Please also fill out this Hazardous Materials Inventory Statement if filing for High Piled Combustible Storage permit. Contact Information Contact Information Business Contact Business Name Email Address Phone Number Business Address Address 2 City State WashingtonAlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Inventory Is this building or Hazardous Materials Storage area protected by an automatic fire sprinkler system? Yes No Enter inventory below. Enter inventory below. Product Name Components (Solid, Liquid or Gas) CAS # Location Where Stored or Used Container Size Hazard Classification Amount in Storage Amount in Use—Closed Systems Amount in Use—Open Systems For Flammable/Combustible Liquids form–Please provide applicable SDS upon request. For Compressed Gasses form–Please provide applicable MSDS upon request. Guidelines for completing a Hazardous Materials Inventory Statement (HMIS) The following information is provided to assist in filling out the Hazardous Materials Inventory Statement (HMIS). The International Fire Code also provides detailed chapters and appendix material to assist in completing this form. Material Safety Data Sheets (MSDS) shall be available for all chemicals indicated and such MSDS shall be provided. Product Name. This is the name of the product being utilized. The product name of the chemical can be found on the MSDS. The Chemical Name is the scientific designation of a chemical in accordance with the nomenclature system developed by the International Union of Pure and Applied Chemistry, or a name which will clearly identify a chemical for the purpose of conducting an evaluation. Component. Indicate whether the chemical is stored or used a solid, liquid, or gaseousstate. Chemical Abstract Service (CAS) number. This is a number assigned to a product following testing and certification. This number must apply to the chemical or mixture as a whole. If a CAS number is not indicated on the MSDS, then indicate “Not Available” in the space. Do Not list CAS numbers for individual ingredients. Location Where Stored or Used. Identify the locations or areas where the chemicals are being stored orused. Container Size. Identify the size of containers the chemicals are stored in. Hazard Classification. Chemicals presenting a hazard must be classified in accordance with each hazard type. Health Hazard is a classification of a chemical for which there is statistically significant evidence that acute or chronic health effects are capable of occurring in exposed persons. The term “health hazard” includes chemicals that are toxic, highly toxic, and corrosive. Physical Hazard is a chemical for which there is evidence that is a flammable or combustible liquid, cryogenic fluid, explosive, flammable (solid, liquid, or gas), organic peroxide (solid or liquid), oxidizer (solid or liquid), oxidizing gas, pyrophoric (solid, liquid, or gas), unstable (reactive) material (solid, liquid, or gas) or water-reactive material (solid or liquid). Amount in Storage. Identify the total amount of the chemical being stored. Amount in use – Closed Systems. Identify the use of a solid or liquid hazardous material involving a closed vessel or system that remains closed during normal operations where vapors emitted by the product are not liberated outside of the vessel or system and the product is not exposed to the atmosphere during normal operations; and all uses of compressed gases. Examples of closed systems for solids and liquids include product conveyed through a piping system into a closed vessel, system or piece of equipment. Amount in use – Open Systems. Identify the use of a solid or liquid hazardous material involving a vessel or system that is continuously open to the atmosphere during normal operations and where vapors are liberated, or the product is exposed to the atmosphere during normal operations. Examples of open systems for solids and liquids include dispensing from or into open beakers or containers, dip tank and plating tankoperations. CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.