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California Hazardousmaterials Inventory Form - Chemical D iption <br />4I WE (2) <br />BUSINESS NAME <br />FARM SERVICE <br />CHEMICAL LOCATION(S) <br />OCT ® 3 2003 <br />= OF(3)= <br />MAP # (6) / GRID # (7) <br />CHEMICAL NAME (8) <br />COMMON NAME (9) <br />CAS # (10) <br />FIRE CODE (13) <br />HAZARD <br />CATEGORIES <br />PETROLEUM DISTILLATE <br />WASTE OIL <br />N/A <br />VE BLANK <br />TRADE SECRET (11) ❑ YES R NO <br />*EHS (12) ❑YES R NO <br />*IF EHS BOX IS "Y" <br />ALL AMOUNTS MUST BE IN LBS <br />TYPE (14) ❑ PURE R MIXTURE ❑ WASTE RADIOACTIVE (15) ❑ YES R NO (16 <br />PHYSICAL STATE (17) ❑ SOLID R LIQUID ❑ GAS CURIES <br />FED HAZARD <br />CATEGORIES (18)R FIRE ❑ REACTIVE ❑ PRESSURE RELEASE R ACUTE HEALTH R CHRONIC HEALTH <br />STATE WASTE (19) <br />CODE <br />DAYS ON SITE (20) <br />N/A <br />365 <br />LARGEST (21 <br />❑YES ❑N <br />CONTAINER <br />125 <br />UNITS* (22) ❑ GAL ❑ LBS <br />❑CU FT ❑TONS MAX DAHYAMT (23 125 <br />ON SITE <br />*If EHS, amounts must be in lbs AVG DAILY AMT (24) 7 U <br />ON SITE <br />ANNUAL WASTE AMT (25) N/A <br />STORAGE (26) R ABOVE GROUND TANK <br />CONTAINER ❑ UNDER GROUND TANK <br />❑ TANK INSIDE BUILDING <br />❑STEEL DRUM <br />[]CARBOY <br />❑ SILO <br />❑ FIBER DRUM <br />DRUM ❑ BAG <br />❑ CYLINDER ❑ <br />❑ GLASS BOTTLE ❑ <br />❑ PLASTIC BOTTLE ❑ <br />❑ TOTE BIN <br />STORAGE (27) R -AMBIENT ❑ ABOVE AMBIENT ❑ BELOW AMBIENT <br />PRESSURE <br />STORAGE (28)IN AMBIENT ❑ ABOVE AMBIENT ❑ BELOW AMBIENT ❑ CRYOGENIC <br />TEMPERATURE <br />29 %WT 30 HAZARDOUS COMPONENT (31) EHS 32 CAS# <br />75 <br />PETROLEUM DISTILLATE ❑YES RN <br />N/A <br />❑YES ❑N <br />❑YES []Nql <br />❑YES ❑N <br />❑YES ❑N <br />ADDITIONAL LOCALLY COLLECTED INFORMATION: (33) UNITED NATIONS ID# (DOT) N/A <br />(34) WHAT IS MATERIAL N/A <br />USED FOR? <br />DATE REC'D: 10/3/03 For Official Use Only: ❑ C ❑ R ❑ S SIC 12/99 <br />