Airfield Pesticide SANGB Form 23.pdf

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Pesticide Treatment
Solicitation number
W50S8521Q0008
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Contractor Hazardous Material Identification Part I

To be completed by Contractor prior to start date and shall be maintained on the job site.

Date: ______________________________

Contractor Company: __________________________________________________________________________

Proposed Work Term: _________________________________ to ____________________________________

Contractor Point of Contact: ___________________________________________________________________

Phone: _________________________

HM to be Used:

MFG. / Product

M.S.D.S.

Attached

QTY

Used

Disposal Procedures Comments

NOTE: This form is to be submitted to the HMPT for initial construction. All Hazardous Material (HM) used thereafter will be identified to Contracting Officer representative and tracked by the HMPT. See Part II for contractor closeout procedures. HMPT phone number is (586) 307-6104.

HMPT Tracking Signatures

CEV: __________________________________________ SGPB: _________________________________________________

HMPT: ________________________________________ CEF: __________________________________________________

Project Name: __________________________________________________

SANGB Form 23, Mar 2003 PREVIOUS EDITION IS OBSOLETE

Contractor Hazardous Material Identification Part II

Closeout Procedures

Contractors will accompany Base Environmental on closeout inspection to ensure all used / unused HM was removed from the Base.

Date: ____________________________________________

Closeout Signatures:

CEV: ________________________________________________________________________________________________________

Contracting Officers Representatve: ___________________________________________________________________________

Contractor: __________________________________________________________________________________________________

SANGB Form 23, Mar 2003 (Reverse)

Project Name:

HM to be used:

MFG/Product

Used/Unused Material Removed from Selfridge

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