Attachment_10_Forms__12_pages.pdf

140R3022R0033 Attachment (10): Forms, 6 Total

1. Contractor's Report of Recordable Injury/Illness, 7-2077 (8-86)

2. Contractor's Monthly Summary of Occupational Injuries/Illnesses Experience, 7-2218 (7-96)

3. Request for Supplies/Services

4. Work Order Approval Form

5. Toxic Release Inventory

6. Chemical Inventory

7-2077 (8-86) Bureau of Reclamation

CONTRACTOR’S REPORT OF RECORDABLE INJURY/ILLNESS

Refer to Section 2 of Construction Safety Standards

Each work related fatality and injury/illness (first aid cases excepted), shall be reported on this form. The completed form will be submitted to the contracting officer’s representative within 3 working days from the date of the incident or onset of illness.

Responsibility for completion and submission of this form for all onsite injuries/illnesses to contractor, subcontractor, or supplier forces rests with the prime contractor. All form terms are as defined on the reverse side.

CONTRACT SPECIFICATIONS (Number and Feature)

DATE OF THIS REPORT

EMPLOYER

INJURED EMPLOYEE’S NAME

SOCIAL SECURITY NO. OCCUPATION

AGE

DATE EMPLOYED DATES OF PREVIOUS INJURIES

DESCRIBE INJURY/ILLNESS

DATE OF INJURY

TIME ATTENDING PHYSICIAN INJURY CLASSIFICATION

MEDICAL ONLY OTHER

STARTED LOSING TIME (Never Date of Injury)

DID INJURY RESULT IN DEATH OR PROBABLE PERMANENT

DISABILITY?

RETURN TO WORK (Date)*

DATE OF DEATH

WORKDAYS LOST TIME*

DAYS OF RESTRICTED WORK OR TRANSFER TO OTHER JOB

*Estimate date of return to full duty to avoid delay in submitting report (see reverse side for estimating instructions)

DESCRIBE ACCIDENT (include Who, What, When, Where, and How)

HOW COULD ACCIDENT HAVE BEEN PREVENTED?

SUPERVISORY

OPINION

(Signature) ______________________________________________

FOREMAN OR IMMEDIATE SUPERVISOR

ACTION TAKEN TO PREVENT A RECURRENCE

PREVENTIVE

ACTION

TAKEN

(Signature) ______________________________________________

PROJECT MANAGER OR SUPERINTENDENT

(NOTE: Information in this report is to be used for the prevention of accidents and is not intended as a basis for injury claims, Recordable injuries/illnesses and workdays lost and injury classification shall be as defined on reverse side of this form.)

7-2077 (8-86) Bureau of Reclamation DEFINITION OF TERMS

Work-related injury/illness: All injuries/illnesses to contractor, • Application of HEAT THERAPY during first visit to medical subcontractor or supplier employees that result from an event or personnel.

exposure on any contractor controlled worksite associated with the • Use of WHIRLPOOL BATH THERAPY during first visit to respective contract. medical personnel.

• NEGATIVE X-RAY DIAGNOSIS

Medical Cases: Injuries/Illnesses are defined as medical cases • BRIEF OBSERVATION of injury during visit to medical personnel.

if (1) they can be treated only by a physician or licensed medical personnel, (2) they result in damage or harm to physical structure Note: The administration of a TETANUS SHOT or BOOSTER, by of a nonsuperficial nature (e.g. hairline fractures), (3) they impair Itself, is not considered medical treatment. However, these shots bodily functions (i.e. normal use of senses, limbs, etc.), (4) they are often given in conjunction with the more serious injuries.

involve complications requiring followup medical treatment. Therefore, injuries requiring tetanus shots may be reportable for other reasons.

The following are generally considered medical treatment:

Illness Cases: Occupational illness of an employee is any abnormal

• Treatment of INFECTION condition or disorder, other than one resulting from an occupational

• Application of ANTISEPTICS during second or subsequent injury caused by exposure to environmental factors associated with visits to medical personnel employment. It includes acute and chronic illnesses or diseases

• Treatment of SECOND OR THIRD DEGREE BURN(S) which may be caused by inhalation, absorption, ingestion, or direct

• Application of BUTTERFLY ADHESIVE DRESSING(S) or contact

STERISTRIPS in lieu of sutures.

• Application of SUTURES (stitches) Some conditions may be classified as either an injury or illness

• Removal of FOREIGN BODIES EMBEDDED IN EYE (but not both), depending upon the nature of the event that produced

• Removal of FOREIGN BODIES from wound; if procedure is the condition. For example, a loss of hearing resulting from an

COMPLICATED because of depths of embedment, size or explosion (an instantaneous event) is classified as an injury, the location same condition arising from exposure to industrial noise over a

• Use of PRESCRIPTION MEDICATIONS (except in a single period of time would be classified as an occupational illness.

dose administered on first visit for minor injury or discomfort) Similarly, irritation of the throat from exposure to chlorine funes

• Use of hot or cold SOAKING THERAPY during second or would be classified as an injury if it resulted from a ruptured tank subsequent visit to medical personnel And an illness if the exposure occurred over a period of time. The

• Application of hot or cold COMPRESS(ES) during second or Adverse reaction to a tetanus shot given for a laceration would be subsequent visits to medical personnel classified as an injury. Back cases should always be recorded as

• CUTTING AWAY DEAD SKIN (surgical debridement) an injury. It should be noted that all occupational illnesses are

• Application of HEAT THERAPY during second or subsequent reportable and recordable incidents regardless of the type of visit of medical personnel treatment provided.

• Use of WHIRLPOOL BATH THERAPY during second or subsequent visit of medical personnel Fatalities: Work related fatalities are reportable and recordable

• POSITIVE X-RAY DIAGNOSIS (fractures, broken bones, etc.) regardless of the time between the injury and the death or the length

• ADMISSION TO A HOSPITAL or equivalent medical facility for of the illness. Lost workdays attributable to the incident are not treatment or prolonged observation. counted and any charged should be removed from the record.

First Aid Cases: Cases (1) limited to one-time treatment and Lost Workdays: Lost workdays are defined as the number of subsequent observation and (2) involve treatment of only minor workdays (consecutive or not), beyond the day of injury or onset injuries, not emergency treatment of serious injuries. Further, any of illness, the employee was away from work or limited to restricted one-time treatment and followup visit for the sole purpose of work activity. The number of days away from work or days of observation of minor scratches, cuts, burns, splinters, and so forth, restricted work activity does not include the day of injury or onset which do not ordinarily require medical care are classified as first of illness or any days on which the employee would not have worked aid treatment. Such one-time treatment and followup visit for the even though able to work, e.g. vacation days, days off, or holidays purpose of observation is considered first aid even though provided are not counted. Termination of employment may stop the count by a physician or registered professional personnel. Visits to a doctor of lost workdays if unrelated to the employee’s injury or illness.

for an examination or other diagnostic procedure to determine If termination is related to injury/illness, an estimate of actual whether the employee has an injury is classified as a first aid case workdays lost shall be made. Retirements unrelated to injury or if no injury is discovered or medical treatment is rendered. Iilness stop the count of lost workdays. Otherwise days lost are Conversely, if treatment is described and medical care is provided estimated. Lost workday counts cease when injury or illness is even by someone other than a physician or registered medical determined as totally disabling. Lost workday count stops when personnel, injury is classified as medical. Other examples of first position employee was in when injured is abolished due to work aid cases not requiring reporting unless they result in loss of completion, e.g. a dozer operator lost workdays count would not consciousness, restriction of work, or motion, or transfer to another continue beyond last day of dozer operations on the project even job are: if the operator still could not perform the operator functions.

• Application of ANTISEPTIC during first visit to medical personnel Restricted work: The number of workdays on which, because of

• Treatment of FIRST DEGREE BURN(S) injury or illness: (1) the employee was assigned to another job on

• Application of BANDAGE(S) during first visit to medical a temporary basis, (2) the employee worked at a permanent job personnel less than full time, or (3) the employee worked at a permanently

• Use of ELASTIC BANDAGE(S) during first visit to medical assigned job but could not perform all duties normally connected personnel. with it. Lost workday count stops when employee is permanently

• Removal of FOREIGN BODIES NOT EMBEDDED IN EYE if only transferred to another permanently established position.

irrigation is required

• Removal of FOREIGN BODIES from wound. If procedure is Contractor-Controlled Worksite Associated with the Contract: The

UNCOMPLICATED, and is, for example, by tweezers or other following and similar locations are considered contractor-controlled simple technique worksites:

• Use of NONPRESCRIPTION MEDICATIONS and administration of single dose of PRESCRIPTION MEDICATION on first visit for All areas within the boundaries of the construction site including minor injury or discomfort shops, plants, storage areas, haul-roads and borrow and fill areas.

• SOAKING THERAPY ON INITIAL VISIT to medical personnel or removal of bandages by SOAKING All offsite locations (plants, shops, rock quarries, borrow areas,

• Application of hot or cold COMPRESS(ES) during first visit to erection sites, etc.) used exclusively for supporting construction medical personnel activities. All roads where traffic control is a contractor

• Application of OINTMENTS to abrasions to prevent drying or responsibility.

cracking

7-2218 (7-96) Bureau of Reclamation

CONTRACTORS MONTHLY SUMMARY OF OCCUPATIONAL INJURIES/ILLNESSES EXPERIENCE

The prime contractor will submit this completed form to the contracting office’s representative by the first day of each month. Included on this form will be the contractors, subcontractors, and suppliers onsite injury/illness experience for the previous reporting period. Reporting period cutoff dates can coincide with appropriate pay periods as long as the ending date of this current report is the beginning date of the next report. All form terms are defined in Appendix DD of Reclamation Safety and Health Standards or elsewhere on this form.

REPORTING PERIOD – STARTING ENDING

RECORDABLE CASES INCIDENT RATES

CONTRACTOR,

SUBCONTRACTOR

SUPPLIER – SPEC. NO.

TYPE OF

CONSTRUCTION

NO.

EMPLOYEES

MAN-HOURS

EXPOSURE

LOST

WORKDAYS

TOTAL

DEATHS

LOST

WORKDAY

CASES

CASES

DEATH

AND LOST

WORKDAY

CASES

LOST

WORKDAYS

1 2 3 4 5 6 7 8 9 10 11

PRIME CONTRACTOR

NAME

SPEC. NO.

SUBCONTRACTOR

SUPPLIERS

CUMULATIVE TOTAL

Column 1. Name of General Contractor and General Specification No. only. Combine all subcontractor and/or supplier data under respective headings. Cumulative totals start from first day of onsite work under the specification.

Column 2. Major classification or type of work for contractor (earth dam, concrete dam, canals, tunnel, pumping plant, power facilities, etc.). Minor classification to supplier or subcontractor (concrete work, earthwork, repair work, etc.).

Column 3. Average number of employees during reporting period. Include only onsite personnel. Number of subcontractor or supplier employees can be estimated by dividing number of estimated man-hours by 8 x number of days in reporting period ( Number of man-hour _ ) (8 x number of days of reporting period) Column 4. Actual man-hours of onsite exposure. Do no include vacation time, holidays, down periods, etc.

Column 5. Lost workdays include actual days from work, restricted workdays, and days worked in another assigned position. (See Appendix DD of Reclamation, Safety and Health Standards for detailed explanation of lost workdays and restricted work.)

Column 6. Total of fatalities, lost workday cases, restricted work cases or transfer to other job cases, and medical cases reported on all forms 7-2077. Contractor’s Report of Recordable injury/illness, submitted during the reporting period covered on this form.

Column 7. Fatalities are charged to date of injury or onset of illness regardless of date of death.

Column 8. Includes all cases submitted during this reporting period on forms 7-2077, Contractor’s Report of Recordable Injury/Illness, that show figures under headings entitled, “Workdays lost time” or “Days of restricted work or transfer to other job.” (See Appendix DD of Reclamation Safety and Health Standards.)

Column 9, 10, 11. Incident rates are defined on the number of injuries/illnesses or lost workdays related to a common exposure base-100 full-time workers or 200,000 man-hours of exposure (100 workmen x 40hrs/week x 50 weeks/year = 200,000). These rates are calculated as follows:

Total Cases (column 9) = Total cases (column 6) x 200,000 Man-hours of Exposure (column 4)

Death, and lost = Deaths (column 7) and lost workday cases (column 8) x 200,000 Workday cases Man-hours of exposure (column 4) (column 10)

Lost workdays = Lost workdays (column 5) x 200,000 (column 11) Man-hours of exposure (column 4)

REQUESTOR WORK ORDER NUMBER:

Company Name:

Estimated Tax

PRIORITY:

Address:

City, State, Zip:

Phone:

E-Mail:

Website:

Fax:

RECOMMENDED SOURCE:

Contact:

DELIVER TO: Bureau of Reclamation, Yuma Area Office 7301 Calle Agua Salada, Yuma AZ 85364

Yes NoMSDS Required:

ITEM

PART NO. DESCRIPTIONQTY

UNIT PRICE TOTAL

Subtotal Pg 2 ofPage

Sole Source Required: Yes

Request for Supplies/Services

If Yes, attach approved MSDS or MSDS No.

CATEGORY:

YDP, PS1, Research, CRADA

DATE:

Requester Signature:

FOR PURCHASE:

MODEL

COR - Bureau of Reclamation Date

APPROVAL

REQUIRED

X

REQUIRED

Contract Manager Date

FOR QUOTATION:

No If Yes, attach justification.

DDN:DATE NEEDED:

EXTENSION:

Estimated Total Cost

Estimated Freight

Subtotal

PR #

PR Justification:

REQUESTOR WORK ORDER NUMBER:

ITEM QTY UNIT PRICE TOTAL PART NO.

Subtotal

FOR PURCHASE:Page of FOR QUOTATION:PR #

MODEL DESCRIPTION

PRIORITY: DATE NEEDED: DDN:

Request for Supplies/Services DATE:

EXTENSION:

Equipment Name: Device Designation Number:

Originator: Date: Date Required:

Contractor Approval:

Approval - Reclamation:

Approved: Signature:

Disapproved: Date:

Description of Work Required:

Mechanical: Emergency:

Electrical: Urgent:

Instrumentation: Scheduled:

Outage:

Estimated Hours: 50

Modification:

PM:

Break Down:

Yes No Are drawings required for this work?

Drawing Number if Applicable:

Work Order Approval Form

Department: Priority:

Classification:

Toxic Release Inventory (TRI) Data - Calendar Year 2024 Pilot System 1

Intake Chlorine - mg/L (From Operator Grab Samples) January February March April May June July August September October November December Avg

2.8 3.7 3.7 3.3 4.1 4.8 5.1 4.3 4.1 3.8 3.5 3.9 3.9 Free Free Free Free Free Free Free Free Free Free Free Free Avg

3.3 4.3 4.3 4.0 4.8 5.5 5.9 5.0 4.9 4.5 4.2 4.6 4.6

Total Total Total Total Total Total Total Total Total Total Total Total

Clearwell Chlorine - mg/L (From Operator Grab Samples) January February March April May June July August September October November December Avg

1.05 1.11 1.06 1.09 1.11 1.07 1.06 1.09 1.12 1.15 1.16 1.17 1.10 Free Free Free Free Free Free Free Free Free Free Free Free Avg

1.31 1.46 1.42 1.36 1.48 1.45 1.43 1.46 1.48 1.50 1.54 1.63 1.46 Total Total Total Total Total Total Total Total Total Total Total Total

Pilot System 1 Monthly Chlorine Usage (kg) January February March April May June July August September October November December Sum

324 426 465 567 530 595 676 552 493 455 403 416 5902 400 500 500 600 700 700 800 600 600 600 500 500 7000

Pilot System 1 Monthly Ammonia Usage (kg) January February March April May June July August September October November December Sum

80 77 82 34 75 79 82 79 79 82 79 82 910 123 118 126 122 126 122 126 122 122 126 122 126 1486 204 195 208 156 202 202 208 202 202 208 202 208 2396 136 340 204 204 204 272 204 204 204 272 204 272 2720

Pilot System 1 Average Monthly Pretreatment Flow Rate (L/s) January February March April May June July August September October November December

37 37 37 37 37 37 38 38 38 37 37 37 Pilot System 1 Pretreatment On-stream Hours

January February March April May June July August September October November December 742 696 744 720 744 720 744 728 720 744 720 744

Pilot System 1 Average Monthly RO Unit 1 Feed Flow Rate (L/s)

11.0 11.2 11.2 4.8 10.3 11.2 11.2 10.9 11.2 11.2 11.2 11.2 Pilot System 1 Average Monthly FS/RO Unit 2 Feed Flow Rate (L/s)

January February March April May June July August September October November December

16.7 17.2 17.2 17.2 17.2 17.2 17.2 16.6 17.2 17.1 17.2 17.2

Pilot System 1 Average Monthly Combined RO Feed Flow Rate (L/s) January February March April May June July August September October November December

27.8 28.4 28.4 22.0 27.5 28.4 28.4 27.5 28.4 28.4 28.4 28.4 Pilot System 1 RO Unit 1 On-stream Hours

January February March April May June July August September October November December

730.167 696 744 306 682.5 720 744 720 719 743.5 720.0 744.0

Pilot System 1 FS/RO Unit 2 On-stream Hours

725.416 696 744 720 744 720 744 720 720.0 742.8 720 744.0

FY 2026

May 31, 2026 Process Area Size Delivered Last Month This Month Used Magnesium Sulfate 50# bag 7.25 7.25 0 Ammonium Chloride 50# bag 2 2 0 Sodium Tripolyphosphate (STPP) 100# bag 22.5 22.5 0 Citric Acid 50# bag 3 3 0 Ammonium Sulfate 50# bag 99 99 0 Rock Salt 40# bag 48 48 0 Manganese Sulfate Kg drum 48 48 0 TI 2906 Ortho/Polyphosphate 55 gallon drum 2 0.3 1.5 0.8 EDTA tetrasodium 50# bag 2 2 0 Glycerin 55 gallon drum 8 8 0 VITEC 5100 gallons tote 225 200 25

Dry Chemical Building Size Delivered Last Month This Month Used Hydrated lime 50# bag 40 30 10 Sodium Bicarbonate 50# bag 50 34 16 Sodium Hypochlorite (Bleach) 50 gallon drum 6.5 6 0.5

East Cold Storage Size Delivered Last Month This Month Used Hydrogen Peroxide 35% 1 gallon jug 0 0 0 1- Propanol 99.9% 1 gallon jug 0 0 0 Isopropyl Alcohol 1 quart can 0 0 0

Diesel Generators Size Delivered Last Month This Month Used Diesel Fuel Area 14 gallons 4410 4372 38 Diesel Fuel Area 11 gallons 605 575 30

Chemical Storage Shelter 1 Size Delivered Last Month This Month Used Aluminum Sulfate 53 gallon drum 8 8 0 Sumachlor 50 53 gallon drum 3 3 0 Polyfloc AS 1002 53 gallon drum 1 1 0 TriClean 214CA 55 gallon drum 0.1 0.1 0 KLEEN MCT 107 55 gallon drum 0.2 0.2 0

Chemical Storage Shelter 2 Size Delivered Last Month This Month Used Vanwet Acid 98 53 gallon drum 1 1 0 Citric Acid (Liquid) 5 gallon 4 2 2 Citric Acid (Liquid) 55 gallon drum 1 1 0 Hydrochloric Acid (Muriatic) 1 gallon 20 18 2 KLEEN MCT 103 55 gallon 0.3 0.3 0 KLEEN MCT 882 55 gallon 1 1 0 KLEEN MCT 113 55 gallon 0.3 0.3 0 TriClean 310 55 gallon 0.1 0.1 0 ROClean L403 55 gallon 2 2 0 Sulfuric Acid 5 gallon 6 6 0

Chemical Storage Shelter 3 Size Delivered Last Month This Month Used Memclean EXA2 5 gallon pail 2.5 2.5 0 Soda Ash 5 gallon pail 5.5 5.5 0 Sodium Phosphate Tribasic 45kg drum 1.5 1.5 0 Ammonium Hydroxide 53 gallon drum 2.75 2.75 0 Ammonium Sulfate 10kg drum 1 1 0 Sodium Hydroxide (Caustic Soda) 53 gallon drum 1.5 0.75 0.75 Sodium Hydroxide (Caustic Soda) 1 gallon 0 0 0 Sodium Perborate TetraHydrate 25 kg bag 1.3 1.3 0

Chemical Storage Shelter 4 Size Delivered Last Month This Month Used Argo SI300 5 gallon pail 1 1 0 Biosoft D-40 475# drum 3 3 0 Tergitol 55 gallon drum 2 2 0 Triton X-100 480# drum 1 1 0

Yuma Desalting Plant Monthly Facility Chemical Inventory

Flocon 260 53 gallon drum 1 1 0 Flocon 135 53 gallon drum 0.2 0.2 0 AWC A-102 Plus 53 gallon drum 1.2 1.2 0 Dextran 1kg drum 1 1 0 Poly Floc AE 1115 5 gallon pail 0.2 0.2 0 EDTA 45kg drum 0.25 0.25 0 ROClean L211 55 gallon drum 1.75 1.75 0 ROClean L607 55 gallon drum 0.75 0.75 0 Spectrus NX 1100 5 gallon pail 1 1 0 Vitec 7000 5 gallon pail 1 1 0

Lube Storage Size On Hand Ultra coolant IR gallon 4

HD 68 Chevron Rando gallon 13 ATF gallon 55 AW 32 wt gallon 15.3

Cutting oil gallon 6

Mobile Syn SHC 630 gallon 4

Chevron GST ISO 32 55 gal drum 1.11

Rugged 400 30 wt oil gallon 9

Valvoline 5-30 oil quarts 4

Chev. Capella 68 WF gallon 24

Conco Transformer Oil gallons 0 Mobil Gear 600XP220 gallon 42 Mobile SAE 15-40 wt oil gallon 3 Mobile Gear Oil 600 gallon 3 Valvoline 10-40 wt oil quarts 3 DA Gearteck Advanced EP gallon 36