Title Page
-
Site
-
Conducted on
-
Prepared by
-
Location
HAZMAT Checklist
Shipping Description (§172.202)
Basic Description (proper sequence §172.202(b))
-
Identification Number (HMT Column 4)
-
Proper Shipping Name (HMT Column 2)
-
Hazard Class (HMT Column 3)
-
Packing Group (HMT Column 5)
Other Information (§172.202)
-
Technical name (“G” in HMT Column 1). See HMR §172.203(k) for specific requirements.
-
Subsidiary hazard(s) (HMT Column 6)
-
Number and type of packages (i.e., “12 drums” or “12 1A1 drums”)
-
Total quantity (by mass or volume, i.e., “200 kgs” or “50 L”)
-
“Net Explosive Mass” for Class 1. See HMR §172.202(a)(5)(i) for specific requirements.
-
“EX-xxxx” for Class 1 materials when not marked on the package.
-
See HMR §172.320(d) for specific requirements.
Additional Descriptions – as applicable (§172.203)
-
“DOT-SPxxxxx” or “DOT-Exxxxx” Special Permit or Exemption number
-
“Ltd Qty” or “Limited Quantity”
-
“RQ” for Reportable Quantity. See Appendix A of the HMT for specific requirements.
-
“RESIDUE: LAST CONTAINED***” (Required for tank car with residue)
-
“Marine Pollutant” (for non-bulk by vessel and bulk in all modes). See Appendix B of the HMT for specific requirements.
-
“Poison-Inhalation Hazard” or “Toxic-Inhalation Hazard“ and applicable Zone, e.g., “Zone A”, “Zone B”, etc., (HMT Column 7 and §172.102)
-
“HOT” for liquid elevated temperature materials, when molten or elevated temperature is not part of proper shipping name. See HMR §172.203(n) for specific requirements.
-
“Organic Peroxides” See HMR §172.203(o) for specific requirements.
-
“Waste” See HMR §171.101(c)(9) for specific requirements.
-
“Radioactive Material” See HMR §172.203(d) for specific requirements.
-
Mode Requirements - Additional information may be required depending on specific mode(s) of transport. See HMR §172.203 for specific requirements.
Emergency Response Telephone Number (§172.201(d), §172.604)
-
“EMERGENCY CONTACT: xxx-xxx-xxxx” (include international access code if applicable).
Shipper’s Certification (§172.204)
-
Signed statement: “This is to certify that the above-mentioned materials...” See HMR §172.204 for specific certification statements.
Completion
-
Comments
-
Conducted by: Name and Signature
