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California Hazardous Materials Inventory Form - CI{EOEWLTINion <br /> (1) 2001 PAGE(2) MOF(3) <br /> ��ADD aDELETE REVISE i <br /> BUSINESS NAME (4) `- SAN EMERGE O U RVICES <br /> CHEMICAL LOCATION(S)(5) : <br /> <br /> CES <br /> MAP#(6)/ GRID#(7) <br /> CHEMICAL NAME (8) TRADE SECRET(11) ❑Y (Z N <br /> *EHS(12) ❑Y IBJ N <br /> COMMON NAME (9) I t <br /> 'IF EHS BOX IS"Y" <br /> CAS # (I(I) '7 - "� ALL AMOUNTS MUST BE IN LBS <br /> FIRE CODE (13) LF/AVE BLANK <br /> HAZARD CLASS <br /> ❑EN <br /> TYPE (14) PUREMIXTURE ❑WASTE RADIOACTIVE(15) <br /> O (16)�� <br /> CURIES <br /> PHYSICALSTATE(17) [:]SOLID ❑ UID LIQGAS <br /> FED HAZARD <br /> CATEGORIES (18) ❑ RETIRE REACTIVE PSSURE REI,GASE ❑ UT <br /> ACE HEALTH [:1CIff HEALTH <br /> STATE WASTE (19) ^ UNITS*(22) ❑GALCU FP MAX DAILY AMT(23) n <br /> /� ON-SITE <br /> CODE V <br /> JE]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 ,n ANNUAL WASTE AMT(25)� <br /> CONTAINER VZ.O(.s <br /> STORAGE (26) []ABOVE GROUND TANK E:] CAN ❑ BOX ❑TANK WAGON <br /> CONTAINER ❑UNDER GROUND TANK ❑CARBOY CYLINDER [-]RAIL CAR <br /> ❑TANK INSIDE BUILDING ❑ SILO ❑GLASS BOTTLE❑------------------- <br /> ❑STEEL DRUM ❑FIBER DRUM ❑ PLASTIC BOTTLE <br /> ❑PLASTIC/NONMETALLIC DRUM ❑ BAC ❑ TOTE BIN <br /> STORAGE (27)1 ❑ AMBIENT ABOVEAMBIENP [:)BELOW AMBIENT <br /> PRESSURE <br /> STORAGE (28) AMBIENT ❑ABOVE AMBIENT EJBELOW AMBIENT ❑ CRYOGENIC <br /> TEMPERATURE <br /> 29 %WT 30 HAZARDOUS COMPONENT 31 EHS 32 CAS# <br /> ❑Y ❑N <br /> ❑Y ❑N <br /> ❑Y ❑N <br /> ❑Y ElN <br /> ❑Y ❑N <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION: (33)UNITED NATIONS ID#(DOT) <br /> (34)WHAT IS MATERIAL <br /> USED FOR? <br /> For Official Use Only: C R S SIC 12/00 <br />