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Read All Instructions Before Competing
<br />Remit Amtop Filing Pee,perFacility
<br />STATE OF HAWAII
<br />CHEMICAL INVENTORY FARM (TIER iI)
<br />ATTACNMF,NT 5
<br />Page
<br />of
<br />• Facility Identification --
<br />Nam"
<br />Strout
<br />City County Slnto Zip
<br />Latitude t Longitude Country USA
<br />OwnertOperator Name
<br />Name Phono
<br />Mall
<br />Address
<br />•Clty.
<br />Slats Zip Country
<br />Mailing Address (If dJfferentfrom facility address)•
<br />• Strad
<br />City • ' Stale Zip Country
<br />Emergency Contact
<br />Nems Vila
<br />Phone 24 Hr. Phan
<br />Nnma Title
<br />• •
<br />Rhona 24 Hr. Phone
<br />SIC Coda Dun & Brad Number NM 1 CS
<br />•
<br />' Chemical Description
<br />'
<br />ChaokI n1Iorlhotn10rmaaon1orIhlaahomloollo
<br />- Idonacal le Iho Informallon oubm#ttod tostyoor
<br />- - - ` ` - - ` -- " - -- - -
<br />CAS Trade Sucre •
<br />Chum•
<br />Namo
<br />Check All ❑ ❑ ❑ ❑ ❑ ❑
<br />That Apply pure Mlx Solid Liquid Gas ENS
<br />Physical
<br />Heath
<br />❑
<br />❑
<br />•
<br />❑
<br />❑
<br />and
<br />Hazards
<br />Piro
<br />Suddon Rottman
<br />of Fromm
<br />Reactivity
<br />immodlnto (oouto)
<br />Dolayad(chronic)
<br />- Inventory
<br />Max.Daily
<br />Amount (code)
<br />Avg. Daily
<br />Amount (code) ,
<br />No. of Days
<br />On -alta (days)
<br />'
<br />3"
<br />E
<br />e
<br />E
<br />Ir
<br />Storage Codes and Locations
<br />(Non -Confidential)
<br />®Check Incall of the Inlonnoian forthla chomlcal Is
<br />(danllel to iho Informnllon submitted loot year_ -
<br />CAS Trade Secret ®
<br />Chem.
<br />Namo
<br />Chuck Al! ❑ ❑ ❑ ❑ ❑ ❑
<br />That Apply Pure • Mlx Solid Liould Gas ENS
<br />0 Fire
<br />❑ Sudden Rolaaso
<br />of Prsssure
<br />❑ Reactivity
<br />❑ }mmodtato(acute)
<br />m Delayed (chronic)
<br />Mox, Daily
<br />Amount(oodaj
<br />-
<br />Avg, Deily
<br />Amount (coda)
<br />No. of Days
<br />On-site (dnya)
<br />•
<br />'
<br />Certification (Read and sign after completing all sections) •
<br />I cattily underpanaity of Ins that I have personally examinod and am familiar with iho Information submitted In pages one through 1,
<br />and that baaud on my Inqulry'of Mona Individuals responsible for obtaining this ldfannatlon, t balloon That Ma submitted information Is truo, acoumta, and comploto.
<br />Optional Attchments
<br />0 I havo attaohud a situ plan •
<br />❑ I have attached a ilat dello coordlnalo abbreviations
<br />_ I havo attached a dascrtpt}on of dikos and other
<br />❑ eafaguards measures
<br />Namo and official Ulla of ownudaperator
<br />DR ownarloporators aulhodnad raprasontatIva Sipnatuio Dato slgndd
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