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California Hazardous P aerials Inventory Form - Chemical r cription <br /> (I) —]REVISE 2005 "ISAGE(2) OF (3) <br /> ❑ADD ❑DELETE � <br /> BUSINESS NAME (4) <br /> CHEMICAL LOCATION(S)(5) / / � SAN JOAQUIN COUNTY <br /> (Within facility,not street address !T Y,,- tf © ES <br /> MAP#(6)/ GRID#(7) E <br /> CHEMICAL NAME (8) lam/ TRADE SECRET(11) ❑Y ❑N <br /> COMMON NAME (9) <br /> *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 ❑MIXTURE EIWASTE RADIOACTIVE(15) ❑Y ICF 1�1 N (16) <br /> PHYSICAL STATE(17) BSOLID [–]LIQUID [:]GAS= CURIES <br /> FED HAZARD <br /> CATEGORIES (18) ❑FIRE ❑REACTIVE []PRESSURE RELEASE ACUCE HEALTH E] CHRONIC HEALTH <br /> STATE WASTE (19)O UNITS*(22) GAL E]CU F1' MAX DAILY AMT(23)� <br /> CODE b❑:LBS ❑TONS ON-SITE ss <br /> DAYS ON SITE (20)� AVG DAILY AMT(24)� <br /> *If EHS, amounts must be in lbs ON-SITE �Q <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 El--------------------- <br /> El STEEL DRUM ❑FIBER DRUM ❑ PLASTIC BOTTLE <br /> CDPLASTIC/NONMETALLIC DRUM ❑ BAG ❑ TOTE BIN <br /> STORAGE (27) ® AMBIENT ❑ABOVE AMBIENT ❑BELOW AMBIENT <br /> PRESSURE <br /> STORAGE (28) [gAMBIENT ❑ABOVE AMBIENT ❑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 /> ❑Y ❑N <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION: (33)UNITED NATIONS ID#(DOT) /® <br /> (34)WHAT IS MATERIAL <br /> USED FOR? a ' //." f <br /> For Official Use Only: 0 C ❑ R S SJC 12/03 <br />