Copy of 2016 APPLICATION FOR CLEANOUT ASSISTANCE.xlsx

8/19/2019 Copy of 2016 APPLICATION FOR CLEANOUT ASSISTANCE.xlsx

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PADEP 2016 School Cleanout Application

School Identification School District Details

School Name: District:

Contact Person: Title: Phone:

Street: City:

Municipality: County: City:

State: Zip Code: State:

Phone No.: Lat/Long: Zip Code:

Fa No.: !mail: County:

Emergency Contacts

Name: Name:

Street: Title:City: State: Phone: "# $r. Phone:

Zip Code: Phone: Name:

%ttention: Title:

Title: Phone: "# $r. Phone:

Optional Attachments

Site Floor Plan

Date of Application (mm-dd-yyyy) :

Mailing %ddress:

ailing Address (if different from School Address)

School !ype (please check all that apply)

Student Population (please check appropriate box)

School Curriculum Information (please check all that apply):

School "acility Information (please check all that apply)

Certi&ication: ' certi&y under penalty o& la( that ' ha)e personally eamined and am &amiliar (ith the in&ormation su*mitted+ and that*ased on my in,uiry o& those indi)iduals responsi*le &or o*taining the in&ormation+ ' *elie)e that the su*mitted in&ormation is true+accurate+ and complete.

High Schooloca ona ec n ca

HSPublic Private

1 - 500 501 - 1,000 , -1 500

, -2 000

, -3 000

, -4 000

, -5 000

5,0

Chei!tr" #iolog" Ph"!ic! Photogra$h" %uto &e$airar$en

rn u! r a e aSho

Paintingart /P "!icaScience

%nato" Ph !iolo

Co!etolog" Culinar" %rt!Con!truction Tra(e!

c enacilitie!

roun(!/an(!ca$inga n enance

e artentecure e ca orage

&ooe c e a ng ne

)aintenance

Parochial Charter

leentar" School )i((le School


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Name and o&&icial title o& authori-ed representati)e

Current ChemicalManagement Plan

!lectronic Signature (optional)

P% Dept. o& La*or 'ndustry $a-ardousSu*stance Sur)eyForm $SSF0


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1+

*%rt


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#uestions $egarding %our Schools Current anagementPractices& Policies and Procedures

#uestions %es'(o

Purchasing

Storage

%re stored chemicals 1ept loc1ed2

%re chemicals accessi*le only to ,uali&ied handlers2

ProgramComponent

Does the school ha)e a purchasing policy or an appro)ed

chemical list2Does one person or a department ma1e all chemicalpurchases2 '& so+ please identi&y the person and/ordepartment.

%re chemicals purchased &or epected use (ithin the calendaror &iscal year2

Does the school ha)e a 3green3 or 3micro4scale3 chemistrycurriculum2

$a)e toic chemicals *een replaced (ith less toicalternati)es2

Does the school ha)e a policy or set o& procedures &or storingchemicals a Chemical Management Plan02

Does the school ha)e one central chemical storage location2'& so+ (here is it located e.g.+ identi&y *y *uilding+ &loor+ (ing+room num*er02

's there a sta&& mem*er assigned to manage e)ery chemicalstorage area2 '& so+ please identi&y that person.

%re chemicals properly stored2 proper storage container+storage area is ade,uately )entilated+ secured+ in a closea*leca*inet+ sturdy shel)ing0

%re all chemicals la*eled+ including name+ purchase/epirationdates+ and storage in&ormation date recei)ed+ date opened02

Do all chemicals ha)e up4to4date Material Sa&ety Data Sheets

MSDS02 '& so+ please identi&y (here the MSDS are stored.


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#uestions %es'(oProgram

Component

Does the school annually su*mit a $a-ardous Su*stance

Sur)ey Form $SSF0 to the Pennsyl)ania Department o&La*or and 'ndustry2 '& so+ please pro)ide a copy o& theschool5s most recent $SSF (ith your application pac1age.


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#uestions %es'(oProgram

Component

'n)entory

6se %re incoming chemicals added to a comprehensi)e list2

Disposal

7e&erence

%re chemicals stored according to type and group instead o&

alpha*etically02 %re chemical groups and types stored an appropriate distancea(ay &rom incompati*le groups and types2

's there a policy or set o& procedures &or identi&ying out o& datechemicals2

's there a comprehensi)e list o& chemicals stored on4site &or alldepartments2

%re chemicals remo)ed &rom the comprehensi)e list (henthey are consumed2

Does my school ha)e a plan &or responding to chemicalemergencies e.g.+ a Chemical $ygiene Plan02

%re students and sta&& ade,uately trained to handle thechemicals they interact (ith2

Do areas (here chemicals are used or handled ha)e up todate sa&ety guides and &unctioning sa&ety e,uipment2

%re ha-ardous/toic (astes disposed o& according to&ederal/state guidelines not disposed o& do(n the drain02

%re used+ outdated+ or surplus chemicals disposed o& (ithin areasona*le time&rame not 3stoc1piled3 in storage rooms02

Does the school retain a (aste remo)al specialist to handleha-ardous/toic chemicals+ a&ter use+ and/or outdatedchemicals2 '& yes+ please identi&y the specialist.

The a*o)e ,uestions ha)e *een deri)ed &rom 8or1sheet 949: Evaluating Your Schools !%SE$A (&'') *uilding Successful $rograms to Address !hemical +isks in Schools: A

Environmental $rotection Agency (%SE$A) E$A012'030'0'' Available at: http:00ep


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Description of Conditions


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emical "anagement Situation# $olicies# and $rocedures of the:orkbook ith .emplates# .ips# and .echni/ues %nited States

agov0sc2


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Chemical In)entory *+no,n-

Chemical (ame

( u m . e r o f C o n t a i n

e r s

C o n t a i n e r S i / e

S D S A ) a i l a . l e * % e s

o r ( o -

$ i s 0 1 e ) e l

2 e a l t h 2 a / a r d $ a t i n g

" l a m m a . i l i t y 2 a / a r d $ a t i n g

$ e a c t i ) i t y $ a t i n g

S p e c i a l 2 a / a r d $ a t i n g

a/ards

5 1 lb gla!! goo( Che ab Sur$lu! e! 3 3 0 0 none

Currentocation

Container!ype

e.g.+ plastic+glass0

Condition of

Container e.g.+ corroded+has crystals

around the cap+*ulging+

degraded top0

Chemical 3ses4e.g.+ chemistryla*+ art room+

schoolmaintenance0

(eeded orin Surplus#uantities

CAS(um.er

&oo 253Cabinet )*EXAMPLE

#ariuchlori(egranular

1032-2-6


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Chemical In)entory *3nno,n-

De&initions: ;C < degrees Celsius mm $g < millimeters o& mercury. Note: %dditional ro(s can *e added as needed on the File menu: select 3'nsert3 then 37o(s

Chemical Container Information

( u m . e r o f C o n t a i n e r s


Density

4 4 5 60A 5i/uid "ilky hite li/uid 60A 60A 60A 60A

Currentocation

E5pirationDate

i& 1no(n0

Physical'Chemical Characteristics(7oes the label provide any information pertaining to the unidentified substances physic

characteristics8)

Container!ype

plastic+glass+ metal0

Condition ofContainer

corroded+ hascrystals around

the cap+ *ulging+degraded top0

PhysicalState

solid+ li,uid+gas0

Appearancecolor+ )iscosity+

phase separation0

oiling Point oC0

7aporPressuremm $g0

Solu.ilityin 8ater

7oom =9"

E9A"$5E 0

$lastic bottle !orroded#

crystals aroundthe cap


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De&initions: ;C < degrees Celsius mm $g < millimeters o& mercury. Note: %dditional ro(s can *e added as needed on the File menu: select 3'nsert3 then 37o(s3

Chemical Container Information

( u m . e r o f C o n t a i n e r s


Density

Currentocation

E5pirationDate

i& 1no(n0

Physical'Chemical Characteristics(7oes the label provide any information pertaining to the unidentified substances physica

characteristics8)

Container!ype

plastic+glass+ metal0

Condition ofContainer

corroded+ hascrystals around

the cap+ *ulging+degraded top0

PhysicalState

solid+ li,uid+gas0

Appearancecolor+ )iscosity+

phase separation0

oiling Point oC0

7aporPressuremm $g0

Solu.ilityin 8ater


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De&initions: ;C < degrees Celsius mm $g < millimeters o& mercury. Note: %dditional ro(s can *e added as needed on the File menu: select 3'nsert3 then 37o(s3.

60A

l0chemical

eltingPoint


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De&initions: ;C < degrees Celsius mm $g < millimeters o& mercury. Note: %dditional ro(s can *e added as needed on the File menu: select 3'nsert3 then 37o(s3.

l0chemical

eltingPoint

Copy of 2016 APPLICATION FOR CLEANOUT ASSISTANCE.xlsx

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