Chemical Dosage Record

Chemical Dosage Record and Service Agreement

This Chemical Dosage Record and Service Agreement (the Agreement) is made between:

Supplier Name:     Facility Name:

WHEREAS

WHEREAS, Supplier is engaged in the supply and regulated application of chemical products for the control and treatment of process water, wastewater, and other systems, and represents that it is qualified and licensed where required to perform such services;

WHEREAS, Facility operates the system(s) identified in this record and desires Supplier to provide dosage services, monitoring, and recordkeeping in accordance with applicable safety practices and the terms set forth in this Agreement;

WHEREAS, the parties desire to document each chemical application event, including dosage target, actual dosage administered, batch identification, monitoring results and any corrective actions, and to memorialize commercial and confidentiality terms.

Scope of Work

Dosage Log (Record each application event)

Instructions: Complete one row per application. Retain copies for compliance and quality control.

Safety, Compliance and Documentation

Supplier certifies that Material Safety Data Sheets (MSDS / SDS) for all chemicals listed are provided to Facility and that personnel applying chemicals are trained in accordance with applicable safety standards.

MSDS Provided: Yes     Trained Applicators on Site: Yes     Required Permits Verified: Yes

Payment Terms

Base Service Fee: $     Payment Schedule:

Late Payment: If payment is not received within days after the invoice due date, a late fee equal to will accrue on the unpaid balance.

Term and Termination

Term Start Date:     Term End Date:

Either party may terminate this Agreement for convenience upon written notice delivered at least days prior to the effective termination date. Termination for cause may occur immediately upon material breach if such breach is not cured within a reasonable cure period specified in a written notice.

Confidentiality

Each party shall treat as confidential all proprietary business information, process parameters, and monitoring results provided by the other party whether marked as confidential or reasonably understood to be confidential. Confidential information shall not be disclosed to third parties except as required by law or to employees and contractors who have a need to know and are bound by comparable confidentiality obligations. Confidentiality obligations survive termination of this Agreement for a period of three (3) years.

Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the State of , without regard to conflict of laws principles.

Entire Agreement

This Agreement, including all schedules, records, and logs incorporated by reference, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes any prior oral or written understandings. Any amendment must be in writing and signed by authorized representatives of both parties.

Compliance Certification

By signing below, the signatory certifies that the information provided in this record is true and accurate to the best of their knowledge, that chemical handling and application were performed in accordance with label directions and applicable laws, and that required training and safety documentation are maintained.

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