Non-Waste Hazardous Materials Inventory Form
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1
2Non-Waste Hazardous Materials Inventory Statement
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Date: ____
____
____
For use by Unidocs Member Agencies or where approved by your Local Jurisdiction
Business Name:
Type of Report on This Page:
1
2
Page ____ of ____
(Same as Facility Name or DBA)
Add;
Delete;
Revise
(One page per building or area)
EPCRA Confidential Location?
Yes;
No
Chemical Location:
Facility ID #
4
3
-
0
1
0
-
(Agency Use Only)
(Building/Storage Area)
Trade Secret Information?
Yes;
No
1.
2.
3.
4.
5.
6.
7.
8.
9.
Hazardous Components
Type
Quantities
Storage Codes
Location
(For mixtures only)
and
Chemical
%
Physical
Max.
Average
Haz.
Code
Largest
Storage
Storage
Hazard
Common Name
Name
Wt. EHS
CAS No.
State
Daily
Daily
Units
Class
Cont.
Pressure
Temp.
Categories
pure
gallons
ambient
ambient
fire
mixture
pounds
> amb.
> amb.
reactive
cu. feet
< amb.
pressure release
< amb.
Curies:
Days On
Storage
solid
acute health
tons
cryogenic
Site:
Container:*
(If radioactive)
liquid
chronic health
gas
radioactive
pure
gallons
ambient
ambient
fire
mixture
pounds
> amb.
> amb.
reactive
cu. feet
< amb.
pressure release
< amb.
Curies:
Days On
Storage
solid
acute health
tons
cryogenic
Site:
Container:*
(If radioactive)
liquid
chronic health
gas
radioactive
pure
gallons
ambient
ambient
fire
pounds
> amb.
> amb.
reactive
mixture
cu. feet
< amb.
pressure release
< amb.
solid
Curies:
Days On
Storage
acute health
tons
cryogenic
Site:
Container:*
liquid
(If radioactive)
chronic health
gas
radioactive
pure
gallons
ambient
ambient
fire
mixture
pounds
> amb.
> amb.
reactive
cu. feet
< amb.
pressure release
< amb.
solid
Curies:
Days On
Storage
acute health
tons
cryogenic
Site:
Container:*
liquid
(If radioactive)
chronic health
gas
radioactive
pure
gallons
ambient
ambient
fire
mixture
pounds
> amb.
> amb.
reactive
cu. feet
< amb.
pressure release
< amb.
solid
Curies:
Days On
Storage
acute health
tons
cryogenic
Site:
Container:*
(If radioactive)
liquid
chronic health
gas
radioactive
pure
gallons
ambient
ambient
fire
mixture
pounds
> amb.
> amb.
reactive
cu. feet
< amb.
pressure release
< amb.
solid
Curies:
Days On
Storage
acute health
tons
cryogenic
Site:
Container:*
(If radioactive)
liquid
chronic health
gas
radioactive
Code Storage Type
Code Storage Type
Code Storage Type
Code
Storage Type
Code Storage Type
Code Storage Type
*
If EPCRA, sign below:
A
Aboveground Tank
D
Steel Drum
G
Carboy
J
Bag
M
Glass Bottle or Jug
P
Tank Wagon
B
Belowground Tank
E
Plastic/Non-metallic Drum
H
Silo
K
Box
N
Plastic Bottle or Jug
Q
Rail Car
__________________________________________
C
Tank Inside Building
F
Can
I
Fiber Drum
L
Cylinder
O
Tote Bin
R
Other
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