Laserfiche WebLink
California Hazardous Materials Inventory Form - Chemical D•ription <br />(1) ® ADD ❑ DELETE ❑ REVISE PAGE (2) = <br />OF (3) F116 <br />BUSINESS NAME <br />CHEMICAL LOCATION(S) <br />FARM SERVICE <br />5) <br /> <br />CHEMICAL NAME (8) <br />COMMON NAME (9) <br />CAS # (10) <br />FIRE CODE (13) <br />HAZARD LEAVE BLANK <br />CATEGORIES <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) ®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 ' ❑ CU FT ❑ TONS MAX DAILY AMT (23) 3,000 <br />ON SITE <br />DAYS ON SITE (20) 365 *If EHS, amounts must be in lbs AVG DAILY AMT (24) 1,500 <br />ON SITE <br />LARGEST (21 5000 ANNUAL WASTE AMT (25) N/A <br />CONTAINER <br />STORAGE (26)®ABOVE <br />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) IN AMBIENT ❑ ABOVE AMBIENT ❑ BELOW AMBIENT ❑ CRYOGENIC <br />TEMPERATURE <br />(29) %WT (30) HAZARDOUS COMPONENT (31) EHS (32) CAS# <br />98.00 PETROLEUM DISTILLATE IF, YES <br />®N 64741-89-5 <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) N/A <br />(34) WHAT IS MATERIAL RETAIL SALE <br />USED FOR? <br />DATE REC'D: 12/14/01 For Official Use Only: ❑ C ® R ❑ S <br />SJC 12/99 <br />