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California Hazardous Akiterials Inventory Form - Chemica cription <br /> (1) ❑ADD ❑DELETE ❑REVISE 2005 PAGE(2) OF(3) <br /> - I QQ;-.i J <br /> BUSINESS NAME (4) <br /> 3 F a/ry <br /> CHEMICAL LOCATIONS)(5) / / DAN JUHuuiN CUUN iY <br /> (Within facility,not street address) , OFFICE OF EMERGENCY SER CE°d <br /> MAP#(6)/ GRID#(7) <br /> CHEMICAL NAME (8) TRADE SECRET(11) ❑Y [9 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 ❑WASTE RADIOACTIVE(15) ❑ Y N (16) <br /> PHYSICAL STATE(17) ❑SOLID OLIQUID ❑GAS CURIES <br /> FED HAZARD <br /> CATEGORIES (18) FIRE ❑REACTIVE []PRESSURE RELEASE ❑ ACUTEHEALTH ❑ CHRoNicHEALTH <br /> STATE WASTE (19) UNITS*(22) [5rGAL [:]CU FT MAX DAILY AMT(23)� <br /> CODE LTJ" ON-SITE <br /> DAYS ON SITE (20) 10LBS ❑TONS AVG DAILY AMT(24) <br /> 3d�! *If EHS, amounts must be in lbs ON-SITE <br /> LARGEST (21) ANNUAL WASTE AMT(25) <br /> CONTAINER i0,O©O <br /> STORAGE (26) R=ER <br /> VE GROUND TANK ❑ CAN ❑ BOX ❑TANK WAGON <br /> CONTAINER GROUND TANK ❑ CARBOY ❑ CYLINDER ❑RAIL CAR <br /> ❑TANK INSIDE BUILDING ❑ SILO ❑ GLASS BOTTLE ❑-------------------- <br /> ❑STEEL DRUM ❑FIBER DRUM ❑ PLASTIC BOTTLE <br /> ❑PLASTICINONMETALLIC DRUM ❑ BAG ❑ TOTE BIN <br /> STORAGE (27) AMBIENT ❑ABOVE AMBIENT ❑BELOW AMBIENT <br /> PRESSURE 1 [9 <br /> STORAGE (28) AMBIENT ❑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 G, <br /> For Official Use Only: 0 C ❑ R ❑ S SIC 12/03 <br />