Attachment 2.13 - HAZMAT Worksheet.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