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California Hazards- _.materials Inventory Form - Ch cal Description <br /> (1) ©ADD ❑DELETE uREVISE 2002 PAGE(2) OF(3) <br /> BUSINESS NAMEal cc <br /> � r <br /> CHEMICAL LOCATION(S) (5) <br /> FUL)a et,Us <br /> MAP# (6)/ GRID#(7) <br /> CHEMICAL NAME (8) ` TRADE SECRET (11) ❑Y ©N <br /> COMMON NAME (9) ��c"TL^ f Ci i I *EHS (12) ❑Y ®N <br /> *IF EHS BOX IS "Y" <br /> CAS # (10) , , Y I t f 4 =C. <br /> ALL AMOUNTS MUST BE IN LBS <br /> FIRE CODE (13) LEAVEBLANK <br /> HAZARD CLASS <br /> TYPE (14)1-0 PURE MIXTURE ❑WASTE RADIOACTIVE(15) ❑ Y [N (16) <br /> PHYSICAL STATE(17) ❑SOLID ®LIQUID [:]GAS CURIES <br /> FED HAZARD <br /> CATEGORIES (18) ❑ FIRE ❑ REACTIVE ❑PRESSURE RELEASE ACUTE HEALTH ❑ CHRONIC HEALTH <br /> STATE WASTE (19) UNITS* (22) SGAL. ❑CU FT MAX DAILY AMT(23) <br /> CODE ON-SITE j <br /> [:]LBS TONS <br /> DAYS ON SITE (20) AVG DAILY AMT(24) <br /> *If EHS, amounts must be in lbs ON-SITE <br /> LARGEST (21) ANNUAL WASTE AMT(25) <br /> CONTAINER ^� C a -- <br /> STORAGE (26) ❑ ABOVE GROUND TANK [:] CAN ❑ BOX ❑TANK WAGON <br /> CONTAINER ❑ UNDER GROUND TANK ❑CARBOY ❑ CYLINDER ❑RAIL CAR <br /> {{❑TANK INSIDE BUILDING ❑ SILO ❑ GLASS BOTTLE ❑-------------------- <br /> 1�J STEEL DRUM ❑ FIBER DRUM ❑ PLASTIC BOTTLE <br /> ❑PLASTIC/NONMETALLIC DRUM ❑ BAG ❑ TOTE BIN <br /> STORAGE (27) ® AMBIENT ❑ABOVE AIVIBIENT ❑BELOW AMBIENT <br /> PRESSURE <br /> STORAGE (28)IS <br /> AMBIENT [:]ABOVE AMBIENT ❑BELOW AMBIENT ❑CRYOGENIC <br /> TEMPERATURE <br /> 29) %WT 30 HAZARDOUS COMPONENT 31)EHS 32) CAS# <br /> F F I ❑Y ❑N <br /> Y ❑N <br /> ❑Y NJ I <br /> ❑Y ❑N <br /> ❑Y ❑N <br /> ADDITIONAL,LOCALLY COLLECTED INFORMATION: (33)UNITED NATIONS ID#(DOT)I tJ1 a <br /> (34)WHAT IS MATERIAL r Jx tom,L;S E Use- <br /> USED FOR? <br /> For Official Use Only: ❑ C ❑ R ❑ S SJC 12/01 <br />