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California Hazardous Matals Inventory Form - Chemical Defription <br />(1) ® ADD ❑ DELETE ❑ REVISE PAGE (2) = <br />OF (3) F116 <br />BUSINESS NAME <br />FARM SERVICE <br />CHEMICAL LOCATION(S) (5) <br /> <br />CHEMICAL NAME (8) <br />COMMON NAME (9) <br />CAS # (10) <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 />FIRE CODE (13) <br />HAZARD LEAVE BLANK <br />CATEGORIES <br />TYPE (14) ❑ PURE ®MIXTURE ❑WASTE RADIOACTIVE (15) ❑ yES ®NO (16) N/A <br />PHYSICAL STATE (17) ❑ SOLID ®LIQUID ❑ GAS CURIES <br />FED HAZARD <br />CATEGORIES (18)1FIRE FIRE ❑ REACTIVE []PRESSURE RELEASE ® ACUTE HEALTH ❑ CHRONIC HEALTH <br />STATE WASTE (19) UNITS* (22) ®GAL ❑LBS <br />CODE N/A ❑ CU FT ❑ TONS MAX DAILY AMT (23)100 <br />ON SITE <br />DAYS ON SITE (20) 365 *If EHS, amounts must be in lbs AVG DAILY AMT (24) 5 0 <br />ON SITE <br />LARGEST (21)GAL ANNUAL WASTE AMT (25) N/A <br />CONTAINER <br />STORAGE (26) <br />CONTAINER <br />❑ ABOVE GROUND TANK ❑ CAN ❑ BOX ❑ TAN <br />❑ UNDER GROUND TANK ❑ CARBOY ❑ CYLINDER ❑ RAI] <br />❑ TANK INSIDE BUILDING ❑ SILO ❑ GLASS BOTTLE ❑ Othe <br />❑ STEEL DRUM ❑ FIBER DRUM ®PLASTIC BOTTLE <br />❑ PLASTIC/NONMETALLIC DRUM ❑ BAG ❑ TOTE BIN <br />STORAGE (27) ® AMBIENT ❑ ABOVE AMBIENT ❑ BELOW AMBI <br />PRESSURE <br />STORAGE (28) IN AMBIENT ❑ ABOVE AMBIENT ❑ BELOW AMBIENT ❑ CRYOGENIC <br />TEMPERATURE <br />091 (71WT (40) HA7ART)OTTS COMPOWNT (3 1) EHS (32) CAS# <br />21.4 IMIDACLOPRID ❑YES ®N <br />138261-41.3 <br />❑YES ❑N <br />❑YES ❑N <br />❑YES ❑N <br />❑YES ❑N <br />ADDITIONAL LOCALLY COLLECTED INFORMATION: (33) UNITED NATIONS ID# (DOT) N/A <br />(34) WHAT IS MATERIAL INSECTICIDE <br />USED FOR; <br />DATE REC'D: 12/14/01 For Official Use Only: ® C 0 R ❑ S SJC 12/99 <br />