This is an aid to assist you in completing the chemical inventory forms. It is only necessary to complete the unshaded areas. Additional instructions are
on the back of each inventory sheet.
Enter the maximum amount of the hazardous material handled or
stored at any one time over the course of the year. This is not the
maximum amount used in one day.
If your business is subject to the Emergency
Planning and Community Right to Know Act
(EPCRA) you must check “Yes” to keep
chemical location information confidential. If
you do not wish to keep chemical location
information confidential check “No”.
Enter the average daily amount of the
hazardous material handled or stored over
the course of the year. This is not the
average amount used in one day.
Indicate the location of the material on your site
map. If using a grid, use the grid coordinates. If
not using a grid, state where material is located.
(e.g. shop, warehouse, etc.)
Hazardous Components
Material
Handled
On Site
EPCRA
Confidenti
al Location
Yes
Yes
No
No
Trade
Secret
Yes
No
Map# __
and/or
Grid# or
Location
Chemical Name
Common Name
%
Wt.
EHS CAS No.
no
oxygen
Enter the total capacity of the largest container in which
the material is stored.
Type
and
Physical
State
Quantities
Max.
Daily
Annual
Waste
Average Largest Amount
Daily Container (if any)
7782-44-7
Type of report for this chemical:
Add
Delete
Revise
Curies:
solid
liquid
gas
(If radioactive)
Days On
Site:
Indicate whether the material is being added
to the inventory, deleted from the inventory,
or if the information previously submitted is
being revised.
Indicate if your business handles, stores, or
uses this material on site.
The forms provided by this office have been developed by the CUPA to assist businesses in submittal
of a Hazardous Materials Business Plan. The forms are an alternative version of the Unified
Program Consolidated Form (UPCF). Businesses have the option to use this form or the UPCF
adopted in state regulations. The CUPA must accept the state UPCF and cannot require a business
to use the alternative version developed by the CUPA. The CUPA can require businesses to provide
additional information on either the UPCF or a supplemental page to that document.
Storage
Container:
*(see below)
State
Waste Code:
Storage Codes
Storage
Pressure
gallons
pounds
cu. feet
tons
pure
mixture
waste
oxygen
Units
ambient
above
ambient
below
ambient
(if EHS,
amount
must be in
pounds)
Using the container codes listed at the
bottom of the Hazardous Material
inventory form, list every type of
container in which the material is
stored/handled.
Enter the total number of days (out of 365)
during the year that the material is handled or
stored on site.
Fed
Hazard
Categories
Storage
Temp.
ambient
above
ambient
below
ambient
cryogenic
Fire
Code
Hazard
Classes
Physical:
Health ___
fire
reactive
pressure
release
Fire
Health:
acute health
chronic
health
___
Reactivity
___
Special ___
Enter the NFPA number (0,
1, 2, 3, or 4) that designates
the severity of the hazard
next to each category. This
information may be
obtained from the Material
Safety Data Sheet.
fg
Hazardous Waste Inventory Statement
Glenn County Air Pollution Control District
Business Name:
(Same as Facility Name or DBA)
Page ____ of ____
Business Address:
Facility
ID #
-
-
(Agency
Use Only)
Hazardous Components
Chemical Name
Common Name
EPCRA
Confidential
Location
Yes
No
Y
Trade Secret
Yes
No
EPCRA
Confidential
Location
Yes
No
EPCRA
Confidential
Location
Yes
No
Material
Handled
On Site
EPCRA
Confidential
Location
Yes
No
Material
Handled
On Site
N
Map#__
and/or
Grid#__
Material
Handled
On Site
Y
Trade Secret
Yes
No
N
Map#__
and/or
Grid#__
Y
Trade Secret
Yes
No
N
Map#__
and/or
Grid#__
Y
Trade Secret
Yes
No
*
Material
Handled
On Site
N
Map#__
and/or
Grid#__
%
Wt.
EHS CAS No.
no
waste filters
mixture
waste filters
Type
and
Physical
State
Quantities
Max.
Daily
solid
liquid
gas
no
used petroleum
mixture
waste oil
(If
radioactive)
waste ethylene glycol
mixture
waste coolant/antifreeze
(If
radioactive)
mixture
Days On
Site:
Storage
Container:
*(see below)
State
Waste Code:
221
waste automotive batteries
pure
mixture
waste
Type of report for this chemical:
Add
Delete
Revise
solid
liquid
gas
(If
radioactive)
Days On
Site:
Storage
Container:
*(see below)
State
Waste Code:
134
Curies:
Days On
Site:
Storage
Container:
*(see below)
State
Waste Code:
792
Code Storage Type
A
Above ground Tank
Code Storage Type
D
Steel Drum
Code Storage Type
G
Carboy
Code
J
Storage Type
Bag
Code Storage Type
M
Glass Bottle
Code Storage Type
P
Tank Wagon
B
Under ground Tank
E
Plastic/Nonmetallic Drum
H
Silo
K
Box
N
Plastic Bottle
Q
Rail Car
C
Tank Inside Building
F
Can
I
Fiber Drum
L
Cylinder
O
Tote Bin
R
Other
ambient
above
ambient
below
ambient
ambient
above
ambient
below
ambient
cryogenic
Fire
Code
Hazard
Classes
Physical:
Health __
fire
reactive
pressure
release
Health:
ambient
above
ambient
below
ambient
cryogenic
Physical:
fire
reactive
pressure
release
Health:
acute health
chronic
health
ambient
above
ambient
below
ambient
(if EHS,
amount
must be in
pounds)
(if EHS,
amount
must be in
pounds)
Storage
Temp.
Fed
Hazard
Categories
acute health
chronic
health
(if EHS,
amount
must be in
pounds)
gallons
pounds
cu. feet
tons
(If
radioactive)
ambient
above
ambient
below
ambient
(if EHS,
amount
must be in
pounds)
gallons
pounds
cu. feet
tons
pure
mixture
waste
solid
liquid
gas
no
waste battery
State
WasteCode
Storage Codes
Storage
Pressure
gallons
pounds
cu. feet
tons
Curies:
Type of report for this chemical:
Add
Delete
Revise
Storage
Container:
*(see below)
pure
mixture
waste
solid
liquid
gas
no
Days On
Site:
N/A
Curies:
Type of report for this chemical:
Add
Delete
Revise
Units
gallons
pounds
cu. feet
tons
pure
mixture
waste
Curies:
Type of report for this chemical:
Add
Delete
Revise
Annual
Waste
Average Largest Amount
Daily Container (if any)
ambient
above
ambient
below
ambient
cryogenic
Physical:
fire
reactive
pressure
release
Health:
acute health
chronic
health
ambient
above
ambient
below
ambient
ambient
above
ambient
below
ambient
cryogenic
Physical:
fire
reactive
pressure
release
Health:
acute health
chronic
health
Fire
__
Reactivity
__
Special __
Health __
Fire
__
Reactivity
__
Special __
Health __
Fire
__
Reactivity
__
Special __
Health __
Fire
__
Reactivity
__
Special __
If EPCRA, sign below:
__________________________________________
Hazardous Waste Inventory Statement
Glenn County Air Pollution Control District
Business Name:
(Same as Facility Name or DBA)
Page ____ of ____
Business Address:
Facility
ID #
-
-
(Agency
Use Only)
Hazardous Components
Chemical Name
Common Name
EPCRA
Confidential
Location
Yes
No
EPCRA
Confidential
Location
Yes
No
EPCRA
Confidential
Location
Yes
No
Trade Secret
Yes
No
EPCRA
Confidential
Location
Yes
No
*
solid
liquid
gas
Days On
Site:
Storage
Container:
*(see below)
State
WasteCode
(If
radioactive)
Days On
Site:
Storage
Container:
*(see below)
State
Waste Code:
solid
liquid
gas
Type of report for this chemical:
Add
Delete
Revise
Material
Handled
On Site
(If
radioactive)
Days On
Site:
Storage
Container:
*(see below)
State
Waste Code:
N
Curies:
solid
liquid
gas
Type of report for this chemical:
Add
Delete
Revise
(If
radioactive)
Days On
Site:
Storage
Container:
*(see below)
State
Waste Code:
Code Storage Type
A
Above ground Tank
Code Storage Type
D
Steel Drum
Code Storage Type
G
Carboy
Code
J
Storage Type
Bag
Code Storage Type
M
Glass Bottle
Code Storage Type
P
Tank Wagon
B
Under ground Tank
E
Plastic/Nonmetallic Drum
H
Silo
K
Box
N
Plastic Bottle
Q
Rail Car
C
Tank Inside Building
F
Can
I
Fiber Drum
L
Cylinder
O
Tote Bin
R
Other
ambient
above
ambient
below
ambient
ambient
above
ambient
below
ambient
cryogenic
Fire
Code
Hazard
Classes
Physical:
Health __
fire
reactive
pressure
release
Health:
ambient
above
ambient
below
ambient
cryogenic
Physical:
fire
reactive
pressure
release
Health:
acute health
chronic
health
ambient
above
ambient
below
ambient
(if EHS,
amount
must be in
pounds)
(if EHS,
amount
must be in
pounds)
Storage
Temp.
Fed
Hazard
Categories
acute health
chronic
health
(if EHS,
amount
must be in
pounds)
gallons
pounds
cu. feet
tons
pure
mixture
waste
ambient
above
ambient
below
ambient
(if EHS,
amount
must be in
pounds)
gallons
pounds
cu. feet
tons
Curies:
Storage Codes
Storage
Pressure
gallons
pounds
cu. feet
tons
pure
mixture
waste
N
Map#__
and/or
Grid#__
(If
radioactive)
Curies:
Type of report for this chemical:
Add
Delete
Revise
Units
gallons
pounds
cu. feet
tons
pure
mixture
waste
N
Map#__
and/or
Grid#__
Y
Trade Secret
Yes
No
Type of report for this chemical:
Add
Delete
Revise
Material
Handled
On Site
Y
Annual
Waste
Max. Average Largest Amount
Daily Daily Container (if any)
Curies:
solid
liquid
gas
Material
Handled
On Site
Map#__
and/or
Grid#__
Quantities
pure
mixture
waste
N
Map#__
and/or
Grid#__
Y
Trade Secret
Yes
No
EHS CAS No.
Material
Handled
On Site
Y
Trade Secret
Yes
No
%
Wt.
Type
and
Physical
State
ambient
above
ambient
below
ambient
cryogenic
Physical:
fire
reactive
pressure
release
Health:
acute health
chronic
health
ambient
above
ambient
below
ambient
ambient
above
ambient
below
ambient
cryogenic
Physical:
fire
reactive
pressure
release
Health:
acute health
chronic
health
Fire
__
Reactivity
__
Special __
Health __
Fire
__
Reactivity
__
Special __
Health __
Fire
__
Reactivity
__
Special __
Health __
Fire
__
Reactivity
__
Special __
If EPCRA, sign below:
__________________________________________