San Juan College

Notification of the Usage of

Acutely Toxic, Carcinogenic, or Reproductive Hazards

 

 

Please complete this form and return it to the Office of Health & Safety.

Lab Supervisor/Lead Instructor: 

Room/Building: 

Phone: 

Department/Program: 

Notification: In accordance with the requirements of the Chemical Hygiene Plan, this document serves as notification to Health & Safety of the use of the following class(es) of chemicals:  

 

Used

Not Used

Carcinogens or suspected carcinogens    

 

 

 
Acutely toxic chemicals    

 

 

 
Reproductive hazards    

 

 

 

Statement of compliance  

I have reviewed the requirements of the College’s Chemical Hygiene Plan and the applicable Standard Operating Procedures as they apply to carcinogens, acutely toxic chemicals, and reproductive hazards, and have complied with all applicable requirements, to the best of my knowledge and to the extent feasible.  

Signature:

 Date: