Attachment 6: HazMaterialAuthorization

LC-035
Document No.: SEMS-F010,
Revision: 6
Document Date: 03/31/2023

Attachment 6

Hazardous Material Authorization
Form
Name of the
Requestor/Contractor:

Section I. Requestor Information

Organization/Dept:

Date:

Section II. Project Information

Project Name:

Project Location:

Section III. Material Information

Material/Product Name:

Quantity to be purchased:

Usage Frequency:

Unit of Issue (Drums, Gal, bottles):

Duration of Task:

Section IV. Process Information

Describe:
1) Work activities and processes in which this material will be used; 2) Storage method/location; 3) Re-use/Recycling method/process; 4) Disposal of hazardous waste materials; 5) Attach Safety Data Sheet (SDS); 6) SDS Issue/Revision Date.

(Additional information may be attached to this form.)

Section V. Sustainability/ Pollution Prevention

List non-hazardous or less hazardous alternatives:

(Complete Hazardous Material Alternative Waiver (Hazardous Material Authorization Form page 2) if non-hazardous or less hazardous material are not available or not viable due to price, schedule, or performance.) Print Requestor’s Supervisor
Name:

Section VI. Supervisor Concurrence

Telephone #:

Date of Concurrence:

Signature:

Section VII. Authorization
Hazardous Material Approval:
___
■
YES
Approved with conditions (if applicable):
Print Name of Hazardous
Material Authorized Designee:

Date of Authorization:

Health and Safety Approval:
___
■ YES
Approved with conditions (if applicable):
Print Name of Health & Safety
Authorized Designee:

Date of Authorization:

___

NO
Reason for disapproval:
Signature:

___

NO
Reason for disapproval:
Signature:

LC-035
Document No.: SEMS-F010,
Revision: 6
Document Date: 08/10/2021

Attachment 6

Hazardous Material Authorization
Information

1.

Definitions
1. Hazardous Materials: A hazardous material is any substance or chemical which poses a risk or has the potential to cause health or physical harm to humans, animals, or the environment, in the course of normal handling, use, storage, spilling, leaking, pumping, pouring, emitting, emptying, discharging, injecting, escaping, leaching, dumping or disposal.

2.

A Hazardous Material Authorization (HMA) is required when: 1. A new Hazardous Material (HM) is purchased for use
2. A change in type/use of HM is required to meet mission needs 3. Additional quantities of HM are needed
4. A contract action allowing a contractor to use or store a HM on-site

3.

Individuals Required to Obtain an HMA