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CODE OF SECTOR
CODE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
TYPE OF SECTOR
MANUFACTURING
MINING AND QUARRYING
CONSTRUCTION
AGRICULTURE
FORESTRY
FISHERY
LOGGING
ELECTRICITY UTILITY
GAS UTILITY
WATER UTILITY
SANITARY UTILITY
TRANSPORT
STORAGE
COMMUNICATION
WHOLESALE
RETAIL TRADES
HOTELS
RESTAURANTS
FINANCE
INSURANCE
REAL ESTATE
BUSINESS SURVICES
PUBLIC SURVICES
STATUTORY AUTHORITIES
APPENDIX 3
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APPENDIX 4
REGISTER OF CHEMICALS HAZARDOUS TO HEALTH
SECTION A : COMPANY INFORMATION
Name
: S Y A R I K A T
R K S
S D N
DOSH Registration No. : S L K
B H D
4 1 0 8
(Refer to Appendix 4 for Code of Sector and Appendix 5 for Class of Industry)
Address : 3 3
L I G H T
City
: S E T A P A K
State
: W
Telephone No.
Email
I N D U S T R I A L
Postcode : 5 3 2 0 0
P E R S E K U T U A N
:
0 3
A R E A
4 2 2 6 0 2 6
: S S S S S @ P O . J A R I N G . M Y
Code of Sector :
0 1
Class of Industry :
3 5 2 9 0
Company Activity (Please enter ( / ) in the appropriate box :
Manufacturer
Distributor
Formulator
Importer
End-User
:
:
:
:
/
SECTION B : LIST OF CHEMICALS HAZARDOUS CHEMICAL TO HEALTH
Location :
F I
N I
Process Operation :
S H E D
F
I
L L
No. of Hazardous Chemical :
P R O D U C T
I N G
Usage Of
Chemical
Type of Control Measures
Name of
Chemical
Product Name
Physical Form
of Chemical
No. of Worker
Exposed
CAS No.
Engineering
Control
Unleaded
Gasoline Premium grade
Not applicable
SAP 9436
Not applicable
No. of Workers :
3
L
PVC Glove
3
L
PPE
2
Respirator
Comply with
Classification,
Name of Active Packaging and Labelling
Regulation, 1977
Ingredients
CSDS
(Y/N)
Class
Label
(Y/N)
Gasoline
Y
Y
Y
Benzene
Y
Y
Y
xylene
Y
Y
Y
Type # Quantity##
P
P
250
m3/mth
3500
m3/mth
86290-81571-43-2
1330-20-7
Male :
4
Female :
3
Name, Address of Supplier
and Contact Number (Tel.
No/email)
XYZ Malaysia Sdn Bhd, 27 Jln
Ipoh, K. Lumpur
Tel. No. 03-2907170
AAA Malaysia Sdn Bhd, Lot 21
Senawang Industrial Estate, N.
Sembilan
Tel. No. 06-4056673
SECTION C : NAME OF PERSON WHO PREPARED OF REVIEWED
PREPARED BY :
REVIEWED BY :
Name :
A L
Title :
S U P E R V
I
Date :
2
0
5
I
0
A H M A D
4
2
0
Name :
L
S O R
Title :
P R O D
0
Date :
2
(Signature)
I
5
M
0
M O
5
I
L
E N G
M A N A G E R
2
0
0
0
(Signature)
APPENDIX 5
REGISTER OF CHEMICALS HAZARDOUS TO HEALTH
SECTION A : COMPANY INFORMATION
Name
DOSH Registration No. :
:
(Refer to Appendix 4 for Code of Sector and Appendix 5 for Class of Industry)
Address :
Code of Sector :
City
:
State
:
Telephone No.
Email
:
Postcode :
Class of Industry :
Company Activity (Please enter ( / ) in the appropriate box :
:
Manufacturer
Distributor
Formulator
Importer
End-User
:
:
:
:
SECTION B : LIST OF CHEMICALS HAZARDOUS CHEMICAL TO HEALTH
Location :
No. of Workers :
No. of Hazardous Chemical :
Female :
Process Operation :
Type of Control Measures
Product Name
Name of
Chemical
Male :
Physical Form
of Chemical
No. of Worker
Exposed
Usage Of
Chemical
CAS No.
Engineering
Control
PPE
Type # Quantity##
Comply with
Classification,
Name of Active Packaging and Labelling
Regulation, 1977
Ingredients
CSDS
(Y/N)
Class
Name, Address of Supplier
and Contact Number (Tel.
No/email)
Label
(Y/N)
SECTION C : NAME OF PERSON WHO PREPARED OF REVIEWED
PREPARED BY :
REVIEWED BY :
Name :
Name :
Title :
Title :
Date :
Date :
(Signature)
(Signature)
SECTION B : LIST OF CHEMICALS HAZARDOUS CHEMICAL TO HEALTH
Location :
No. of Workers :
No. of Hazardous Chemical :
Process Operation :
Female :
Type of Control Measures
Product Name
Name of
Chemical
Male :
Physical Form
of Chemical
No. of Worker
Exposed
Usage Of
Chemical
CAS No.
Engineering
Control
PPE
Type # Quantity##
Comply with
Classification,
Name of Active Packaging and Labelling
Regulation, 1977
Ingredients
CSDS
(Y/N)
Class
Label
(Y/N)
Name, Address of Supplier
and Contact Number (Tel.
No/email)
Type of Control Measures
Product Name
Name of
Chemical
Physical Form
of Chemical
No. of Worker
Exposed
Usage Of
Chemical
CAS No.
Engineering
Control
PPE
Type # Quantity##
Comply with
Classification,
Name of Active Packaging and Labelling
Regulation, 1977
Ingredients
CSDS
(Y/N)
Class
Name, Address of Supplier
and Contact Number (Tel.
No/email)
Label
(Y/N)
SECTION C : NAME OF PERSON WHO PREPARED OF REVIEWED
PREPARED BY :
REVIEWED BY :
Name :
Name :
Title :
Title :
Date :
Date :
(Signature)
(Signature)