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i <br /> California Hazardou . aterials Inventory Form . Chen4k] Description <br /> ` (1) UJADD E:IDELETE REVISE PAGE(2) OF(3)� <br /> BUSINESS NAME (4) <br /> CHEMICAL LOCATION(S)(5) <br /> (Within facility,not street address) <br /> <br /> <br /> CHEMICAL NAME (8) TRADE SECRET(11) Y ©N <br /> COMMON NAME (9) *EHS (12) ❑Y N <br /> *IF EHS BOX IS "Y" <br /> CAS # (10) 1,Y,` ALL AMOUNTS MUST BE IN LBS <br /> FIRE CODE (13) LEAVE BLANK <br /> HAZARD CLASS <br /> TYPE (14) ❑PURE ❑MIXTURE EWASTE RADIOACTIVE(15) ❑ �, n N (I6) <br /> PHYSICAL STATE(17) ❑SOLID ❑LIQUID ❑GAS LJ CURIES <br /> FED HAZARD <br /> CATEGORIES (18) ❑ARE ❑REACTIVE ❑PRESSURE RELEASE 1_`_I ACUTE HEALTH Q CHROMC HEALTH <br /> STATE WASTE (19) UNITS*(22) �'ir GAL ❑CU FT MAX DAILY AMT(23) <br /> CODE [:]LBS TONS ON-SITE I <br /> © <br /> DAYS ON SITE (20) AVG DAILY AMT(24) <br /> \' *If EHS, amounts must be in lbs ON-STYE <br /> LARGEST (21) - ANNUAL WASTE AMT(25) <br /> CONTAINER OC I <br /> STORAGE (26) ❑ABOVE GROUND TANK ❑ CAN ❑ BOX ❑TANK WAGON <br /> CONTAINER ❑UNDER GROUND TANK ❑CARBOY ❑ CYLINDER [—]RAIL CAR <br /> ❑TANK INSIDE BUILDING ❑ SILO ❑ GLASS BOTTLE ❑-------------------- <br /> STEEL DRUM ❑FIBER DRUM ❑ PLASTIC BOTTLE <br /> ❑PLASTIC/NONMETALLIC DRUM ❑BAG ❑ TOTE BIN <br /> PRESSURE <br /> STORAGE (27) ❑ AMBIENT [—]ABOVE AMBIENT. ❑BELOW AMBIENT <br /> STORAGE (28) ❑AMBIENT ❑ABOVE AMBIENT []BELOW AMBIENT ❑CRYOGENIC <br /> TEMPERATURE <br /> 29 %WT 30 HAZARDOUS COMPONENT 31 EHS 32 CAS# <br /> D ❑N <br /> ❑Y ❑'N <br /> ❑Y QN <br /> ❑Y ❑N <br /> F - Y ❑N <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION: (33)UNITED NATIONS ID#(DOT) <br /> (34) WHAT IS MATERIAL <br /> USED FOR? � <br /> For Official Use Only: El C L] R ❑ S SJC 12101 <br />