Attachment 1 - FY22Kitchen Hoods and Ducts PWS.pdf

PERFORMANCE WORK STATEMENT

FOR

KITCHEN HOODS AND DUCTS

CLEANING SERVICES

Dover Air Force Base, Delaware 24 February 2021

Reviewed:

______________________________ _______16 Mar 2021_____

Quality Assurance Program Coordinator Date

Approved:

Contracting Officer Date

PERFORMANCE WORK STATEMENT

FOR

KITCHEN HOODS AND DUCTS CLEANING SERVICES

1. DESCRIPTION OF SERVICES: The contractor shall provide all management, tools, supplies, equipment, and labor necessary to ensure that kitchen hoods, ducts and dryer ventilation duct cleaning services are performed at Dover AFB in a manner that will conform to all local, state and federal regulations.

1.1. KITCHEN EXHAUST CLEANING SERVICES: The contractor shall inspect, clean, and maintain kitchen hoods and ducts systems in accordance with National Fire Protection

Association (NFPA) Standard 96. The contractor and the Contracting Officer Representative

(COR) shall review the current inspection, test, and maintenance status of all hood, duct, and exhaust systems included in this contract. The contractor shall submit a planned work schedule to the COR for approval annually. The contractor shall submit a documented report to the COR on each hood, duct, and exhaust system’s inspection, test or maintenance work, noting discrepancies, system impairments and recommendations, within 10 calendar days after each inspection and cleaning.

1.2. CERTIFICATIONS: The contractor is required to be a certified member of the

International Kitchen Exhaust Cleaning Association (IKECA) certified by IKECA and remain certified throughout the duration of the contract. The contractor shall have an IKECA Certified

Exhaust Cleaning Specialist CECS on site and be present throughout each scheduled cleaning.

The contractor shall submit IKECA and CECS certificates to the Contracting Officer with their bid schedule prior to award of contract.

1.3. DRYER DUCT CLEANING & INSPECTION SERVICES: The contractor shall inspect and clean dryer ventilation ductwork semi-annually in dormitory buildings 212, 401, 402, 430, 435, 515, 639 and annually clean dryer ducts in dormitories 414 and 445. All lint shall be removed from the piping and ductwork of each dryer starting from the wall connection inside the laundry room to the exhaust outlet of the facility. Facilities 414 and 445 have existing power booster ventilation blowers in line on the outlet side of the dryer units. The contractor shall clean the powered booster ventilation units without removal or disassembly of the unit other than the removable lint screen. The contractor shall submit a planned work schedule to the COR for approval annually. See Appendix C for dryer ventilation ductwork quantities.

1.4. DRYER VENTS LINT SCREEN AND INSPECTION SERVICE: The contractor shall provide all management, tools, supplies, equipment, and labor necessary to ensure that dryer ventilation lint screens are cleaned both inside the clothes dryers and on the lint screens of the power ventilators on the discharge duct within the dryer closets of facilities 414 and 445. The contractor shall submit a planned work schedule to the COR for approval annually.

See Appendix C for dryer ventilation ductwork quantities. These two screens shall be cleaned on a Monthly basis in a manner that will conform to all local, state and federal regulations.

2. HAZMAT REQUIREMENTS: The contractor shall submit Material Safety Data Sheets

(MSDS) of all chemicals planned for usage on Dover AFB.

2.1. Purpose. As required by AFI 32-7086, paragraphs 2.5.5.2.4, 2.5.5.2.8 and 2.5.5.2.9;

requires Dover AFB to account for all hazardous materials (HAZMATs) brought on the facility to include contractors as well as providing procedures for the reporting of those items.

2.2. This part outlines actions to be taken by the contractor in the request for approval of hazardous materials prior to initiating field activities associated with the subject project and the reporting of approved hazardous materials usage during contract performance.

2.3. Compliance with this part is mandatory and contractor failure to comply will result in the contractor not being allowed to bring any hazardous materials on Dover AFB. Contractors must also comply with mandatory Federal, State and local guidelines, regarding storage and management of hazardous materials, failure to comply can result in legal action by Federal, State or local enforcement officers against the offender.

2.4. RESPONSIBILITIES: Contractor Reported Usage of HAZMAT.

2.4.1. Contractors must submit to the associated Contracting Office the information and supporting documentation (including Material Safety Data Sheets (MSDSs)) necessary to obtain

HAZMAT usage authorization. Report data on the HAZMAT used during the performance of the contract at intervals and in the format specified by Dover AFB.

2.4.2. The contractor shall provide a completed Dover AFB HAZMAT Chemical Worksheet for each HAZMAT to be used during the duration of the contract to include MSDS. This list of all

HAZMATs shall be provided at the beginning of the contract. Any additional HAZMATs required during the course of the contract shall be requested for approval at that time. In addition, the quantity of chemicals expended will be reported to the Dover AFB Hazardous

Materials Pharmacy (HAZMART) by filling out the Contractor’s Monthly Report for

HAZMATS. Both the Worksheet and Monthly Report forms shall be provided upon award of contract. (Appendices D and E).

3. WASTE and HAZARDOUS WASTE REMOVAL: The contractor shall dispose of all wastes generated in the performance of their task. No hazardous waste or solid waste materials shall be placed in any trash receptacle on Dover AFB. The Contractor must comply with all federal, state, and local regulations regarding the transport and disposal of any and all hazardous wastes generated as a result of kitchen hood and duct cleaning operations under this contract.

4. SERVICE SUMMARY:

Performance Objective PWS Para Performance Threshold

Perform Inspections & Cleaning Services. Inspect, clean and maintain kitchen hoods & ducts systems in accordance with NFPA 96.

1.1, 1.3, 5.3, 6.2

100% compliance of NFPA

96 for all systems listed in

PWS.

Submit Hoods & Ducts

Systems Inspection/Cleaning

Reports.

Accurate reports are delivered within

10 calendar days.

1.1 100% of all reports are timely and accurate.

5. GENERAL INFORMATION:

5.1. QUALITY CONTROL: Contractor shall develop and maintain a quality program to ensure cleaning services are performed in accordance with the NFPA Standard 96 and other commonly accepted commercial practices. The contractor shall develop and implement procedures to identify and prevent defective services from recurring.

5.2. QUALITY ASSURANCE: The government will evaluate the contractor’s performance for each job.

5.3. HOURS OF OPERATION: Actual hours of operation are according to the building where work is to be performed and shall be coordinated with the building manager prior to providing cleaning services. Buildings’ availability is stated below:

(1) Bldg. 810, Golf Course 2x a year: Mon - Friday from 3 p.m. to 5 p.m.

(2) Bldg. 212, Child Development Center (Semi-Annual): Mon - Thurs from 3 p.m. to 6 p.m.

(3) Bldg. 222, Burger King (Monthly): Mon - Thurs from 7 p.m. to 10 p.m.

(4) Bldg. 417, Chapel Center (Annual): Mon - Thurs from 12 p.m. to 5 p.m.

(5) Bldg. 403, Dining Facility (Monthly- System (Sys) 7 & 8): Mon - Thurs 10 p.m. to 2 a.m.

(6) Bldg. 403, Dining Facility (Quarterly- Sys. 5): Mon - Thurs from 12:30 a.m. to 4:30 a.m.

(7) Bldg. 403, Dining Facility (2X a year Sys. 1- 4, 6, & 9): Mon - Thurs from 10 p.m. to 2 a.m.

(8) Bldg. 420, Bowling Center (Monthly-Exhaust Sys. 1): Mon - Thurs 9:30 p.m. to 11 p.m.

(9) Bldg. 479, Landing Club (2x a year - Sys. 1, 2, & 3): Mon - Thurs 2 p.m. to 5 p.m.

(10) Bldg. 2998, Base Chapel 2 Kitchen (Annual): Mon - Thurs from 12 p.m. to 5 p.m.

(11) Bldg. 864, Youth Center (Annual): Mon - Thurs from 9 a.m. to 5 p.m.

(12) Bldg. 140, Fire Department (2x a year): Mon - Thurs from 9 a.m. to 5 p.m.

(13) Bldg. 414 & 445, Dryer Duct Cleaning (Monthly): Mon - Fri from 6:30 a.m. to 3:30 p.m.

(14) Bldg. 140, 212, & 401 Dryer Duct Cleaning (2x a year): Mon - Fri 6:30 a.m. to 3:30 p.m.

(15) Bldg. 402, 430 & 435 Dryer Duct Cleaning (2x a year): Mon - Fri 6:30 a.m. to 3:30 p.m.

(16) Bldg. 639 & 515 Dryer Duct Cleaning (2x a year): Mon - Friday 6:30 a.m. to 3:30 p.m.

5.4. The kitchen hoods and exhaust cleaning work shall be performed on a day Monday (M) through Thursday (TH), as indicated in section 5.3, excluding Federal Legal Holidays or days not worked when a holiday falls on a weekend. Listed above are the hours when the kitchen exhaust equipment will be made available to the Contractor for cleaning. However, the

Government reserves the right to change these days/times on an exception basis when special events warrant. The following days are Federal Government holidays:

New Year’s Day, Martin Luther King Day, President’s Day, Memorial Day, Independence

Day, Labor Day, Columbus Day, Veterans Day, Thanksgiving Day, and Christmas Day, as prescribed by law.

5.5. GOVERNMENT FURNISHED PROPERTY AND SERVICES:

Electricity and Water.

6. SPECIAL REQUIREMENTS AND SCHEDULING: Due to the nature of the work being performed, the contractor shall be required to furnish a ladder, as a part of their equipment, to gain access to the roofs. Location of exterior exhaust fans and height of roofs are as follows:

BLDG NO. LOCATION HEIGHT +/- 1 foot (from ground level)

140 Roof 17 Feet

212 Roof 14 Feet

222 Roof 16 Feet

403 Roof 15 Feet

417 Roof 15 Feet

420 Roof 13 Feet

479 Roof 15 Feet

864 Roof 18 Feet

2998 Roof 18 Feet

SPECIFIC TASKS

6.1. GENERAL INFORMATION: The work shall consist of furnishing all parts, labor, tools, equipment, appliances, supplies, materials, transportation, and performing all operations necessary to de-grease and clean the interior surfaces, electric fans and other equipment installed in the air stream of existing kitchen exhaust systems subject to the terms and conditions of this contract.

6.2. KITCHEN EXHAUST SYSTEM CLEANING SERVICE:

6.2.1. SCHEDULING: The contractor shall coordinate scheduling the work with the building managers of each facility. The contractor shall refer to para. 5.3. - Hours of Operation, for building availability and frequency of cleaning. The cleaning shall be scheduled between the first two weeks of each month. All scheduling shall be done by the contractor and be given to the COR at least one week prior to work being done. See the listing of building managers and phone numbers below:

BUILDING TEL# BLDG. MNGR. FACILITY

810 677-2988 Mr. Tworig Golf Course

140 677-4410 Mr. Weisenberger Fire Station

212 677-3716 Mrs. Santo Child Development Center

734-7464 677-3932

Mrs. Vazquez

Sgt Johnson

Burger King Chapel

Center 403 677-3925 SSgt White Patterson Dining Facility

420 677-3950 Mr. Weber Eagle Lanes Bowling Center

479 677-6345 Mr. Collins The Landings (Collated Club)

515 677-5131 Mrs. Rivera Base Supply

638 677-6218 TSgt Rogers CE Readiness

2998 677-3932 TSgt Purnell Chapel 2

864 677-6377 Mrs. McGill Youth Center

6.2.2. Due to the hours of operations of certain facilities, the contractor shall clean the kitchen exhaust system and shall not discontinue normal operations, while the facility remains in use. The contractor shall schedule and perform their work to minimize the interruption of essential government operations. The contractor shall shut down the kitchen exhaust systems to perform the cleaning operations.

6.2.2.1. PRE CLEANING:

6.2.2.2. The contractor shall take necessary precautions to prevent damage to any of the kitchen equipment throughout cleaning operations. The contractor is responsible for any damage caused while performing cleaning services.

6.2.2.3. LIST OF FIRE EXTINGUISHING SYSTEM MANUFACTURING:

Building Number of

Systems

Systems Manufacturer

140 1 Ansul

212 1 Ansul

222 2 Ansul

403 9 Ansul/Kidde

420 1 Rangeguard

479 3 Ansul

2998 1 Kidde

864 1 Ansul

810 1 Pyro-Chem

417 1 Ansul

6.3. CLEANING:

6.3.1. All kitchen exhaust hoods (interior/exterior), ductwork, electrical fans, fan blades, fan housing and supports, all splash backs and louvers, deflectors and dampers, grease filters and filter racks, roof vents, and any other equipment in the air stream of each kitchen exhaust system shall be thoroughly cleaned to remove all accumulated grease, dust, dirt, and lint on their interior and exterior surfaces down to the bare metal. The contractor shall use containment methods to capture water run-off from hood and duct cleaning operations and direct it into drainage systems that are connected to an oil separator/grease trap. The contractor is responsible for all disassembling and reassembling of the kitchen exhaust system essential to perform the cleaning of the hoods.

6.3.2. The work shall be subject to inspection at any and all times. The presence or absence of a government inspector shall not relieve the contractor from strict compliance with this Performance

Work Statement, nor will the presence of a government inspector relieve the contractor from any deficiency that may be noted.

6.4. POST CLEANING:

6.4.1. FIRE PREVENTION. The work is a fire reduction function and the contractor shall perform their work in strict accordance with National Fire Protection Association (NFPA) Code

96.

6.4.2. Fifteen minutes prior to the completion of work in any one building, the contractor shall notify the on-shift Chief of Operations at the Fire Department (ext. 4401) that the cleaning is nearing completion in that building. The contractor shall not replace the filters or roof vent hoods until a member of the Fire Department has inspected the system and verified that the system is in compliance with Code 96 of the National Fire Protection Association. However, if a member of the Fire Department does not arrive within 15 minutes after contractor has completed the cleaning, contractor shall reinstall filters and roof vent hood. Replacing the filters and roof vent hood does not relieve the contractor of the requirements of this statement.

6.4.3. After the Fire Department’s inspection has been completed and approved, the contractor shall attach a label to the exterior of the exhaust hood that indicates the date cleaned, the name of the servicing company, areas not cleaned(if any) and the date of the next scheduled cleaning.

6.4.4. CLEAN UP. The contractor shall upon completion of all duct cleaning operations in each building, clean the work areas (interior and exterior), polish hoods (streakless), remove all grease, dirt, and debris generated by the cleaning at no additional charge to government. The disposal of the grease, dirt, and debris shall be in accordance with current Environmental Protection Agency

(EPA) rules and/or state/local regulations. The contractor shall also clean the surrounding area

(including walls, floors, kitchen equipment, and any item) of any dirt, grease, and debris, cleaning agents, etc., generated as a result of work performance under this contract. All equipment moved for cleaning shall be positioned in its original position upon completion of cleaning. The contractor shall re-ignite pilot lights shut down due to cleaning of hoods and ducts.

7. SCHEDULE: The contractor shall submit a work schedule for the year prior to starting this contract.

8. RECORDS MANAGEMENT: The contractor understands that when creating, handling and maintaining records for the Air Force, either electronic or paper, you must meet the requirements established in AFRIMS Records Disposition Schedule (RDS), AFI 33-322, Records Management Program. In order to meet the requirement established IAW the above mentioned regulation contact the Base Records Management Office (436 CS/SCXK, Bldg. 310) at (302) 677-5157 for guidance and training.

9. SECURITY:

9.1. INSTRUCTIONS AND DIRECTIVES: All personnel employed by the contractor in the performance of this contract, or any representative of the contractor entering the governmental installation shall abide by all security instructions and directives of Dover AFB. Employees are responsible for safeguarding all government property provided for contractor use.

9.2. END OF WORK: At the close for each work period, government facilities, equipment and materials shall be secured, lights, heat and water turned off and all doors and window secured.

9.3. EMPLOYMENT ELIGIBILTY: The contractor and, as applicable, subcontractor shall not employ persons for work on this contract if such employee is identified as a potential threat to the health, safety, security, general wellbeing or operational mission of the installation and its population, nor shall the contractor or subcontractor employ persons under this contract who have an outstanding criminal warrant as identified during the Criminal Background Check

(CBI).

9.4. CREDENTIALS: Contractors shall ensure their employees and those of their subcontracts have the proper credentials allowing them to work in the United States. Employees and subcontractors later found to be undocumented or illegal aliens will be remanded to the proper authorities.

9.5. COMPENSATION FOR DELAYS: The contractor shall submit any request for compensation on delays to the Contracting Office for approval. The contractor shall notify the

Contracting Office or authorized representative as soon as the contractor realizes/determines of any potential delays in accordance with the terms and conditions of this requirement.

9.6. CONTROLLED/RESTRICTED AREAS: All contractors and subcontractors when working in a Controlled, Restricted or other sensitive areas must be escorted at all times. The military agency or unit responsible for the project or work is responsible for providing the escorts.

The Contractor shall follow existing procedures and instructions for obtaining entrance to restricted or controlled areas.

10. CONTRACTOR BADGE POLICIES:

10.1. BADGE REQUEST: All requests for contractor badges will be submitted through the Base

Contracting Squadron Office and/or the requesting agencies base point of contact. The

Contracting Squadron Office or base point of contact will then fill out an Operational Risk

Management Assessment Form (ORM) for the requesting agency and submit it to the Pass and

Registrations section for approval IAW OPlan 31-101. As a minimum the ORM will be submitted 10-days prior to the requested date of employment.

10.2. CRIMINAL BACKGROUND INVESTIGATION: All contactor employees who’ll be granted unescorted access to the installation are required to consent to a Criminal Background

Investigation (CBI) prior to being granted entry to the installation. Continued employment is contingent upon successful completion and favorable reporting of the criminal background check.

10.3. BADGE DURATIONS: DAFB Contractor badges will be issued for a maximum period of one year. Prior to reissuing new badges, all old badges must be returned to 436 SFS, Pass and

Registration for destruction. Also before a new badge will be issued an ORM must be resubmitted to the Pass and Registration section for approval again. In the event a badge is lost or stolen, immediately contact the 436 SFS, Pass and Registration office. The badge holder must accomplish the Loss/Theft of Identification Worksheet and provide it to his/her supervisor. The supervisor of the contractor will investigate the loss and report in writing the circumstances in which the badge was lost to the 436th Contracting Squadron and 436 SFS, Pass and Registration office and submit a new request for badge before a new badge can be reissued.

10.4. EMPLOYMENT TERMINATION: Base Contracting Office or base point of contact will immediately notify Security Forces, Pass and Registration when a contractor’s employment has been terminated. The Agency Chief or Site Supervisors are responsible for notifying and returning the contractor’s badge to Pass and Registration when this occurs. At no time will a contractor contact Security Forces directly regarding badge denial; they need to contact the

Contracting Squadron.

11. INSTALLATION ACCESS:

11.1. CONTRACTOR ID BADGES: The contractor shall obtain personal contractor identification badge for all employees and vehicle passes for all contractor and personal vehicles requiring entry onto Dover AFB from Pass and Registration, for the duration of the contract.

Employees are only permitted to enter the installation during the date and time periods indicted on their contractor badge.

11.2. DRIVING REQUIREMENTS: Vehicle registration, proof of insurance and a valid driver’s license must be presented for all vehicles while operating on the Installation. All vehicles entering the DAFB Main Base, Military Family Housing or sensitive areas are subject to search. Any refusal or non-consent by an employee will result in termination of their base access and immediate confiscation of this access badge.

11.3. FPCON NORMAL AND ALPHA: During Force Protection Condition (FPCON)

Normal and Alpha, personnel without base issued badges must be sponsored onto the installation.

11.4. FPCON BRAVO, CHARLIE AND DELTA. During FPCON Bravo, Charlie and Delta, personnel without base issued identification shall be physically escorted onto the installation.

11.5. NON ESSENTIAL OPERATIONS: During Higher FPCONs (Charlie and Delta) the base will normally curtail non-essential operations/functions; access by non-essential

Contract operations will be suspended at the direction of the Installation Commander.

12. FLIGHT LINE DRIVING: Contractors will have to adhere to the provisions in DAFBI 13-

202 if operating on the airfield.

13. ANTITERRORISM AWARENESS LEVEL I TRAINING: DoD Contractors supporting a Base Service Contract (e.g., Custodial Services, Ground Maintenance, etc.) are highly encouraged to complete AT Awareness Level I training IAW AFI 10-245, Antiterrorism, Standard 25, by completing the - Force Protection computer based training

(CBT) course through the Advanced Distributed Learning System (ADLS) site or the

Defense Technical Information Center (DTIC) at https://atlevel1.dtic.mil/ for individuals without access to government Non-classified Internet Protocol Router Network (NIPRNET) computer and who do not possess a CAC card.

14. MANPOWER REPORTING: The contractor shall report ALL contractor labor hours

(including subcontractor labor hours) required for performance of services provided under this contract for the Kitchen Hoods and Ducts Cleaning Service via data collection site. The contractor is required to completely fill in all required data field at http://www.ecmra.mil.

Reporting inputs will be for the labor executed during the period of performance for each

Government Fiscal Year (FY), which runs 1 October through 30 September. While inputs may be reported any time during the FY, all data shall be reported no later than 31 October of each calendar year. The contractor may direct questions to the CMRA help desk.

15. USES AND SAFEGUARDING INFORMATION: Information from the secure web site is considered to be proprietary in nature when the contract number and contractor identity are associated with the direct labor hours and direct labor dollars. At no time will any data be released to the public with the contractor name and contract number associated with the data.

User Manuals: Data for Air Force service requirements must be input at the Air Force CMRA link.

However, user manuals for government personnel and contractors are available at the Army

CMRA link at http://www.ecmra.mil.

16. OPSEC: 436 AW Group OPSEC Coordinators, of the respective unit having work performed, will provided a copy of the Dover AFB Critical Information and Indicators List (CIIL) and Operations Security (OPSEC) Supplementary Guidance (SG) Tri-fold, to the contractors for their review, understanding, compliance to safeguard Dover AFB Critical Information (CI).

17. PHYSICAL SECURITY: The Contractor shall be responsible for safeguarding all government property and controlled forms provided for Contractor use. At the end of each work period, all government facilities, equipment, and materials shall be secured.

18. APPENDICES:

A. Estimated Workload Data

B. Government Furnished Property/Services/Equipment

C. Dryer Ventilation Ductwork Quantities https://atlevel1.dtic.mil/ http://www.ecmra.mil/ http://www.ecmra.mil/

D. DAFB HAZMAT Chemical Worksheet

E. Contractor Monthly Reports for HAZMATS

APPENDIX A

ESTIMATED WORKLOAD DATA

ITEM

NAME

ESTIMATED

QUANTITY

1 General inspection, testing, and maintaining hood and duct systems

10 Unit

2 Monthly cleaning service. Systems using solid cooking fuels or 24 hour high volume frying, char broiling, or Oriental cooking.

4 Systems

3 Quarterly cleaning service. Systems using high volumes of fast food frying, char broiling, or Oriental cooking.

6 Systems

4 Semi-annual cleaning service. Systems using normal volumes of commercial cooking or baking.

8 Systems

5 Annual cleaning service. Systems using low vapor producing cooking (pizza ovens, steam tables, etc.).

3 Systems

6 Estimated repair service calls 3 Calls per year

APPENDIX B

GOVERNMENT FURNISHED PROPERTY/SERVICES/EQUIPMENT

ELECTRICAL

POWER

POTABLE

WATER

APPENDIX C

Dryer Ventilation Ductwork Quantities

Dormitory Ductwork Linear Footage

445 Inspect / Clean 27 rooms

435 Approx. 435 LF

430 Approx. 125 LF

402 Approx. 115 LF

401 Approx. 115 LF

414 Inspect / Clean 37 rooms

140 Inspect / Clean

212 Inspect / Clean

639 Approx. 40 LF

515 Approx. 115 LF

APPENDIX D - DOVER AFB HAZMAT CHEMICAL

WORKSHEET

Contractor Name:

[Company preforming the work] Contract Number and Title:

Project Number (FJXT):

Estimated Start Date: Estimated Completion Date:

Shop Code (DV):

[To be completed by base personnel]

PROCESS CODE:

[To be completed by Bioenvironmental Engineering]

National Stock Number (NSN), or Part Number:

Manufacture:

Material Name: Size:

[Be Specific] [ounces, gallons or pounds,etc.] Amount used: Container type:

[Per week, month, year] [box, bottle, can, tube, drum etc.] Unit of Issue: Units per container:

[each, dozen, kit, etc.] [2 ea., one dz., 3 part kit, etc.] Will the process be performed inside or outside?

Will the process be performed on equipment, structure or aircraft?

Physical location of process performance:

Location Of stored Material:

Is a Hazardous Waste Generated? YES NO If yes, how is waste disposed:

[remarks] Is a site diagram available? YES NO [remarks] Does the site have a listing of base procedures for reporting a spill? YES NO

[remarks]

This request requires both the contractors and COR signature for processing.

Contractor and Title:

Phone

Date

Government Representative:

Phone

Date

APPENDIX E - DOVER AFB HAZMAT CHEMICAL WORKSHEET

CONTRACTOR’S MONTHLY REPORT FOR HAZMATS

Contractor: Shop Code:

Contract# Location:

The following information is required for tracking of Hazardous Materials on Dover

AFB. For contracts exceeding six months, this form is required to be filled out on a monthly basis and returned to the Government

Representative (COR). Contracts less than six months, this form is required at the beginning and at the completion of the work.

The COR will provide a copy to the Hazmart Pharmacy. This information is required to comply with State, Federal and Air Force laws and regulation.

Material Name Manufacture NSN/Part # Start

Balance

Amount

Used

Use additional sheets as required

Contractor printed and name and date:

Signature:

Government Rep. printed name and date: Signature: