USEB262315 - 5c. Template - Hazardous Material Identification Form.pdf
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- Attached to
- USEB262315 - B302 ISRG Ops HVAC Increase
- Solicitation number
- W50S9A26QA015
About this file
This is a Hazardous Material Identification Form used by Salt Lake City, Utah for construction projects requiring the reporting and documentation of hazardous materials usage.
The form establishes requirements for reporting any item or agent (biological, chemical, or physical) with the potential to cause harm to humans, animals, or the environment. Materials requiring reporting include all substances affecting air emissions, materials generating hazardous waste, Class I and II ozone-depleting substances, and extremely hazardous materials. Examples of reportable materials include strippers, acid wash, refrigerants, diesel fuel, oil-based paints, concrete sealers, herbicides, gasoline, polyurethane paint, roof sealers, asphalt, stains, and industrial adhesives. Contractors must complete the form prior to construction start and submit monthly updates during project execution. Required pre-construction information includes Part Number (alphanumeric code from product containers used by Hazmart Pharmacy), Material Name (brand name, as specific as possible), Manufacturer Name, and Container Size. Monthly reporting requires documentation of Actual Amount Used with units consistent with container labeling. Safety Data Sheets must be provided once for each new chemical introduced. The form includes a pre-construction section and a monthly section with separate columns for tracking purposes. An example table demonstrates proper completion with entries for Engine degreaser (3 x 13 oz. cans), Maskout Paint (2 x 13 oz. cans), and Rubber Silicone Sealant (1 x 2.8 FL oz. Tube).
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Text version
SALT LAKE CITY - UT Hazardous Material Identification Form
Reporting on Hazardous Material Usage A hazardous material is “any item or agent (biological, chemical, physical) which has the potential to cause harm to humans, animals, or the environment, either by itself or through interaction with other factors.”
Therefore, materials that must be reported are:
ALL materials that will affect air emission reporting
ANY Materials whose intended use will generate hazardous waste ALL class I & II ozone depleting substances
Extremely Hazardous materials
Following are examples of materials that must be reported (this list is NOT all inclusive).
Strippers Acid wash Refrigerants Diesel fuel Oil based paints
Concrete sealer Herbicides Gasoline Polyurethane paint Roof Sealer
Asphalt (report in yrds) Stains Industrial adhesives
Reporting Instructions
Prior to start of construction
Complete the following sections:
Part Number – An alphanumeric code found on each product container used by the Hazmart Pharmacy to help locate an MSDS
Material Name – Brand name; be as specific as possible
Manufacturer Name
Amount – Report monthly; be sure to include units consistent with the units on the container
*Provide a Safety Data Sheet once for each new chemical.*
Report on Hazardous Material Usage Report Month__ June 2015 Project Name____ “Fixing That Thing ‐USEB0015” General Contractor __ AB Construction
Part Number Material Names Manufacturer Actual Amount Used (To be re‐ ported monthly)
6850012110986 Engine degreaser Engine bright 3 x 13 0z. cans
TAN S‐249 Maskout Paint Uline 2 x 13 0z. cans
0006451413 Rubber Silicone Sealant Dap 1 x 2.8 FL oz. Tube
Pre-construction Monthly
Example
*Provide a Safety Data Sheet once for each new chemical.*
Report Month: _______________
Project Name:_____________________________ Prime Contractor:__________________
Part Number Material Name Manufacturer Container Size Actual Amount Used
Pre-construction Monthly
| Report Month: |
| Project Name: |
| Prime Contractor: |
| Part NumberRow1: |
| Material NameRow1: |
| ManufacturerRow1: |
| Container SizeRow1: |
| Actual Amount UsedRow1: |
| Part NumberRow2: |
| Material NameRow2: |
| ManufacturerRow2: |
| Container SizeRow2: |
| Actual Amount UsedRow2: |
| Part NumberRow3: |
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| Container SizeRow3: |
| Actual Amount UsedRow3: |
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