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RECEIVL� <br /> California Hazardous Materials Inventory Form - Chemical Description <br /> (1) DADD F]DELEI'E REVISE 2001 JAN 11 2001 PACE(2) OF(3) <br /> BUSINESS NAME (41tmt <br /> r,� m s tmS sic. <br /> CHEMICAL LOCATION(S)(5) <br /> <br /> <br /> CHEMICAL NAME (8) TRADE SECRET(11) 1 ❑Y ®N <br /> COMMON NAME (9) *EHS(12) ❑Y [MN <br /> *IF EHS BOX IS"Y" <br /> CAS # <br /> (10) hn l'X f u {r e— ALL AMOUNTS MUST BE IN LBS <br /> FIRE CODE (13) LEA' <br /> V,/E BLANK <br /> HAZARD CLASS <br /> TYPE (14) ❑PURE MIXTURE ❑WASTE RADIOACTIVE(15) ❑Y ®N (16)�� <br /> PHYSICAL STATE(17)1 SOLID ®LIQUID ❑GAS CURIES <br /> FED HAZARD <br /> CATEGORIES (18) WFIRE [:]REACTIVE ❑PRESSURE RELEASE ❑ ACUTEHEALTH ® CHRONIC HEALTH <br /> STATE WASTE (19)® UNITS*(22) [GAL ❑CU FC OMAX N-SITE <br /> ❑LBS ILY AMT(23) J 00 <br /> CODE <br /> ❑TONS <br /> DAYS ON SITE (20) AVG DAILY AMT(24)� <br /> II fj *If EHS, amounts must be in lbs ON-SITE <br /> LARGEST P� (211 ANNUAL WASTE AMT(25) IVA <br /> CONTAINER r pl W" <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❑-------------------- <br /> ❑STEEL DRUM ❑FIBER DRUM ❑ PLASTIC BOTTLE <br /> ❑PLASTIC/NONMETALLIC DRUM ❑ BAG ❑ TOTE BIN <br /> STORAGE (27) AMBIENT ❑ABOVE AMBIENT ❑BELOW AMBIENT <br /> PRESSURE ILA <br /> STORAGE (28) AMBIENT ❑ABOVE AMBIENT ❑BELOW AMBIENT ❑CRYOGENIC <br /> TEMPERATURE 10 <br /> (29JJ %WT 30)HAZARDOUS COMPONENT (3 1)EHS 32 CAS# <br /> // <br /> JJ 79, 2— �� E Y ®N <br /> ` ��J � ❑Y N —dG— <br /> ❑Y ❑N <br /> ❑Y N <br /> ❑Y ON <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION: (33)UNITED NATIONS ID#(DOT) <br /> (34)WHAT IS MATERIAL <br /> USED FOR? <br /> For Official Use Only: C [_] R ❑ S SIC 12/00 <br />