APPENDIX 5

REGISTER OF CHEMICALS HAZARDOUS TO HEALTH

SECTION A : COMPANY INFORMATION

Name : Dosh Registration No.:

(Refer to Appendix 4 for Code of Sector and Appendix 5 for Class of Industry)

Address : Code of Sector :

City : Postcode: Class of Industry :

State : Company Activity (Please enter (/) in the appropriate box) :

Telephone No.: Manufacture : /

Distributor :
e-mail : Formulator :
Importer :
End-User :
SECTION B : LIST OF CHEMICALS HAZARDOUS CHEMICAL TO HEALTH

Location : No. of Hazardous Chemical: No. of Workers:

Process Operation: Male:

Female:

Comply with Classification, Name, Address of Suplier and Contact Number (Tel. No/e-mail)
Physical No. of Type of Control Usage Of Chemical CAS No. Name of Packaging and Labelling
Product Name of
Form of Worker Active Regulation, 1977
Name Chemical
Chemical Exposed Engineering Type# Quantity# Ingredients CSDS Class Label
PPE
Control (Y/N) (Y/N)
SECTION C: NAME OF PERSON WHO PREPARED OF REVIEWED
PREPARED BY : REVIEWED BY:

Name: Name:

Title: Title:

Date: Date:
(Signature) (Signature)