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Appendix C: Point-of-Use Storage Request Form Example


POINT-OF-USE STORAGE REQUEST FORM Page 1 of 2
1. REQUESTORS NAME AND PHONE NUMBER
 
 
2. REQUESTORS ORGANIZATION
 
 
3. DATE
 
 
4. BUILDING/SHOP
 
 
5. HAZARDOUS MATERIALS MANAGEMENT SYSTEM ZONE
 
 
General Information Regarding the POU Area:
6. SUPERVISOR RESPONSIBLE FOR POU AREA
 
 
7. OFFICE
 
 
8. PHONE NUMBER
 
 
9. E-MAIL ADDRESS
 
 
10. PARTY RESPONSIBLE FOR MAINTAINING THE HAZARDOUS MATERIALS IN THE POU AREA (E.G., PHARMACY, TOOL CRIB, ETC.)
 
 
11. INSTRUCTIONS

The attached checklist is to be used as an internal procedure to provide information to ensure that the Point-of-use (POU) method for issuing hazardous material is appropriate from a compliance standpoint. This form should be submitted to the Environmental Health and Safety Department for review. Procedures for the POU cabinet should be attached.

The form is designed so that if all of the questions are answered with Yes responses, the application can be approved. If any question is answered with a No response, additional sheets outlining the proposed procedure(s) must be attached for review. Questions should be directed to the Environmental Coordinator. For general questions, contact ____ at XXX-XXX-XXXX.


What chemical(s) will be placed in the POU area?
  Chemical Name NSN Unit of Issue Process Code Total Volume
a.          
b.          
c.          
d.          
e.          
(attach additional sheets if required)
13. INITIATORS SIGNATURE
 
 
ORGANIZATION
 
 
PHONE
 
 
DATE
 
 
14. APPROVAL SIGNATURE
 
 
ORGANIZATION
 
 
PHONE
 
 
DATE
 
 


POINT-OF-USE STORAGE REQUEST FORM Page 2 of 2
If any of the following questions are answered No, additional sheets outlining the proposed procedure must be attached.
General Criteria: Y N
Has a map showing the locations of all flammable and corrosive cabinets (including this POU area) that are bounded within the fire zone been attached to this application?    
If there are multiple cabinets within the fire zone, have the volume and type of chemical in each cabinet been indicated on the map?    
Environmental Criteria: Y N
Will the volume of each chemical used be recorded in the hazardous materials management
system at least 3 times per week?
   
Will each chemical stored at the POU area be directly attributed to a single process code?    
Is the current issue method a hazardous material pharmacy?    
Are there procedures to ensure that no more than a 2-day supply of chemicals is maintained at the POU are?    
Are there procedures to check shelf life expiration for each chemical at the POU area?    
Is there a stocked, serviceable spill kit within 25 feet of the proposed POU area?    
Will the existing IAPs be used with no changes to the waste descriptions or additional drums needed?    
Safety Criteria: Y N
Do the flammable storage cabinets conform to OSHA and NFPA 30 Standards?    
Do the corrosive storage cabinets conform to appropriate safety standards?    
Location/area was inspected to ensure all safety requirements are met (e.g. electrical hazards, operational compatibility, etc.)    
Fire Protection Criteria: Y N
Including the chemicals at this POU area, will the total volume of Class I, II, and IIIA chemicals be less than 360 gallons in the fire area?    
Will the total volume of Class I, II, and IIIA liquids stored in any one cabinet be less than 120 gallons?    
Will the total volume of Class I and II liquids stored in any one cabinet be less than 60 gallons?    
Are the cabinets in the fire zone, including the cabinets for this POU, numbered and are the numbers indicated on the attached map?    
Is there an ABC fire extinguisher within 50 feet of the proposed POU area?    
Is there a procedure in place to ensure that flammables are returned to the cabinets at the end of each shift?    
Concur/Nonconcour - See Attachment _____ Concur/Nonconcour - See Attachment _____
 
______________________________________
Environmental Management
______________________________________
Safety

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