10. AF Form 3952 Chemical Hazardous Material Request.pdf
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1. TYPE OF REQUEST
2. PROCESS CODE
CHEMICAL/HAZARDOUS MATERIAL REQUEST AUTHORIZATION FORM
PART I - MATERIAL REQUEST
SECTION I. REQUESTOR INFORMATION
3. COMMAND/INSTALLATION/ORGANIZATION/OFFICE SYMBOL:
4. WORKCENTER TITLE:
5. DODAAC and SUPPLY ACCOUNT CODE(S)
6. BUILDING NUMBER
7. LOCATION (Be specific) SECTION II. MATERIAL INFORMATION (Attach copy of MSDS)
8. MATERIAL NAME
9. NSN/LSN/MSN
10. MATERIAL SPECIFICATION
11a. SOLE SOURCE MANUFACTURER NAME/CAGE 11b. SOLE SOURCE PART NUMBER/TRADE NAME
15. DRAW FREQUENCY
12. MSDS REFERENCE #/DATE
14. DRAW AMOUNT
13. UNIT OF ISSUE
SECTION III. REQUIRING DOCUMENT(S) (Attach copies of specified pages) 16a. DOCUMENT NUMBER 16b. PARAGRAPH NUMBER 16c. PAGE NUMBER 16d. REVISION/CHANGE NUMBER 16e. REVISION/CHANGE DATE
SECTION IV. PROCESS INFORMATION
17. IS THIS REQUEST FOR A NEW WORKLOAD OR PROCESS IN THIS SHOP? (Circle one):
YES
NO
18.PROCESS (Fully describe the process in which this material is used.)
19. AMOUNT OF MATERIAL USED PER PROCESS
20. FREQUENCY OF PROCESS
21. DURATION OF PROCESS
22. DESCRIBE ANY ENGINEERING CONTROLS IN USE DURING THE PROCESS (such as exhaust/ventilation systems, enclosures, covered tanks, cooling coils, etc.)
23. INDICATE ANY PERSONAL PROTECTIVE EQUIPMENT (PPE) CURRENTLY BEING USED IN CONJUNCTION WITH THIS PROCESS
24. DESCRIBE THE METHOD OF DISPOSAL FOR THE WASTE THAT IS GENERATED
SECTION V. REMARKS
25. PROVIDE ADDITIONAL INFORMATION
SECTION VI. CERTIFICATION
26a. REQUESTER'S NAME/ORGN SYMBOL, AND PHONE 26b. SIGNATURE "I certify that material will be used as stated above."
26c. DATE 27a. CERTIFYING OFFICIAL'S NAME/ORGN SYMBOL/TELEPHONE NO.
27b. SIGNATURE "I certify that material is required as stated above."
27c. DATE
AF IMT 3952, 20050301, V1
AUTHORIZED WITH THE
RESTRICTIONS LISTED IN PART
1 SECTION IV AND THOSE
LISTED BELOW (IF ANY)
NOT
AUTHORIZED
BLANKET
AUTHORIZED
REMARKS
For information on specific health hazards or precautions for use, consult the manufacturer's MATERIAL SAFETY DATA SHEET (MSDS) or your
BIOENVIRONMENTAL ENGINEERING REVIEWER.
BIOENVIRONMENTAL ENGINEERING REVIEWER'S NAME, TITLE, ORGANIZATION OFFICE,
SYMBOL, AND PHONE NO.
SIGNATURE
DATE
AUTHORIZED WITH THE
RESTRICTIONS LISTED IN PART
1 SECTION IV AND THOSE
LISTED BELOW (IF ANY)
BLANKET
AUTHORIZED
NOT
AUTHORIZED
REMARKS
SAFETY OFFICE REVIEWER'S NAME, TITLE, ORGANIZATION, OFFICE SYMBOL, AND
SYMBOL, AND PHONE NO.
SIGNATURE
DATE
AUTHORIZED WITH THE
RESTRICTIONS LISTED IN PART
1 SECTION IV AND THOSE
LISTED BELOW (IF ANY)
BLANKET
AUTHORIZED
NOT
AUTHORIZED
ODS SAO APPROVAL NUMBERr
REMARKS
CIVIL ENGINEERING REVIEWER'S NAME, TITLE, ORGANIZATION OFFICE SYMBOL, AND
TELEPHONE NUMBER
SIGNATURE
DATE
ANY changes to the conditions or process stated on the AF Form 3952 invalidate this authorization. Notify the HAZMART of any changes or resubmit your AF Form 3952.
AF IMT 3952, 20050301, V1 (REVERSE)
SECTION III. ENVIRONMENTAL AND FIRE PROTECTION REVIEW (To be filled in by Civil Engineering/Environmental Management).
CONTRACTOR SUBMITTED 3952-REVIEWED FOR
INFORMATION PURPOSES ONLY (This does not involve evaluation and approval of the conractor's safety and health programs) SECTION II. SAFETY REVIEW (To be filled in by the Safety Office)
CHEMICAL/HAZARDOUS MATERIAL REQUEST/AUTHORIZATION
PART II - MATERIAL AUTHORIZATION
SECTION I. HEALTH REVIEW (To be filled in by the Bioenvironmental Engineer)
CONTRACTOR SUBMITTED 3952-REVIEWED FOR
INFORMATION PURPOSES ONLY (This does not involve evaluation and approval of the conractor's safety and health programs) 8.2.1.3158.1.475346.466429
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| TypRqest: |
| ProsCode: |
| Command: |
| WorkCtr: |
| DODSupplyCd: |
| BuildNo: |
| Location: |
| MatlName: |
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| Process: |
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| Please use Y2K format: YYYYMMDD 19 August 1946 should be entered as 19460819: |
| CertName: |
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| Please use Y2K format: YYYYMMDD 19 August 1946 should be entered as 19460819: |
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| Contr1: 0 |
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| RemrksA: |
| BioEngrInfo: |
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| EnvRInfo: |
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