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� ppm�pp ,,// <br /> California hazardous Materials Inventory Form - t;htinl. 91wption <br /> (1) p� � OF(3)� <br /> QADD DELETE REVISE 2(101 DEC 1 9PL (2) <br /> BUSINESS NAME (4) 1 E MERGENCY SERNCES <br /> Vjq <br /> CHEMICAL LOCATION(S)(5) <br /> <br /> )E ❑Y N <br /> COMMON NAME (9) ' <br /> *IF EHS BOX IS"Y" <br /> CAS # (10) yn 1 u rt ALL AMOUNTS MUST BE IN LDS <br /> FIRE CODE (13) LEAVE BLANK <br /> HAZARD CLASS <br /> TYPE (14) ❑PURE MIXTURE ❑WASTE RADIOACTIVE(15) ❑Y N (16)�� <br /> PHYSICAL STATE(17)1 ❑SOLID LIQUID ❑GAS CURIES <br /> FED HAZARDFIRE REACT ❑ <br /> IVE PRESSURE RELEASE ACUTE H <br /> CATEGORIES (18) ❑ FALTIi ❑ CHRONIC HEALTH <br /> J <br /> STATE WASTE (19) A '� UNITS*(22) [X]GAL ❑CU FT MAX DAILY AMT(23) <br /> CODE /v 0ON-SITE <br /> LDS ❑"fONS <br /> DAYS ON SITE (20) AVG DAILY AMT(24) n <br /> 3�= *If EHS, amounts must be in lbs ON-SITE <br /> LARGEST (21 S// ANNUAL WASTE AMT(25)I I <br /> CONTAINER 77 —J <br /> STORAGE (26) ❑ABOVE GROUND TANK CAN ❑ BOX ❑FAN K 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 H BAG ❑ TOTE BIN <br /> STORAGE (27) ❑ AMDIENT ABOVE AMBIENT [:]BELOW AMBIENT <br /> PRESSURE <br /> STORAGE (28) W AMBIENT ❑ABOVE AMBIENT ❑BELOW AMBIENT ❑CRYOGENIC <br /> TEMPERATURE <br /> 29goWT (3� U)HAZARDOUS COMPONENT 31 EHS 32 CAS# <br /> ❑Y QN <br /> ❑Y ❑N <br /> ❑Y ❑N <br /> ❑Y Ej N <br /> ❑Y ❑N <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION: (33)UNITED NATIONS ID#(DOT) <br /> (34)WHAT IS MATERIAL <br /> USED FOR7I Abe- <br /> [ <br /> , <br /> For Official Use Only: C [_] R u S SJC 12/00 <br />