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California Hazardous Materials Inventory Reporting Form i Chemical Description Page <br /> (1) =ADD =DELETE REVISE 1997 ML. - PAGE(2) OF(3) <br /> BUSINESS NAME (4) <br /> CHEMICAL LOCATION(S)(5) <br /> <br /> MAP# (6) / GRID#(7) <br /> CHEMICAL NAME (8) TRADE SECRET(11) ❑Y ❑N <br /> *EHS (12) ❑Y ❑N <br /> COMMON NAME (9) <br /> *IF EHS BOX IS "Y" <br /> CAS # (10) ALL AMOUNTS MUST BE IN LBS <br /> FIRE CODE (13) <br /> HAZARD <br /> CATEGORIES <br /> TYPE (14)19PURE ❑MIXTURE ❑WASTE RADIOACTIVE(15) ❑ Y [:IN] (16) <br /> PHYSICAL STATE (17)1 ❑SOLID ❑LIQUIDQGAS CURIES <br /> FED HAZARD <br /> CATEGORIES (18) ® FIRE []REACTIVE ❑PRESSURE RELEASE ❑ACUTE HEALTH ❑CHRONICHFALTH <br /> STATE WASTE (19) UNITS*(22) ❑GAL �CU FT MAX DAILY AMT(23) O <br /> CODE (9- <br /> ❑LBS ❑ TONS <br /> DAYS ON SITE (20)�� AVG DAILY AMT(24) O <br /> *If EHS, amounts must be in tbs (� <br /> LARGEST (21 ANNUAL WASTE AMT(25) <br /> CONTAINER <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 <br /> STORAGE (28) ❑AMBIENT ❑ABOVEAMBIENT ❑BELOW AMBIENT ❑ CRYOGENIC <br /> TEMPERATURE <br /> (29)%WT (30)HAZARDOUS COMPONENT (31)EHS (32) CAS# <br /> ❑Y ❑N <br /> ❑Y ❑N <br /> ❑Y ❑N <br /> ❑Y ❑N <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION(33): DOT# 1 tbc/l <br /> For Official Use Only: C R ❑ S SJC 12/96 <br />