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1. General Information
1.1  Involved Ministry:
1.2  Name of Establishment:
1.3  Nature of Establishment:
 Industrial     Commercial
1.4  Site of Establishment:
. Address  
. Tel            
. Fax
. Email
1.5  No. of workers:
1.6  EIA:
 Yes     No     Current situation
 If yes:  White  Grey  Black
1.7  Date of operation:
1.8  Nature of surrounding area:
 Agriculture     Desert     Housing     Industrial
1.9  Industrial record:
1.10  Commercial record:
1.11  Main products:
1.12  Annual production:
1.13  Total quantity imported/year:
1.14  Responsible manager:
. Name  
. Tel            
. Fax
. Email
1.15  Personal license no.:
 (In case of radioactive substance)
1.16  Responsible of radiation safety:
1.17  No. of workers dealing with chemical/radioactive substances:
1.18  Safety equipment:
1.19  Insurance data:


2. Hazardous Substances Information
2.1  Chemical name:
2.2  Trade names:
2.3  Chemical formula:
2.4  CAS No.:
2.5  UN No.:
2.6  Amount to be imported/produced:
.  Volume       .  Weight       .  No. of units
2.7  Quantity already imported/produced during the current year:
2.8  Annual needs:
2.9  Country of origin:
2.10  Exporting country:
. Address  
. Tel            
. Fax
. Email
2.11  Uses:
2.12  % of H.S in final product:
2.13  General dangerous group:
 explosive     oxidizing     highly flammable
 flammable  high toxic  toxic
 harmful  corrosive  irritant
 allergic  carcenogenious  mutation
 harmful to fertility  harmful to env.  radioactive
2.14  Degree of danger:
 High     Medium     Limited     
2.15  Nature of substance:
 Solid     Liquid     Gas     
2.16  Responsible of radiation safety:
.  Odor       .  Color
.  Density .  Solubility
.  Flammable point .  Auto ignition
.  Fire point .  Flash point
.  Melting point .  Freezing point
.  Polymerization .  Thermal stability

3. Handling
3.1

  Packing:
- Type of packing
 Barrels  Reservoirs    Cans    Packages    Others
- Material of packing
 Plastic  Steel  Glass  Paper  Carton     Others
- Are the type and material of packing suitable for the type of H.S?
 Yes  No
- Is the inner lining not affected by storage?
 Yes  No

3.2

  
 Storage:
- Storage (site):
- Incompatible materials:
 No. of rows          No. of columns  Space distance  
- Are the preceding conditions suitable for safe storage?
Yes   No  
- Storage conditions:
Ventilation:   Ambient temperature:             Humidity:
- Storage period:
- Are safety equipment in the establishment safeguard for:
 Leakage         Explosion        Fire        Oxidation
- Approved of ministry of housing to the specifications of storage site?
Yes No
- Storage description:
3.3
 Transportation:
- Transportation means:
 Shipping         Railway        On roads
- Approved of ministry of transportation on the trucks routing?
 Yes         No   
- Approved of ministry of interior (Traffic Sector and Civil Defense)?
 Yes         No   
- Are transportation trucks implies with safety conditions?
 Yes         No   
- Approved of ministry of housing to the specifications of storage site?
 Yes         No   
- Are transportation trucks provided with safety equipment?
 Yes         No   
- Was the driver trained on dealing with H.S?
 Yes         No   
- Are there clear signs (labels) for the dangerous group of H.S on transportation trucks?
 Yes         No   
- Transportation company:
 Authorized name:
. Address  
. Tel            
. Fax
. Email

3.2
 Labeling:
- Container contents and its concentration:
- Total weight:                                     Net weight:
- Danger phrases:
- Safety phrases:
- Label of dangerous group of H.S.
- Storage conditions:
- Symptoms of toxicity:
- First aids in case of exposure:
- Method of disposal of empty containers:
 Treatment         Crushing          Grinding         Recycling
 Burning  Disinfecting  Other
- Producer:
- Production date:
- Expiry date:
- Batch No.:
- Was the driver trained on dealing with H.S?
 Yes         No   
- Are there clear signs (labels) for the dangerous group of H.S on transportation trucks?
 Yes         No   
- Transportation company:
 Authorized name:
. Address  
. Tel            
. Fax
. Email

3.3
 Protection means used during handling:
3.4

  Safety precautions during handling:

To the best of my knowledge, the information hereby presented are correct. In case of discrepancy, I shall promptly report and make corrective action, otherwise I would be fully liable to permit withdrawal/ and any other liabilities mandated by the laws and regulations.
 Name:  
 Job:  
 ID No.:  
 Signature:  
 Date: