STATE OF WEST VIRGINIA



STATE OF WEST VIRGINIA

DEPARTMENT OF ENVIRONMENTAL PROTECTION

DIVISION OF MINING AND RECLAMATION

HAZ-MAT Evaluation and Inventory

|Company Name: |      |Permit No.: |      |

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|1. |Does the permit area have materials stored on it that you believe could be considered hazardous to humans, animals, or aquatic life? |

| |YES NO |

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|2. |If yes, list the different types of materials and estimated quantities (Number of barrels, tank sizes in gallons, etc.) For example: |

| |1 – |1000 Gal. Diesel fuel tank, estimate 500 gal. (1/2 full) |

| |10 – |55 Gal. Drums hydraulic fluid – full |

| |20 – |Lead Acid Batteries |

| |2 – |500 Gal. Tanks NaOH – Appear Empty |

| |1 – |Tank for Anyhydrous Ammonia – size and contents unknown |

| |2 – |Powder magazines – contents and quantity unknown |

| |1 – |Anfo Bin – contents and quantity unknown |

| |5 – |55 Gal. Drums – full – contents unknown |

| |(Material and Estimated Quantities List) |

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|3. |Is site access controlled? (locked gate, fenced) YES NO |

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|ADDITIONAL COMMENTS: |      |

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|Supervisor/Specialist Signature | |Date |

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