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Hazardous Materials Profile Form

Name:

Telephone:

Email address:

 Principle Investigator:

Department Name:

Campus Address:

Your Mailing Address
Street:

City:

State:

Zip:

When do you need it there?
Date:

Ship to Address:
Name:

Address:

City:

State:

Zip:

Phone:
Location of Hazardous Material:

Special Instructions:

Name of Chemical:

Amount:

Type of current container and Size:
(Example - 2.5 gallon plastic)

Chemical Contents:
(if different from the name)

 Is the chemical in the original outer packaging? Yes: No:

Do you have the original shipping paper?
Yes: No:
If yes, please fax it to 585-9958 with reference to this profile.

MSDS is available: Yes: No:
If yes, please fax it to 585-9958 with reference to this profile.

Hazardous Information - please check all that apply:
Explosive
Nonflammable
Flammable
Poison Gas
Flammable Liquid
Flammable Solid
Spontaneously Combustible
Dangerous When Wet
Oxidizer
 Gas Organic Peroxide
Gas Poison
Poison Inhalation Hazard
Infectious Substance
Radioactive
Corrosive
Other - specify: