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0 <br />California Hazardous Materials Inventory <br />(1) ® ADD ❑ DELETE ❑ REVISE <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 />Form - Chemical Desl1`iption <br />LEAVE BLANK <br />PAGE (2) = <br />OF (3) F116 <br />TRADE SECRET (11) ❑YES ®NO <br />*EHS (12) ❑YES ®NO <br />*IF EHS BOX IS "Y" <br />ALL AMOUNTS MUST BE IN LBS <br />TYPE (14) ❑ PURE ®MIXTURE ❑WASTE RADIOACTIVE (15) ❑ yES ®NO (16) N/A <br />PHYSICAL STATE (17) IN SOLID ❑ LIQUID ❑ GAS CURIES <br />FED HAZARD <br />CATEGORIES (18)❑ FIRE []REACTIVE ❑PRESSURE RELEASE ® ACUTE HEALTH ❑ CHRONIC HEALTH <br />STATE WASTE (19) N/A <br />CODE <br />DAYS ON SITE (20) 365 <br />LARGEST (21� <br />CONTAINER 5 LBS <br />UNITS* (22) ❑ GAL ®LBS <br />❑ CU FT ❑ TONS MAX DAILY AMT (23) 3,000 <br />ON SITE <br />*If EHS, amounts must be in Ibs AVG DAILY AMT (24) 800 <br />ON SITE <br />ANNUAL WASTE AMT (25) N/A <br />STORAGE (26) ❑ ABOVE GROUND TANK <br />CONTAINER ❑ UNDER GROUND TANK <br />❑ TANK INSIDE BUILDING <br />❑STEEL DRUM <br />❑CAN <br />LJ BOX LJ <br />❑ CARBOY <br />❑ CYLINDER ❑ <br />❑ SILO <br />❑ GLASS BOTTLE ❑ <br />❑ FIBER DRUM <br />® PLASTIC BOTTLE <br />❑ BAG <br />❑ TOTE BIN <br />STORAGE (27) ® AMBIENT ❑ ABOVE AMBIENT ❑ BELOW AMBI <br />PRESSURE <br />STORAGE (28) ® AMBIENT ❑ ABOVE AMBIENT []BELOW AMBIENT []CRYOGENIC <br />TEMPERATURE <br />(29) %WT (30) HAZARDOUS COMPONENT (31) EHS <br />(32) CAS# <br />75.00 <br />METRIBUZIN ❑YES ®N <br />21087-64-9 <br />❑YES ❑N <br />❑YF,S ❑N <br />❑YES ❑N <br />❑YES ❑N <br />ADDITIONAL LOCALLY COLLECTED INFORMATION: (33) UNITED NATIONS ID# (DOT) <br />(34) WHAT IS MATERIAL RETAIL SALE <br />USED FOR? <br />DATE REC'D: 12/14/01 For Official Use Only: Mc ❑ R ❑ S SIC 12/99 <br />