2013 RIGHT TO KNOW SURVEY UPDATE
CHEMICAL INVENTORY FOR SMALL QUANTITIES
THIS FORM IS ONLY TO BE USED FOR PRODUCTS WITH A SINGLE HAZARDOUS INGREDIENT IN A LABORATORY.
(PHOTOCOPY THIS SHEET IF YOU NEED ADDITIONAL FORMS)
NJEIN
SIC
ENTER CODES
(See Page 2 of Survey for Codes)
9 9 9 9 9 9 3 3 0 0 0
8
2
2
NAICS
1
6
1
1
3
1
0
EMPLOYER NAME
The College of New Jersey
FACILITY NAME
(1)
SUBSTANCE
NUMBER
(2)
(3)
HAZARDOUS CHEMICAL NAME
CAS NUMBER
(4)
DOT
NUMBER
C
O
N
T
A
I
N
E
R
M
I
X
T
U
R
E
I
N
V
E
N
T
O
R
Y
(5)
(6)
(7)
U
N
I
T
NUMBER
OF EMPLOYEES
EXPOSED
OR
POTENTIALLY
EXPOSED
SPECIAL
HEALTH
HAZARD
CODES
LOCATION
(Optional)
(8)
(9)
(10)
(11)
PRODUCT NAME:
*
PRODUCT NAME:
*
PRODUCT NAME:
*
PRODUCT NAME:
*
PRODUCT NAME:
*
PRODUCT NAME:
*
PRODUCT NAME:
*
PRODUCT NAME:
*
OCC-51B
JAN 13
Check  If Ingredient is the same as Product Name
Page _____ of _____
HAZARDOUS CHEMICAL INVENTORY CODES
COLUMN 5
New Codes Added (2006)
COLUMN 6
MIXTURE CODES
COLUMN 8
UNITS OF MEASURE
61
60
59
58
57
56
55
54
53
52
51
C = Cubic feet for gases
P = Pounds for solids
G = Gallons for liquids
CONTAINER CODES
TA
TB
TI
DS
DP
DF
CN
CB
SI
BA
BX
CY
BG
BP
BN
TW
RC
BT
HV
EE
OT
Above ground tank
Below ground tank
Tank inside building
Steel drum
Plastic drum
Fiber drum
Can
Carboy
Silo
Bag
Box
Cylinder
Bottles or jugs (glass)
Bottles or jugs (plastic)
Tote bin
Tank wagon
Railcar
Battery
HVAC
Electrical Equipment
Other (describe)
Unknown
100%
90 to 99%
80 to 89%
70 to 79%
60 to 69%
50 to 59%
25 to 49%
10 to 24%
1 to 9%
0.1 to 0.9%
COLUMN 7
Revised (2005)
INVENTORY RANGE CODES
20
19
18
17
16
15
14
13
12
11
10
09
10 Million or Greater
1,000,000 to 9,999,999
500,000 to 999,999
100,000 to 499,999
25,000 to 99,999
10,000 to 24,999
1,000 to 9,999
500 to 999
100 to 499
10 to 99
1 to 9
Less than 1
COLUMN 9
Enter the estimated number of exposed
or potentially exposed employees.
COLUMN 10
SPECIAL HEALTH HAZARD CODES
(See RTK Hazardous Substance List SHH Column)
CA
MU
TE
CO
F4
F3
R4
R3
R2
Carcinogen
Mutagen
Teratogen
Corrosive
Flammable - Fourth Degree
Flammable - Third Degree
Reactive - Fourth Degree
Reactive - Third Degree
Reactive - Second Degree