The Vancouver Fire Department

HAZARDOUS MATERIALS MAXIMUM QUANTITY DECLARATION

Instructions:

  1. If downloaded as a Word Document, add rows as needed and delete rows that are not applicable. If downloaded as an Adobe Acrobat document – print entire form.
  2. This form should be filled outcompletely by the business owner or a designee authorized to sign on behalf of the owner and should include a scale diagram.
  3. Where a commodity listed is a combination of ingredients, list only the product name, CAS, hazard ratings and quantity information for the single commodity. If the CAS and hazard ratings are not available then under the product name and quantity information then as a subset, list the chemical names, concentrations,CAS and hazard ratings for each ingredientbelow the product name.
  4. The unit section should indicate gallons or pounds as applicable.
  5. Use a separate form for each control area and a separate form for the building’s total amounts. Include a diagram indicating the location of the control areas if applicable.
  6. In the Hazard Ranking section Health, Fire, Reactivity are to be listed along with blank section which indicates other hazards (i.e. Water reactive, OXidizer, CORRosive, etc)
  7. Exempt amounts are from the IFC and include amounts allowed by applicable footnotes (i.e. double for fire sprinklers, etc). The aggregate amount for storage, use open and use closed cannot exceed the amount listed for storage unless it is in an “H” occupancy. If an “H” occupancy, indicate H-1, H-2 or H-3 as it applies.
  8. Reported quantities reflect the maximum potential (high season, all containers full).
  9. The storage column reflects only commodities stored and not in use.
  10. The notes section should explain storage information (i.e. 750 gallon combustible totes stacked 1 high; etc.)
  11. Check all that apply:

This company utilizes ____ (#) control area(s), as defined by the IBC, in this building.

Approved chemical storage cabinets are utilized where indicated.

This area is protected by an automatic wet/dry (circle one) automatic fire sprinkler system. The sprinkler system design area is ______GPM over ______square feet. Sprinkler heads have a K factor of ______and a temperature rating of _____ degrees F.

A scale diagram showing control area locations and storage configuration is attached.

This company will not store hazardous materials in any amount. (If checked then onlypage 1 is required to be submitted)

  1. Our Fire Department hazardous material liaison contact information is:

______

This form is true and accurate as of ______(date).The Vancouver Fire Marshal’s Office will be contacted for review and approval of future proposed increases in quantities and/or to proposed storage of hazardous materials not listed in this document prior to any actual changes.

Signature: X______Date: ______

Printed name: ______, Title: ______

E-mail: ______, Telephone: ______, Fax: ______

Company name: ______

Location address: ______

City permit number(s) if applicable (PRJ, ENG, COM) ______

This listof quantities pertains to control areaidentified as:

______

______

Hazard / CAS Number / Hazard Ranking / Indoor / Outdoor
Concentration / Storage / Use / Unit / Storage / Use / Unit
H / F / R / Open / Closed / Open / Closed
PHYSICAL HAZARDS
Blasting agents
TOTAL
Total Exempt Amount Allowed
Carcinogens, irritants, sensitizers, other health hazards ( These are not specifically regulated by the Fire Code but potentially important firefighter safety information)
TOTAL
Total Exempt Amount Allowed
Combustible fibers – baled
TOTAL
Total Exempt Amount Allowed
Combustible fibers - loose
TOTAL
Total Exempt Amount Allowed

Notes: ______

______

______

______

Hazard / CAS Number / Hazard Ranking / Indoor / Outdoor
Concentration / Storage / Use / Unit / Storage / Use / Unit
H / F / R / Open / Closed / Open / Closed
Combustible liquids, class II
TOTAL
Total Exempt Amount Allowed
Combustible liquids, class III-A
TOTAL
Total Exempt Amount Allowed
Combustible liquids, class III-B
TOTAL
Total Exempt Amount Allowed
Compressed gasses (physical hazard)
TOTAL
Total Exempt Amount Allowed

Notes: ______

______

______

______

______

Hazard / CAS Number / Hazard Ranking / Indoor / Outdoor
Concentration / Storage / Use / Unit / Storage / Use / Unit
H / F / R / Open / Closed / Open / Closed
Corrosives liquids/solids (circle one)
TOTAL
Total Exempt Amount Allowed
Cryogenic Fluids (flammable)
TOTAL
Total Exempt Amount Allowed
Cryogenic Fluids (oxidizing) (includes LOX)
TOTAL
Total Exempt Amount Allowed
Explosives (indicate division) or Fireworks (indicate division)
TOTAL
Total Exempt Amount Allowed

Notes: ______

______

______

______

______

Hazard / CAS Number / Hazard Ranking / Indoor / Outdoor
Concentration / Storage / Use / Unit / Storage / Use / Unit
H / F / R / Open / Closed / Open / Closed
Flammable Gases (gaseous)
TOTAL
Total Exempt Amount Allowed
Flammable Gases (liquefied)
TOTAL
Total Exempt Amount Allowed
Flammable Liquid, class I-A
TOTAL
Total Exempt Amount Allowed
Flammable Liquid, class I-B
TOTAL
Total Exempt Amount Allowed

Notes: ______

______

______

______

______

Hazard / CAS Number / Hazard Ranking / Indoor / Outdoor
Concentration / Storage / Use / Unit / Storage / Use / Unit
H / F / R / Open / Closed / Open / Closed
Flammable Liquid, class I-C
TOTAL
Total Exempt Amount Allowed
Flammable Solids
TOTAL
Total Exempt Amount Allowed
Gunpowder
TOTAL
Total Exempt Amount Allowed
Highly toxic, gases
TOTAL
Total Exempt Amount Allowed

Notes: ______

______

______

______

______

Hazard / CAS Number / Hazard Ranking / Indoor / Outdoor
Concentration / Storage / Use / Unit / Storage / Use / Unit
H / F / R / Open / Closed / Open / Closed
Highly toxic, liquids
TOTAL
Total Exempt Amount Allowed
Highly toxic, solids
TOTAL
Total Exempt Amount Allowed
Organic Peroxides, class I
TOTAL
Total Exempt Amount Allowed
Organic Peroxides, class II
TOTAL
Total Exempt Amount Allowed

Notes: ______

______

______

______

______

Hazard / CAS Number / Hazard Ranking / Indoor / Outdoor
Concentration / Storage / Use / Unit / Storage / Use / Unit
H / F / R / Open / Closed / Open / Closed
Organic Peroxides, class III
TOTAL
Total Exempt Amount Allowed
Organic Peroxides, class IV
TOTAL
Total Exempt Amount Allowed
Organic Peroxides, class V
TOTAL
Total Exempt Amount Allowed
Organic Peroxide, Unclassified Detonatable
TOTAL
Total Exempt Amount Allowed

Notes: ______

______

______

______

______

Hazard / CAS Number / Hazard Ranking / Indoor / Outdoor
Concentration / Storage / Use / Unit / Storage / Use / Unit
H / F / R / Open / Closed / Open / Closed
Oxidizer Class 4 - gaseous/liquefied – (circle one)
TOTAL
Total Exempt Amount Allowed
Oxidizer Class 3 - gaseous/liquefied – (circle one)
TOTAL
Total Exempt Amount Allowed
Oxidizer Class 2 - gaseous/liquefied – (circle one)
TOTAL
Total Exempt Amount Allowed
Oxidizer Class 1 - gaseous/liquefied – (circle one)
TOTAL
Total Exempt Amount Allowed

Notes: ______

______

______

______

______

Hazard / CAS Number / Hazard Ranking / Indoor / Outdoor
Concentration / Storage / Use / Unit / Storage / Use / Unit
H / F / R / Open / Closed / Open / Closed
Pyrophoric
TOTAL
Total Exempt Amount Allowed
Toxics
TOTAL
Total Exempt Amount Allowed
Unstable (reactive), class 1
TOTAL
Total Exempt Amount Allowed
Unstable (reactive), class 2
TOTAL
Total Exempt Amount Allowed

Notes: ______

______

______

______

______

Hazard / CAS Number / Hazard Ranking / Indoor / Outdoor
Concentration / Storage / Use / Unit / Storage / Use / Unit
H / F / R / Open / Closed / Open / Closed
Unstable (reactive), class 3
TOTAL
Total Exempt Amount Allowed
Unstable (reactive), class 4
TOTAL
Total Exempt Amount Allowed
Water Reactive, class 3
TOTAL
Total Exempt Amount Allowed
Water Reactive, class 2
TOTAL
Total Exempt Amount Allowed

Notes: ______

______

______

______

______

Hazard / CAS Number / Hazard Ranking / Indoor / Outdoor
Concentration / Storage / Use / Unit / Storage / Use / Unit
H / F / R / Open / Closed / Open / Closed
Water Reactive, class 1
TOTAL
Total Exempt Amount Allowed

Notes: ______

______

______

______

______

Omit unused pages and send this form to the City of Vancouver’s Fire Code Plans Examiner at Community and Economic Development.

If convenient you may send it electronically via an Adobe Acrobat email attachment.

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