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California Hazardous Materials Inventory Form - Chemical Description OF O <br /> (1) OADD aDELETE REVISE <br /> 2001 PAGE(2) F <br /> BUSINESS NAME (4) � � W e <br /> <br /> <br /> <br /> <br /> <br /> J RGENCYSERVIC S <br /> CHEMICAL NAME (8) TRADE SECRET(11) ❑Y N <br /> *EHS(12) ❑Y N <br /> COMMON NAME (9) <br /> *IF EHS BOX IS"Y" <br /> CAS # (10) 1 _ S I — ALL AMOUNTS MUST BE IN LBS <br /> FIRE CODE (13j LEAVEBLANK <br /> HAZARD CLASS <br /> TYPE (14) PURE ❑MIXTURE ❑WASTE RADIOACTIVE(IS) ❑Y (16) <br /> CURIES <br /> PHYSICAL STATE(17) ❑SOLID ❑LIQUID GAS <br /> FED HAZARD FIRE REACTIVE PRESSURERELEASE ❑ ACUTEHEALTH ❑ CHRONIC HEALTH <br /> CATEGORIES (18) ❑ ❑ <br /> STATE WASTE (19)�� UNITS* (22) ❑GAL ❑CU FT MAX DAILY AMT(23) l 1 <br /> CODE ON-SITE <br /> []LBS ❑ TONS <br /> DAYS ON SITE (20) l r AVG DAILY AMT(24) <br /> b *If EHS, amounts must be in lbs ON-SITE <br /> LARGEST (21 I ANNUAL WASTE AMT(25) I <br /> CONTAINER J <br /> STORAGE (26) ❑ABOVE GROUND TANK ❑ CAN ❑ BOX ❑TANK WAGON <br /> CONTAINER ❑UNDER GROUND TANK ❑CARBOY �YLINDER ❑RAIL CAR <br /> ❑TANK INSIDE BUILDING ❑ SILO ❑GLASS BOTTLE ❑------------------- <br /> ❑STEEL DRUM ❑FIBER DRUM ❑ PLASTIC BOTTLE <br /> ❑PLASTICINONMETALLIC DRUM ❑BAG ❑ TOTE BIN <br /> STORAGE (27)roAMBIENT ❑ABOVE AMBIENT ❑BELOW AMBIENT <br /> PRESSURE <br /> STORAGE (28) AMBIENT ❑ABOVEAMBIENT []BELOW AMBIENT ❑ CRYOGENIC <br /> TEMPERATURE <br /> 29 %WT (30)HAZARDOUS COMPONENT 3l EHS (32 CAS# <br /> ❑Y ❑N _� <br /> ❑Y ❑N <br /> ❑Y ❑N <br /> ❑Y ❑N <br /> ❑Y ❑N <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION: (33)UNITED NATIONS ID#(DOT)El � <br /> (34)WHAT IS MATERIAL / e <br /> USED FOR? fly fZ U <br /> For Official Use Only: 11 C R S SJC 12/00 <br />