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California_Hazard_ous`Materials Inventory Form - Chemical Description <br /> (1) ❑ADD ❑DELETE ❑REVISE 2001 PAGE(2) � OF(3)= <br /> BUSINESS NAME (41 I-4T#" P_(_ * 4 FOLD 04""r �k=CEO u <br /> CHEMICAL LOCATIONS)(5) / <br /> MAP# (6)/ GRID#(7) tFFICEOFE GENCYSERVICEf <br /> CHEMICAL NAME (R) /�GOOf�! { TRADE SECRET 0 I) ❑Y ®N <br /> f / <br /> COMMON NAME (9) L-e- *EHS(12) ❑Y ®` <br /> N <br /> *1F EHS BOX IS"Y" <br /> CAS # 00) ALL AMOUNTS MUST BE 1N LBS <br /> FIRE CODE (13) LEAVE BLANK <br /> HAZARD CLASS <br /> TYPE tl4) ®PURE ❑MIXTURE [:]WASTE RADIOACTIVE(15) ❑Y ®N (16)(��j <br /> PHYSICAL STATE(17)1 ❑SOLID ®LIQUID ❑GAS CURIES <br /> FED HAZARD <br /> CATEGORIES (18) ®FIRE ❑REACTIVE ❑PRFSSLRE RELEASE ® ACL-M HEALTH ® CHRONIC HEALTH <br /> CODE [-]LBS <br /> WASTE (19) UNITS* (22) GAL ❑CU FT MAX DAILY ANIT(23)((I'' <br /> ONSITE <br /> ®LAS ❑TONS <br /> DAYS ON SITE (20) _ AVG DAILY AMT(24) <br /> (�S *If EHS, amounts must be in lbs ON-SITE 3,Oc7O <br /> LARGEST (21 ANNUAL WASTE AMT(25)® <br /> CONTAINER <br /> STORAGE (26) ❑ABOVE GROUND TANK ❑ CAN ❑ BOX [3TANK 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) [�g AMBIENT ❑ABOVE AMBIENT ❑BELOW AMBIENT <br /> PRESSURE <br /> STORAGE (28) [AMBIENT ❑ABOV'E AMBIENT []BELOW AMBIENT []CRYOGENIC <br /> TEMPERATURE <br /> (291%WT (30)HAZARDOUS COMPONENT (31)EHS (32)CAS# <br /> ❑ Y ❑N <br /> _ - ❑ Y ❑N <br /> Y ❑N <br /> ❑Y ❑N <br /> ADDITIONAL LOCALLY COLLEC D INFORMATION: (33) LNFFED NATIONS ID#(DOT) / ?A <br /> 31)WHAT IS MATERIAL <br /> USED FOR <br /> For Official Use Only: y C �� R ( S � SIC 1:X') <br />