CHEMICAL APPROVAL FORM

Chemical Name: POLINTEK LINING & PROTECTION

__________________________ Approval Number: __________________________

Date of Approval: _________________________ MAINTENANCE EXECUTION (MECH)

User: ____________________________________

YOSEP SASADA
Requestor: ______________________________ ABDUL RAHMAN
Chemical Assessor: ________________________

Date of Request: 30 AUGUST 2021

_________________________ Date of Assessment: _______________________

NAP, ANP, and OBL

Location / Area of Use: ___________________________________________________________________

As a sealing chemical for leak in the valves, pipe, and connections

Purpose of Use: ________________________________________________________________________

N/A (will not be stored)

Storage Location: _______________________________________________________________________

Hazard & Risk Information:

Please describe all hazards and risks associated with the chemical

Clear to dark, t
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Risk Control Information:

Please describe all required controls to be implemented when using this chemical

Elimination or Substitution Controls:

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Engineering Controls:

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Administrative Controls:

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Required Mandatory PPE:

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Potential Process Safety Hazards:

(i.e. potential compatibility issues between substance and anything in the process)

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Process Safety Risk Controls:

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Training Requirement

Training Required? YES / NO Date of Training Conducted: ________________________

Special Procedures Required? YES / NO Is Procedure Available? YES / NO

Compatibility Testing Required? YES / NO

For chemicals with potential to be in direct contact with AN, compatibility with AN test is required

Management of Change Required? YES / NO

Approval Signatures:

Chemical Assessor: __________________________________________ Date: ______________

Site Hygiene Officer: __________________________________________ Date: ______________

Technical Manager: __________________________________________ Date: ______________

SHES Manager: __________________________________________ Date: ______________