[share-ebook]Chemical Description Facility Identification Owner Operator Name


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Facility Identification Owner/Operator Name
  Name     Name   Phone (   )  
Tier Two Street     Mail Address    
EMERGENCY City   County   State   Zip      
AND   Emergency Contact
HAZARDOUS NAICS

Code

   Dun & Brad Number      
Chemical   Name   Title    
INVENTORY       Phone (   ) 24 Hr. Phone (   )  
  FOR ID #      
Specific OFFICIAL     Name   Title    
Information USE Date Received     Phone (   ) 24 Hr. Phone (   )  
by Chemical ONLY      
         
Important:  Read all instructions before completing form Reporting Period From January 1 to December 31, 20     [ ]  Check if information below is identical to the information submitted last year.
         
 
 
Chemical Description		  
Physical

and Health

Hazards

(check all that apply)

  
 
Inventory		          
 
Storage Codes and Locations

(Non-Confidential) 
 

Storage Locations

  
          Trade
                    
CAS   Secret     [ ]  Fire
      Max. Daily
                
Chem. Name     [ ]  Sudden Release       Amount (code)                
           of Pressure                  
Check all [ ] [ ] [ ] [ ] [ ] [ ] [ ]  Reactivity       Avg. Daily Amount                
that apply Pure Mix Solid Liquid Gas EHS [ ]  Immediate (acute)
      (code)
                
EHS Name     [ ]  Delayed (chronic)         No. of Days               [ ]
       
      On-site (days)
                
                     
          Trade
                    
CAS   Secret     [ ]  Fire
      Max. Daily
                
Chem. Name     [ ]  Sudden Release       Amount (code)                
           of Pressure                  
Check all [ ] [ ] [ ] [ ] [ ] [ ] [ ]  Reactivity       Avg. Daily Amount                
that apply Pure Mix Solid Liquid Gas EHS [ ]  Immediate (acute)
      (code)
                
EHS Name     [ ]  Delayed (chronic)         No. of Days               [ ]
       
      On-site (days)
                
                     
          Trade
                    
CAS   Secret     [ ]  Fire
      Max. Daily
                
Chem. Name     [ ]  Sudden Release       Amount (code)                
           of Pressure                  
Check all [ ] [ ] [ ] [ ] [ ] [ ] [ ]  Reactivity       Avg. Daily Amount                
that apply Pure Mix Solid Liquid Gas EHS [ ]  Immediate (acute)
      (code)
                
EHS Name     [ ]  Delayed (chronic)         No. of Days               [ ]
       
      On-site (days)
                
                     
Certification  (Read and sign after completing all sections) Optional Attachments
I certify under penalty of law that I have personally examined and am familiar with the information submitted in pages one through   , and that based [ ]  I have attached a site plan
on my inquiry of those individuals responsible for obtaining the information, I believe that the submitted information is true, accurate, and complete. [ ]  I have attached a list of site coordinate abbreviations
              [ ]  I have attached a description of dikes and other
  Name and official title of owner/operator OR owner/operator’s authorized representative   Signature   Date signed   safeguards measures
   






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    Chemical Description Facility Identification Owner Operator Name

    Facility Identification Owner/Operator Name
      Name     Name   Phone (   )  
    Tier Two Street     Mail Address    
    EMERGENCY City   County   State   Zip      
    AND   Emergency Contact
    HAZARDOUS NAICS

    Code

    		   Dun & Brad Number      
    Chemical   Name   Title    
    INVENTORY       Phone (   ) 24 Hr. Phone (   )  
      FOR ID #      
    Specific OFFICIAL     Name   Title    
    Information USE Date Received     Phone (   ) 24 Hr. Phone (   )  
    by Chemical ONLY      
             
    Important:  Read all instructions before completing form Reporting Period From January 1 to December 31, 20     [ ]  Check if information below is identical to the information submitted last year.
             
     
     
    Chemical Description    		  
    Physical

    and Health

    Hazards

    (check all that apply)

    		  
     
    Inventory    		          
     
    Storage Codes and Locations

    (Non-Confidential) 
     

    Storage Locations

    		  
            Trade
    		                    
    CAS   Secret     [ ]  Fire
        Max. Daily
    		                
    Chem. Name     [ ]  Sudden Release       Amount (code)                
               of Pressure                  
    Check all [ ] [ ] [ ] [ ] [ ] [ ] [ ]  Reactivity       Avg. Daily Amount                
    that apply Pure Mix Solid Liquid Gas EHS [ ]  Immediate (acute)
        (code)
    		                
    EHS Name     [ ]  Delayed (chronic)         No. of Days               [ ]
           
        On-site (days)
    		                
                         
            Trade
    		                    
    CAS   Secret     [ ]  Fire
        Max. Daily
    		                
    Chem. Name     [ ]  Sudden Release       Amount (code)                
               of Pressure                  
    Check all [ ] [ ] [ ] [ ] [ ] [ ] [ ]  Reactivity       Avg. Daily Amount                
    that apply Pure Mix Solid Liquid Gas EHS [ ]  Immediate (acute)
        (code)
    		                
    EHS Name     [ ]  Delayed (chronic)         No. of Days               [ ]
           
        On-site (days)
    		                
                         
            Trade
    		                    
    CAS   Secret     [ ]  Fire
        Max. Daily
    		                
    Chem. Name     [ ]  Sudden Release       Amount (code)                
               of Pressure                  
    Check all [ ] [ ] [ ] [ ] [ ] [ ] [ ]  Reactivity       Avg. Daily Amount                
    that apply Pure Mix Solid Liquid Gas EHS [ ]  Immediate (acute)
        (code)
    		                
    EHS Name     [ ]  Delayed (chronic)         No. of Days               [ ]
           
        On-site (days)
    		                
                         
    Certification  (Read and sign after completing all sections) Optional Attachments
    I certify under penalty of law that I have personally examined and am familiar with the information submitted in pages one through   , and that based [ ]  I have attached a site plan
    on my inquiry of those individuals responsible for obtaining the information, I believe that the submitted information is true, accurate, and complete. [ ]  I have attached a list of site coordinate abbreviations
                  [ ]  I have attached a description of dikes and other
      Name and official title of owner/operator OR owner/operator’s authorized representative   Signature   Date signed   safeguards measures
       

    << Chemical and Biomolecular Engineering Department To educate undergraduate and graduate students in Chemical and Biomolecular Engineering and foster cross fertilization of allied fieldsThis procedures explains the process of disposal of the empty chemical bottles for all the hoods in the lab >>