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California Hazardous Materials Inventory Form <br />H ADD ❑ DELETE ❑ REVISE <br />BUSINESS NAME <br />CHEMICAL LOCATIONS) <br />MAP # (6) / GRID # (7) <br />CHEMICAL NAME (8) <br />COMMON NAME (9) <br />CAS # (10) <br />FARM SERVICE <br /> <br />NALED <br />DIBROM SE <br />300-76-5 <br />FIRE CODE (13) <br />HAZARD LEAVE BLANK <br />CATEGORIES <br />Chemical Desliption <br />PAGE (2) = <br />OF (3) 116 <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)0PURE ®MIXTURE ❑WASTE RADIOACTIVE (15) ®NO(16)N/A <br />PHYSICAL STATE (17) ❑ SOLID H LIQUID ❑GAS CURIES <br />FED HAZARD <br />CATEGORIES (18)® FIRE ❑ REACTIVE ❑ PRESSURE RELEASE ® ACUTE HEALTH ®CHRONIC HEALTH <br />STATE WASTE (19) UNITS* (22) ® GAL ❑ LBS <br />CODE N/A ❑ CU FT ❑ TONS MAX DAILY AMT (23) 200 <br />ON SITE <br />DAYS ON SITE (20) *If EHS, amounts must be in Ibs AVG DAILY AMT (24) <br />365 <br />ON SITE 2(1 <br />LARGEST (21) GAL ANNUAL WASTE AMT (25) N/A <br />CONTAINER <br />STORAGE (26) <br />❑ ABOVE GROUND TANK <br />❑ CAN <br />❑ BOX <br />❑ <br />CONTAINER <br />❑ UNDER GROUND TANK <br />❑ CARBOY <br />❑ CYLINDER <br />❑ <br />❑ TANK INSIDE BUILDING <br />❑ SILO <br />❑ GLASS BOTTLE <br />❑ <br />❑ STEEL DRUM <br />❑ FIBER DRUM <br />® PLASTIC BOTTLE <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 (32) CAS# <br />58 NALED ❑YES <br />ON 300-76-5 <br />❑YES <br />❑N <br />❑YES <br />❑N <br />❑YES <br />❑N <br />❑YES <br />❑N <br />ADDITIONAL LOCALLY COLLECTED INFORMATION: (33) UNITED NATIONS ID# (DOT) 3017 <br />(34) WHAT IS MATERIAL RETAIL SALE <br />USED FOR? <br />DATE REC'D: 12/14/01 For Official Use Only: 9 C ❑ R ❑ S SJC 12/99 <br />