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California Hazardous Mats Inventory Form - Chemical Deetription <br />(1) H ADD ❑ DELETE ❑ REVISE PAGE (2) = <br />OF (3) 116 <br />BUSINESS NAME <br />CHEMICAL LOCATION(S) <br />FARM SERVICE <br />5) <br />MAP # (6) / GRID # (7) <br />CHEMICAL NAME (8) <br />COMMON NAME (9) <br />CAS # (10) <br />DICOFOL <br />KELTHANE 35 W <br />115-32-2 <br />FIRE CODE (13) <br />HAZARD LEAVE BLANK <br />CATEGORIES <br />TRADE SECRET (11) <br />*EHS (12) ❑YES ®NO <br />*IF EHS BOX IS "Y" <br />ALL AMOUNTS MUST BE IN LBS <br />TYPE <br />(14) <br />❑ PURE ®MIXTURE ❑WASTE <br />RADIOACTIVE (15) ❑ YES H NO <br />(16) <br />N/A <br />PHYSICAL STATE (17) <br />❑YES ❑N <br />CURIES <br />IN SOLID [:]LIQUID <br />❑GAS <br />FED HAZARD <br />CATEGORIES <br />(18)10 <br />FIRE []REACTIVE <br />❑ PRESSURE RELEASE ® ACUTE HEALTH ® CHRONIC HEALTH <br />STATE WASTE <br />(19) <br />UNITS* <br />(22) <br />❑ GAL ®LBS <br />CODE <br />N/A <br />❑ CU FT ❑TONS <br />MAXDAII.YAMT (23)1,000 <br />ON SITE <br />DAYS ON SITE <br />(20) <br />365 <br />*If EHS, amounts must be in lbs AVG DAILY AMT (24) 2 50 <br />ON SITE <br />LARGEST <br />(21) <br />4 LBS <br />ANNUAL WASTE AMT (25) <br />N/A <br />CONTAINER <br />STORAGE <br />(26) <br />❑ ABOVE GROUND <br />TANK []CAN ❑ BOX ❑ TAN <br />CONTAINER <br />[]UNDER GROUND <br />TANK []CARBOY ❑ CYLINDER ❑ RAI <br />❑ TANK INSIDE BUILDING ❑ SILO ❑ GLASS BOTTLE ❑ Othe <br />❑ STEEL DRUM <br />❑ FIBER DRUM ❑ PLASTIC BOTTLE <br />STORAGE (27) ® AMBIENT ❑ ABOVE AMBIENT ❑ BELOW AMBI <br />PRESSURE <br />STORAGE (28) ® AMBIENT []ABOVE AMBIENT ❑ BELOW AMBIENT ❑ CRYOGENIC <br />TEMPERATURE <br />(99) %WT (7(1) TTA7ARnOTTR rnMPONRNT (3 1) FT4S (711 (`A CiF <br />35.00 DICOFOL <br />❑YES ®N <br />115-32-2 <br />❑YES ❑N <br />❑YES ❑N <br />❑YES ❑N <br />❑YES ❑N <br />ADDMONAL LOCALLY COLLECTED INFORMATION: (33) UNITED NATIONS ID# (DOT) N/A <br />(34) WHAT IS MATERIAL RETAIL SALE <br />USED FOR? <br />DATE RECD: 12/14/01 For Official Use Only: ®C ❑ R ❑ S SIC 12/99 <br />