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California Hazardous Materials Inventory Form - Chemical Description (1) ❑ADD ❑DELETE ❑REVISE 2001 PAGE (2) =OF(3)� BUSINESS NAME CHEMICAL LOCATION(S) MAP # (6) / GRID # (7) , _ CHEMICAL NAME (8)1 1 AD / TRADE SECRET (I I) Y N COMMON NAME (9) CAS # (10) FIRE CODE (13) HAZARD CLASS TYPE (14 PHYSICAL STATE (17) i FED HAZARD �� e�Z� f� r1 CATEGORIES (18; STATE WASTE (19; CODE DAYS ON SITE (20 LARGEST (21 CONTAINER STORAGE (26 CONTAINER STORAGE (27 PRESSURE STORAGE (28 TEMPERATURE ADDITIONAL LOCALLY COLLECTED INFORMATION (34) WHAT IS MATERIAL �Ic�I USED FOR? UUI 1191 CAS# (33) UNITED NATIONS 1D # (i)OT) �1 U For Official Use Only: C ❑ R [-] S I SJC 12/00 �� e�Z� f� r1 ❑ *EHS (12) ❑Y N *IF EHS BOX IS "Y" ALL AMOUNTS MUST BE IN LBS to A�,tleez LEAVE BLANK RADIOACTIVE (15) ❑Y N (16)� CURIES [:]PURE [:]MIXTURE WASTE [:]SOLID ®'LIQUID [:]GA=S ❑ FIRE ❑ REACTIVE ❑ PRESSURE RELEASE ACUTE HEALTH [:1 HEALTH UNITS* (22) GAL ❑ CU FT MAX DAILY AMT (23) ION-SITE 1[:]LBS E] TONS 'AMT (24) 3 3l_.V *If EHS, amounts must be in lbs ON-SITE �� ANNUAL WASTE AMT (25) IOC LJ Recy c, l ❑ ABOVE GROUND TANK ❑ CAN ❑ UNDER GROUND TANK ❑ CARBOY ❑ TANK INSIDE BUILDING ❑ SILO ❑ STEEL DRUM ❑ FIBER DRUM MPLASTIC/NONMETALLIC DRUM ❑ BAG ❑ BOX ❑TANK WAGON ❑ CYLINDER ❑ RAIL CAR ❑ GLASS BOTTLE ❑-------------------- ❑ PLASTIC BOTTLE ❑ TOTE BIN 1 ® AMBIENT ❑ ABOVE AMBIENT ❑BELOW AMBIENT AMBIENT ❑ ABOVE AMBIENT ❑BELOW AMBIENT ❑ CRYOGENIC ADDITIONAL LOCALLY COLLECTED INFORMATION (34) WHAT IS MATERIAL �Ic�I USED FOR? UUI 1191 CAS# (33) UNITED NATIONS 1D # (i)OT) �1 U For Official Use Only: C ❑ R [-] S I SJC 12/00