Document MMdpo8kebRZxRJb3Yb8G692Gk

HASKELL LABORATORY SAMPLE EVALUATION FORM 1. Fill out a sample evaluation fora as completely as possible for each sample Submitted. ii. If a sample is being submitted for mutagenicity testing, pay special attention to Sections 6, 8 and 9. Lii. The Haskell number will be assigned by Haskell Lab personnel. iv. Unless otherwise requested, samples will be destroyed six months after the final report is written. The sender should retain a suitably identified portion of the sample. . Haskell No.:_______/ HAZARDOUS MATERIAL Q NO C2. YES (If yes, complete classification below) . HAZARD CLASSIFICATION FOR SHIPPING. LABELING. AND PACKAGING (Check PRIMARY hazard applicable and identify all other hazards by underlining). Explosive, Class A O B Etiologic Agent Radioactive Material (**) Poisonous Gas, Class A Poisonous Liquid, Class A Flammable Compressed Gas Nonflammable Compressed Gas Flammable Liquid (*) Oxidizing Material cO o CL i_J O CD tc a Flammable Solid Corrosive Material - Liquid Poisonous Liquid, Class B Poisonous Solid, Class B Corrosive Material - Solid Irritating Material Combustible Liquid (*) Excepted - Limited Quantity CD O W. --i CD. I--l O O (*) Flash Point- ________ *F Explosive Concentration: 1. Chemical Abstracts nomenclature: Chemical Abstracts Registry number: 2. Other n*e M,K 3. Department identification code and/or lot number: 4. Structural formula: (a) Molecular weight: 5. Composition of mixtures by Z: * r i DUP040002348 TO: INFORMATION SECTION HASKELL LABORATORY SAMPLE EVALUATION FORM 1. Fill out a sample evaluation form as completely as possible for each sample submitted. " ii. If a sample is being submitted for mutagenicity testing, pay special attention to Sections 6, 8 and 9. Lii. The Haskell number will be assigned by Haskell Lab personnel. iv. Unless otherwise requested, samples will be destroyed six months after the final report is written. The sender should retain a suitably identified portion of the sample. . Haskell No.: HAZARDOUS MATERIAL D NO 0 YES (If yes, complete classification below):. HAZARD CLASSIFICATION FOR SHIPPING, LABELING, AND PACKAGING (Check PRIMARY hazard applicable and identify all other hazards by underlining). Explosive, Class A O B O Etiologic Agent Radioactive Material (**) Poisonous Gas, Class A Poisonous Liquid, Class A Flammable Compressed Gas Nonflammable Compressed Gas Flammable Liquid (*) Oxidizing Material CO D G O J23L Q O G Flammable Solid Corrosive Material - Liquid Poisonous Liquid, Class B Poisonous Solid, Class B Corrosive Material - Solid Irritating Material Combustible Liquid (*) Excepted - Limited Quantity a O G Q G G O (*) Flash Point-' __ ______*F Explosive Concentration: 1. Chemical Abstracts nomenclature: Chemical Abstracts Registry number: 2. Other na,e ^ 'UiiUtf 3. Department identification code and/or lot number: 4. Structural formula: (a) Molecular weight: 5. Composition of mixtures by Z: r i , DUP040002349 TO:^ INFORMATION 5ECXAUM HASKELL LABORATORY SAMPLE EVALUATION FORM i. Fill out a sample evaluation form as completely as possible for each sample submitted. ii. ill. If a sample is being submitted for mutagenicity testing, pay special attention to Sections 6, 8 and 9. .4* The Haskell number will be assigned by Haskell T-afc personnel. iv. Unless otherwise requested, samples will be destroyed six months after the final report is written. The sender should retain a suitably identified portion, of . the sample.- , . Haskell No = /3.S.S-'/ HAZARDOUS MATERIAL EZJ NO C3 YES (If yes, complete classification below) HAZARD CLASSIFICATION FOR SHIPPING, LABELING, AND PACKAGING (Check PRIMARY hazard applicable and identify all other hazards by underlining). Explosive, Class AO B Etiologic Agent Radioactive Material (**) Poisonous Gas, Class A Poisonous Liquid, Class A 'Flammable Compressed Gas Nonflammable Compressed Gas Flammable Liquid (*) Oxidizing Material C CrjJ a O a a a a Flammable Solid Corrosive Material - Liquid Poisonous Liquid, Class B Poisonous Solid, Class B Corrosive Material - Solid Irritating Material . Combustible Liquid (*) Excepted - Limited Quantity D O I--! O i--i O O (*) Flash PointExplosive Concentration: Chemical Abstracts nomenclature: Chemical Abstracts Registry number: Otter name (s): 3. Department identification code and/or lot number: 4. Structural formula: /yyionj^J fi- (a) Molecular weight: Composition of mixtures by %r * 2# K C. 0 syj . . & - a 'z- \ /ra-19 a i~ t?-2.- 2-(cfb s /ere DUP040002350 6, Purity: % (a) Contaminants present (including processing Solvents); (fa) Inhibitors, carriers or additives present: 7. Physical Characteristics: (a) Color: (b) Form: . (c) Melting point (d) Boiling point at 760 mm Hg:_ (e) Density: (f)pH:___ (g) Vapor pressure at 25 C:____ (Attach curve if available) 37C: . (h) Vapor density (airl) (i) Maximum process temperature _____in presence/absence (delete one) of air. 8. Solubility: <.1Z (a) Water:__________ (c) Ethanol: .1Z-1Z, 1Z-10Z or >10Z (b) Dimethylsulfoxide:__ _______ (d) Acetone: (e) Vegetable Oil: 9. Reactivity: (a) Will there be any significant reaction with water:_______ If so, would the half-life be: _____________ <10 min., 10 min.-l hr-, 1 hr."24 hrs., . >24 hrs. (fa) .Will there be any significant reaction expected with either the solvents specified in (8) or sugars or amino acids? ______ _ 10- Spatial Handling Instructions and/or Toxicity Information: 11. Name of person having knowledge of chemical properties of the compound: - ___________________ f ___________ __ Location:______ ________________ Phone No.: Revised 4/4/77 DUP040002351