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California Hazardous Matals Inventory Form - Chemical (1) I ® ADD ❑ DELETE ❑ REVISE BUSINESS NAME CHEMICAL LOCATION(S) FARM SERVICE '5) RADIOACTIVE (15) PTFT ®NO(16)N/A PHYSICAL STATE (17) CURIES ❑ SOLID ®LIQUID ❑GAS FED HAZARD CATEGORIES (18)10 ❑YES ❑N CHEMICAL NAME (8) CYANAMIDE STATE WASTE (19) CODE TRADE SECRET (11) ❑YES ®NO (20) 6 0 *If EHS, amounts must be in lbs AVG DAILY AMT (24) 180 ON SITE LARGEST (21) *EHS (12) ❑YES ®NO COMMON NAME (9) DORMEX 55 GAL N/A STORAGE (26) *IF EHS BOX IS "Y" CAS# (10) 00420-04-2 ❑ UNDER GROUND TANK ALL AMOUNTS MUST BE IN LBS FIRE CODE (13) ❑ TANK INSIDE BUILDING ❑ SILO ❑ GLASS BOTTLE ❑ Othe HAZARD LEAVE BLANK ❑ FIBER DRUM ❑ PLASTIC BOTTLE CATEGORIES ® PLASTIC/NONMETALLIC DRUM []BAG ❑ TOTE BIN TYPE (14)❑PURE ®MIXTURE ❑WASTE RADIOACTIVE (15) PTFT ®NO(16)N/A PHYSICAL STATE (17) CURIES ❑ SOLID ®LIQUID ❑GAS FED HAZARD CATEGORIES (18)10 ❑YES ❑N FIRE ❑ REACTIVE ❑ PRESSURE RELEASE ® ACUTE HEALTH ❑ CHRONIC HEALTH N/A UNITS* (22) ® GAL ❑ LBS MAX DAILY AMT (23) 600 ❑ CU FT ❑ TONS ON SITE STATE WASTE (19) CODE DAYS ON SITE (20) 6 0 *If EHS, amounts must be in lbs AVG DAILY AMT (24) 180 ON SITE LARGEST (21) ANNUAL WASTE AMC (25) CONTAINER 55 GAL N/A STORAGE (26) ❑ ABOVE GROUND TANK []CAN ❑ BOX ❑ TAN CONTAINER ❑ UNDER GROUND TANK []CARBOY ❑ CYLINDER ❑ RAI ❑ TANK INSIDE BUILDING ❑ SILO ❑ GLASS BOTTLE ❑ Othe ❑ STEEL DRUM ❑ FIBER DRUM ❑ PLASTIC BOTTLE ® PLASTIC/NONMETALLIC DRUM []BAG ❑ TOTE BIN STORAGE (27) ® AMBIENT ❑ ABOVE AMBIENT ❑ BELOW AMBI PRESSURE STORAGE (28) ® AMBIENT ❑ ABOVE AMBIENT ❑ BELOW AMBIENT ❑ CRYOGENIC TEMPERATURE (29) %WT (30) HAZARDOUS COMPONENT (3 1) EHS (32) CAS# 51.00 CYANAMIDE ❑ YES ON 00420-04-2 ❑YES ❑N ❑YES ❑N ❑YES ❑N ❑YES ❑N ADDITIONAL LOCALLY COLLECTED INFORMATION: (33) UNITED NATIONS ID# (DOT) 2922 (34) WHAT IS MATERIAL RETAIL SALE USED FOR? DATE REC'D: 12/14/01 For Official Use Only: 9 C ❑ R ❑ S SIC 12/99