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Read All Instructions Before Competing
<br />Remit $100;00 Filin1 Fee,per ynclllty
<br />STATE OF HAWAII
<br />CHEMICAL INVENTORY FARM [71E_• R 11) W
<br />AT.TAC'1 E,NT 5
<br />Page
<br />or
<br />• Facility identification -`
<br />Nnmo
<br />Strout
<br />t
<br />City County Slate Zip
<br />Latitude Longitude) Country USA
<br />Owner/Operator Name ,
<br />Nama Phone
<br />Mall
<br />Addrasa
<br />city.
<br />Stain Zip Country .
<br />Mailing Address (if different from facility address)
<br />. • Siraut
<br />City • ' Stale Zip Country
<br />Emergency Contact .
<br />Nnmo Title
<br />Phvno 24 Hr. Phono
<br />SIC Code Dun & Hrad Number NA 1 CS
<br />• •
<br />Name Title
<br />• •
<br />Plume 24 Hr. )Phone
<br />Chemical Description
<br />DChooltlt nil of iha infamia{lon for ihtc ohominnl to
<br />Identical to the Intortnnllan submitted tnstyonr
<br />- - - ' -
<br />Physical and
<br />Heath Hazards
<br />❑ Piro
<br />- inventory
<br />h a E
<br />err
<br />E
<br />1
<br />It'
<br />Storage Codes and Locations
<br />(Non -Confidential)
<br />•
<br />- -• - '» - - - - ' - ' - - - -
<br />CAS ' Trada Sacral ®
<br />❑ Sudden Roloaaa
<br />of Prosouro
<br />Max. Dally
<br />Amount (coda)
<br />Ohm
<br />Noma
<br />❑ Reactivity
<br />Avg, Dally
<br />'
<br />-
<br />❑ Immdiato (nouta)
<br />❑ Dulayad (chronic)
<br />Amount (code) ,
<br />•
<br />Chock All ❑ ❑ ❑ ❑ ❑ ®
<br />That Apply pure Mk Solid Liquid Gas vs
<br />Na. at Doyo
<br />On -alto (dayn)
<br />®hoalt it Volof the intannutlan far this chomicot Is
<br />Idonllnnl tIho Intormvtlonsubmittod lostyaer
<br />CAS Trade Sacral
<br />Chum.
<br />Namo •Avg.
<br />Chock All 0 ❑ ❑ ❑ ❑
<br />ThntApply Nun Mlx Solid Ltould Ens
<br />•1
<br />®
<br />EHS
<br />❑ Piro
<br />❑ Sudden Release
<br />of Pressure
<br />❑ Razcltvlty
<br />❑ Immediate (Banta)
<br />❑ Delaysd (chronic)
<br />Max. Daily
<br />Amount (Dodo)
<br />.
<br />.
<br />Daily
<br />Amount tooda)
<br />No. otDays
<br />On -alto (days)
<br />Certification (Read and sign after completing -all sections)
<br />1 codify under penalty al Saw that I hove personally examined and am familiar with the Information eubmltted In papas one Ihrough'I.
<br />and that basod on my Inquiryof Ewan Individuals rosponslblo for obtaining this Idformallon,1 hollow) that the submitted Intonation Is truth =undo, and oampioto,
<br />optional Attchments
<br />0 I have attoohod a alto plan .
<br />0I have attached a Het of silo caardlnala abbrovialions
<br />Nemn and official (Ilia of awnudopatator
<br />DR owndopuratoes authorized reprnsontailva 6lpnaturo Data slenod
<br />t!'!'!
<br />• 1 hovs attached a doscdption of dikes and other
<br />safeguards measures
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