Public Employees' Chemical Right To Know Act Page 20
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31APPENDIX A TO SAFETY CODE NO. 12
ARKANSAS WORKPLACE CHEMICAL LIST
NAME
OF
EMPLOYER:_______________________________________________________
_
CONTACT
PERSON:______________________________________PHONE:_____________
__
WORKPLACE
LOCATION:_____________________________________________________
MAILING
ADDRESS:________________________________________________________
__
CITY
AND
ZIP
CODE:_________________________________________________________
List below each hazardous chemical used, generated, or stored in the workplace
in an amount equal to or greater than fifty-five (55) gallons or five hundred (500)
pounds. Fill in the appropriate information in each of the listed columns. If you
have any questions contact the Arkansas Department of Labor at 501-682-4521
or 501-682-9091.
________________________________________________________________
_______________
Chemical Name or Common CAS Number
Location of the
Amount
Name Used on the MSDS
(if on the
Chemical in the
Present
or the Container Label
MSDS)
Workplace
________________________________________________________________
________________
1.
___________________________________________________________
_____________
2.
___________________________________________________________
_____________
3.
___________________________________________________________
_____________
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