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California Hazardous Mat als Inventory Form - Chemical Deetription <br />(1) ® ADD ❑ DELETE ❑ REVISE PAGE (2) 5 9 OF (3)] 16 <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 <br />CATEGORIES <br />GASOLINE <br />GASOLINE <br />5006-61-9 <br />LEAVE BLANK <br />TRADE SECRET (11) ❑YES ONO <br />*EHS (12) ❑YES R NO <br />*IF EHS BOX IS "Y" <br />ALL AMOUNTS MUST BE IN LBS <br />TYPE (14)IMPURE ❑ MIXTURE ❑ WASTE RADIOACTIVE (15) ❑ yES R NO (16) N/A <br />PHYSICAL STATE (17) ❑ SOLID R LIQUID ❑ GAS CURIES <br />FED HAZARD <br />CATEGORIES (18) R FIRE ❑ REACTIVE ❑ PRESSURE RELEASE R ACUTE HEALTH ❑ CHRONIC HEALTH <br />STATE WASTE (19) N/A UNITS* (22) R GAL ❑ LBS MAX DAILY AMT (23) 300 <br />CODE ❑ CU FT ❑ TONS <br />ON SITE <br />DAYS ON SITE (20) 365 *If EHS, amounts must be in lbs AVGDAILY AMT (24) 300 <br />ON SITE <br />LARGEST (21)300 ANNUAL WASTE AMT (25) N/A <br />CONTAINER <br />STORAGE <br />(26) <br />R ABOVE GROUND TANK <br />❑ CAN <br />❑ BOX <br />❑ TAN <br />CONTAINER <br />❑YES ❑N <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 />STORAGE <br />(27) <br />❑ AMBIENT ❑ ABOVE AMBIENT <br />❑ BELOW AMBI <br />PRESSURE <br />STORAGE <br />(28) <br />R AMBIENT ❑ ABOVE AMBIENT <br />❑ BELOW AMBIENT []CRYOGENIC <br />TEMPERATURE <br />(29) %WT <br />(30) HAZARDOT IS COMPONENT <br />(31) EHS <br />(32) CAS# <br />ADDITIONAL LOCALLY COLLECTED INFORMATION: (33) UNITED NATIONS ID# (DOT) 1203 <br />(34) WHAT IS MATERIAL EQUIPMENT <br />USED FOR? <br />DATE REC'D: 12/14/01 For Official Use Only: 0 C 0 R ❑ S SIC 12/99 <br />GASOLINE ❑YES RN 5006-61-9 <br />❑YES ❑N <br />❑YES ❑N <br />❑YES ❑N <br />❑YES ❑N <br />ADDITIONAL LOCALLY COLLECTED INFORMATION: (33) UNITED NATIONS ID# (DOT) 1203 <br />(34) WHAT IS MATERIAL EQUIPMENT <br />USED FOR? <br />DATE REC'D: 12/14/01 For Official Use Only: 0 C 0 R ❑ S SIC 12/99 <br />