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California Hazardous Materials Inventory Form - Chemical Description <br /> (1) ADD ❑DELETE ❑REVISE 2001 PAGE(2 G <br /> BUSINESS NAME (4) JAN <br /> E i2/�v <br /> CHEMICAL LOCATION(S)(5) , / EpFEMER <br /> MAP#(6)/ GRID#(7) <br /> CHEMICAL NAME (8) ASTM F>/G TRADE SECRET(l 1) ❑Y ❑N <br /> *EHS (12) ❑Y ❑N <br /> COMMON NAME (9) ! e144s <br /> *IF EHS BOX IS"Y" <br /> CAS # (10) ALL AMOUNTS MUST BE IN LBS <br /> FIRE CODE (13) LEAVE BLANK <br /> HAZARD CLASS <br /> TYPE (14) []PURE [:]MIXTURE ASTE RADIOACTIVE(15) ❑Y (16)� <br /> CURIES <br /> PHYSICAL STATE(17) ❑SOLID a LIQUID ❑GAS <br /> i FED HAZARD FIRE ❑REACnVE ❑PRESSURE RELEASE ❑ ACUTE HEALTH [:] CHRONIC HEALTH <br /> CATEGORIES (18) <br /> STATE WASTE (19)�� UNITS*(22) AI, ❑CU FT MAX DAILY AMT(23) <br /> CODEON-SITE j <br /> [:]LBS []TONS <br /> DAYS ON SITE (20) � AVG DAILY AMT(24) <br /> S *If EHS, amounts must be in lbs ON-SITE <br /> LARGEST (21 ANNUAL WASTE AMT(25) <br /> CONTAINER <br /> STORAGE (26) ❑ABOVE GROUNDTANK ❑ CAN ❑ BOX ❑TANK WAGON <br /> CONTAINER ❑UNDER GROUND TANK ❑CARBOY ❑ CYLINDER ❑RAIL CAR <br /> ❑T NK INSIDE BUILDING ❑ SILO ❑GLASS BOTTLE El-------------------- <br /> STEEL DRUM ❑ FIBER DRUM ❑ PLASTIC BOTTLE <br /> ❑PLASTIC/NONMETALLIC DRUM ❑ BAG ❑ TOTE BIN <br /> STORAGE (27) BIENT ❑ABOVE AMBIENT [:]BELOW AMBIENT <br /> PRESSURE <br /> STORAGE (28) AMBIENT ❑ABOVE AMBIENT ❑BELOW AMBIENT ❑CRYOGENIC <br /> TEMPERATURE <br /> (29)%WT (30)HAZARDOUS COMPONENT (❑31)EHS[:] <br /> H❑S N (32) CAS# <br /> IF <br /> ❑Y ❑N <br /> YEJ❑N <br /> ❑Y ❑N <br /> IF <br /> ❑Y ❑N <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION: (33)UNITED NATIONS ID#(DOT) f Q <br /> (34)WHAT IS MATERIAL <br /> USED FOR? <br /> For Official Use Only: A C ❑ ❑ SIC 12/00 <br />