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, P.A. 207 of 1941, as amended.

Instructions: Indicate below whether your site uses or produces any of the chemical types listed. 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), see definitions. Each chemical group listed in this survey includes a specified quantity. Indicate the quantity category for each chemical group on your site. To complete this survey, you may need to reference Material Safety Data Sheets or SARA Title III reporting forms, along with the attached definitions.

(Note: You must complete each line. Do not leave blanks. If you do not use a chemical group listed, mark the “DO NOT HAVE” box.)

When substantial changes occur in the quantity or type of chemical use, manufacture or related storage, a revised survey must be submitted to the Fire Chief. In addition, a revised survey will be requested periodically as the Fire Chief deems necessary, but at least once every five years.

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

WYOMING FIRE DEPARTMENT HAZARDOUS CHEMICAL INVENTORY SURVEY
This site is a...*
Chemical User (chemicals used in the activities on site)		A selection is required
Chemical Producer (chemicals manufactured at this site, including packaging)
Other (e.g., chemicals are stored on site but not used or produced such as a service station, retail store, storage facility, etc.)
None of the Above (chemicals not stored, used or produced)
Name of Premises:* A value is required
Site Address:* A value is required
Suite No:	Zip Code* A value is required		Site Phone Number: A value is required
Emergency Contacts: (Include Private Alarm/Security Companies)
Name/Title* A value is required	Business Phone* A value is required		Home/Cell Phone* A value is required


CLASS 1 - Explosives
Explosive & Blasting Agents (Not including Class C Explosives)	Any Quantity		Choose One* A value is required
CLASS 2 - Gases
Poison Gas	Any Quantity		Choose One* A value is required
Flammable Gas	100 gal. water capacity		Choose One* A value is required
Non-Flammable Gas	100 gal. water capacity		Choose One* A value is required
CLASS 3 - Flammable and Combustible Liquids
Flammable Liquid	1,000 gal.		Choose One* A value is required
Combustible Liquid	10,000 gal.		Choose One* A value is required
CLASS 4 - Flammable Solids
Flammable Solid (Dangerous when wet)	100 lbs.		Choose One* A value is required
Flammable Solid	500 lbs.		Choose One* A value is required
Spontaneously Combustible Material	100 lbs.		Choose One* A value is required
CLASS 5 - Oxidizing Substances, Organic Peroxides
Oxidizer	500 lbs.		Choose One* A value is required
Organic Peroxide	250 lbs.		Choose One* A value is required
CLASS 6 - Toxic Substances and Infectious Substances
Poison	500 lbs.		Choose One* A value is required
Irritating Material: Liquid	1,000 gal.		Choose One* A value is required
Irritating Material: Solid	500 lbs.		Choose One* A value is required
CLASS 7 - Radioactive Materials
Radioactive Material (Yellow III Label)	Any Quantity		Choose One* A value is required
CLASS 8 - Corrosives
Corrosives: Liquid	1,000 gal.		Choose One* A value is required
Corrosives: Solid	500 lbs.		Choose One* A value is required
No D.O.T. Category
Known Human Carcinogen	Any Quantity		Choose One* A value is required



Submit
* Required

Chemical Survey

CLASS 1 - Explosives

CLASS 2 - Gases

CLASS 3 - Flammable and Combustible Liquids

CLASS 4 - Flammable Solids

CLASS 5 - Oxidizing Substances, Organic Peroxides

CLASS 6 - Toxic Substances and Infectious Substances

CLASS 7 - Radioactive Materials

CLASS 8 - Corrosives

No D.O.T. Category

City of Wyoming, Michigan | 1155 28th St SW, Wyoming, MI 49509 | 616-530-7226 | Fax 616-530-7200Hours of Operation: Monday - Thursday, 7:00 A.M. to 5:00 P.M. | Closed Friday - Sunday

City of Wyoming, Michigan | 1155 28th St SW, Wyoming, MI 49509 | 616-530-7226 | Fax 616-530-7200
Hours of Operation: Monday - Thursday, 7:00 A.M. to 5:00 P.M. | Closed Friday - Sunday