Appendix F - Notification Forms

Notification of the Usage of

Acutely Toxic, Carcinogenic, or Reproductive Hazards


Please complete this form and return it to the Environmental Health Office.


Lab Supervisor/Lead Instructor:








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



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.






Gary Lee
Director, Environmental Health

San Juan College
4601 College Blvd.
Farmington, NM  87401
(505) 566-3063