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California Hazardou:,,aterials Inventory Form - Chemica:...scription <br /> (I) []ADD ❑DELETE REVISE PAGE(2) D <br /> BUSINESS NAME (4) 1 <br /> i <br /> J <br /> CHEMICAL LOCATION(S)(5) NIY <br /> (Within facility,not street address 1 l amm <br /> MAP#(6)/ GRID#(7) E= <br /> CHEMICAL NAME (8) 'TRADE SECRET(11) ❑Y N <br /> COMMON NAME (9) *EHS(12) ❑Y N <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) ❑PURE MMIXTURE ❑WASTE RADIOACTIVE(15) ❑ Y N (I6) <br /> PHYSICAL STATE(17) []SOLID ❑LIQUID taGAS CURIES <br /> FED HAZARD FlIZE <br /> CATEGORIES (18) ❑ ❑�t'7fVE PRESSURE RELEASE ACUTE HEALTH ❑ CHROPIIC HEALTH <br /> STATE WASTE (19) / UNITS*(22) []GAL E4CU FT MAX DAILY AMT(23) <br /> CODE ��/ ON-SITE <br /> ❑LBS E]TON S <br /> DAYS ON SITE (20) AVG DAILY AMT(24) <br /> *If EHS, amounts must be in lbs ON-SITE <br /> LARGEST (21 / ,q y ANNUAL WASTE AMT(25) <br /> CONTAINER h L13� �, / -r N <br /> STORAGE (26) ❑ABOVE GROUND TANK ❑ CAN ❑ BOX []TANK WAGON <br /> CONTAINER ❑UNDERGROUND 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 ❑ABOVE AMBIENT ❑BELOW AMBIENT ❑CRYOGENIC <br /> TEMPERATURE <br /> 29 %WT 30 HAZARDOUS COMPONENT 31 EHS 32 CAS# <br /> ❑Y ON <br /> ❑Y ❑ N <br /> ❑ Y ❑ <br /> N <br /> ❑ Y ❑ N <br /> ❑ Y ❑N <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 12/03 <br />