CONTRACTOR NAME:
Manufacture Name:
Trade Name / Product Code:
POC Name / Phone Number:
HMRB SUBMITTAL FORM for CONTRACTORS
MSDS No:

Site(s): Marietta

Type of Use:Facilities Contractor Use Only

1 / Material description *

(Note: See Page 2 for complete pick-list)

2 / Aerosol?* Yes No / 3 / Radioactive?* Yes No / 4 / Contains nano material? Yes No
5 / Maximum quantity used per day: / 6 / UOM: / ______OuncesFluid ouncesPoundsGallonsLitersGramsKilogramsMillilitersPintsQuartsCubic ftPiece(s) / 7 / Estimated annual usage: / UOM: / ______OuncesFluid OuncesPoundsGallonsLitersGramsKilogramsMillilitersPintsQuartsCubic ftPiece(s)
8 / Multi-component system?* Yes No
Process Information
9 / Process Description* / ______Apply heatBrushCureDipDischarge to sinks/drainsDrinking water treatmentExtrudeFlush cleanHand lay-upMaterial machinedOther-describe belowProcessing tankRollSpraySpray gun cleaningThinningWipeWipe Solvent / 10 / Substrate applied on / ______CompositeMetalOtherPlasticWood
11 / Additional Description (if multi-component system, specify other MSDS(‘s))
12 / Materials thinned?*
Yes No
If Yes: Thinner MSDS / 13 / Mix ratio: / parts material to / parts thinner By / Weight
Volume

For questions concerning use of this form, contact George Loch at 770-494-6407

1. Material Descriptions

Important Notice: A hard copy of this blank form may not be the version currently in effect.

The current version of this form is the version in the LM Intranet. 11247-09102008

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Abrasive Mate

Important Notice: A hard copy of this blank form may not be the version currently in effect.

The current version of this form is the version in the LM Intranet. 11247-09102008

Page 1 of 3

Absorbent Materials

Adhesives (non-aerospace)

Antifreeze

Batteries

Biocide

Bldg/Maint Materials (asphalt/concrete filler, caulk, plaster, etc.)

Catalysts (curing agents, accelerators) (non-aerospace)

Cement/Glue (non-aerospace)

Ceramic Material

Chemicals

Cleaner Material/Degreaser (non-aerospace)

Composites (Ceramic fiber reinforced)

Composites (Glass fiber reinforced)

Composites (Graphite/carbon fiber reinforced)

Composites (Kevlar fiber reinforced)

Coolant/Cutting Fluid

Desiccant

Fabrics/Films/Sheets

Fire fighting agents

Fluxes

Foams (syntactic, packing, etc.)

Fuels

Fungicide/Herbicides

Gases (cylinders or bulk)

Glass Beads/Spheres

Housekeeping Materials

Inks (Silk Screen)/Marking Materials (non-aerospace)/Dyes

Insulation/Insulating Materials

Lubricants/Grease

Metal coating – chemical milling maskants

Metal coating – Clear Coat

Metal coating – Coatings that utilizes air or forced air driers

Metal coating – Extreme performance coating

Metal coating – Low-bake coating

Metal coating – Other coating appls-including high-bake coatings

Metallic Core

Metallic Shims

Metals

Modeling Clay/Molding Compound

Non-metallic Core

Non-metallic Shims

Office Materials

Oils

Packing Materials

Paints (non-aerospace)

Part Marking Materials (non-aerospace)

Personal Use Item (hand cleaners, lotions, soaps)

Pesticide/Insecticide

Polish/Waxes

Potting compounds

Preservative Materials

Refrigerant

Rubber and Rubber like materials

Sealants (non-aerospace)

Solder

Solvents (all other uses)

Stripping Materials

Tapes

Thermoplastic Resins/materials

Thermosetting Resins/gel coat

Welding Wire/Rods

Wiping cloths (no solvent)

Wood and Woodlike materials

Wood coating – Clear sealers

Wood coating – Clear shellac

Wood coating – Clear topcoats

Wood coating – Final repair coats

Wood coating – Opaque ground coats and enamels

Wood coating – Opaque shellac

Wood coating – Semitransparent wiping and glazing stains

Wood coating – Varnish

Wood coating – Wash Coats

Important Notice: A hard copy of this blank form may not be the version currently in effect.

The current version of this form is the version in the LM Intranet. 11247-09102008

Page 1 of 3

6. UOM

10. Substrate Applied on

Important Notice: A hard copy of this blank form may not be the version currently in effect.

The current version of this form is the version in the LM Intranet. 11247-09102008

Page 1 of 3

Ounces Kilograms

Fluid Ounces Milliliters

Pounds Pints

Gallons Quarts

Liters Cubic ft.

Grams Piece(s)

9. Process Description

Apply heat Processing tank

Brush Roll

Cure Spray

Dip Spray gun cleaning

Discharge to sinks/drains Thinning

Drinking water treatment Wipe

Extrude Wipe solvent

Flush clean

Hand lay-up

Material machined

Other-describe below

Composite

Metal

Other

Plastic

Wood

Important Notice: A hard copy of this blank form may not be the version currently in effect.

The current version of this form is the version in the LM Intranet. 11247-09102008

Page 1 of 3

INSTRUCTIONS FOR COMPLETING THE HMRB SUBMITTAL FORM

  1. Material Description*: Select material type from the pick-list. (Note: See page 2 for complete pick-list) If exact material type is not found, select the most similar choice and describe the material further in the “Additional Description” box at the bottom of the form.
  1. Aerosol*: (Yes / No) Is the material in an aerosol can? Select “Yes” or “No”.
  1. Radioactive*: (Yes / No) Is the material radioactive? This information can be found on the MSDS. Note: The form default answer is “No”.
  1. Contains NANO Material: (Yes / No) Does the material contain “NANO” materials? This information may be on the MSDS, technical data sheet or product information page. If you don’t know, leave blank.
  1. Maximum Quantity Used Per Day: On average, how much material will be used for a job/project per day? Enter a number here: 5, 10, 100, etc.
  1. UOM: Select the appropriate unit of measure: Ounces, Fluid ounces, Pounds, Gallons, Liters, Grams, Kilograms, Milliliters, Pints, Quarts, Cubic ft, Piece(s).
  1. Estimated Annual Usage: On average, how much material will be used for one calendar year? Enter a number here: 5, 100, 1000, etc. Select the appropriate UOM.
  1. Multi-Component System*: (Yes / No) Does the material require mixing of multiple components? For example, base and catalyst, paint and thinner, etc.
  1. Process Description: Select process description from the pick-list. (Note: See page 2 for complete pick-list) If “Other” is selected, provide process information in the “Additional Description” box at the bottom of the form.
  1. Substrate Applied on: If applicable, select the type of surface the material will be applied on. (Note: See page 2 for complete list of Substrates)
  1. Additional Description: Explain how/where the material will be used/applied. Identify the component MSDSs (if any) or any other pertinent information.
  1. Material Thinned*: (Yes / No) Is the material thinned with a solvent? If yes, indicate the thinner MSDS if known. If MSDS number not known, describe thinner in the “Additional Description” box.
  1. Mix Ratio: If the material is thinned, indentify the mix ratio of material to thinner. Indicate ratio by “Weight” or “Volume”.

* Indicates required field

Note: Approval is typically granted within 4-5 working days. A notification letter will be issued to the submitter via e-mail upon completion.

Important Notice: A hard copy of this blank form may not be the version currently in effect.

The current version of this blank form is the version in the LM Intranet. 11247-09102008

Page 1 of 3