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California Hazardouverials Inventory Form - Chemicawription G 3 0 2W4 <br />PAGE (2) "F (3)= <br />BUSINESS NAME <br />CHEMICAL LOCATION(S) <br />MAP # (6) / GRID # (7) <br />CHEMICAL NAME (8) <br />COMMON NAME (9) <br />CAS # (10) <br />FIRE CODE (13) <br />HAZARD <br />CATEGORIES <br />FARM SERVICE <br />(5) <br /> <br />LEAVE BLANK <br />TRADE SECRET (11) ❑YES ®NO Tra <br />*EHS (12) ❑YES ®NO <br />*IF EHS BOX IS "Y" <br />ALL AMOUNTS MUST BE IN LBS <br />TYPE <br />(14) ❑ PURE ®MIXTURE ❑ WASTE <br />RADIOACTIVE (15) ❑ y ES ®NO (16) <br />PHYSICAL STATE (17) ❑ SOLID H LIQUID ❑ GAS <br />CURIES <br />FED HAZARD <br />® TIRE ❑REACTIVE ❑ PRESSURE RELEASE H ACUTE HEALTH El CHR HEALTH <br />CATEGORIES <br />(18) <br />STATE WASTE <br />(19) UNITS* (22) ® GAL ElLBS MAX DAILY AMT (23)100 <br />N/A <br />CODE <br />❑ CU <br />FT ❑ TONS <br />ON SITE <br />DAYS ON SITE <br />(20) *If EHS, amounts <br />must be in lbs AVG DAILY AMT (24) 20 <br />365 <br />ON SITE <br />LARGEST <br />(21) 2 5 <br />ANNUAL WASTE AMT (25)N/A <br />CONTAINER <br />STORAGE <br />(26) ❑ ABOVE GROUND TANK <br />❑ CAN []BOX <br />❑ TANI <br />CONTAINER <br />[]UNDER GROUND TANK <br />[]CARBOY ❑ CYLINDER <br />❑ RAIL <br />❑ TANK INSIDE BUILDING <br />❑ SILO ❑ GLASS BOTTLE <br />❑ OTH] <br />❑ STEEL DRUM <br />❑ FIBER DRUM ® PLASTIC BOTTLE <br />❑ Othet <br />❑ PLASTIC/NONMETALLIC DRUM []BAG ❑ TOTE BIN <br />STORAGE <br />(27) ® AMBIENT []ABOVE AMBIENT <br />❑ BELOW AMBIENT <br />PRESSURE <br />STORAGE <br />(28) ® AMBIENT ❑ ABOVE AMBIENT <br />❑ BELOW AMBIENT ❑ CRYOGENIC <br />TEMPERATURE <br />29 %WT <br />30 HAZARDOUS COMPONENT <br />(3 1) EHS 32 CAS# <br />54 CHLOROTHALONIL ❑YES ®N <br />1897-45.6 <br />❑YES ❑N <br />❑YES ❑N <br />❑YES ❑N <br />❑YES ❑N <br />ADDITIONAL LOCALLY COLLECTED INFORMATION: (33) UNITED NATIONS ID# (DOT) N/A <br />(34) WHAT IS MATERIAL IPT TN(TTC'Tnp <br />USED FOR? — <br />DATE REC'D: 12/30/04 lFor Official Use Only: 74,C 'R ❑ S SIC 12/99 <br />