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California Hazardous Materials Inventory Reporting Fajen[ h4mcal Description Page <br /> (1) ❑ADD ❑DELETE ❑REVISE 1998 I� '�, _ PAGE(2) E-1OF(3)� <br /> BUSINESS NAME (4) A( O <br /> CHEMICAL LOCATION(S)( <br /> <br /> <br /> CHEMICAL NAME (8) C< I U� r tl % /C TRADE SECRET(11) ❑Y N <br /> (' C(� *EHS(12) ❑Y <br /> COMMON NAME (9) 411 f •U <br /> IF EHS BOX IS "Y" <br /> J;L <br /> CAS # (10) _3 _o, ALL AMOUNTS MUST BE IN LBS <br /> FIRE CODE (13) LEAVE BLANK / <br /> HAZARD CLASS <br /> TYPE (14)1 WPURE []MIXTURE ❑WASTE RADIOACTIVE(15) ❑Y N (16) <br /> PHYSICAL STATE(17) ❑SOLID LIQUID ❑GAS CURIES <br /> FED HAZARD E]FIRE ❑REACTIVE PRESSURE REI.EAS ACUIE HEALTH ❑ <br /> CATEGORIES (18) CHRONIC HEALTH <br /> STATE WASTE (19) UNITS*(22) [—]GAL C FT MAX DAILY AMT(23)�/ <br /> CODE LBS TONS ON-SITE DQ L <br /> DAYS ON SITE (20) AVG DAILY AMT(24)� <br /> *If EHS, amounts mus[be in lbs ON-SITE 2 �� <br /> LARGEST (2l / ANNUAL WASTE AMT(25) <br /> CONTAINER &)/ <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 El-------------------- <br /> STEEL DRUM ❑FIBER DRUM ❑ PLASTIC BOTTLE <br /> ❑PLASTIC/NONMETALLIC DRUM ❑ BAG ❑ TOTE BIN <br /> STORAGE (27) ❑ AMBIENT ABOVE AMBIENT ❑BELOW AMBIENT <br /> PRESSURE <br /> STORAGE (28) ❑AMBIENT ❑ABOVE AMBIENT BELOW AMBIENT CRYOGENIC <br /> TEMPERATURE <br /> 29 %WT 30 HAZARDOUS COMPONENT 331 EHS 32 CAS# <br /> ❑Y ❑N <br /> ❑Y ❑N <br /> ❑Y ❑N <br /> ❑Y ❑N <br /> ❑Y ❑N <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION: (33)UNITED NATIONS ID#(DOT) <br /> (34)WHAT IS MATERIAL <br /> USED FOR? <br /> For Official Use Only: E] C R S SJC 12/97 <br />