L 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