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California Hazards r serials Inventory Form - Che 'Description <br /> (1) ADD ❑DELETE ❑REVISE 2002 PAGE(2) = OF(3) <br /> BUSINESS NAME (4) F --,:: <br /> CHEMICAL LOC <br /> c� <br /> CHEMICAL NAME (8) TRADE SECRET(11) ❑Y ©N <br /> Amrnon�u � �1s�l�'�Ve <br /> COMMON NAME (9) �J/A *EHS (12) ❑Y ®N <br /> *IF EHS BOX IS "Y" <br /> CAS # (10) q oZ -30 -O ALL AMOUNTS MUST BE IN LBS <br /> FIRE CODE (13) LEAVE BLANK <br /> HAZARD CLASS <br /> TYPE (14)1 []PURE ®MIXTURE ❑WASTE RADIOACTIVE(15) ❑y a 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) ®GAL ❑CU FT MAX DAILY AMT(23) <br /> CODEI i ❑LBS TONS <br /> ON-SITE 3(on O <br /> ❑ <br /> DAYS ON SITE (20) AVG DAILY AMT(24) <br /> UG *If EHS, amounts must be in lbs ON-SITELARGEST <br /> <<© <br /> CONTAINER (21) ANNUAL WASTE AMT(25) <br /> 1.�vM <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)12] AMBIENT ❑ABOVE AMBIENT ❑BELOW AMBIENT <br /> PRESSURE <br /> STORAGE (28)12 AMBIENT [:]ABOVE AMBIENT ❑BELOW AMBIENT ❑CRYOGENIC <br /> TEMPERATURE <br /> 29 %WT 30 HAZARDOUS COMPONENT 31 EHS 32 CAS# <br /> q5-7o A78is ,,l = [_[:1YZ1N`jj t01ga-30--o <br /> �p -�� Wck �er ❑Y ©N '773a- 1e -5 <br /> ❑Y ❑N <br /> ❑Y <br /> aN: <br /> ❑Y ❑N <br /> 1DDITIONAL LOCALLY COLLECTED INFORMATION: (33)UNITED NATIONS ID#(DOT) Q(,q3; <br /> (34)WHAT IS MATERIAL <br /> USED FOR? Fo t 5CL le <br /> For Official Use Only: J�j C [] R [] S SJC 12/01 <br />