PPM.5280.634.2018.01 Cross Connection Program

City of Raleigh Backflow Assessment Form Chemical List Please list any products (chemical or biological) used for processing/manufacturing, stored at facility, or cleaning purposes.

Quantity

NFPA Rating Please list number rating or hazard code

Chemical Name

Common Name

Manufacturer

Pounds (lbs.)

Gallons (gal.)

Health (Blue) Flammability (Red)

Instability/Reactivity (Yellow)

Special Hazards (White)

99