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California HazardofKaterials Inventory Form - Chetcal Description <br /> (1) ADD ❑DELETE ❑REVISE 2001 PAGE(2) = OF(3)� <br /> BUSINESS NAME (4) <br /> CHEMICAL LOCATION(S)(5) / <br /> MAP#(6)/ GRID#(7) © = E= <br /> CHEMICAL NAME (8) TRADE SECRET(1 1) ❑Y N <br /> �r v <br /> COMMON NAME (9) *EHS(12) ❑Y N <br /> *IF EHS BOX IS "Y" <br /> CAS # (10) -7 ALL AMOUNTS MUST BE IN LBS <br /> FIRE CODE (13) LEAVE BLANK <br /> HAZARD CLASS <br /> TYPE (14)JE]PURE MMIXTURE ❑WASTE RADIOACTIVE(15) ❑Y N (16)� <br /> PHYSICAL STATE(17)1 ❑SOLID ULIQUID ❑GAS CURIES <br /> FED HAZARD <br /> CATEGORIES (18)1 ,9 FIRE EJR.EAC7IVE []PRESSURE RELEASE ❑ ACUTEHEALTH ❑ CHRONIC HEALTH <br /> STATE WASTE (19) UNITS*(22) aGAL ❑CUFT MAX DAILY AMT(23)� <br /> CODE �f <br /> rO LBS E:] ' )INS ON-SITE <br /> DAYS ON SITE (20)0 AVG DAILY AMT(24)� <br /> �S *If EHS, amounts mus[ be in Ibs ON-SITE 3 5— <br /> LARGEST (21) _ ANNUAL WASTE AMT(25) <br /> CONTAINER S S <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 ❑-------------------- <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 [-]BELOW AMBIENT ❑CRYOGENIC <br /> TEMPERATURE 191 <br /> (29)%WT (30)HAZARDOUS COMPONENT (3l)EHS _ (32)CAS# <br /> 2� �� ❑❑ 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? vG�iG :H S b/ <br /> For Official Use Only: ` C R ❑ S SIC 12/00 <br />