Attachment_10_Forms_D,_E,_and_Hazardous_Material_Authorization.pdf

Document No.

140R3019R0001

Document Title Turbine and Generator Hydroelectric Component Manufacturing and Rehabilitation IDIQ

Attachment 10 - Forms D, E, and Hazardous Material Authorization

LC-042

Document No.: SEMS-F004 Revision No.: 4 Document Date: 08/20/2013

FORM D

Recovered Materials Content/Energy Savings Details

Project Name or Title: _____________________________________________ Contact: ____________ Phone: ______________ Product/Material Check the

Appropriate Mandatory Purchasing List(s)1

Product Quantity to be Procured (i.e. volume, number of containers, etc.)

Percent (%) Total Recovered Materials Content Identified on Product Label (if applicable)

Estimated Percent Recovered Materials Content/Energy Saved (if applicable)

Calculation used to Estimate the Percent Recovered Materials Content/Energy Saved (if not listed in the appropriate website) (if applicable)2

Cost ($) and Estimated or Actual Date (DD/MM/YYYY) of Procurement for the Product/Material

1. � US EPA (Recycled Content)

� USDA

(Biobased/BioPerf erred)

� Energy Star®

� FEMP

2. � US EPA (Recycled Content)

� USDA

(Biobased/BioPerf erred)

3. � US EPA (Recycled

� USDA

(Biobased/BioPerf erred)

4. � US EPA (Recycled

� USDA

(Biobased/BioPerf erred)

1 U.S. EPA Recycled Content – Products or category of products which meet the Environmental Protection Agency’s Comprehensive Procurement Guidelines (CPG), published at:

http://www.epa.gov/epawaste/conserve/tools/cpg/directory.htm. For each product or category of products listed, the CPG identifies the percentage of recovered material content;

USDA Biobased/BioPreferred – Products which have Biobased/BioPreferred content are listed by the U.S. Department of Agriculture at: http://www.biopreferred.gov/;

Energy Star® - Product Listings are published at http://www.energystar.gov/index.cfm?c=products.pr_find_es_products;

FEMP Low Standby Power - Product Listings are published at https://www1.eere.energy.gov/femp/technologies/eep_purchasingspecs.html.

2 Identify the calculation or other basis for estimation used to determine the percent recycled content in a product if the manufacturer’s specification or product label does not identify the percent of recycled content.

http://www.epa.gov/epawaste/conserve/tools/cpg/directory.htm http://www.biopreferred.gov/ http://www.energystar.gov/index.cfm?c=products.pr_find_es_products https://www1.eere.energy.gov/femp/technologies/eep_purchasingspecs.html

LC-042

Document No.: SEMS-F004 Revision No.: 5 Document Date: 12/24/2015

FORM E

Waste Diversion Table

Project Name or Title: ______________________________________________ Contact:____________ Phone______________ Waste Name/description (One Waste Material per Row)

Total Quantity of Waste Generated

Unit (lbs/ gal/to n/cf)

Quantity of Waste Recycled/Reus ed1

Unit (lbs/gal /ton/cf)

Date Waste Disposed

(DD/MM/YYYY)

Date Waste Recycled/Reuse

(DD/MM/YYYY)

Description of the Disposition/Diversion of Material

1 Quantity of Waste Recycled/Reused – The amount of material/waste that is recycled or re-used.

LC-035 Attachment 8 Document No.: SEMS-F010, Revision: 5 Document Date: 11/18/2016

Hazardous Material Authorization

Form

Section I. Requestor Information Name of the Requestor/Contractor:

Organization/Dept: Date:

Section II. Project Information Project Name: Project Location:

Section III. Material Information Material/Product Name: Quantity to be purchased: Unit of Issue (Drums, Gal, bottles):

Usage Frequency: Duration of Task:

Section IV. Process Information Describe:

1) Work activities and processes in which this material will be used; 2) Storage method/location; 3) Re-use/Recycling method/process; 4) Disposal of hazardous waste materials; 5) Attach Safety Data Sheet (SDS):

(Additional information may be attached to this form.)

Section V. Sustainability/ Pollution Prevention List non-hazardous or less hazardous alternatives:

(Complete Hazardous Material Alternative Waiver (Hazardous Material Authorization Form page 2) if non-hazardous or less hazardous material are not available or not viable due to price, schedule, or performance.)

Section VI. Supervisor Concurrence Print Requestor’s Supervisor Name:

Telephone #: Date of Concurrence: Signature:

Section VII. Authorization Hazardous Material Approval:

___ YES

Approved with conditions (if applicable):

___NO

Reason for disapproval:

Print Name of Hazardous Material Authorized Designee:

Date of Authorization: Signature:

Health and Safety Approval:

___ YES

Approved with conditions (if applicable):

___NO

Reason for disapproval:

Print Name of Health & Safety Authorized Designee:

Date of Authorization: Signature:

LC-035 Attachment 8 Document No.: SEMS-F010, Revision: 5 Document Date: 11/18/2016

Hazardous Material Authorization Information

1. Definitions

1. Hazardous Materials: A hazardous material is any substance or chemical which poses a risk or has the potential to cause health or physical harm to humans, animals, or the environment, in the course of normal handling, use, storage, spilling, leaking, pumping, pouring, emitting, emptying, discharging, injecting, escaping, leaching, dumping or disposal.

2. A Hazardous Material Authorization (HMA) is required when:

1. A new Hazardous Material (HM) is purchased for use

2. A change in type/use of HM is required to meet mission needs

3. Additional quantities of HM are needed

4. A contract action allowing a contractor to use or store a HM on-site

3. Individuals Required to Obtain an HMA Persons responsible for purchasing or using HM and/or persons responsible for Contractors using HM.

4. Hazardous Materials Authorization Process The Requester will ensure:

1. A separate HMA form (page 1) is completed for each hazardous material requested for authorization.

2. A current copy of the HM Safety Data Sheet (SDS) is attached to each HMA form.

3. The HMA form and SDS is submitted to and approved by the Authorized Designees for hazardous materials and health and safety prior to purchase of HMs.

4. If non-hazardous or less hazardous alternatives do not exist, or are not viable due to: 1) price, 2) schedule, 3) performance, 4) availability, complete hazardous materials Alternative Waiver (below).

5. The Authorized Designee for Hazardous Materials and Health and Safety will:

1. Ensure the legal and internal requirements related to the HM are considered when authorizing the HM.

2. Provide an evaluation/determination within 10 business days from the time an HMA Form is received by the Authorized Designee unless otherwise negotiated.

3. Provide the Requestor an approved HMA Form (when appropriate).

6. Conditional Authorization/ No Authorization 1.If conditions to approval have been granted by the Authorized Designee, the Requestor/Contractor is responsible for ensuring the conditions are met.

2.If the HM is not approved for use, the Authorized Designee will document the reason(s), contact the Requestor or their Supervisor, and discuss potential alternative(s) to the HM.

Questions regarding the HMA Form or the authorization process can be directed to the Authorized Designee for Hazardous Materials and Health and Safety. Incomplete forms or documentation may delay the authorization process. The Authorized Designee(s) for Hazardous Materials and Health and Safety must sign the authorization for it to be valid. The Requestor should submit the approved HMA Form to the Contractor for their records (if applicable).

For Reclamation Use Only

Alternative Waiver Based on the Executive order 13514, Reclamation Acquisition Regulations, and DOI Sustainability Strategic Performance Plan, I have determined that non-hazardous or less hazardous alternatives are not available for this product due to the following:

[ ] Alternative to the HM is not available within a reasonable period of time.

Date HM Needed: Date available:

[ ] Potential alternative(s) to the HM fail to meet a performance standard in project/design specifications. Describe the performance standard, why the standard is required, and how the alternative(s) to the HM fails to meet the standard:

[ ] Potential alternative(s) to the HM are not available from 2 or more sources. List the vendor name and contact information that is able to provide the alternative(s) to the HM:

[ ] Potential alternative(s) to the HM are only available at an unreasonable cost.

Cost of the Alternative to the HM: $ HM Cost:

Requestor Signature: Date:

Requestor’s Manager/Supervisor Signature: Date:

Document No.

140R3019R0001

Document Title Turbine and Generator Hydroelectric Component Manufacturing and Rehabilitation IDIQ

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