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California Hazardous Ma ert s Inventory Form - Chemical Des"n <br /> (1) <br /> []ADD ❑DELETE []REVISE PAGE(2) = OF(3) <br /> BUSINESS NAME (4) AUTOFIX OF STOCKTON <br /> CHEMICALLOCATION(S)(5)SHOP <br /> MAP#(6)/ GRID#(7) I-1 H-3 <br /> CHEMICAL NAME (8) ANTI-FREEZE WASTE TRADE SECRET(11) ❑YES ®NO <br /> COMMON NAME (9) ANIT-FREEZE WASTE *EHS(12) ❑YES ®NO <br /> *IF EHS BOX IS"Y" <br /> CAS # (10) 107-21-1 ALL AMOUNTS MUST BE IN LBS <br /> FIRE CODE (13) <br /> HAZARD LEAVE BLANK <br /> CATEGORIES <br /> TYPE (14) 0PURE ❑MIXTURE ®WASTE RADIOACTIVE(15) ❑yES ®NO (16)� <br /> PHYSICAL STATE(17) ❑SOLID R LIQUID ❑GAS CURIES <br /> FED HAZARD R FIRE ❑REACTIVE []PRESSURE RELEASE R ACUTE HEALTH ❑CHRONIC HEALTH <br /> CATEGORIES (l8) <br /> STATE WASTE (19) UNITS*(22) R GAL ❑LBS MAX DAILY AMT(23 140 <br /> CODE 343 ❑CU FT ❑TONS ON SITE <br /> DAYS ON SITE (20)365 *If EHS, amounts must be in lbs AVG DAILY AMT(24) 7 0 <br /> ON SITE <br /> LARGEST (21 140 ANNUAL WASTE AMT(25) 900 <br /> CONTAINER <br /> STORAGE (26) R ABOVE GROUND TANK ❑CAN ❑BOX ❑TAN <br /> CONTAINER ❑UNDER GROUND TANK ❑CARBOY ❑CYLINDER ❑RAI <br /> ❑TANK INSIDE BUILDING ❑SILO ❑GLASS BOTTLE ❑Othe <br /> ❑STEEL DRUM ❑FIBER DRUM ❑PLASTIC BOTTLE <br /> ❑PLASTIC/NONMETALLIC DRUM ❑BAG ❑TOTE BIN <br /> STORAGE (27) R AMBIENT ❑ABOVE AMBIENT []BELOW !MBI <br /> PRESSURE <br /> STORAGE (28) R AMBIENT ❑ABOVE AMBIENT []BELOW AMBIENT ❑CRYOGENIC <br /> TEMPERATURE <br /> 29)%aWT 30)HAZARDOUS COMPONENT (3 1)EHS 32)CAS# <br /> ❑YES ❑N <br /> [I YE ❑N <br /> ❑YES ❑N <br /> ff—YE ST❑N <br /> 11❑YES ❑N <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION: (33)UNITED NATIONS ID#(DOT) 1142 <br /> (34)WHAT IS MATERIAL <br /> USED FOR? <br /> DATE REC'D: 3/1/01 For Official Use Only: R C ❑R ❑S SIC 12/99 <br />