TE B-Hazardous Material Authorization Request.pdf

COMPANY

NAME

COMPANY

NAME

ADDRESS ADDRESS

PHONE/FAX PHONE/FAX

NEW

CURRENT

(phone) (name) (phone)

AUTHORIZATION

CONTROL

NUMBER

MSDS

SERIAL

NUMBER

NFPA 704 LABEL

DATA

HEALTH: FLAMMABILITY: REACTIVITY: SPECIAL INSTRUCTIONS:

A. ON THE END ITEM, EQUIPMENT, OR

PRODUCT

13. ESTIMATE WHAT PERCENTAGE OF THE PRODUCT ENDS UP IN THE

LISTED LOCATIONS

B. INTO THE AIR

DPW-ENVIRONMENTAL USE ONLY

21. DATE REQUESTED19. TECHNICAL POC AND PHONE

NUMBER

18. REQUESTER NAME AND PHONE

NUMBER

20. ORGANIZATION

(name)

9. TYPE CONTAINER

(CAN, BOTTLE, TUBE, PLASTIC, METAL, GLASS, AEROSOL, etc.)

8. UNIT OF USE (must be weight or volume, e.g., pounds, gallons, etc.)

10. SUGGESTED SOURCE OF SUPPLY 11. MANUFACTURE INFORMATION

(complete if different than supplier)

C. INTO A WASTE DRUM

E. CENTRAL WASTE TREATMENT OR SEWER

TE B-HAZARDOUS MATERIAL AUTHORIZATION REQUEST

REQUESTOR USE

1. NOMENCLATURE/TRADE NAME

2. STOCK NUMBER (NSN, LSN, MCN, etc.) 3. PART NUMBER

16. PROCESS

(Circle or check (x) one)

4. QUANTITY REQUESTED

7. UNIT OF MEASURE (must be weight or volume)6. UNIT OF ISSUE (EA, GL, CAN, etc.)

5. MONTHLY REQUIREMENT

(estimate monthly usage or a one-time purchase)

F. OTHER

D. INTO THE TRASH DUMPSTER

12. DESCRIBE THE WORK OR PROCESS IN WHICH THE MATERIAL WILL BE USED

REMARKS

(Alternate material available?)

14. LIST BUILDING OR AREA WHERE THIS

MATERIAL WILL BE USED

15. COST CENTER/DODAC

AUTHORIZED TO USE THIS

MATERIAL

17. TECHNICAL REFERENCE REQUIRING

SPECIFIC USE

TE-F-1 Form Dated: October 2003

Block Description Information Required 1 Nomenclature If not a government source NSN, enter a descriptive noun for the item you are purchasing, i.e., SAE 30 oil, yellow spray paint, lead acid battery…

2 NSN Enter NSN if item is from a government source of supply. If it is, skip to block 4.

3 Part Number Enter as appropriate, using the most specific information available

4 Quantity Requested Make every effort to enter only how much you will need to sustain your process for 7-10 days. The only exceptions should be for those items where the smallest size procurable (UI) lasts longer in your process. If a weekly or monthly interval does not work in your process, contact the HMCG to establish special tracking requirements.

5 Monthly Requirement How much do you use per Month ? Enter a quantity and select the appropriate unit: FL OZ, Gallon, Gram, KG, LB, Liter, OZ, Pint, Quart, Troy Oz. An example would be using 5 qts to change oil in car.

6 Unit of Issue Unit of issue. Examples are ea, gal, qt, oz…

7 Unit of Measure Enter the quantity of the size, and select the appropriate measuring unit: Fluid Oz, Gallon, Gram, KG, LB, Liter, Oz, Pint, Quart, Troy Oz.

8 Unit of Use If decanting, what unit will you issue/use

9 Type Container Select the appropriate container description. Bottle, Box, Can, Cartridge, Drum. If not listed, fill in the container type next to “other”

10 Suggested Source of Supply

Name of Brand Name or source of supply

11 Manufacturer Information

Enter the manufacturer information. This is very important to determine the correct MSDS and chemical formulation. You may also find this on the container.

A full description of the work activity and process in which the HAZMAT is used. More detail in this block enhances your chances of approval, i.e., Application method, such as hand, brush, spray gun/nozzle, or vapor condensation Type of industrial equipment, such as open tanks, closed tanks, vapor degreaser, spray booth, mechanical equipment, or other system If the HAZMAT are transferred to industrial equipment, list the equipment number and specify whether the transfer will occur by pouring, pumping, or another method The process codes located in Section 8.6 may help to identify the use or application of the HAZMAT.

List the process code that best describes the application or use for the HAZMAT.

Method by which HAZMAT may be mixed or combined with other ingredients, such as hand, mixer, open container, closed container Explain what will happen to the HAZMAT in the process, such as heated in an oven, soldering iron, torch, or heated to facilitate parts washing, or even used to facilitate removal of other HAZMAT by wire brush, sander, grinder.

The important thing here is to be as specific as possible, which can shave days off the approval process – use additional paper if necessary and remember your reviewers don’t do your work – explain it so they can understand it (some of them are not as smart as you).

13 Product Use Make a best estimate (%) for each item

14 Where is the product used

Provide a building number or location

15 DODAC/Cost Center Enter your DODAC for your unit/activity 16 Process Circle the appropriate answer

17 Technical Reference Where is the authorization to use this HAZMAT? I.E, TM,LO,Etc.

18 Requestor Name Your name

19 Technical POC Who can answer questions about the process using the HAZMAT

20 Organization Where do you come from

21 Date Requested Date HMAR form is completed

12 Work or process description

Information required for your Hazardous Material Authorization Request .

NOTE: Contractors are strongly encouraged to purchase hazardous materials at the HazMart . On those rare occasions that short-term contractors use non-government furnished HAZMAT, they must use the Hazardous Material Authorization Request t o notify Fort Hood of HAZMAT usage and submit an MSDS for all materials. In these cases, MSDS are used for tracking purposes and does not imply endorsement of any product by Fort Hood.