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California Hazardousterials Inventory Form - Chemical cription <br /> (1) EIADD ❑DELETE FIRE E AGE(2) = OF(3)� <br /> BUSINESS NAME (4) <br /> A• <br /> ICAL LOCATION(S)(5) �+ <br /> (Within facility,not street address <br /> MAP#(6)/ GRID#(7) _ = <br /> HEMICAL NAME (8) y' ��� TRADE SECRET(11) ❑Y P_?F <br /> COMMON NAME (9) I *EHS (12) ❑Y E!I-?I <br /> *IF EHS BOX IS"Y" <br /> CAS # (10) ALL AMOUNTS MUST BE IN LBS <br /> FIRE CODE (13) <br /> HAZARD CLASS <br /> TYPE (14) ❑PURE1'URE ❑WASTE RADIOACTIVE(15) ❑YCgN (16) <br /> PHYSICAL STATE(17) ❑SOLID RLIQUID [:]GAS CURIES <br /> FED HAZARD <br /> CATEGORIES (18) AFIRE ❑REACTIVE ❑PRESSURE RELEASE ❑ ACUIEHEALTH [—] CHRONIC HEALTH <br /> STATE ODE WASTE (19) UNITS* (22)'BUAL F]UNITS* FT MAX DAILY AMT(23) <br /> ❑LES [:] TONS ON-SITE <br /> JAYS ON SITE (20)�� AVG DAILY AMT(24)� <br /> *If EHS, amounts must be in lbs ON-SITE <br /> yAASTER (21) -7f ^�� ANNUAL WASTE AMT(25) <br /> ONTSTORAGE (26) ❑ABOVE GROUND TANK ❑CAN ❑ BOX ❑TANK WAGON <br /> CONTAINER UNDER GROUND TANK ❑CARBOY ❑ CYLINDER ❑RAII, 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) � MB <br /> AIENT ❑ABOVE AMBIENT ❑BELOW AMBIENT <br /> PRESSURE <br /> STORAGE (28) "'AMBIENT ❑ABOVE AMBIENT ❑BELOW AMBIENT ❑CRYOGENIC <br /> TEMPERATURE <br /> (29)%WT30 HAZARDOUS COMPONENT ❑31YEHS N 32 CAS# <br /> ❑Y ❑N <br /> ❑Y ❑N <br /> ❑Y ❑N <br /> ❑Y ❑N �— <br /> 4 ONAL LOCALLY COLLECTED INFORMATION: (33)UNTIED NATIONS ID#(DOT)E==3 T IS MATERIAL <br /> USED FOR? <br /> For Official Use Only: [] C El R S SIC 12/03 <br />