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California Hazardous Matals Inventory Form - Chemical Dopription <br />(1) ® ADD ❑ DELETE ❑ REVISE PAGE (2) = <br />OF (3) 116 <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 />VE 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 ❑WASTE RADIOACTIVE (15) ❑ YES ® N01(16) N/A <br />PHYSICAL STATE (17) ❑ SOLID ®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 N/ ❑ CU FT ❑ TONS MAX DAILY AMT (23)100 <br />ON SITE <br />DAYS ON SITE (20) *If EHS, amounts must be in lbs AVG DAILY AMT O <br />9 0 ON SITE 5 0 <br />LARGEAST (21) 2.5 gal ANNUAL WASTE AMT (25)CONTN/A <br />STORAGE <br />(26) <br />❑ABOVE GROUND TANK <br />❑ CAN <br />❑ BOX <br />❑ TAN <br />CONTAINER <br />❑ UNDER GROUND TANK <br />❑ CARBOY <br />❑ CYLINDER <br />❑ RAI <br />❑ TANK INSIDE BUILDING <br />❑ SILO <br />❑ GLASS BOTTLE <br />❑ Othe <br />❑ STEEL DRUM <br />❑ FIBER DRUM <br />® PLASTIC BOTTLE <br />❑ PLASTIC/NONMETALLIC DRUM <br />❑ BAG <br />❑ TOTE BIN <br />❑ AMBIENT ❑ ABOVE AMBIENT <br />❑ BELOW AMBI <br />STORAGE (27) <br />PRESSURE <br />STORAGE <br />TEMPERATURE <br />(28) ® AMBIENT ❑ ABOVE AMBIENT <br />❑ BELOW AMBIENT ❑ CRYOGENIC <br />(29) %aWT <br />(30) HA7ARDC)l iS rOM-PONFNT <br />(3 1) EHS <br />l321 CARO <br />30.5 DIMETHOATE ❑YES ®N <br />60-51-5 <br />❑YES ❑N <br />❑YES ❑N <br />❑YES ❑N <br />❑YES ❑N <br />ADDITIONAL LOCALLY COLLECTED INFORMATION: (33) UNITED NATIONS ID# (DOT) 9188 <br />(34) WHAT IS MATERIAL INSECTICIDE <br />USED FOR? <br />DATE REC'D: 12/14/01 For Official Use Only: 0 C 0 R ❑ S SIC 12/99 <br />