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California Hazardous Materials Inventory Form - Chemical Destiption <br />1 ® ADD ❑ DELETE ❑ REVISE <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 />METHYL ZIRAM <br />ZIRAM 70W <br />137-30-4 <br />LEAVE BLANK <br />PAGE (2) = <br />OF (3) F116 <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 I RADIOACTIVE (15) ❑ yES ®NO (16) N/A <br />PHYSICAL STATE (17) IN SOLID ❑ LIQUID ❑ GAS CURIES <br />FED HAZARD <br />CATEGORIES (18)❑ FIRE ❑ REACTIVE ❑ PRESSURE RELEASE H ACUTE HEALTH ❑ CHRONIC HEALTH <br />STATE WASTE (19) <br />CODE <br />DAYS ON SITE (20) <br />N/A <br />365 <br />LARGEST (21)� <br />❑BOX <br />❑ <br />CONTAINER <br />40 LBS <br />UNITS* (22) ❑GAL ®LBS <br />❑ CU FT ❑ TONS MAX DAILY AMT (23) 3,000 <br />ON SITE <br />*If EHS, amounts must be in lbs AVG DAILY AMT (24) 200 <br />ON SITE <br />ANNUAL WASTE AMT (25) N/A <br />STORAGE <br />(26)❑ABOVE <br />GROUND TANK <br />El CAN <br />❑BOX <br />❑ <br />CONTAINER <br />❑YES ❑N <br />❑ UNDER GROUND TANK <br />❑ CARBOY <br />❑ CYLINDER <br />❑ <br />❑YES ❑N <br />❑ TANK INSIDE BUILDING <br />❑ SILO <br />❑ GLASS BOTTLE <br />❑ <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 (28) IN AMBIENT ❑ ABOVE AMBIENT ❑ BELOW AMBIENT ❑ CRYOGENIC <br />TEMPERATURE <br />(29) %WT (30) HAZARDOUS COMPONENT (31) EHS <br />(32) CAS# <br />76 METHYL ZIRAM <br />❑YES ON <br />137-30-4 <br />❑YES ❑N <br />❑YES ❑N <br />❑YES ❑N <br />❑YES ❑N <br />ADDITIONAL LOCALLY COLLECTED INFORMATION: (33) UNITED NATIONS ID# (DOT) <br />(34) WHAT IS MATERIAL RETAIL SALE <br />USED FOR? <br />DATE REC'D: 12/14/01 For Official Use Only: 0 C ❑ R ❑ S SJC 12/99 <br />