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Hazardous Chemical Survey

  2. Fire Patch Original blk wht red09.jpg

  4. Information

    This survey is requested to determine the quantity of specific chemical groups used, produced or stored in your facility. Fire Chiefs are required to collect data under the Michigan Occupational Safety and Health Act (MIOSHA), P.A. 154 of 1974, as amended and the Fire Prevention Code, PA 207 of 1941, as amended.

  6. Instructions

    Indicate below whether your site uses or produces any of the chemical types listed. Check all categories that apply when a chemical has more than one characteristic, (example: both a Class 3 flammable and a Class 6 poison), see definitions. Each chemical group listed in this survey includes a specified quantity. Indicate the quantity category for each chemical group on your site. To complete this survey, you may need to reference Material Safety Data Sheets, SARA Title III reporting forms, along with the attached definitions.

  8. NOTE:

    You must complete each line. Do not leave blanks. If you do not use a chemical group listed, mark "DO NOT HAVE" BOX.

  10. Hazardous Chemical Definitions

  12. When substantial changes occur in the quantity or type of chemical use, manufacture or related storage, a revised survey must be submitted to the Fire Chief. In addition, a revised survey will be requested periodically as the Fire Chief determines necessary, but at least once every five years. This survey may be followed-up with a request for more detailed information. This may include a request for Material Safety Data Sheets, chemical lists maintained under the Employee Right to Know provisions of MIOSHA and other information.

  14. This site is:*

  16. Other

  23. Please enter your phone number in the format xxx-xxx-xxxx.

  26. Emergency Contacts:

  30. Please enter your phone number in the format xxx-xxx-xxxx.

  35. Please enter your phone number in the format xxx-xxx-xxxx.

  40. Please enter your phone number in the format xxx-xxx-xxxx.

  43. Respond based on the maximum quantity you would have on-site, including storage, at any one time during the year.

  46. Note: If you have any hazardous chemical/s "At or Above Specified Quantity" enter chemical name, maximum quantity at any given time, upload MSDS and Site Plan.

  48. Class 1 - Explosives & Blasting Agents (Not including Class C Explosives) Any Quantity*

  49. If Have at or Above Specified quantity, enter name and quantity. For reporting more than one chemical, separate them by pressing "ENTER".

  52. Class 2 - Poison Gas - Any quantity*

  53. If Have at or Above Specified quantity, enter name and quantity. For reporting more than one chemical, separate them by pressing "ENTER".

  56. Class 2 - Flamabable Gas - 100 Gal. water capacity*

  57. If Have at or Above Specified quantity, enter name and quantity. For reporting more than one chemical, separate them by pressing "ENTER".

  60. Class 2 - Non-Flammable Gas - 100 Gal. water capacity*

  61. If Have at or Above Specified quantity, enter name and quantity. For reporting more than one chemical, separate them by pressing "ENTER".

  64. Class 3 - Flammable Liquid - 1,000 Gallons*

  65. If Have at or Above Specified quantity, enter name and quantity. For reporting more than one chemical, separate them by pressing "ENTER".

  68. Class 3 - Combustible Liquid - 10,000 Gallons*

  69. If Have at or Above Specified quantity, enter name and quantity. For reporting more than one chemical, separate them by pressing "ENTER".

  72. Class 4 - Flammable Solid - dangerous when wet 100 lbs*

  73. If Have at or Above Specified quantity, enter name and quantity. For reporting more than one chemical, separate them by pressing "ENTER".

  76. Class 4 - Flammable Solid - 500 lbs.*

  77. If Have at or Above Specified quantity, enter name and quantity. For reporting more than one chemical, separate them by pressing "ENTER".

  80. Class 4 - Spontaneously Combustible Material - 100 lbs*

  81. If Have at or Above Specified quantity, enter name and quantity. For reporting more than one chemical, separate them by pressing "ENTER".

  84. Class 5 - Oxidizer - 500 Lbs*

  85. If Have at or Above Specified quantity, enter name and quantity. For reporting more than one chemical, separate them by pressing "ENTER".

  88. Class 5 - Organic Peroxide - 250lbs*

  89. If Have at or Above Specified quantity, enter name and quantity. For reporting more than one chemical, separate them by pressing "ENTER".

  92. Class 6 - Poison - 500 lbs*

  93. If Have at or Above Specified quantity, enter name and quantity. For reporting more than one chemical, separate them by pressing "ENTER".

  96. Class 6 - Irritating Material: Liquid - 1000 gal*

  97. If Have at or Above Specified quantity, enter name and quantity. For reporting more than one chemical, separate them by pressing "ENTER".

  100. Class 6 - Irritating Material: Solid - 500 lbs*

  101. If Have at or Above Specified quantity, enter name and quantity. For reporting more than one chemical, separate them by pressing "ENTER".

  104. Class 7 - Radioactive Material (Yellow III Label) - any quantity*

  105. If Have at or Above Specified quantity, enter name and quantity. For reporting more than one chemical, separate them by pressing "ENTER".

  108. Class 8 - Corrosives - Liquid - 1000 gal.*

  109. If Have at or Above Specified quantity, enter name and quantity. For reporting more than one chemical, separate them by pressing "ENTER".

  112. Class 8 - Corrosives: Solid - 500 lbs*

  113. If Have at or Above Specified quantity, enter name and quantity. For reporting more than one chemical, separate them by pressing "ENTER".

  116. No DOT Category - Known Human Carcinogen*

  117. If Have at or Above Specified quantity, enter name and quantity. For reporting more than one chemical, separate them by pressing "ENTER".

    121. Leave This Blank:

  123. This field is not part of the form submission.