Harmful Material / Chemical

ALERT
Date: Name of Receiving Agent:

The Name we call this Material:

Supplier:

Item Name:

Description:

Part Number:

Circle one:
Used by: Plant / Facility Maintenance

Circle one:
SDS sheet Attached: YES NO

Purchasing Agent & Date:

Safety Tech & Date:

Notes:

Instructions:
Receiving is to complete this Form for all New or Unknown Harmful Materials / Chemicals received that do not appear on the Approved Harmful
Chemicals list. This form is submitted to Purchasing to acquire the SDS sheet and then this Form with the SDS sheet is filed with the Safety Tech.
If there is no Safety Tech assigned then the Form is submitted to the Plant Manager to be filed by the Local Safety Committee. The Safety Tech or
Local Safety Committee will ensure the SDS sheet has been acquired and filed in the SDS book, and affected employees have received training on
this item.