Document LpMw4R92D1aQmgQRqkEEboZ0w

U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH REQUEST FOR HEALTH HAZARD EVALUATION This form is provided to assist in registering a request for a health hazard evaluation with the U.S. Department of Health, Education, and Welfare as provided in Section 20(a)(6) of the Occupational Safety and Health Act of 1970 and 42 CFR Part 85. (See Statement of Authority on Reverse Side). Name of Establishment Where Alleged Hazard(s) Exist Amboy Terminaling Company Company j Street .,..5.6 Q_ St Sts St. ^ Address 1 City Perth Amboy, State ___________ Telephone New Jersey 442-9550 08861 Zip Code pac]cj_ng and 1. Principal Company Activity transportation of bulk chemicals namely.P.V.C. , and. (fnantjf.n timny, construction* tr<in*ooitaiion, services, `tc.) cilliSCi CilGHliCcllS .2 Specify the particular building or worksite where the alleged hazard is located, including address_____ _______ at factory at 560 State St.,Perth Amboy,N.J. 3. Specify the name and phone number of employer's agent!s) in charge. 4. Describe briefly the hazard(s) which exists by completing the following information. PVC,VC Monemers, identification of Hazard or Toxic Snhst.mceis) Bisphenyls, Polystyren,& other organic VC Trade Name (If Applicable) ahnva SUSpensioiffigmjg^ res^-ns- Manufacturer Carbidc^oeS ,*le ma,eria* have a wurning label7____________ YesNo If Yes, attach copy of label or a copy of the information contained on the label, only PVC as of recent Physical Form: Dust (x] Gas CH Liquid [J Other [7] Type of Exposure7 Breathing [X] Swallowing Skin Contact [3 Number cf People Exposed_______ _ . __ ______ Length of Exposure (Hours/Dny) Occupations of Exposed Employees all employees are exposed to handling the products and are known as material handlers. 5. Using the space below describe further the nature of the conditions or circumstances which prompted this re quest and other relevant aspects which you may consider important, such as the nature of the illness or symp toms of exposure, the concern for the potentially toxic effects of a new chemical substance introduced mto the workplace, etc. It appears that there have been at least four known cases of ------------cancer and probably many-more which are not known - a s~of - this-- timfi_..and_it_is__ important_for _the .employee .who _are no longer there.to know what their physical condition may be doing due to ------------ thirs 'exposure as weld.-as~for~those~who- are 'still--working-to know what hazard exists for them by virtue of this exposure. NIOSH-4 (Cinl 9/72 FORM APPROVtO OMB NO. 68-R1236 UCC 090276 =-t:----- = j # '* - r. * - G. (<)> To your knowlorirjp lids Hus hazard bomi coiiudi-red previously by any Government agency? (b) If so, give the name and address of each. (c) and, the approximate date it was so considered. _______ . . - - _______________ 7. (a) Is this request, or a request aliening a similar hazard, being filed with any other Government agency? __________ (b> If so, give the name and address of each. The undersigned (check one) [71 Employer [^] Authorized Representative of ''mployoes` Chief Shop Steward & President " *> (circle one) befiMvei<flfi$iubt&r?ce (or substances I norma I ly found at the following place of employment may have potentially toxic effects in the concentration used or found. Signature, Date Typed or Printed Name --William odor----------------------Telephone: Home * _ l Street_____ J.54_Smnmit _______________________ Business Address | City Perth AmboystateN.J. Nov.11/1976 Zip Code 08861 If you are a representative of employees, state the name and address of your organization. Chief Shop Steward & President of International Union of Operating Engineers, Local 825 Please indicate your desire: S O I do not want my name revealed to the employer. My name may be revealed to the employer. Authority: Section 20la)|6) of the Occupational Safety and Health Act. (29 U. S. C. 669(al(6l ) provides as follows: the Secretory of Health, Education, and Welfare shall. . .determine following a written request by any employer or authorized representative of employees, specifying with reasonable particularity the grounds on which the request is made, whether any substance normally found in the place of employment has potentially toxic effects <n such concentrations as used or found: and shall submit such determination both to employers and affected employees as soon as possible. If the Secretary of Health. Education, and V.nifate determines that any substance is potentially toxic at the concentrations in which it is used or found in a place of em ployment. and such substance is not covered hy an occupational safety or health standard promulgated under sect mu n. tim Secretary of Health. Education, and Welfare shall immediately submit such determination to the Secretary of Labor, together with all pertinent criteria. "Authorized representative of employees" means any person or organization meeting the conditions specified in 42 CFR Part 85.3 (b) 14) (i|, (ii) or (in|: (i) -- that he is an autliorized reixosontative of, or an officer of the organization representing, the employees for ixirpnsns ,tl collective bargaining; or I nl -- that he >s an employee of the employer aod is autliorized hy two or more employees employed in the workplace whore the substance IS normally found, to represent them for purposes of the Act. Each Such authorization shall be in writing am) in cluded in the request; or (in) -- that he is one of three or less employees employed m the workplace where the substance is normally found. Send the completed form to: National Institute for Occupational Safety and Health Hazard Evaluation Services Branch U.S- Department of Health, Education, and Welfare Cincinnati, Ohio 45202 Ucc 090277 us W#t*Hni|Wfnwmct3fici o'* *** * i .