmental Protection Agency. 207. COMMON NAME - Enter the common name or trade name of the hazardous material or mixture (e.g. gasoline). 208. EHS - Check "Yes" if the hazardous material is an Extremely Hazardous Substance (EHS) as defined in 40 CFR, Part 355, Appendix A. If the material is a mixture containing an EHS, leave this section blank and complete the section on hazardous components, below. 209. CAS # - Enter the Chemical Abstract Service (CAS) number for the hazardous material. For mixtures, enter the CAS number of the mixture if it has been assigned a number distinct from its components. If the mixture has no CAS number, leave this column blank and report the CAS numbers of the individual hazardous components in the appropriate section, below. 210. FIRE CODE HAZARD CLASSES - Provide this information if required by your local agency. A list of hazard classes and instructions on how to determine which class a material falls under are included in the appendices of Article 80 of the Uniform Fire Code. If a material has more than one applicable hazard class, include all. Contact your local agency for guidance. 211. HAZARDOUS MATERIAL TYPE - Check the one box that best describes the type of hazardous material: pure, mixture or waste. If the material is a waste, check only the "Waste" box. 212. RADIOACTIVE - Check "Yes" if the hazardous material is radioactive or "No" if it is not. 213. CURIES - If the hazardous material is radioactive, use this area to report the activity in curies. 214. PHYSICAL STATE - Check the one box that best describes the physical state of the hazardous material. 215. LARGEST CONTAINER - Enter the total capacity of the largest container in which the material is stored. 216. FEDERAL HAZARD CATEGORIES - Check all categories that describe the physical and health hazards associated with the hazardous material. PHYSICAL HAZARDS HEALTH HAZARDS Fire: Flammable Liquids and Solids, Combustible Liquids, Pyrophorics, Acute Health (Immediate): Toxics, Highly Toxics, Irritants, Sensitizers, Oxidizers Corrosives, other hazardous chemicals with an adverse effect with short-term exposure Reactive: Unstable Reactives, Organic Peroxides, Water Reactives, Radioactives Pressure Release: Explosives, Compressed Gases, Blasting Agents Chronic Health (Delayed): Carcinogens, other chemicals with an adverse effect with long-term exposure 217. AVERAGE DAILY AMOUNT - Calculate the average daily amount of the hazardous material or mixture in this building or outside area. If this is a material that is new to this location, the amount shall be the average daily amount you project to be on hand during the course of the year. This amount must be consistent with the units reported in box 221 and must not exceed that of maximum daily amount. 218. MAXIMUM DAILY AMOUNT - Enter the maximum amount of each hazardous material or mixture handled in this building or outside area at any one time over the course of the year. This amount must contain, at a minimum, last year's reported inventory with the reflection of additions, deletions, or revisions projected for the current year. This amount must be consistent with the units reported in box 221. 219. ANNUAL WASTE AMOUNT - If the material is a hazardous waste, enter the estimated annual amount handled. 220. STATE WASTE CODE - If the material is a hazardous waste, enter the appropriate California 3-digit hazardous waste code as listed on the back of the Uniform Hazardous Waste Manifest. 221. UNITS - Check the unit of measure most appropriate for the material. [Note: If the material is a federally defined Extremely Hazardous Substance (EHS) and is not a mixture, all amounts must be reported in pounds.] 222. DAYS ON SITE - List the total number of days during the year that the material is on site. 223. STORAGE CONTAINER - Check the boxes that describe the types of containers in which the material is stored. 224. STORAGE PRESSURE - Check the box that best describes the pressure at which the material is stored. 225. STORAGE TEMPERATURE - Check the box that best describes the temperature at which the material is stored. 226. HAZARDOUS COMPONENT (% BY WEIGHT) - If the material is a mixture, enter the percentage weight of the hazardous component(s). If a range of percentages is available, report the highest percentage in that range. (Repeat for components 2-5.) 227. HAZARDOUS COMPONENTS 1-5 NAME - If the material is a mixture, list the chemical name of each hazardous component in the mixture ranked by percent weight (refer to the MSDS or manufacturer). All hazardous components present at greater than 1% by weight if non-carcinogenic, or 0.1% by weight if carcinogenic, must be reported. If more than five hazardous components exceed these percentages, you may attach an additional sheet of paper to report the required information. When reporting wastes, mineral and chemical composition must be listed. (Repeat for components 2-5.) 228. HAZARDOUS COMPONENTS 1-5 EHS - Check "Yes" if the component of the mixture is considered an Extremely Hazardous Substance as defined in 40 CFR, Part 355, or "No" if it is not. (Repeat for components 2-5.) 229. HAZARDOUS COMPONENTS 1-5 CAS - List the Chemical Abstract Service (CAS) numbers as related to the hazardous components in the mixture. (Repeat for components 2-5.) 246. LOCALLY COLLECTED INFORMATION Sign in this section if material is subject to EPCRA.

Provide NFPA ratings for Health, Fire, Reactivity, and any Special Hazards associated with material[e.g. Oxidizer(OX),water reactive(WR)] NFPA ratings are often found on MSDS’s. If not contact supplier.

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