Attachement 6 - Appendix C -- Hazardous Materials Form.pdf

ATTACHMENT 1

CAFB & MAFR Contractor

HAZMAT Worksheet

1. Contractor Information

Contractor Name:

Contract Number:

Project Number:

Estimated Start Date:

Estimated Completion Date:

Assigned Shop Code, if known:

2. Material Information

Material Name (from SDS):

Material Stock No. (MSN), or National Stock No.

(NSN), or Local Stock No. (LSN), enter if known:

Container Type (check one):

Box

Bag Tube

Bottle Can

Drum

Container Volume or Weight (check one):

Weight Oz. GramsPounds Tons

Quarts

Gallons

Other(Specify):

Total No. of Containers: Container Size: Total HAZMAT

Quantity:

3. Process Information

Process Type:

Process Description:

4. Engine ering

Describe process engineering controls:

5. Personal Protective Equipment (PPE)

Describe process PPE:

6. Location Information

Process will be performed on/at (check all that apply):

Existing Facility Aircraft Outdoors

E quipment New Facility

Other (Specify):

Physical location of process:

Staging location of HAZMAT:

Other (Specify)

Kilograms Fluid Oz Pints

Cartridge

ATTACHMENT A-1

Cannon AFB & Melrose AFR

Contractor HAZMAT

IAW FAR 52.223-3/AFI 32-7086 3.4.1; All HAZMAT brought onto an installation for use shall be authorized via the process described in this section.

NOTE: Manufacturer’s Safety Data Sheet (SDS) is required for every worksheet

The information submitted is complete. The HAZMAT noted above may enter Cannon AFB and/or Melrose AFR

The information submitted is incomplete and/or erroneous. Please follow the instruction below and resubmit.

7. Additional Information

Will a hazardous waste be generated (circle one)?

Yes No TBD Describe method(s) of waste management, transport, and disposal:

8. Contractor Signature Block

Title Phone Number

Printed Name Date

Signature

9. Environmental Approval Signature Block

Title Phone Number

Printed Name Date

Signature

“Description of Material”. The completed form should be returned to the Contracting Office for review by the HMMP Team, including Hazmart.

7.4 Instructions for Attachment 1, CAFB & MAFR Contractor HAZMAT Worksheet:

Attachment 1 information is required for the HMMP Team to authorize and track HAZMATs on CAFB and MAFR. A worksheet must be filled out for each HAZMAT and container combination, and a GHS Compliant SDS must accompany each Attachment 1. For example:

• If you have 5 HAZMATs for your contract performance, you will have 5 Attachment 1 forms and 5 SDSs.

• If you have 1 HAZMAT that will be used in two different containers sizes, you will have 2 Attachment 1 forms and 2 SDSs.

• All blocks must be filled in, unless noted.

Section 1. Contractor Information Contractor Name Enter the name of the contracting company performing the work.

Contract Number Enter the contract number.

Project Number Enter the project number.

Estimated Start Date Enter the estimated state date.

Estimated Completion Date Enter the estimated completion date.

Assigned Shop Code, if known

You may be assigned a Shop Code for tracking HAZMAT usage.

If you know the Shop Code, enter it here. Otherwise, leave blank.

Section 2. Material Information Material Name (from SDS) Enter the EXACT material name from the HAZMAT’s SDS.

Material Stock No. (MSN), or National Stock No.

(NSN) or Local Stock No.

(LSN), if known

These are Air Force tracking numbers. If you know the federal MSN, NSN, or the LSN, enter it here. If unknown, leave blank. Do not enter a contractor’s or manufacturer’s stock number.

Container Type Type of the HAZMAT container. Will be the smallest container that holds the HAZMAT. For example, if a box contains 12 tubes of caulk, the container type is “tube.” For un-containerized bulk loads to be delivered by truck, such as ready-mix concrete, enter “Un-containerized Bulk Delivery” after “Other (Specify)”.

Container Volume or

Weight Select the units of weight or volume measure of the container. For un-containerized bulk loads to be delivered by truck, enter the bulk unit of measure, i.e., cubic yards or tons.

If completing the form electronically, delete non-applicable units.

Total No. of Containers Enter the total number of containers expected to be used under the contract. For un-containerized bulk loads too be delivered by truck, enter “Bulk Delivery”.

Container Size Enter the size of the container. For example, if a tube of caulk holds 4 lbs., enter “4 lbs.” For un-containerized bulk loads too be delivered by truck, enter “Bulk Delivery”.

Total Volume or Weight Multiply the total number of containers times the volume or weight of each container. For example, for 72 tubes of caulk, with each tube weighing 4 pounds, enter “288 pounds” (72 tubes x 4 pounds).

For un-containerized bulk loads to be delivered by truck, enter the total bulk amount and the bulk units.

Section 3. Process Information

Process Type Consult Table B at the end of this appendix for a listing of Air Force-defined Environmental Process Types. Enter the number and process type. Enter only one process that best describes the process in which the HAZMAT will be used.

Process Description Enter a brief description of the process in which the HAZMAT will be used. Examples may include: “Priming & painting”, “Plumbing soldering”, “Paving, walkways & parking areas”, or “Abate rodent infestation”. Avoid very general descriptions, like “Construct building” or “Landscaping”.

Section 4. Engineering Controls Describe process engineering controls

Enter a brief description of any engineering controls to be used in the process to mitigate or reduce HAZMAT risks to human health or the environment. For example, “Ventilate area to reduce concentration of fumes”.

Section 5. Personal Protective Equipment (PPE) Describe process PPE Enter a brief description of any PPE to be used to mitigate or reduce

HAZMAT risks to human health. For example, “Tyvek coveralls”, “Nitrile outer-gloves with latex inner-gloves”, “Dust Mask”, or “Air Purifying Respirator with Organic Vapor Cartridge”.

Section 6. Location Information Process will be performed on/at

Select the process location.

Physical location of process

Enter the physical location of the process in which the HAZMAT will be used. For example, “Inside Building 355”, “Parking Lot of Building 600”, or “Runway 29”.

Staging Location of

HAZMAT

HAZMATs may NOT be stored9 on CAFB or MAFR.

HAZMATs may be staged immediately before use. Enter the HAZMAT staging location. For example, “In carton on pickup truck bed”, “Truck materials cabinet”, and/or “Material pallet in parking lot”.

Section 7. Additional Information Will a hazardous waste be generated?

Circle “Yes”, “No”, or “TBD” (To Be Determined) depending on whether the process in which the HAZMAT will be used will generate hazardous waste.

Describe method(s) of waste management, transport, and disposal

Briefly describe how any waste generated by the process using the HAZMAT will be disposed. For example “Solid waste will be collected in 10 yd. roll off”, “Potentially hazardous waste soil will be stored in covered bins pending analysis”.

Section 8. Signature Block Several Entries Enter the name of the contractor (representative), title, phone number and date in the upper portion of the block. Enter printed name in the lower portion of the block and sign.

Section 9. Environmental Approval Signature Block Several Entries Enter the name of the Environmental Representative, title, phone number and date in the upper portion of the block. Enter printed name in the lower portion of the block and sign. Environmental Representative will finish section below block 9.

9 “Stored” means a non-transitory, semi-permanent or permanent holding, placement, or leaving of material. It does not include a temporary accumulation of a limited quantity of a material used or a waste generated or resulting from authorized activities, such as servicing, maintenance, or repair of Department of Defense (DoD) items, equipment, or facilities. Source: DFARS 252.223-7006.

Table B Air Force Environmental Process Types Listing

1. Adhering / Bonding / Sealing

2. Administrative

3. Aids to Navigation

4. Aircraft/Flight line Operations

5. Asbestos Work

6. Brazing / Soldering /

Welding / Cutting

7. Cementing and Related Tasks

8. Civil Disaster Response

(FEMA)

9. Cleaning – Chemical and Degreasing

10. Cleaning – Mechanical

11. Cleaning – Other

12. Coating /Paint Removal /

Abrading

13. Coating / Painting Operations

14. Communications

15. Composite Work

16. Crafts

17. Cultural Resource Management

18. Dental

19. Drinking Water System /

Treating; Water /Wastewater Plant Operations; Water / Wastewater Treatment

20. Drywall / Plastering

21. Electric Arc / Flame /

HVOF / Thermal / Plasma Spraying

22. Electrical / Electronics

23. Electroplating

24. Energy Management

25. Engine Testing

26. Environmental and Remediation

27. Environmental

Response (Biological, Chemical, Oil, Radiological)

28. Equipment Installation / Repair / Preventative Maintenance / Charging/ Recharging/ Lubricating, NOC

29. Fabric Work

30. Food Service /

Preparation / Handling / Cleaning

31. Fuels (e.g. Combusting, Dispersing, Fuel Cell, Defueling, Distribution)

32. Hazardous Materials / Hazardous Waste Handling / Cleanup / Recycling / Reclaiming

33. Housekeeping / Janitorial / Facility Maintenance

34. HVAC

35. Hyperbaric Atmospheres

36. Incinerating

37. Insulation / Man-Made Fibers

38. Integrated Solid

Waste Management

39. Laboratory Operations

40. Lead Paint Abatement

41. Marine

42. Medical

43. Metal Forming

44. Metal Foundry Operations

45. Metal Machining

46. Metals Treatment

(e.g., Heat Treating / Hardening; Etching

47. Miscellaneous Operations

48. Natural Resource

Management

49. NOC

50. Non-Destructive

Inspection / Testing

51. Pest Control or Pesticide

Disposal / Mixing / Storage

52. Photography / Graphic Arts

53. Plastics / Rubber Processing

54. Plumbing

55. Port Security

56. Printing / Reproduction

57. Professional / Technical / Sampling / Surveying / Training

58. Protective Services – Fire

59. Protective Services – Security

60. Recreation / Services

61. Roads and Ground

Maintenance

62. Search and Rescue

63. Semiconductor Manufacturing

64. Shipboard Duties

65. Stone / Mineral Handling

66. Storage (of Materials, of

Waste, ASTs, USTs, Testing of Storage)

67. Structure Demolition

68. Structure Fabrication / renovation; General Construction

69. Supplies / Materials Handling

70. Supplies / Materials

Handling – Assemble / Disassemble

71. Transportation (e.g., Dispatching, Driving, Rail, Watercraft)

72. Utility Production / distribution

73. Vehicle Maintenance / Repair / Testing

74. Veterinary Services / Animal Care

75. Waterways

76. Weapons and Ordnance

77. Weapons and Ordnance - EOD

78. Weapons and

Ordnance – Explosive Production

79. Weapons and Ordnance – Mixing / Bagging / Handling

80. Weapons and Ordnance - Torpedo

81. Weapons and Ordnance – Weapons / Small Arms

82. Woodworking

83. X-Ray Processing