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California Hazardo► slaterials Inventory Form - Che :al Description <br /> (1) ©ADD ❑DELETEREVISE 2002 PAGE(2) OF(3) <br /> BUSINESS NAME (4) 17— P. —I <br /> slerrc) Ch emleciI Co . �- <br /> CHEMICAL LOCA-HON(S) (5) U:J t j L'LL <br /> (, <br /> <br /> CHEMICAL NAME (8) I TRADE SECRET (11) ❑Y Q N <br /> er)e GiLiC.vl <br /> COMMON NAME (9) -free3e *EHS (12) ❑Y ©N <br /> *IF EHS BOX IS "Y" <br /> CAS # (10) (0-7 ALL AMOUNTS MUST BE IN LBS <br /> FIRE CODE (13) LEAVEBLANK <br /> HAZARD CLASS <br /> TYPE (14) ❑PURE ®MIXTURE ❑WASTE RADIOACTIVE(15) ❑ Y ©N (16) <br /> PHYSICAL STATE(17) [:]SOLID LIQUID ❑GAS CURIES <br /> FED HAZARD <br /> CATEGORIES (18) ❑ TIRE ❑ RE4CTIVE ❑PRESSURE RELEASE © ACUfE HEALTH ❑ CHRONIC HEALTH <br /> STATE WASTE (19) UNITS* (22) ©GAL ❑CU FT MAX DAILY AMT(23) <br /> CODE ON-SITE SS 9c,t . <br /> [:]LBS ❑ TONS <br /> DAYS ON SITE (20) 3 4S AVG DAILY AMT(24) <br /> *If EHS, amounts must be in lbs ON-SITE <br /> LARGEST (21) ANNUAL WASTE AMT(25) <br /> CONTAINER � 5 8�1 ] I <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 /> STEEL DRUM ❑ FIBER DRUM ❑ PLASTIC BOTTLE <br /> ❑PLASTIC/NONMETALLIC DRUM ❑ BAG ❑ TOTE BIN <br /> STORAGE (27) © AMBIENT ❑ABOVE AMBIENT [:]BELOWAMBIENT <br /> PRESSURE <br /> STORAGE (28) ® AMBIENT ❑ABOVE AMBIENT ❑BELOW AMBIENT ❑CRYOGENIC <br /> TEMPERATURE <br /> 29) %WT 30)HAZARDOUS COMPONENT31)EHS 32 CAS# <br /> ❑Y [:]N—1 F <br /> ❑Y [:j NJ <br /> F I I ❑YE]N <br /> 110YON11 <br /> F i ❑Y ❑N <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION: (33) UNITED NATIONS ID#(DOT) N A <br /> (34)WHAT IS MATERIAL -rn �D,,Se v S e <br /> USED FOR? <br /> For Official Use Only: ❑ C ❑ R ❑ S SJC 12/01 <br />