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Chemical Survey Form

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, PA 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, 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 "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 determines 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.

Please submit this questionnaire as indicated in the cover letter.

Complete the entire form before submitting.

If you have any questions regarding the Right-to-Know form, Please contact the Mt. Pleasant Fire Department at 989-779-5105. E-mail: ffrtkgroup@mt-pleasant.org

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