Royal Oak Fire Department Chemical Survey

Date Completed

Name of Premises

Site Phone Number

This site is: (please check one)

Chemical User – Chemicals used in activities on site

Chemical Producer – Chemicals manufactured at this sire, includes packaging

Other – Check this if chemicals are stored on site, but not used or produced. Please Specify (Examples: service station, retail store, storage facility)

Please Specify (Examples: service station, retail store, storage facility)

Emergency Contacts (Include Private Alarm/Security Companies)

Contact #1

Title

Business Phone Number

Home Phone Number

Contact #2

Title

Business Phone Number

Home Phone Number

Contact #3

Title

Business Phone Number

Home Phone Number

Contact #4

Title

Business Phone Number

Home Phone Number

Respond based on the maximum quantity you would have on-site, including storage, at any one time during the year.

Class 1

Explosives & Blasting Agents (Not Including Class C Explosives)

Class 2

Poison Gas

Flammable Gas

Non-Flammable Gas

Class 3

Flammable Liquid

Combustible Liquid

Class 4

Flammable Solid (Dangerous when wet)

Flammable Solid

Spontaneously Combustible Material

Class 5

Oxidizer

Organic Peroxide

Class 6

Poison

Irritating Material: Liquid

Irritating Material: Solid

Class 7

Radioactive Material (Yellow III Label)

Class 8

Corrosive: Liquid

Corrosive: Solid

No DOT Category

Known Human Carcinogen

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Last Name

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