Fillable Non-Waste Hazardous Materials Inventory Form (Page 2 of 2) in pdf

Non-Waste Hazardous Materials Inventory Statement Instructions

(Modified UPCF Hazardous Materials Inventory - Chemical Description Page)

All non-waste hazardous materials stored at the facility must be listed on the Non-Waste Hazardous Materials Inventory Statement [or the Unified Program Consolidated Form

(UPCF) Hazardous Materials Inventory - Chemical Description form (available on the Internet at )]. This form allows you to report up to six

chemicals on a single page. Do not list hazardous wastes on the Non-Waste Hazardous Materials Inventory Statement form.

You must complete a separate inventory line for each individual hazardous material 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 inventory lines for unique occurrences of physical state, storage temperature, or

storage pressure. Trade secret materials must be listed on separate pages. 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 materials having this hazard class which individually are below the threshold reporting quantity. Make additional copies of this form if needed.

DATE - In the space at the top left side of the form, enter the date this inventory statement page was prepared.

BUSINESS NAME - Enter the complete Facility Name.

TYPE OF REPORT ON THIS PAGE - Indicate whether the material is being added to the inventory, deleted from the inventory, or if the information previously

submitted is being revised. (Note: You may leave this blank if you resubmit your entire inventory annually.)

PAGE NUMBER - Number each page of the inventory appropriately.

CHEMICAL LOCATION - Enter the name of the building or outside area where the hazardous materials reported on this page are handled. A chemical stored at the

same pressure and temperature in multiple locations in one building or area can be reported on a single line.

EPCRA CONFIDENTIAL LOCATION - You must check "Yes" to keep chemical location information confidential. If you do not wish to keep chemical location

information confidential check "No." If "Yes," a signature is required on the line provided at the bottom of the form.

TRADE SECRET INFORMATION- 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.

FACILITY ID NUMBER - This number is for agency use only. Leave this space blank.

HAZARD CLASS - In Column 1 of the inventory table, enter the hazard class for each material. Use the following abbreviations

Code

Classification/Division

Code

Classification/Division

Code

Classification/Division

EXP

Explosive ( 1.1, 1.2, 1.3, 1.4, 1.5, 1.6)

Flammable Solid(4.1)

POIS

Poisonous Liquid or Solid(6.1)

Flammable Gas(2.1)

PYR

Spontaneously Combustible(4.2)

ETI

Etiological /Infectious Substance(6.2)

NFG

Nonflammable Gas(2.2)

Dangerous When Wet(4.3)

RAD

Radioactive(7)

POIS G

Poison Gas(2.3)

OXY

Oxidizer(5.1)

CORR

Corrosive(8)

Flammable Liquid(3)

Organic Peroxide(5.2)

ORM

Other Regulated Material(9)

Combustible Liquid(3)

10. LOCATION CODE - In Column 2, enter the page number of the Storage Map where the location of the hazardous material is shown, along with the Location Code from

your Storage Map that correspond to the location of the hazardous material..

11. COMMON NAME: - In Column 3, enter the Common Name or Trade Name of the hazardous material or mixture (e.g. Gasoline, Acme Super Solvent).

12. HAZARDOUS COMPONENTS - (Note: If the material is not a mixture, only fill in the CAS Number and check if the material is an Extremely Hazardous Substance.)

In column 4, enter the following information regarding Hazardous Components that make up the material listed in Column 3:

• CHEMICAL NAME - If the Chemical Name is the same as the Common or Trade Name shown in Column 3, you may leave this space blank. 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.

• % BY WEIGHT - Enter the percentage weight of each hazardous component. If a range of percentages is available, report the highest percentage in that range.

• EHS - Check the box provided if the component of the mixture is considered an Extremely Hazardous Substance as defined in 40 CFR, Part 355, Appendix A.

• CAS NUMBER - List the Chemical Abstract Service (CAS) number for each hazardous component.

13. TYPE & PHYSICAL STATE - In column 5, identify the material type and physical state by checking the “pure” or “mixture box and the “solid”, “liquid”, or “gas” box.

14. QUANTITIES - In the appropriate spaces within column 6, list:

• MAXIMUM DAILY AMOUNT* - Enter the maximum amount of the 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.

• 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 should be the average daily amount you project to be on hand during the course of the year.

• LARGEST CONTAINER* - Enter the volume of the largest container in which the material is handled at the location.

• CURIES - If the material is radioactive, use the space provided to report the activity in curies.

• DAYS ON SITE - Enter the total number of days (e.g. 365) during the year that the material is on site.

• STORAGE CONTAINER - Using the container codes listed at the bottom of the inventory statement, list every type of container in which the material is

stored/handled.

* Except for Curies, units of measure must be the same as that indicated in Column 7.

15. UNITS - In column 7, check the appropriate unit of measure: gallons for liquids, pounds or tons for solids, and cubic feet for gases. If the material is a federally defined

EHS and is not a mixture, all amounts must be reported in pounds.

16.

STORAGE CODES - In the appropriate spaces within Column 8, list:

• STORAGE PRESSURE - Check the box that best describes the pressure at which the material is stored: ambient (standard), > amb. (greater than ambient), < amb.

(less than ambient), or cryogenic.

• STORAGE TEMPERATURE - Check the box that best describes the temperature at which the material is stored.

17. HAZARD CATEGORIES - In column 9, check the box(es) to describe all physical, health, and radioactivity hazards associated with the hazardous material.

PHYSICAL HAZARDS

HEALTH HAZARDS

Fire:

Flammable Liquids and Solids, Combustible Liquids, Pyrophorics, Oxidizers

Acute Health (Immediate): Toxics, Highly Toxics, Irritants, Sensitizers,

Corrosives, other hazardous chemicals with an adverse effect with

Reactive: Unstable Reactives, Organic Peroxides, Water Reactives, Radioactives

short-term exposure

Pressure Release: Explosives, Compressed Gases, Blasting Agents

Chronic Health (Delayed): Carcinogens, other chemicals with an adverse

effect with long-term exposure