Emergency Contact, Response Information and Site Specific Chemical Assessment
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, PA 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.  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 Safety Data Sheets (SDS or formerly MSDS's), SARA Title III reporting forms, along with definitions provided to you in the mailing notice.  
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Property/Building name (if applicable) & Business name *
 Building/Business Address (include Unit/Suite #) *
Business Phone Number *
Business Email
Fire Hydrant Locations (closest two): *
May we contact you via email for future correspondence? *
Principal Building Use: *
Number of People in Building (Day, Evening, Overnight):
Business Hours: *
Utility (Gas, Water, Electricity) Shut-off Locations:
Automated External Defibrillator (AED) on Premises: *
Owner & Owner's Address/phone: *
Emergency Contacts (list nearest person 1st) Include Name, Title, Contact Ph. # of up to three (3) people: *
Entry Points of Building:
Ventilation Points (skylights, etc.):
Construction Type (check all that apply):
# of Stories (include ground level and above): *
Square feet per floor:
Roof Material (check all that apply):
Roof Construction (check all that apply):
Basement:
Clear selection
Basement Access Points:
Attic Space
Clear selection
Attic Use & Access location
Fire Department Lock Box:
Clear selection
Automatic Fire Suppression/Sprinkler System: *
Type of Fire Suppression/Sprinkler System (Kitchen Hood, Wet, Dry, Special or Combination):
FDC (Fire Department Connection) for Fire Suppression System?
Clear selection
Standpipe System (for Automatic Fire Suppression):
Clear selection
Name & Phone # of Fire Alarm Company:
Alarm System Types (Burglar, Fire, Smoke, Carbon Monoxide):
Detectors (check all that apply):
Hazardous Materials Survey Questions
Respond based on the maximum quantity you would have on-site, including storage, at any one time during the year.  Please check one (1) box for each category.  Class 2, 3, 4, 5, 6, and 8 have multiple categories.
Class 1 *
Any quantitiy
Have at or above specified amount
Have bue below specified amount
Do not have
Explosives and Blasting Agents (Not including Class C explosives)
Class 2 *
Any quantity
Have at or above specified quantity
Have but below specified quantity
Do not have
Poison Gas
Class 2 *
100 gallon water capacity
Have at or above specified amount
Have below specified amount
Do not have
Flammable Gas
Class 2 *
100 gallon water capacity
Have at or above specified amount
Have below specified amount
Do not have
Non-Flammable Gas
Class 3 *
1,000 gallons
Have at or above specified amount
Have but below specified amount
Do not have
Flammable Liquid
Class 3 *
10,000 gallons
Have at or above specified amount
Have but below specified amount
Do not have
Combustible Liquid
Class 4 *
100 lbs.
Have at or above specified amount
Have below specified amount
Do not have
Flammable Solid (Dangerous when wet)
Class 4 *
500 lbs.
Have at or above specified amount
Have below specified amount
Do not have
Flammable Solid
Class 4 *
100 lbs.
Have at or above specified amount
Have below specified amount
Do not have
Spontaneous Combustible Material
Class 5 *
500 gallons
Have at or above specified amount
Have below specified amount
Do not have
Oxidizer
Class 5 *
250 gallons
Have at or below specified amoount
Have below specified amount
Do not have
Organic Peroxide
Class 6 *
500 lbs.
Have at or above specfied amount
Have below specified amount
Do not have
Poison
Class 6 *
1,000 gallons
Have at or above specified amount
Have below specified amount
Do not have
Irritating Material: Liquid
Class 6 *
500 lbs.
Have at or above specified amount
Have below specified amount
Do not have
Irritating Material: Solid
Class 7 *
Any Quantity
Do not have
Radioactive Material (Yellow III Label)
Class 8 *
1,000 gallons
Have at or above specified amount
Have below specified amount
Do not have
Corrosives: Liquid
Class 8 *
500 lbs.
Have at or above specified amount
Have below specified amount
Do not have
Corrosives: Solids
No DOT Category *
This site is a: *
Chemical User - (Chemicals used in activities on site)
Chemical Producer - (Chemicals manufactured at this site, includes packaging)
Other - Check this option if chemicals are stored on site, but not used or produced. Please specify (Examples: service station, retail store, storage facility)
Not Applicable
Check all that apply
This concludes the survey.  Dependent on answers to specific questions, you may be presented with follow-up questions from Adrian Fire Department Representatives at a later date.  Your cooperation in the completion of this survey is greatly appreciated.  Please enter the date you completed this survey.  Thank you. *
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