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O.& O. JIMENEZ FARM <br /> 22355 N.HWY.99 <br /> ACAMPO, CALIFORNIA <br /> aef[3J5/S7� 95220 <br /> AG. HAZARDOUS MATERIALS FERTILIZERS& SOIL AM NDM NT - <br /> WORKSHEET (Side One) Mark Box if 55 gallons, 500 pounds or <br /> more: <br /> INSTRUCTIONS: Review the list of ❑ Ammonium Nitrate fertilizer(2067) <br /> materials. Mark the box for any material in ❑ Ammonium Nitrate fertilizer mixture (2069) <br /> stock any day during the ❑ Ammonium Sulfate (2506) <br /> ti year in amounts ❑ Ammonium ThiosuHate =Thiosul (9093) <br /> equal to or more than the limits in each ❑ Copper Sulfate = Blue Stone (9109) <br /> section. When finished with worksheet, ❑ Lime- Calcium Oxide (1910) <br /> transfer material name and DOT# to ❑ Fertilizer n.o.s. (9188) <br /> inventory for each material marked on ❑ <br /> worksheet, and then provide the requested o <br /> information about how, when and where ❑ <br /> the material is handled. This Worksheet ❑ <br /> has two (2) sides: -QQMPLETE BOTH ❑ <br /> SIDES. <br /> FUELS OILS & PETROLEUM PR D TS- <br /> NOTES: Vark Box If 55 gallons or more: <br /> (1) Use the blank spaces to include other potentially 1Diesel = F12 iii (1993) <br /> El <br /> hazardous materials which would be of concern ❑ Gasoline (1203) <br /> to you or the fire department. ❑ Grease = Lube Grease (1993) <br /> (2) "n.o.s." = not otherwise specified ❑ Kerosene (1223) <br /> (3) DOT#= iri (parenthesis) after name ❑ Oil=Motor, Hydraulic &Transmission (1270) <br /> ❑ Solvents (1993) <br /> EXTREMELY H ZARDOUS Sl IReTer CES- ❑ Thinner (1263) <br /> Mark Box If 10 lbs or more of: ❑ <br /> ❑ Furadan = Carbofuran (2757) ❑ <br /> ❑ DNOC or Sinox = Dinitro-o-Cresol (1598) ❑ <br /> ❑ Diphacinone= PCO, Parapel& Ramik (2902) ❑ <br /> ❑ Nemacur= Fenamiphos (2783) <br /> ❑ GutImidan <br /> = hosmeos 902) Mark Box If 55 gallons, 500 pounds or <br /> ❑ Imidan= Phosmet (2902) <br /> ❑ Paraquat = Gramoxone (2781) more: <br /> ❑ Thimet= Phorate (2902) ❑ Waste or Used Anti-Freeze (9189) <br /> ❑ Thiodan = Endosulfan (2761) ❑ Waste or Used Oil (9189) <br /> ❑ Waste or Used Solvent (9189) <br /> Mark Box If 100 lbs or more of: ❑ Hazardous Waste n.o.s. (9189) <br /> ❑ Anhydrous Ammonia (1005) ❑ <br /> ❑ Arsenic Pentoxide (1 COMPRESSED ,AS S: no es <br /> ❑ Arsenic Trioxide = White <br /> ite Arsenic (1561) non-pesticide: Mark Box <br /> ❑ Bidrin = Dicrotophos (2783) If 55 gallons, 200 cubic ft (cf) or more: <br /> ❑ Chlorine (1017) ❑ Acetylene (1001) <br /> ❑ Cyciohexamide = Acti-Dione& Actispray (2902) ❑ Argon (1006) <br /> ❑ Dinoseb= Dinitro... (1599) ❑ Carbon Dioxide = CO2 (1013) <br /> ❑ Methyl Parathion = Penncap (2783) ❑ Ethylene Gas = Ripening gas (1962) <br /> ❑ Mevinphos = Phosdrin (2783) ❑ Freon, liquid or gas (1078) <br /> ❑ Monitor= Methamidiphos (2783) ❑ Helium (1046) <br /> ❑ Parathion (2783) ❑ Liquid Petroleum Gas = LPG(1075) <br /> ❑ Phosphamidon = Dimecron (2783) ❑ Methane (1971) <br /> ❑ Phosphorus (138 1) ❑ Nitrogen, gas (1066) <br /> ❑ Sodium Cyanide = Cymag (1689) ❑ Nitrogen, liquid (1977) <br /> ❑ Strychnine & Srychnlne Salts, rodent baits ❑ Oxygen = 02 (1072) <br /> (1692) 9 Propane = Natural Gas (1978) <br /> ❑ Sulfur Dioxide = S02 (1079) ❑ Tri Mix welding gas (1956) <br /> ❑ Temik= Aidicarb (2757; ❑ \ / (", <br /> ❑ Vydate = Oxamyl (2902) ❑ ECEI <br /> �/ �,,,/ <br /> NOV 21 2014 <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br />