Chemical Survey

Information: Completion of the Chemical Survey is requested to determine the quantity of specific chemical groups used, produced or stored in facilities within the jurisdiction of the Portage Department of Public Safety. The Michigan Occupational Safety and Health Administration (MIOSHA), P.A. 154 of 1974, as amended, and the Fire Prevention Code, PA 207 of 1941, as amended, require that any firm handling hazardous chemicals provide information to the Fire Chief upon request.

Instructions: Indicate below whether the firm is a user, producer or storer of any of the chemical types listed. Select all the categories that apply when a chemical has more than one characteristic (e.g., both a Class 3 flammable and a Class 6 poison). Each chemical group listed in the Chemical Survey includes a specific quantity. Select the appropriate quantity category for each chemical group on site. Note: Each line of the Chemical Survey must be completed. Do not leave blanks. If a chemical group listed is not used, produced or stored, select "Do Not Have." Reference to Material Safety Data Sheets, SARA Title III reporting forms and/or the Hazardous Chemical Definitions may be required to complete the Chemical Survey.

When substantial changes occur n the quantity or type of chemical use, manufacture or related storage, a revised survey must be submitted to the Fire Chief. In addition, a revised survey will be requested periodically as the Fire Chief determines necessary, but at a minimum, once every five years.

If the information provided in the Chemical Survey indicates that the firm is a user, producer or storer of hazardous chemicals and the chemicals on site meet or exceed the specified quantities, the Portage Department of Public Safety - Fire Division will request further information. this may include a request for Material Safety Data Sheets, chemical lists maintained under the Employee Right to Know provisions of MIOSHA and other information.

This firm is a ...
(Select all that apply)

Date  Name of Firm 
Physical Address 
Mailing Address (if different) 
Name & Title of Person Completing Survey 
Telephone Number 
Email Address 

EMERGENCY CONTACTS (Including private alarm/security companies)
Name and Title Daytime Telephone Evening Telephone

Please complete the Chemical Survey based on the maximum quantity the firm would have on-site, including storage, at any one time during the yar.
Chemical Type Specified Quantity
Class 1
Explosives & Blasting Agents (Not including Class C Explosives) Any Quantity
Class 2
Poison Gas Any Quantity
Flammable Gas 100 gal. water capacity
Non-flammable Gas 100 gal. water capacity
Class 3
Flammable Liquid 1,000 gallons
Combustible Liquid 10,000 gallons
Class 4
Flammable Solid (Dangerous when wet) 100 lbs.
Flammable Solid 500 lbs.
Spontaneously Combustible Material 100 lbs.
Class 5
Oxidizer 500 lbs.
Organic Peroxide 250 lbs.
Class 6
Poison 500 lbs.
Irritating Material: Liquid 1,000 gal.
Irritating Material: Solid 500 lbs.
Class 7
Radioactive Material (Yellow III Label) Any Quantity
Class 8
Corrosives: Liquid 1,000 gal.
Corrosives: Solid 500 lbs.
No DOT Category
Known Human Carcinogen Any Category

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Carcinogen – A chemical is considered to be a carcinogen if: 1) it has been evaluated by the International Agency for Research on Cancer (IARC) and found to be a carcinogen or potential carcinogen; or 2) it is listed as a carcinogen or potential carcinogen in the Annual Report on Carcinogens published by the National Toxicology Program (NTP) (latest edition), or 3) it is regulated by OSHA as a carcinogen.

Combustible liquid – Any liquid having a flashpoint at or above 100 degrees F (37.8 degrees C), but below 300 degrees F (93.3 degrees C), except any mixture having components with flashpoints of 200 degrees F (93.3 degrees C), or higher, the total volume of which make up 99 percent or more of the volume of the mixture.

Corrosives – liquid and solid – Any liquid or solid that causes visible destruction or irreversible damage to human skin tissue. Also, it may be a liquid that has a severe corrosion rate on steel.

Explosives and blasting agent – (not including Class C explosives) – “Explosive” means a chemical that causes a sudden, almost instantaneous release of pressure, gas, and heat when subjected to sudden shock, pressure, or high temperature. “Blasting Agent” means a material designed for blasting. It must be so insensitive that there is a very little probability of: 1) accidental explosion, or 2) going from burning to detonation.

Flammable liquid – Any liquid having a flashpoint below 100 degrees F (37.8 degrees C), except any mixture having components with flashpoints of 100 degrees F (37.8 degrees C) or higher, the total of which makes up 99 percent or more of the total volume of the mixture.

Flammable gas – A gas that can burn with the evolution of heat and a flame. Flammable compressed gas is any compressed gas of which: 1) a mixture of 13 percent or less (by volume) with air is flammable, or 2) the flammable range with air is under 12 percent.

Flammable solid – A solid, other than a blasting agent, or explosive, that is liable to cause fire through friction, absorption or moisture, spontaneous chemical change, or retained heat from manufacturing or processing, or which can be ignited readily and when ignited burns so vigorously and persistently as to create a serious hazard.

Flammable solid (dangerous when wet) – Water Reactive Material (Solid) – Any solid substance (including sludges and pastes) which react with water by igniting or giving off dangerous quantities of flammable or toxic gases. (Sec. 171.8)

Irritating material – liquid and solid – A liquid or solid substance which, upon contact with fire or air, gives off dangerous or intensely irritating fumes.

Non-flammable gas – Any compressed gas other than a flammable compressed gas.

Organic peroxide – An organic compound that contains the bivalent -0-0 structure and which may be considered to be a structural derivative of hydrogen peroxide where one or both of the hydrogen atoms has been replaced by an organic radical.

Oxidizer – A chemical that initiates or promotes combustion in other materials, thereby causing fire either of itself or through the release of oxygen or other gases. Example being: chlorate, permanganate, inorganic peroxide, or a nitrate, that yields oxygen readily.

Poison gas – Less dangerous poisons, toxic substances, liquid or solids (including pastes and semi-solids) so toxic to man that they are a hazard to health during transportation.

Poison gas – Extremely dangerous poisons, highly toxic poisonous gases or liquids – a very small amount of the gas, or vapor of the liquid, mixed with air is dangerous to life.

Radioactive material (yellow 111 label) – Any material, or combination of materials, that spontaneously gives off ionizing radiation.

Spontaneously combustible material – (Solid) A solid substance (including sludges and pastes) which may undergo spontaneous heating or self-burning under normal transportation conditions. These materials may increase in temperature and ignite when exposed to air.