Name/Shipper

Name of material:

Name of the manufacturer:

Name of the shipper:

Address of shipper:

Name of the Consignee:

Address of the Consignee:

Emergency Contact Phone Number:

U.N. identification number:

Hazard Class:

ERG guide number:

Is it a TIH (Toxic Inhalation Hazard)?                                                  Yes          No

Is it a Chemical Warfare Agent?                                                             Yes          No

Is it a Dangerous Water Reactive Material?                                        Yes          No

Is the guide number supplemented with the letter "P"?                   Yes          No

Spill size:    Large        Small                    Quantity:

Circle one:    Solid    Liquid       Gas

 

Isolation distance:

Initial:                       downwind day:                        downwind night:

 

Is there any special evacuation information?

What are the health hazards?

Is there any special information about potential hazards of fire or explosion?

Is there any special information about public safety protective clothing?

What is the emergency response information in case of fire?

What is the emergency response information in case of spill or leak?

What is the emergency response information for first aid?

What are the environmental considerations?

Container

Railroad Car Number:

 

Pressure    Non-pressure

 

Highway truck type:

306  307  312  331  338  Box  Hopper  Flatbed

 

Smaller container type: