Attachment 4 - Green Procurement Form.pdf

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Headquarters 628th Air Base Wing

Joint Base Charleston, South Carolina 29404

May 2017

CAFB GREEN PROCUREMENT PLAN

APPENDIX C

GREEN PRODUCTS DETERMINATION FORM

Green Products Determination Form

User’s Guide

Purpose of Form: The “Green Products Determination Form” (GPDF) is utilized to clearly document compliance with the Joint Base Charleston Green Procurement Program (GPP) Plan. This includes compliance with seven elements of the program as follows: Recovered Materials (formerly referred to as Affirmative Procurement which covers the Comprehensive Procurement Guideline [CPG] requirements for recycled and reclaimed content of products); Biobased Products; Energy and Water Efficient Products; Alternative Fuels and Fuel Efficiency; Non-

Ozone Depleting Substances (ODS); Priority Chemicals; and Environmentally Preferable Products. It is also used to document the use of applicable exemptions taken for the Recovered Materials and Biobased items not selected for procurement.

OPR: (fill in org symbols), and all other purchasers making procurements other than through utilizing the

Government-wide Purchase Card (GPC).

OCR: (fill in org symbols – include 628 CONS and 628 CES/CEV).

Applicability: The GPDF applies to all procurement actions (other than GPC purchases) covered by the

Joint Base Charleston GPP. This includes items that are listed in the CPG, Biobased, Energy Star®, FEMP

Low Standby Power, Water Efficiency, Non-ODS, Alternative Fuel and Fuel Efficiency, and Priority

Chemical programs.

Intent for Use:

a. GPC holders will not complete this form and will use the “GPC Coordination Sheet” instead.

b. Everyone on base who purchases products or services via purchase order, blanket purchase agreement, contract, and so forth (except for GPC purchase) are responsible for completing a

GPDF. The OCR organizations listed above will be responsible for verifying that GPDFs are completed for all procurement actions.

Filing Procedure: The completed GPDFs will be included in the purchasing or contracting file. 628 CONS is responsible for ensuring that a GPDF is included in contracting files.

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Green Products Determination Form (GPDF) Joint Base Charleston

Instructions: This form is to be completed by the requiring activity to comply with the Joint Base Charleston Green Procurement Program (GPP). The completed form becomes part of the contract file and/or the purchasing file to document GPP compliance.

If applicable, insert Solicitation/Contract/Project No.: DKGV 13-2150 Work Order No.: 33889

Contact 628 CES/CEV or 628 CONS for further information on GPP.

Recovered Materials (i.e., recycled-content) and/or Biobased products are listed below. Place a check next to all products that are to be purchased or insert an exemption number (e.g., “E1”) from the bottom of the page. If these GPP Elements are not applicable to this procurement, indicate this below and proceed to back of form.

These GPP Elements are not applicable to this purchase.

Construction Products Paper and Paper Products

X Building insulation products Commercial/industrial sanitary tissue products

Polyester Carpet Miscellaneous papers (tray liners)

X Cement and concrete containing: coal fly ash, ground granulated blast furnace slag, cenospheres, or silica flume

Newsprint

Paperboard and packaging products

Consolidated and reprocessed latex paint and coatings Printing and writing papers

X Floor tiles Park and Recreation Products

Laminated paperboard Plastic fencing (snow or erosion control, safety barriers)

Patio blocks Playground surfaces

Shower and restroom dividers/partitions Running tracks

Structural fiberboard Park benches and picnic tables

Carpet cushion Playground equipment

X Flowable fill (backfill) Bike racks

Railroad grade crossings/surfaces Transportation Products

Modular threshold ramps Channelizers

Nonpressure pipe Delineators

X Roofing materials Flexible delineators

X Roof coatings Parking stops

Blasting grit X Traffic barricades

X Adhesives X Traffic cones

Landscaping Products Vehicular Products

Garden and soaker hoses Lubricants and functional fluids

Hydraulic mulch Engine Coolants

Lawn and garden edging Re-refined lubricating oils

Compost (e.g., food, yard trimmings, livestock or crop residues) Fuels and fuel additives

Landscaping timbers and posts (plastic lumber) Retread tires

Non-Paper Office Products Rebuilt vehicular parts

Binders (paper, solid plastic, or plastic covered) Mobile equipment hydraulic fluids

Office recycling containers Diesel fuel additives

Office waste receptacles Miscellaneous Products

Office furniture Penetrating lubricants

Plastic desktop accessories Pallets

Plastic envelopes Sorbents

Plastic trash bags Awards and plaques

Printer ribbons Industrial drums

Toner cartridges Mats

Plastic clipboards X Signage

Plastic clip portfolios Strapping

Plastic file folders Plastics – monomers and polymers

Plastic presentation folders Solvents and cleaners

______ Inks Other (insert product____________________________)

EXEMPTIONS: The Air Force requires purchase of recycled-content or biobased products meeting EPA or USDA recommended levels unless one of the following four exemptions apply:

E1. The product does not meet appropriate performance standards.

E2. The product is not available within a reasonable time frame.

E3. The product is not available competitively (from two or more sources).

E4. The product is only available at an unreasonable price (compared with a comparable green product).

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GPDF (Continued)

Energy- and Water-efficient eligible products being procured are (check all that apply)

This GPP Element is not applicable to this purchase.

Energy (FEMP/Energy Star) Water (FEMP/AFCESA)

X HVAC systems and components Irrigation

Commercial appliances Toilets and urinals

Residential appliances Faucets and showerheads

Pumps Boiler and steam systems

Motors Single-pass cooling equipment

Transformers Cooling tower

X Lighting products ______ Other (insert product____________________________)

Computers and office equipment (e.g., fax, copier, printer, etc.)

Renewable energy or renewable energy certificates

Alternative (green) power

______ Other (describe_________________________________)

Alternative Fuels and Fuel Efficiency Products being procured (or leased) are (check all that apply)

X This GPP Element is not applicable to this purchase.

Fuel-efficient vehicle Biodiesel fuel

Advanced technology vehicle/hybrid Ethanol fuel

______ Other (describe_________________________________) Hydrogen fuel

Natural gas fuel

______ Propane fuel

Non-Ozone Depleting Substances (ODS) Element (check all that apply)

NOTE: Air Force purchasers must maximize the use of safe alternatives to ODSs, phase-out the procurement of Class I ODS products, utilize the Defense Logistics Agency (DLA) ODS Reserve to reclaim and recycle Class I ODSs for mission-critical uses, and work towards phasing-out use of all ODS products.

Examples of products that include ODSs are refrigeration and air conditioning systems and components, foam insulation, cleaning solvents, fire suppressants, aerosol solvents and propellants, sterilants, adhesives, coatings, and inks.

X This GPP Element is not applicable to this purchase.

ODS product purchased from DLA ODS Reserve ______ Other (describe_________________________________)

Class I or II ODS alternative being purchased (list below)

--alternative product being procured______________________

Priority Chemicals Element (check the EPA priority chemical below for which an alternative was purchased)

NOTE: Air Force purchasers must look for alternatives to the five priority chemicals (or products containing these chemicals) listed below. Contact your Pollution Prevention Program Manager within 628 CES/CEV for non-hazardous alternatives for these chemicals or products.

Examples of products that include these chemicals are batteries; some pigments, metal coatings, and plastics; solder; thermostats, calculators, thermometers, barometers and other small appliances; light fixtures and lamps; electrical switches, cameras, and cathode tubes; household cleaners; mothballs and moth repellants, and toilet deodorant blocks.

X This GPP Element is not applicable to this purchase.

Cadmium Mercury

Lead ______ Naphthalene

Polychlorinated Biphenyls (PCBs)

SIGNATURES:

Requiring Activity: 628 CES/CENMP, 5/24/18 Concurrence by Contracting: Signature, Office Symbol, Date