Chemical Hazardous Material Declaration Form

1. Declarant Information

Name Position Department Contact Number Email Date

2. Chemical Information

Chemical Name	CAS Number	Quantity	Unit	Physical State	Hazard Class	Storage Location
			g kg L mL	Solid Liquid Gas
			g kg L mL	Solid Liquid Gas
			g kg L mL	Solid Liquid Gas

3. Purpose of Use

Describe the purpose for which the chemicals will be used

4. Safety Precautions / Handling Procedures

Briefly describe the safety precautions and handling procedures

5. Waste Disposal Method

Outline the method for disposal of hazardous chemical waste

6. Additional Remarks

Any additional information