Sample appointment of Site Manager letter

COMPANY NAME & LOGO/LETTERHEAD

OCCUPATIONAL HEALTH AND SAFETY ACT, 85 of 1993

SECTION 16(2) – ASSISTANT TO THE CHIEF EXECUTIVE OFFICER APPOINTMENT

(Appointee’s Name)

I, (Appointer’s Full Name) the (Legislative reference of appointment) appointee of (Appointer’s Area)
hereby appoint you (Appointee’s Full Name) as the Section 16(2) (Assistant to the CEO) appointee
responsible for the area k nown as (Appointee’s Area).

In terms of this appointment, you are responsible for Occupational Health and Safety matters at the
aforementioned area. In order to ensure that you meet this responsibility you must familiarise yourself with
the Occupational Health and Safety Act and its Regulations. You are also required to ensure that all
statutory requirements are met at all times.

You may not further assign this duty.

Your appointment is valid from (Start Date) to (End Date).

You shall report (Time Period) directly to myself on all occupational health and safety matters arising out
of (Appointee’s Area).

……………………………… ……………………………………
(Appointer’s Full Name) Date

Kindly confirm your acceptance of this appointment by completing the following:

ACCEPTANCE
I, (Appointee’s Full Name) understand the implications of the appointment as detailed above and confirm
my acceptance.

………………………………. …………………………………..
(Appointee’s Full Name) Date

Sample Site Construction Supervisor form

OCCUPATIONAL HEALTH & SAFETY ACT, 85 OF 1993

Construction Regulation 6

SUPERVISION OF BUILDING/CONSTRUCTION WORK

I, …………………………………………………, designated as the

…………………………………………………… for ……………………………………………… do hereby
appoint you in terms of Section 6 of the Construction Regulations as

SUPERVISOR OF BUILDING WORK

Your area of responsibility will be …………………………………………………………………………...

Your duties will include:

1. Familiarise yourself with the relevant legislation.

 2. Supervise the safe performance of building work and also in regard to health.
3. Cause every excavation to be inspected by a competent person once before each shift or
after any rain, and ensure that these inspections are recorded in a register.
4. Ensure that all work ers understand the hazards attached to work performed by them.
5. Be in possession of proof that all work ers have attended formal training regarding their job
hazards and the precautionary measures to be tak en.
6. Report to your superior immediately all incidents and accidents that come to your attention.
7. In the case of building work tak ing longer than three months and in which the excavation is
more than 1m deep or requires a person to work at a height exceeding 3m above ground,
inform the Regional Director in writing, prior to starting work , as required in terms of Section 3
of the Construction Regulations.
8. Comply and ensure compliance with the Contractors Regulations GN1010 of 18/07/03 and
the relevant sections of the OHSA.

………………………………………….…. ..…………………
Signature of CEO/Employer Date

ACCEPTANCE
I, ………………………………………………………… hereby accept this designation and understand and
agree to comply with the requirements.

……………………………………… ..………………………………
Signature Date

Sample Assistant Site Construction Supervisor form

OCCUPATIONAL HEALTH AND SAFETY ACT, 85 OF 1993

Construction Regulation 6

APPOINTMENT OF ASSISTANT CONSTRUCTION WORK SUPERVISOR

I, ________________________________________ (Employer), for ______________________

(Company) do hereby appoint __________________________________________ (Employee) as the
Assistant Supervisor of Construction Work at
_______________________________________________________________________________
(Site/address).

Special Instructions/Information:
1. Assist the employer to comply with the Occupational Health and Safety Act, and especially the
Construction Regulations.
2. Endorse Safety Representatives’ reports/Minutes of the Health and Safety meeting.
3. Report and investigate any incident/accident/injury.
4. Ensure the terms of the “Agreement with Mandatory” as per Section 37(1)(2) of the Act are complied
with.
5. Ensure risk assessments are conducted within your area of responsibility and are regularly updated.
6. Assist in compiling Method Statements and the development of Safe Work Procedures.

Signature: ________________________________________
(for Employer)
Date: ________________________________________

Designation: ________________________________________

ACCEPTANCE OF APPOINTMENT
I, __________________________________________________________ hereby accept and
understand this designation.

Signature: _____________________________________ Date: ___________________

Designation: ____________________________________

Sample Health and Safety Officer appointment form

OCCUPATIONAL HEALTH & SAFETY ACT, 85 OF 1993

Construction Regulation 6

HEALTH AND SAFETY OFFICER

I, _________________________ (Employer), for __________________________ (Company) do hereby

appoint:____________________ as the Health and Safety Officer for ____________________

________________________________ (site/address).

Duties:
1. Assist in compiling the SHE Plan.
2. Assist with risk identification, evaluation and development of safe work procedures.
3. Conduct or have conducted a risk and hazard analysis and tak e the necessary corrective action.
4. Ensure all accidents are properly recorded, reported and investigated.
5. Ensure Health and Safety Representatives are appointed.
6. Ensure Safety Meetings are held regularly and the results recorded.
7. Ensure Health and Safety Representatives conduct monthly inspections and submit the required
reports.
8. Ensure Contractors comply with the Health and Safety Specifications.
9. Assist with establishment of the Fall Protection Plan.
10. Where it is not possible to remove any remaining hazard/s you are to inform employees thereof
and what precautionary action is to be tak en.
11. Ensure appropriate restoration of areas affected by construction.
12. Detail mitigating measures required to be tak en, and the procedures for their implementation to
the Project Manager.
13. Establish the reporting system to be undertak en during construction and ensure effective
reporting to management on the deviations identified and required action to be tak en.
14. Ensure EMP compliance.
15. Ensure monthly Safety, Health and Environmental reports are submitted to the Project Manager.
16. Carry out toolbox talk s.
17. Ensure training needs are identified and implemented.
18. Assist with Induction training.

Signature:_______________________________________________
(for Employer)

Designation:_____________________________________________

Date:_____________________________________ ______________

ACCEPTANCE OF APPOINTMENT

I,____________________________________ hereby accept and understand this appointment.

Signature:_______________________________________ Date:
_______________________________

Designation:_____________________________________________

Sample appointment of Fall Protection Planner form

OCCUPATIONAL HEALTH AND SAFETY ACT, 85 of 1993

Construction Regulation 8

APPOINTMENT OF FALL PROTECTION PLANNER

I, ___________________________(Employer), for _____________________________(Company) do

hereby appoint : ________________________(Employee) as the Fall Protection Planner for:
___________________________ at _____________________________________(Site/Address).

Duties:
1. Ensure compliance with Construction Regulation 8.
2. Compile a Fall Protection Plan for the project.
3. Implement the Fall Protection Plan and amend where required.
4. Tak e steps to ensure all employees adhere to the plan.
5. Ensure risk assessments are conducted prior to commencing work in elevated positions.
6. Ensure persons required to work in elevated positions are physically and psychologically fit.
7. Ensure all employees required to work in elevated positions are trained.
8. Ensure all fall arrest equipment is inspected and maintained.
9. Ensure the construction supervisor is issued the latest version of the Fall Protection Plan.
10. Ensure all check lists are k ept up to date, with copies in the Health and Safety File.
11. Ensure roof work is included in the planning.

Signature:_______________________________________________
(for Employer)
Designation:_____________________________________________

Date:___________________________________________________

ACCEPTANCE OF APPOINTMENT

I______________________________ hereby accept and understand this appointment.

Signature:______________________ Date: _______________________________

Designation:_____________________________________

Sample appointment of Excavation Supervisor form

OCCUPATIONAL HEALTH AND SAFETY ACT, 85 of 1993

Construction Regulation 11

EXCAVATION INSPECTOR/SUPE RVIS OR

I, ______________________ (Employer), for ______________________________(Company), do

hereby appoint __________________________ (Employee) as Excavation Inspector/Supervi sor at
_______________________________________________________(Site/ address) you will be required
to ensure that all the provisions of Construction Regulation 11 are complied with and all necessary
records, registers and check lists are k ept up to date and included in the Health and Safety File.
Signature:_______________________________________________
(for Employer)
Designation:_____________________________________________

Date:___________________________________________________

ACCEPTANCE OF APPOINTMENT

I __________________________________hereby accept and understand this appointment.

Signature:_______________ Date: ___________________________

Designation:_____________________________________________

Sample appointment of Demolition Supervisor form

OCCUPATIONAL HEALTH AND SAFETY ACT, 85 OF 1993

Construction Regulation 12

APPOINTMENT OF DEMOLITION SUPERVISOR

I,__________________(Employer), for ___________________(Company) hereby appoint

________________________________ (Employee) as the Demolition Supervisor at
______________________________________________________________(Site/ address).

Signature:_______________________________________________
(for Employer)
Designation:_____________________________________________

Date:___________________________________________________

ACCEPTANCE OF APPOINTMENT

I, ______________________________ hereby accept and understand this appointment.

Signature: _______________________________________

Date: _______________________________

Designation: ______________________________________

Sample appointment of Scaffold Erector form

OCCUPATIONAL HEALTH AND SAFETY ACT, 85 OF 1993

Construction Regulation 14

APPOINTMENT OF SCAFFOLD ERECTOR

I, _____________________________(Employer), for __________________________(Company) hereby

appoint _____________________________(Employee) as the Scaffold Erector at
___________________________________________(Site/ address).

Special Instructions/Information:
____________________________________________________________________________________
____________________________________________________________________________________
_____________________________________________________________________

Signature:_______________________________________________
(for Employer)
Designation:_____________________________________________

Date:___________________________________________________

ACCEPTANCE OF APPOINTMENT

I, ___________________________________________ hereby accept and understand this appointment.

Signature:_______________________________________

Date: _______________________________

Designation:_____________________________________________

Sample appointment of Scaffold Team Leader form

OCCUPATIONAL HEALTH AND SAFETY ACT, 85 OF 1993

Construction Regulation 14

APPOINTMENT OF SCAFFOLD TEAM LEADER

I, ________________________ (Employer), for ________________________ (Company) hereby

appoint ___________________ (Employee) as the Scaffold Team Leader at
____________________________________________________(Site/address).

Instructions/ Information:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________

Signature:_______________________________________________
(for Employer)
Designation:_____________________________________________

Date:___________________________________________________

ACCEPTANCE OF APPOINTMENT

I, ______________________________hereby accept and understand this appointment.

Signature:_______________________________________

Date: _______________________________

Designation:_____________________________________________

Sample appointment of Scaffold Inspector form

OCCUPATIONAL HEALTH AND SAFETY ACT, 85 OF 1993

 Construction Regulation 14

APPOINTMENT OF SCAFFOLD INSPECTOR

I, __________________________(Employer), for __________________________(Company) hereby

appoint ____________________________ (Employee) as the Scaffold Inspector at
________________________________________________________________(Site/address).

Signature:_______________________________________________
(for Employer)
Designation:_____________________________________________

Date:___________________________________________________

ACCEPTANCE OF APPOINTMENT

I, ______________________________ hereby accept and understand this appointment.

Signature:________________________________

Date: _______________________________

Designation:______________________________________

Sample appointment of Scaffold Supervisor form

OCCUPATIONAL HEALTH AND SAFETY ACT, 85 OF 1993

Construction Regulation 14

APPOINTMENT OF SCAFFOLD SUPERVISOR

I, _____________________(Employer), for _________________________________ (Company) hereby

appoint _________________________(Employee) as the Scaffold Supervisor at
____________________________________________________________(Site/address).

Signature:_______________________________________________
(for Employer)
Designation:_____________________________________________

Date:___________________________________________________

ACCEPTANCE OF APPOINTMENT

I, ___________________________________hereb y accept and understand this appointment.

Signature:__________ _________________________

Date: _______________________________

Designation:_______________ _________________________

Sample appointment of Material Hoist Inspector form

OCCUPATIONAL HEALTH AND SAFETY ACT, 85 OF 1993

Construction Regulation 17
 APPOINTMENT OF MATERIAL HOIST INSPECTOR

I,_____________________(Employer), for _____________________ (Company) hereby appoint

______________ (Employee) as the Material Hoist Inspector for __________________________
(Site/address)

Duties:

Inspect Material Hoist daily and ensure compliance with Regulations.

Signature:_______________________________________________
(for Employer)
Designation:_____________________________________________

Date:___________________________________________________

ACCEPTANCE OF APPOINTMENT

I ____________________________ hereby accept and understand this appointment.

Signature:_________________________

Date: __________________________

Designation:_________________________________ _____

Sample appointment of Batch Plant Inspector form

OCCUPATIONAL HEALTH AND SAFETY ACT, 85 OF 1993

Construction Regulation 18

REF BPL 1
APPOINTMENT OF BATCH PLANT INSPECTOR

I, _____________(Employer), for _______________________(Company) hereby appoint

__________________________ (Employee) as Batch Plant Inspector for
________________________________________________________ (Site/address).

Signature:_______________________________________________
(for Employer)
Designation:_____________________________________________

Date:___________________________________________________

ACCEPTANCE OF APPOINTMENT

I, __________________________hereby accept and understand this appointment.

Signature:______________________

Date: ______________________

Designation:_____________________________________________
Sample appointment of Batch Plant Operator form

OCCUPATIONAL HEALTH AND SAFETY ACT, 85 OF 1993

Construction Regulation 18

APPOINTMENT OF BATCH PLANT OPERATOR

I, ____________________(Employer), for ______________________ (Company) hereby appoint

______________________________ (Employee) as Batch Plant Operator for
_____________________________________________________________ (Site/address).

Signature:_______________________________________________
(for Employer)
Designation:_____________________________________________

Date:___________________________________________________

ACCEPTANCE OF APPOINTMENT

I, _______________________hereb y accept and understand this appointment.

Signature:_________________________________

Date:_______________________________

Designation:________________________________________

Sample appointment of Tower Crane Operator form

OCCUPATIONAL HEALTH AND SAFETY ACT, 85 OF 1993

Construction Regulation 20

APPOINTMENT OF TOWER CRANE OPERATOR

I, ______________________ (Employer), for _____________________________(Company) hereby

authorise ___________________(Employee) to operate as the Tower Crane Operator at
__________________________________________________________________(Site/address).

Signature:_______________________________________________
(for Employer)
Designation:_____________________________________________

Date:___________________________________________________

ACCEPTANCE OF APPOINTMENT

I, _________________________________ hereby accept and understand this appointment.

Signature:____________________________ _______

Date: _______________________________

Designation:_____________________________________________

Sample appointment of Construction Vehicle and Mobile Plant Inspector form

 OCCUPATIONAL HEALTH AND SAFETY ACT, 85 OF 1993
Construction Regulation 21

APPOINTMENT OF CONSTRUCTION VEHICLE

& MOBILE PLANT INSPECTOR

I, __________________(Employer), for ______________________________(Company) hereby appoint

__________________________ (Employee) as the Construction Vehicle & Mobile Plant Inspector at
___________________________________________________(Site/address).

Duties:
1. Ensure compliance with Construction Regulation 21.
2. Ensure all construction vehicles and mobile plant are inspected daily prior to use.
3. Ensure construction vehicles and mobile plant which are found to be unsafe are withdrawn
from use until the required repairs are effected.
4. Ensure record is k ept of all inspections and the register is made available as required.

Signature:_______________________________________________
(for Employer)
Designation:_____________________________________________

Date:___________________________________________________

ACCEPTANCE OF APPOINTMENT

I, __________________________hereby accept and understand this appointment.

Signature:_______________________________________

Date: _______________________________

Designation:_____________________________________________

Sample appointment letter for Stacking and Storage Supervisor

OCCUPATIONAL HEALTH & SAFETY ACT, 85 OF 1993

General Safety Regulations Section 8

STACKING AND STORAGE SUPERVISOR

I, ______________________ (Employer), for ________________________ (Company) do hereby

appoint ____________________ (Employee) as the Stacking and Storage Supervisor for
_____________________________________________________________ (Site/address).

Your duty will be to ensure that all stack ing/storage is carried out in accordance with Regulation 8 of the
General Safety Regulations made under the Occupational Health and Safety Act 85/93 and any other
legal requirement or exemptions which may apply.

Signature:_______________________
(for Employer)

Date: ________________________________________

Designation: ________________________________________
 ACCEPTANCE

I, _____________________ hereby accept and understand the requirements of this designation.

Signature: _______________________________ Date: ___________________

Designation: ____________________________________

Sample appointment letter as Fire Prevention and Protection Control person

FIRE PREVENTION AND CONTROL

(INCLUDING EQUIPMENT SUITABILITY, MAINTENANCE & USAGE).

Branch/site……………………………………Date …………………………………
Dear …………………………………………………

APPOINTMENT AS FIRE PREVENTION AND PROTECTION OFFICER

I hereby, appoint you as the FIRE PREVENTION AND PROTECTION OFFICER for
………………….…………… (location) for the period of ………………… months from the date of this letter.

Your duties will be to co-ordinate and control the Fire Protection and Prevention Programme. This will
include:

• To select Fire Fighting Teams (for the Day shift and the Night shift).
• To carry out/organise fire extinguishing training as agreed.
• To have regular MONTHLY Fire Drill Practices.
• To ensure that correct Fire Fighting Equipment is available and that it is in serviceable condition at
all times.
• To have an organised EVACUATION ROUTINE PROGRAMME and to have staff trained according
to the programme.
• To report to ………………………………………… on any Fire Risk s on the premises.

Your duties as the Fire Prevention and Protection Officer will form part of your normal duties and be
performed during work ing hours.

Employer ………………………………………..… Date …………………………………

I, ………………..………………, hereby accept this appointment and ack nowledge that I understand the
nature of my duties relating thereto.

Signed ………………………………………. Date …………………………………

Sample personal protective clothing acknowledgement form

ISSUE OF PERSONAL PROTECTIVE EQUIPMENT

NAME: …………………………………………………..…………. COMPANY NO : ……………………….…………….

I, ……………………………………………… hereby accept responsibility for the items below, which I have signed for. I
realise that I will not be permitted to work without them.
I agree to wear or use, in the proper manner, the equipment issued to me for MY safety and health, as well as this being a
legal requirement.

I realise that if I fail to wear/use this equipment and as a result, I sustain an injury, the Compensation Commissioner for
Occupational Injury and Diseases or FEM will be informed and this may jeopardise my right to compensation.

Signed …………………………… Date ………………………………..

Witness …………………………………. Date ……………………….

DATE DATE DATE

OF OF OF
DESCRIPTION ISSUE SIGNATURE DESCRIPTION ISSUE SIGNATURE DESCRIPTION ISSUE SIGNATURE

Sample appointment of Incident Investigator form

ACCIDENT AND INCIDENT INVESTIGATION

INCIDENT INVESTIGATOR IN TERMS OF GAR 6 AND 8 AND SECTION 24 OF THE OCCUPATIONAL

HEALTH AND SAFETY ACT, 85 OF 1993

I, …………………………………………designated as the ………………………………… for

..………………………………… do hereby designate you as ACCIDENT/INCIDENT INVESTIGATOR with
the following duties and responsibilities:

1. Investigate all incidents and accidents.

2. Report the findings of the investigation on the Annexure 1 or 1(a) forms.
3. Ensure that the employer endorses the Annexure 1 or 1(a) forms and also the Chairman of the
Health and Safety Committee in terms of Section (8)3 GAR.

…………………………..…….…. ..………………………
Signature of CEO/Employer Date

Acceptance

I, ……………………………………… hereby accept this designation, understand the contents and agree to
comply.

……………………………………..…….…. ..………… ………………………….

Signature Date

Annexure 1: Use this form to record and investigate incidences

Occupational Health and Safety Act, 1993 (Act No. 85 of 1993)

ANNEXURE 1
Regulation 8 and 9 of the General Administrative Regulations
Recording and investigation of incidents

A. Recording of incident
1. Name of employer ……………………………………………………………………………………………
2. Name of affected person …………………………ID No …………………………………………………………..
3. Date of incident …………………………………. 4. Time of incident ……………………………………….
Head or neck Eye T runk Finger Hand
5. Part of body affected
Arm Foot Leg Internal Multiple

Sprains or Contusions or Fractures Burns Amputation

6. Effect on person strains wounds
Unconscious- Occupational
Electric shock Asphyxiation Poisoning
ness Disease
> 52 weeks or
0 – 13 2–4 > 4 – 16 > 16-52 permanent
days weeks weeks weeks Killed
7. Expected period of disablement disablement

8. Description of Occupational disease ………………………………………………………………………………………...

9. Machine/process involved/type of work performed/exposure ………………………………………………………………
…………………………………………………………………………………………………………
………………………………………………………………………………………………………
10. Was incident reported to the Compensation Commissioner? Yes……………..No……………..Ref…………………
11. Was incident reported to SAPS? Yes ………..No ……………….Ref…………………………..
12. Was incident reported to Provincial Director? Yes……….No…………Ref……………………..
** in case of a hazardous chemical substance, indicate substance exposed to
B. Investigation of the above incident by a person designated thereto
1. Name of investigator ……………………………………… 2. Date of investigation ……………………………
3. Designation of investigator …………………………………………………………………………………..
……………………………………………………………………………………………………………………
4. Short description of incident ……………………………………………………………………………………………..
………………………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………………….
5. Suspected cause of incident ……………………………………………………………………………………………
…………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………
6 Recommended steps to prevent a recurrence …………………………………………………………………………..
……………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………..
……………………………………. …………………………………….
Signature of investigator Date
6. Action taken by employer to prevent the recurrence of a similar incident
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
……………………………………. …………………………………….
Signature of investigator Date
7. Remarks by Health and Safety Committee
Remarks ………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………………………….
 Signature of Chairman of the Health & Safety Committee ………………………………………………………………………

Use this form to record and investigate injuries to non-employees

OCCUPATIONAL HEALTH & SAFETY ACT, 85 OF 1993

REGULATION 8 AND 9 OF THE GENERAL ADMINISTRATIVE REGULATIONS (ACCIDENTS
AFFECTING NON-EMPLOYEES)

(a) Name and Identity no of injured person …………………………………………………

(b) Address and phone numbers of injured person …………………………………………….

………………………………………………………………………………………………………………
………………………………………………………………………………………………
(c) Name and address and phone number of employer/user/self employed person
……………………………………………………………………………………………………………….
………………………………………………………………………………………………………………
……………………………………………………………………………………
(d) Contact person (Name)……………………………………………………………………..

(e) Details of incident…………………………………………………………………………

……………………………………………………………………………………………

(i) What happened.

…………………………………………………..……………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
……………
(ii) Place where it happened
………………………………………………………………………………………………………
………………………………………………………………………………………

(iii) Time and date when it happened

……………………………………………………………………………………………

(iv) How it happened

………………………………………………………………………………………………
(v) Why it happened
…………………………………………………………………………………………

(vi) Details of witnesses

………………………………………………………………………………………………………………
………………………………………………………………………………

(f) Reported to Provincial Director by (fax etc)…………………………………………………...

At (time) ……………….on (date) ……………………..by ........................................................

Name of inspector receiving details ………………………………………………………….

Sample of a Hazardous Chemicals Controller appointment letter

OCCUPATIONAL HEALTH & SAFETY ACT, 85 OF 1993

 CONTROL OF HAZARDOUS SUBSTANCES

To …………………………………………………………………………..

Dear …………………………………………………………………………

The control over purchase, storage, issue, accounting for any substances used on our premises which (if
not properly supervised) could result in death/injury/illness to any of our staff or the public, or in product
contamination,is essential.

I hereby appoint you (if necessary, here add “as part of a team, the other members of which are”)
………………………………………………………….. to perform this function. You must familiarise yourself
with the contents of the Regulations for Hazardous Chemical Substances and prepare a list of hazardous
substances, the properties and “antidotes”, and to do this obtain information from all suppliers.

• Update this list at least monthly.

• Ensure new materials purchased conform to the specifications.
• Ensure such materials are secured and issued with the necessary authority.
• Ensure that correct mixes/concentration are used (this may be an overview function).
• Ensure antidote lists are updated.
• Ensure first aiders are k ept apprised of changes.
• Ensure the correct protective measures are tak en.
• Ensure an education and training programme is devised and carried out in consultation with
Health and Safety Representatives and the Health and Safety Committee.
• Display Hazchem data sheets at points of use.
• Ensure that, where possible, Hazchem items are removed or reduced in quantity by substitution
or that the risk is reduced where possible by engineering means.

SIGNED: ………………………………….… DATE: …………………………….………..

I hereby accept this appointment:

SIGNED: …………………………………………… DATE: ………………………………….………..

ALPHABETICAL LIST
HAZARDOUS CHEMICAL SUBSTANCES

MAXIMUM
QUANTITIES
STORED AT ANY
SUBSTANCE ONE TIME W HERE LOCATED
1.

2.

3.

4.

5.

6.

7.
8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

DATE: …………….……………….… COMPLETED BY: ………………………………….………..

DATE: ………………………………… REVISED: ………………………………………………..