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California Hazard%'aterials Inventor Form <br />Inventory - <br />Che.wcal Description <br />(1) ©ADD ❑DELETE ❑REVISE 2002 PAGE (2) OF (3) <br />BUSINESS NAME (4) <br />CHEMICAL LOCATION(S) ( <br /> V v IU �:; t1��L <br />MAP # (6) / GRID # (7) � <br />CHEMICAL NAME (8 <br />COMMON NAME (9. <br />CAS # (10; <br />FIRE CODE (13) <br />HAZARD CLASS <br />TYPE (14 <br />PHYSICAL STATE (17; <br />FED HAZARD <br />CATEGORIES (18. <br />STATE WASTE (19 <br />CODE <br />DAYS ON SITE (20 <br />LARGEST (21 <br />CONTAINER <br />STORAGE (26; <br />CONTAINER <br />STORAGE (27) <br />PRESSURE <br />STORAGE (28) <br />TEMPERATURE <br />29) CV WT <br />L(!llC%i,lzf4!1 Ddo 4LIC) <br />TRADE SECRET (11) ❑Y [qN <br />*EHS (12) I [:]Y ®N <br />*IF EHS BOX IS "Y" <br />ALL AMOUNTS MUST BE IN LBS <br />n, <br />II rr <br />n eJ Orl" n r s ci L, <br />LEAVE BLANK <br />❑PURE NMIXTURE F_JWASTEj <br />RADIOACTIVE(15)(16) <br />I, N (16) <br />CURIES <br />[-]SOLID ®LIQUID [:]GAS <br />❑ FIRE ❑ REACTIVE ❑ PRESSURE RELEASE Z ACUTE HEALTH ❑ CHRONIC HEALTH <br />UNITS* (22) SGAL E] CU FT MAX DAILY AMT (23) <br />L] TONS ON-SITE 5 7 µ f <br />[:]LBS ❑ <br />*If EHS, amounts must be in lbs AVG DAILY AMT (24)ON-SITE 10 C{ <br />ANNUAL WASTE AMT (25) <br />❑ ABOVE GROUND TANK ❑ CAN ❑ BOX ❑TANK WAGON <br />❑ UNDER GROUND TANK ❑ CARBOY ❑ CYLINDER ❑RAIL CAR <br />❑ TANK INSIDE BUILDING ❑ SILO ❑ GLASS BOTTLE ❑ -------------------- <br />9 STEEL DRUM ❑ FIBER DRUM ❑ PLASTIC BOTTLE <br />❑ PLASTIC/NONMETALLIC DRUM ❑ BAG ❑ TOTE BIN <br />® AMBIENT ❑ ABOVE AMBIENT ❑BELOW AMBIENT <br />AMBIENT [:]ABOVE AMBIENT ❑BELOW AMBIENT ❑ CRYOGENIC <br />.)Ur A4AtcUUUJ UUMVUNhN1 31 EHS <br />❑Y ❑N <br />❑ YE] N <br />❑Y ❑N <br />❑Y ❑N <br />❑Y ❑N <br />DITIONAL LOCALLY COLLECTED INFORMATION: (33) UNITED NATIONS ID # (DOT) tai <br />(34) WHAT IS MATERIAL <br />USED FOR? use <br />- <br />USED <br />Official Use Only: [Z C ❑ R ❑ S SJC 12/01 <br />