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40 <br />California Hazardous Materials Inventory Form - Chemical <br />ADD DELETE REVISE 2001 <br />BUSINESS NAME <br />w'i <br />CHEMICAL LOCATION(S) (5) <br />( <br /> <br />CHEMICAL NAME (8) <br />COMMON NAME (9) <br />CAS # (10) <br />FIRE CODE (13) <br />HAZARD CLASS <br />TYPE (14) <br />PHYSICAL STATE (17) <br />FED HAZARD <br />CATEGORIES (18) <br />STATE WASTE (19) <br />CODE <br />DAYS ON SITE (20) <br />LARGEST (21' <br />CONTAINER <br />STORAGE (26) <br />CONTAINER <br />STORAGE (27) <br />PRESSURE <br />STORAGE (28) <br />TEMPERATURE <br />(29) %WT (30) HAZARDOUS COMPONENT 3 32 CAS# 71 <br />❑Y ❑N <br />❑Y ❑N <br />❑Y ❑N <br />❑Y N <br />❑Y ❑N <br />ADDITIONAL LOCALLY COLLECTED INFORMATION: (33)UNITED NATIONS ID # (DOT) I i <br />(34) WHAT IS MATERIAL <br />USED FOR? <br />For Official Use Only: El C R S SJC 12/00 <br />TRADE SECRET (1 1) ❑ Y N <br />*EHS (I ❑Y N <br />IF EHS BOX IS "Y" <br />ALL AMOUNTS MUST BE IN LBS <br />�f(0y JD d <br />LEAVE BLANK <br />RADIOACTIVE (15) ❑ Y N (16) <br />CURIES <br />[-]PURE ®MIXTURE <br />[]WASTE <br />❑SOLIDIQUID ®GAS <br />❑ FIRE ❑ REACTIVE 0 <br />PRESSURE RELEASE D <br />ACUTE HEALTH [:]C 1-IEAI.TH <br />Q UNITS* (22) []GAL ❑ CU FT MAX DAILY AMT (23)® <br />ON-SITE <br />®LBS ❑TONS <br />AVG DAILY AMT (24) <br />3�5 ,*If EHS, amounts must be in lbs ON-SITE �� a <br />A' I ANNUAL WASTE AMT (25)� <br />❑ ABOVE GROUND TANK ❑ CAN <br />❑ UNDER GROUND TANK ❑ CARBOY <br />❑ TANK INSIDE BUILDING ❑ SILO <br />STEEL DRUM ❑ FIBER DRUM <br />STEEL <br />❑ PLASTIC/NONMETALLIC DRUM ❑ BAG <br />❑ BOX ❑TANK WAGON <br />fgCYLINDER [:]RAIL CAR <br />- - <br />❑ GLASS BOTTLE ❑-------------------- <br />❑ PLASTIC BOTTLE <br />❑ TOTE BIN <br />❑ AMBIENT RABOVEAMBIENT ❑BELOW AMBIENT <br />❑ AMBIENT ❑ ABOVE AMBIENT <br />BELOW AMBIENT <br />CRYOGENIC <br />TEMPERATURE <br />(29) %WT (30) HAZARDOUS COMPONENT 3 32 CAS# 71 <br />❑Y ❑N <br />❑Y ❑N <br />❑Y ❑N <br />❑Y N <br />❑Y ❑N <br />ADDITIONAL LOCALLY COLLECTED INFORMATION: (33)UNITED NATIONS ID # (DOT) I i <br />(34) WHAT IS MATERIAL <br />USED FOR? <br />For Official Use Only: El C R S SJC 12/00 <br />