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California HazardoqulMaterials Inventory Form - CherHScal Description <br /> (U ADD ❑DELETE ❑REVISE 2001 PAGE(2) OF(3) <br /> BUSINESS NAME (4) <br /> CHEMICAL LOCATION(S)(5) -' <br /> <br /> MAP#(6)/ GRID#(7) <br /> CHEMICAL NAME (8) TRADE SECRET(I I) ❑Y N <br /> G <br /> N <br /> *EHS(12) ❑Y <br /> COMMON NAME (9) �•� � <br /> *IF EHS BOX IS "Y" <br /> CAS # (10) 7.11 <br /> ALL AMOUNTS MUST BE IN LBS <br /> FIRE CODE (13) LEAVE BLANK <br /> HAZARD CLASS <br /> TYPE (14) []PURE MIXTURE ❑WASTE RADIOACTIVE(15) ❑Y N (16) <br /> PHYSICAL STATE(17) ❑SOLID LIQUID []GASCURIES <br /> FED HAZARD <br /> CATEGORIES (18) FIRE [:]REACTIVE ❑PRESSURE RELEASE ❑ ACUTE HEALTH CHRONIC HEALTH <br /> STATE WASTE (19) UNITS*(22) GAL ❑CU FT MAX DAILY AMT(23)� <br /> CODE ❑LBS ❑TONS I ON-SITE p pip <br /> DAYS ON SITE (20) AVG DAILY AMT(24) <br /> *If EHS, amounts must be in lbs ON-SITE p0 <br /> LARGEST (21) ANNUAL WASTE AMT(25)D <br /> CONTAINER ZO OO <br /> STORAGE (26) ABOVEGROUNDTANK 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 [:]BELOWAMBIENT [—]CRYOGENIC <br /> TEMPERATURE <br /> (29)%WT (30)HAZARDOUS COMPONENT (31 EHS (32)CAS# <br /> 11 ONIF <br /> ❑Y ❑N <br /> ❑Y ❑N <br /> ❑Y ❑N <br /> ❑Y E]N11 <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION: (33)UNITED NATIONS ID#(DOT) �y <br /> (34)WHAT IS MATERIAL <br /> USED FOR? G/ <br /> For Official Use Only: [9 C ❑ R [] S SIC 12/00 <br />