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California Hazard-Materials Inventory Form - Chocal Description <br /> (1) -ADD DELETE REVISE 2001 PAGE(2) <br /> � OF <br /> (3)® <br /> BUSINESS NAME (4) GAP. RECEIVE <br /> CHEMICAL LOCATION(S)(5) b c <br /> MAP#(6)/ GRID#(7) <br /> CHEMICAL NAME (R) W ( (� �'/j '( �i \ TRADE SECRET(11) I❑Y N <br /> COMMON NAME (9) G�/ / V *EHS(12) IJ ❑N <br /> *IF EHS BOX IS "Y" <br /> CAS # (10) ALL AMOUNTS MUST BE IN LBS <br /> FIRE CODE (13) LEAVE BLANK <br /> HAZA <br /> TYPE RD CLASS (14) ❑PURE ❑MIXTURE WASTE ❑Y N <br /> RADIOACTIVE(15) (I6) <br /> PHYSICAL STATE (17) SOLID ❑LIQUID ❑GAS CURIES <br /> FED HAZARD <br /> CATEGORIES (1g) ❑ FIRE REACTIVE ❑PRESSURERELEASE ACUIEHE4LTIi CFIRO�ICHEALTH <br /> STATE WASTE (19) UNITS*(22) ❑GAL ❑CU FT MAX DAILY AMT(23) <br /> CODEI3 ON-SITE DDO <br /> ❑'CBS ❑TONS <br /> DAYS ON SITE (20) ^ r �i AVG DAILY AMT(24) �DO <br /> rJ(g *If EHS, amounts must be in lbs ON-SITE <br /> LARGEST (21) I�O ANNUAL WASTE AMT(25) 500 <br /> CONTAINER <br /> STORAGE (26) ❑ABOVE GROUND TANK CAN [:]_BOX ❑TANK WAGON <br /> CONTAINER F] UNDERGROUND TANK ❑CARBOY ❑ CYLINDER ❑ AIL PAR <br /> ❑TANK INSIDE BUILDING ❑ SILO ❑ CLASS BOTTLEa ��� <br /> ❑STEEL DRUM ❑ FIBER DRUM ❑.PLASTIC BOTTLE <br /> ❑PLASTIC/NONMETALLIC DRUM ❑ BAG E'TOTE BIN <br /> STORAGE (27)1 EJAMWENT [:]ABOVE AMBIENT ❑BELOW AMBIENT <br /> PRESSURE <br /> STORAGE (28)MAMBIENT []ABOVEAMBIENT ❑BELOW AMBIENT ❑CRYOGENIC <br /> TEMPERATURE <br /> (29�)90\VT (30)HAZARDOUS COMPONENT (31) HS (32) CAS# <br /> JII SuLJJ R[C PVI�) ❑ N - (.pUq-q�-� <br /> ❑Y ❑N <br /> ❑Y ❑ N <br /> �Y ❑N <br /> FE-1Y ❑N <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION: (33) UNITED NATIONS ID#(DOT)Elj�i� <br /> (34)WHAT IS MATERIAL <br /> USED FOR? <br /> For Official Use Only: C ❑ R ❑ S SJC 12/00 <br />