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California Hazardous Maft ials Inventory Form - Chemical DOription <br />R 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 /> <br /> <br /> <br /> <br /> <br /> <br />116 <br />TRADE SECRET (11) ❑YES B NO <br />*EHS (12) ❑YES R NO <br />*IF EHS BOX IS "Y" <br />ALL AMOUNTS MUST BE IN LBS <br />TYPE (14) ❑PURE RMIXTURE ❑WASTE RADIOACTIVE(15) ❑yES RNO (16) N/A <br />PHYSICAL STATE (17) ❑ SOLID B LIQUID ❑GAS CURIES <br />FED HAZARD <br />CATEGORIES (18)B FIRE ❑ REACTIVE ❑ PRESSURE RELEASE R ACUTE HEALTH R CHRONIC HEALTH <br />STATE WASTE <br />CODE <br />DAYS ON SITE <br />(19) <br />(20) <br />N/A <br />365 <br />LARGEST <br />(21 <br />CONTAINER <br />CONTAINER <br />❑ CARBOY <br />1 GAL <br />UNITS* (22) R GAL ❑ LBS <br />N SITE <br />❑ CU FT ❑ TONS]OY AMT (23)144 <br />ONSITE <br />*If EHS, amounts must be in lbs AVG DAILY AMT (24) 5 0 <br />ON SITE <br />ANNUAL WASTE AMT (25) N/A <br />STORAGE <br />(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 />❑YES ❑N <br />❑ STEEL DRUM <br />❑ FIBER DRUM <br />B PLASTIC BOTTLE <br />❑ PLASTIC/NONMETALLIC DRUM <br />❑ BAG <br />❑ TOTE BIN <br />STORAGE <br />(27) <br />B AMBIENT ❑ ABOVE AMBIENT <br />❑ BELOW AMBI <br />PRESSURE <br />STORAGE (28) R AMBIENT ❑ ABOVE AMBIENT ❑ BELOW AMBIENT ❑ CRYOGENIC <br />TEMPERATURE <br />(29) %WT (30) HAZARDOUS COMPONENT (31) EHS <br />(32) CAS# <br />38.4 <br />PERMITHREN <br />❑YES BN <br />52645-53-1 <br />❑YES ❑N <br />❑YES ❑N <br />❑YES ❑N <br />❑YES ❑N <br />ADDITIONAL LOCALLY COLLECTED INFORMATION: (33) UNITED NATIONS ID# (DOT) <br />(34) WHAT IS MATERIAL RETAIL. SALES <br />USED FOR? <br />DATE RECD: 12/14/01 For Official Use Only: R C 0 R ❑ S SJC 12/99 <br />