CONTINGENCY PLAN CHECK LIST
Retain this form with your CIL and MSDS/s
| Department: | |
| Building: | Room: |
| Location
of Chemical Inventory List (CIL) & Contingency Plan:
|
|
| Location
of Material Safety Data Sheets (MSDS/s): |
|
Contact List (Dept. Head, Safety Officer, and Alternate)
| Department
Head Name: |
Office Phone | Home Phone |
| Safety
Officer Name: |
Office Phone | Home Phone |
| Alternate
Safety Officer Name: |
Office Phone | Home Phone |
Evacuation Information:
| Evacuation
Route:
|
| Alternate
Route (in case primary route is blocked):
|
Evacuation Personnel List
| Evacuation
Coordinator (or Bldg. Mgr.) Name: |
Office Phone | Home Phone |
| Alternate
Evacuation Coordinator Name: |
Office Phone | Home Phone |
| Person
who alerts the Bldg. Mgr. Name: |
Office Phone | Home Phone |
| Alternate
Evacuation Informant: Name: |
Office Phone | Home Phone |
Locations of Emergency Equipment:
| Nearest Pull-Box Fire Alarm: |
| Nearest Fire Extinguisher: |
| Nearest Fire Hydrant/Water Source: |
| Nearest Storm Drain or Water Run-off Point: |
| Are
absorbent materials available in the area to stop a spill from spreading? (Yes) (No) |
Please submit a copy of
your completed form to:
Environmental Health & Safety
Department
120 Physical Plant Services Bldg.