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California HazardOL- .materials Inventory Form - Chen,, ,al Description <br />(1)E ADD ❑DELETE ❑REVIS2002 PAGE (2) OF (3)� <br />BUSINESS NAME (4) , . <br />5 i e rrte.. ch em i e ct l (b. 9 Aklo/W..i V �.. <br />CHEMICAL LOCATIONS) (5) <br />[A, )_O_ Ce G D us e <br />MAP # (6) / GRID # (7)_� <br />F__ F - <br />CHEMICAL NAME (8)+i TRADE SECRET (11)❑Y X❑ N <br />COMMON NAME (9)`e e3 le <br />*EHS (12) ❑ Y © N <br />CAS # (10)*IF EHS BOX IS "Y" <br />(0--7 -a — j ALL AMOUNTS MUST BE IN LBS <br />FIRE CODE (13) LEAVE BLANK <br />HAZARD CLASS <br />TYPE <br />(14) <br />❑PURE MIXTURE [:]WASTE <br />RADIOACTIVE (15) ❑ y ©N (16)1 <br />PHYSICAL STATE <br />(17) <br />[[:]SOLID LIQUID❑ GAS <br />CURIES <br />FED HAZARD <br />CATEGORIES <br />(18) <br />® FIRE ❑ REACTIVE ❑PRESSURE RELEASE ©ACUTE HEALTH ❑ CHRONIC HEALTH <br />STATE WASTE <br />CODE <br />(19) <br />UNITS* (22) <br />©GAL ❑ CU FT <br />MAX DAILY AMT (23) <br />ON-SITE <br />s� <br />[:]LBS TONS <br />c ic, <br />DAYS ON SITE <br />(20) <br />3 GSAVG <br />DAILY AMT (24) <br />*If EHS, amounts must be in lbs ON -SI'Z'E <br />S ��( <br />LARGEST <br />CONTAINER <br />(21) <br />5 5 8d . <br />ANNUAL WASTE AMT (25) <br />STORAGE (26) <br />CONTAINER <br />STORAGE <br />PRESSURE <br />STORAGE <br />TEMPERATURE <br />(29) %WT <br />❑ ABOVE GROUND TANK [:]CAN - ❑ BOX ❑TANK WAGON <br />❑ 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 />(27) AMBIENT ❑ ABOVE AMBIENT ❑BELOW AMBIENT <br />(28) ® AMBIENT ❑ ABOVE AMBIENT ❑BELOW AMBIENT ❑ CRYOGENIC <br />HALARUMS UUMPONENi' <br />31 EHS <br />❑Y ❑N <br />LOCALLY COLLECTED INFORMATION: (33) UNITED NATIONS ID # (DOT) <br />UAS#P <br />(34) WHAT IS MATERIAL -ra � 0.Se u 5 e <br />USED FOR? <br />For Official Use Only: LA C ❑ R ❑ S SJC 12/01 <br />