Chemical Survey

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 chemical 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.

Instructions
1. Indicate below whether your site uses or produces any of the chemical types listed. Complete or revise the site information.

2. Gather information to complete the chemical inventory sheet. refer to the Hazardous Chemical Definitions (at the bottom of this form), the Safety Data Sheets, and/or SARA Title III reporting forms.

3. Check all the categories that apply. When a chemical has more than one characteristic (example: both a Class 3 flammable and a Class 6 poison), check both Poison and Class 3 Flammable Liquid based on the specified quantity for each class.

4. Each chemical listed in this survey includes a specified quantity. Indicate the quantity category for each chemical class on your site. mark at least one box for each chemical. If you do not use or produce a chemical group listed, mark the "DO NOT HAVE" box.

5. Click Submit

6. If you have trouble filling out or submitting, please contact the Community Risk Reduction Division at 248-656-4717.

When a substantial change occurs in the quantity, type of chemical, use and manufacturing or related storage, a revised survey must be submitted to the Fire Chief. In addition, a revised survey will be requested every five years or as the Fire Chief deems necessary.

This survey may be followed-up with a request for more detailed information. This may include a request for Safety Data Sheets, chemical lists maintained under the Employee Right to Know provisions of MIOSHA and other information.

Business Name*

Business Address*

Business Phone Number*

Email*

First Name*

Last Name*

Cell Phone Number*

Emergency Contacts
First Name

Last Name

Cell Phone

Email:

Contact Type: (please check those below that apply)

 Owner
 Key Holder
 Occupant

First Name

Last Name

Cell Phone

Email

Contact Type: (please check those below that apply)
 Owner
 Key Holder
 Occupant

Class1
Explosives & Blasting Agents (Not including Class C Explosives): Any Quantity


Class2
Poison Gas: Any Quantity

Flammable Gas: 100 gal. Water Capacity

Non-Flammable Gas: 100 gal. Water Capacity

Class3
Flammable Liquid: 1,000 Gallons

Combustible Liquid: 10,000 Gallons

Class4
Flammable Solid (Dangerous when Wet): 100 lbs.

Flammable Solid: 500 lbs.

Spontaneously Combustible Material: 100 lbs.

Class5(2)
Oxidizer: 500 lbs.

Organic Peroxide: 250 lbs.

Class6
Poison: 500 lbs.

Irritating Material - Liquid: 1,000 gal.

Irritating Material - Solid: 500 lbs.

Class7
Radioactive Material (Yellow III Label): Any Quantity


Class8
Corrosives - Liquid: 1,000 gal.

Corrosives - Solid: 500 lbs.

NoDOTCategory2
Known Human Carcinogen: Any Category


HazardousChemcialDefinitions

     

Subscribe to NotificationsStay up-to-date on what's happening by subscribing below