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California Hazardou*terials Inventory Form - Chemica*-cription <br />PAGE (2) <br />BUSINESS NAME <br />CHEMICAL LOCATION(S) (5) <br />MAP # (6) / GRID # (7) <br />FARM SERVICE <br /> <br /> <br /> <br />CHEMICAL NAME (8) DICAMBA <br />COMMON NAME (9) CLARITY, BANVEL <br />CAS # (10) 104040-79-1 <br />FIRE CODE (13) <br />HAZARD <br />CATEGORIES <br />LEAVE BLANK <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 El WASTE RADIOACTIVE (15) ❑VES ®NO(16)� <br />PHYSICAL STATE (17) ❑ SOLID ®LIQUID ❑ GAS CURIES <br />FED HAZARD CATEGORIES (18)1FIRE FIRE ❑ REACTIVE ❑ PRESSURE RELEASE ® ACUTE HEALTH ❑ CHRONIC HEALTH <br />STATE WASTE (19) <br />CODE <br />DAYS ON SITE (20) <br />NA/ <br />365 <br />LARGEST (21)2 <br />CONTAINER <br />5 <br />UNITS* (22) ® GAL ❑ LBSMAX DAILY AMT (23) 80 <br />❑ CU FT ❑ TONS ON SITE <br />*If EHS, amounts must be in lbs AVG DAILY AMT (24) 3 0 <br />ON SITE <br />ANNUAL WASTE AMT (25) NA/ <br />STORAGE (26) ❑ ABOVE GROUND TANK <br />CONTAINER ❑ UNDER GROUND TANK <br />❑ TANK INSIDE BUILDING <br />❑STEEL DRUM <br />❑ CARBOY <br />❑ SILO <br />❑ FIBER DRUM <br />❑ CYLINDER ❑ <br />❑ GLASS BOTTLE ❑ <br />® PLASTIC BOTTLE ❑ <br />❑ TOTE BIN <br />STORAGE (27) ® AMBIENT ❑ ABOVE AMBIENT ❑ BELOW AMBIENT <br />PRESSURE <br />STORAGE (28) ® AMBIENT []ABOVE AMBIENT ❑ BELOW AMBIENT ❑ CRYOGENIC <br />TEMPERATURE <br />(29) %WT (30) HAZARDOUS COMPONENT (3 1) EHS (32) CAS# <br />T <br />56.8 <br />DICAMBA <br />[:]YES ®N <br />I04040-79-1 <br />❑YES ❑N <br />❑YES ❑N <br />❑YES ❑N <br />IF <br />❑YES ❑N <br />ADDITIONAL LOCALLY COLLECTED INFORMATION: (33) UNITED NATIONS ID# (DOT) <br />(34) WHAT IS MATERIAL HERBICIDE <br />USED FOR; <br />DATE REC'D: 12/30/04 IFor Official Use Only: I0 C ❑ R ❑ S <br />SIC 12/99 <br />Tra <br />