ATTACHMENT 3 - 180FW FORM 50.pdf

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Attached to
Air Compressor BLDG 124
Solicitation number
W50S8S25QA008
Issued by

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Written by GovTribe AI ·

This document is a Hazmat Authorization Form for Contractors (180FW Form 50), dated 14 February 2024, designed to track and authorize the use of hazardous materials on a project site. The form requires contractors to provide comprehensive details for each hazardous material, including product name, part/stock number, unit of issue, storage location, frequency and location of use, proposed quantity, brief description of use, and intended disposal method. Additionally, contractors must attach a current Safety Data Sheet (SDS) for each item and submit the form to the Contracting Officer.

The form includes sections for Environmental, Safety, and Occupational Health (ESOH) office reviews, with checkboxes for authorization, comments, and change requests from Bioenvironmental Engineering, Environmental Management, and Safety/Fire Protection. The purpose of this authorization is strictly to gather information on hazardous materials usage for regulatory reporting and to ensure the health and safety of government employees. The form explicitly states that it is not an indication of material suitability or an evaluation of the contractor's environmental, safety, or health programs. A companion Contractor Hazmat Use Summary form is also included to track the actual total quantity of hazardous materials used throughout the project.

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Other files

File Type Posted
Mech Room B124.docx DOCX document
Bldg-124 Overview.pdf PDF
ATTACHMENT 1 - PWS for B124 Air Compressor_Rev1.pdf PDF
Combined Synopsis W50S8S25QA008.pdf PDF
ATTACHMENT 4 - Solid Waste Tracking Form.pdf PDF
ATTACHMENT 2 - Clause and Provision.pdf PDF

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HAZMAT AUTHORIZATION FOR

CONTRACTORS

NO HAZARDOUS MATERIAL WILL BE

DELIVERED, STORED, OR USED ON-SITE

UNTIL IT HAS BEEN AUTHORIZED BY

ENVIRONMENTAL, SAFETY, AND

OCCUPATIONAL HEALTH

Project:

Contractor:

Contractor will provide ALL of the information required below for each hazardous material (hazmat) item used on the job site; this form will be submitted to the Contracting Officer

Attach a current Safety Data Sheet (SDS) for each item.

A copy of this form will be returned to the contractor after all reviews have been completed.

At project close-out, provide the ACTUAL quantity of the item used during the project on the Hazmat

Use Summary Form This authorization is used strictly to gather information on hazardous materials usage to address regulatory reporting requirements, as well as ensure the health and safety of government employees. This authorization is

NOT:

An indication that the material meets the intent of the project plans and specifications.

An evaluation or approval of the contractor’s environmental, safety, or health programs

Product Name: Product Part/Stock Number:

Material Unit of Issue (55-gallon drum, 5-gallon pail, 16 oz box, 10 lbs bag, etc.):

Storage Location:

Frequency of Use (one-time, one week, throughout project):

Location of Use (if other than on the immediate project site):

Proposed Quantity of Material to be Used On-Site (gallons, pounds, etc.):

Brief Description of Use (what is the hazmat being used for):

Intended Disposal (how will excess material, empty containers, and clean up materials be disposed of):

FOR ESOH OFFICE USE (use reverse if needed) This item is exempt from Hazmart tracking; no further evaluation required; contractor does not need to track use Authorized Bioenvironmental Engineering - Comments

Authorized with comment Change requested

Signature

Authorized Environmental Management - Comments Subject to EPCRA

312 Subject to

EPCRA 313

Authorized with comment Change requested

Signature

Authorized Safety/Fire Protection - Comments Authorized with comment

Change requested Signature

180FW FORM 50, 14 FEBRUARY 2024

Prescribed by 180FWI32-7002

ADDITIONAL COMMENTS

CONTRACTOR HAZMAT USE SUMMARY

• Contractor will provide ALL the information required below for each hazardous material

(hazmat) item used on the job site; this form will be submitted to the Contracting Officer.

• Provide enough information that quantities can be converted to total pounds.

Product Name: Product Part/Stock Number:

Material Unit of Issue (55-gallon drum, 5-gallon pail, 16 oz box, 10lbs bag, etc.):

ACTUAL total quantity of product used throughout the project

Project:
Contractor:
Product Name:
Product PartStock Number:
Material Unit of Issue 55gallon drum 5gallon pail 16 oz box 10 lbs bag etc:
Storage Location:
Frequency of Use onetime one week throughout project:
Location of Use if other than on the immediate project site:
Proposed Quantity of Material to be Used OnSite gallons pounds etc:
Brief Description of Use what is the hazmat being used for:
Intended Disposal how will excess material empty containers and clean up materials be disposed of:
This item is exempt from Hazmart tracking no further evaluation required contractor does not need to: Off
Signature:
Bioenvironmental Engineering Comments_2:
Signature_2:
Environmental Management Comments:
Signature_3:
SafetyFire Protection Comments_2:
ADDITIONAL COMMENTSRow1:
Product NameRow1:
Product PartStock NumberRow1:
Material Unit of Issue 55 gallon drum 5gallon pail 16 oz box 10lbs bag etcRow1:
ACTUAL total quantity of product used throughout the projectRow1:
Product NameRow2:
Product PartStock NumberRow2:
Material Unit of Issue 55 gallon drum 5gallon pail 16 oz box 10lbs bag etcRow2:
ACTUAL total quantity of product used throughout the projectRow2:
Product NameRow3:
Product PartStock NumberRow3:
Material Unit of Issue 55 gallon drum 5gallon pail 16 oz box 10lbs bag etcRow3:
ACTUAL total quantity of product used throughout the projectRow3:
Product NameRow4:
Product PartStock NumberRow4:
Material Unit of Issue 55 gallon drum 5gallon pail 16 oz box 10lbs bag etcRow4:
ACTUAL total quantity of product used throughout the projectRow4:
Product NameRow5:
Product PartStock NumberRow5:
Material Unit of Issue 55 gallon drum 5gallon pail 16 oz box 10lbs bag etcRow5:
ACTUAL total quantity of product used throughout the projectRow5:
Product NameRow6:
Product PartStock NumberRow6:
Material Unit of Issue 55 gallon drum 5gallon pail 16 oz box 10lbs bag etcRow6:
ACTUAL total quantity of product used throughout the projectRow6:
Product NameRow7:
Product PartStock NumberRow7:
Material Unit of Issue 55 gallon drum 5gallon pail 16 oz box 10lbs bag etcRow7:
ACTUAL total quantity of product used throughout the projectRow7:
Product NameRow8:
Product PartStock NumberRow8:
Material Unit of Issue 55 gallon drum 5gallon pail 16 oz box 10lbs bag etcRow8:
ACTUAL total quantity of product used throughout the projectRow8:
Product NameRow9:
Product PartStock NumberRow9:
Material Unit of Issue 55 gallon drum 5gallon pail 16 oz box 10lbs bag etcRow9:
ACTUAL total quantity of product used throughout the projectRow9:
Product NameRow10:
Product PartStock NumberRow10:
Material Unit of Issue 55 gallon drum 5gallon pail 16 oz box 10lbs bag etcRow10:
ACTUAL total quantity of product used throughout the projectRow10:
Product NameRow11:
Product PartStock NumberRow11:
Material Unit of Issue 55 gallon drum 5gallon pail 16 oz box 10lbs bag etcRow11:
ACTUAL total quantity of product used throughout the projectRow11:
Product NameRow12:
Product PartStock NumberRow12:
Material Unit of Issue 55 gallon drum 5gallon pail 16 oz box 10lbs bag etcRow12:
ACTUAL total quantity of product used throughout the projectRow12:
Product NameRow13:
Product PartStock NumberRow13:
Material Unit of Issue 55 gallon drum 5gallon pail 16 oz box 10lbs bag etcRow13:
ACTUAL total quantity of product used throughout the projectRow13:
Product NameRow14:
Product PartStock NumberRow14:
Material Unit of Issue 55 gallon drum 5gallon pail 16 oz box 10lbs bag etcRow14:
ACTUAL total quantity of product used throughout the projectRow14:
Product NameRow15:
Product PartStock NumberRow15:
Material Unit of Issue 55 gallon drum 5gallon pail 16 oz box 10lbs bag etcRow15:
ACTUAL total quantity of product used throughout the projectRow15:
Product NameRow16:
Product PartStock NumberRow16:
Material Unit of Issue 55 gallon drum 5gallon pail 16 oz box 10lbs bag etcRow16:
ACTUAL total quantity of product used throughout the projectRow16:
Product NameRow17:
Product PartStock NumberRow17:
Material Unit of Issue 55 gallon drum 5gallon pail 16 oz box 10lbs bag etcRow17:
ACTUAL total quantity of product used throughout the projectRow17:
Product NameRow18:
Product PartStock NumberRow18:
Material Unit of Issue 55 gallon drum 5gallon pail 16 oz box 10lbs bag etcRow18:
ACTUAL total quantity of product used throughout the projectRow18:
EP: Off
E2: Off
S2: Off
B2: Off
S3: Off
S1: Off
E3: Off
E1: Off
B3: Off
B1: Off
EP2: Off

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