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• • <br />California Hazardous M to ials Inventory Form - Chemical Description <br />(I) ❑ADD ❑DELETE. EVISE 2001 PAGE (2) OF (3) <br />BUSINESS NAME (4) 1 <br />CHEMICAL LOCATION(S) (5) <br /> <br /> �-- <br />CHEMICAL NAME (8 <br />COMMON NAME (9) <br />CAS # (10) <br />FIRE CODE <br />(13) <br />HAZARD CLASS <br />TYPE <br />(14 <br />PHYSICAL STATE (17) <br />FED HAZARD <br />CATEGORIES <br />(I 8 <br />STATE WASTE <br />(19_ <br />CODE <br />[:]WASTE <br />DAYS ONSITE (20 <br />LARGEST (21 <br />CONTAINER <br />STORAGE (26) <br />CONTAINER <br />STORAGE (27) <br />PRESSURE <br />STORAGE (28) <br />TEMPERATURE <br />l291 0/.WT <br />(301 HAZARDOUS COMPONENT 131 1 FH.¢ <br />(4)1f Agik <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?1�^`e <br />For Official Use Only: C ❑ R L] S <br />61,14SP111IU <br />SECRET (L 1) ❑Y N <br />*EHS (12) Y N <br />*IF EHS BOX IS "Y" <br />ALL AMOUNTS MUST BE IN LBS <br />$✓ <br />LEAVE BLANK <br />PURE [:]MIXTURE <br />[:]WASTE <br />RADIOACTIVE (15) ❑� n,� (16) r� <br />L d" NCURIES <br />[]SOLID ❑LIQUID AS <br />FIRE ❑ REACPIVE aPRFSSURE RELEASE ❑ ACUTEHEALTH ❑CHRONIC HEALTH <br />UNITS* (22) GAL ❑ CU FT MAX DAILY AMT (23) <br />ON-SITE <br />BS ❑ TONS <br />AVG DAILY AMT (24) <br />*If EHS, amounts must be in lbs ON-SITE <br />ANNUAL WASTE AMT (25) <br />[D,,'(BOVE 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 />LaAMBIENT ABOVE AMBIENT ❑BELOW AMBIENT <br />IWAMBIENT ❑ ABOVE AMBIENT <br />❑BELOW <br />AMBIENT ❑ CRYOGENIC <br />(301 HAZARDOUS COMPONENT 131 1 FH.¢ <br />(4)1f Agik <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?1�^`e <br />For Official Use Only: C ❑ R L] S <br />61,14SP111IU <br />