ATTACHMENT_9_Hazardous_Material_Authorization_Form.pdf

Solicitation: 140R3021B0004

Escalator Replacement Hoover Dam Visitors Center

Attachment 9 Hazardous Material Authorization Form

LC-035 Attachment 8 Document No.: SEMS-F010, Revision: 5 Document Date: 11/18/2016

Hazardous Material Authorization

Form

Section I. Requestor Information Name of the Requestor/Contractor:

Organization/Dept: Date:

Section II. Project Information Project Name: Project Location:

Section III. Material Information Material/Product Name: Quantity to be purchased: Unit of Issue (Drums, Gal, bottles):

Usage Frequency: Duration of Task:

Section IV. Process Information Describe:

1) Work activities and processes in which this material will be used; 2) Storage method/location; 3) Re-use/Recycling method/process; 4) Disposal of hazardous waste materials; 5) Attach Safety Data Sheet (SDS):

(Additional information may be attached to this form.)

Section V. Sustainability/ Pollution Prevention List non-hazardous or less hazardous alternatives:

(Complete Hazardous Material Alternative Waiver (Hazardous Material Authorization Form page 2) if non-hazardous or less hazardous material are not available or not viable due to price, schedule, or performance.)

Section VI. Supervisor Concurrence Print Requestor’s Supervisor Name:

Telephone #: Date of Concurrence: Signature:

Section VII. Authorization Hazardous Material Approval:

___ YES

Approved with conditions (if applicable):

___NO

Reason for disapproval:

Print Name of Hazardous Material Authorized Designee:

Date of Authorization: Signature:

Health and Safety Approval:

___ YES

Approved with conditions (if applicable):

___NO

Reason for disapproval:

Print Name of Health & Safety Authorized Designee:

Date of Authorization: Signature:

LC-035 Attachment 8 Document No.: SEMS-F010, Revision: 5 Document Date: 11/18/2016

Hazardous Material Authorization Information

1. Definitions

1. Hazardous Materials: A hazardous material is any substance or chemical which poses a risk or has the potential to cause health or physical harm to humans, animals, or the environment, in the course of normal handling, use, storage, spilling, leaking, pumping, pouring, emitting, emptying, discharging, injecting, escaping, leaching, dumping or disposal.

2. A Hazardous Material Authorization (HMA) is required when:

1. A new Hazardous Material (HM) is purchased for use

2. A change in type/use of HM is required to meet mission needs

3. Additional quantities of HM are needed

4. A contract action allowing a contractor to use or store a HM on-site

3. Individuals Required to Obtain an HMA Persons responsible for purchasing or using HM and/or persons responsible for Contractors using HM.

4. Hazardous Materials Authorization Process The Requester will ensure:

1. A separate HMA form (page 1) is completed for each hazardous material requested for authorization.

2. A current copy of the HM Safety Data Sheet (SDS) is attached to each HMA form.

3. The HMA form and SDS is submitted to and approved by the Authorized Designees for hazardous materials and health and safety prior to purchase of HMs.

4. If non-hazardous or less hazardous alternatives do not exist, or are not viable due to: 1) price, 2) schedule, 3) performance, 4) availability, complete hazardous materials Alternative Waiver (below).

5. The Authorized Designee for Hazardous Materials and Health and Safety will:

1. Ensure the legal and internal requirements related to the HM are considered when authorizing the HM.

2. Provide an evaluation/determination within 10 business days from the time an HMA Form is received by the Authorized Designee unless otherwise negotiated.

3. Provide the Requestor an approved HMA Form (when appropriate).

6. Conditional Authorization/ No Authorization 1.If conditions to approval have been granted by the Authorized Designee, the Requestor/Contractor is responsible for ensuring the conditions are met.

2.If the HM is not approved for use, the Authorized Designee will document the reason(s), contact the Requestor or their Supervisor, and discuss potential alternative(s) to the HM.

Questions regarding the HMA Form or the authorization process can be directed to the Authorized Designee for Hazardous Materials and Health and Safety. Incomplete forms or documentation may delay the authorization process. The Authorized Designee(s) for Hazardous Materials and Health and Safety must sign the authorization for it to be valid. The Requestor should submit the approved HMA Form to the Contractor for their records (if applicable).

For Reclamation Use Only

Alternative Waiver Based on the Executive order 13514, Reclamation Acquisition Regulations, and DOI Sustainability Strategic Performance Plan, I have determined that non-hazardous or less hazardous alternatives are not available for this product due to the following:

[ ] Alternative to the HM is not available within a reasonable period of time.

Date HM Needed: Date available:

[ ] Potential alternative(s) to the HM fail to meet a performance standard in project/design specifications. Describe the performance standard, why the standard is required, and how the alternative(s) to the HM fails to meet the standard:

[ ] Potential alternative(s) to the HM are not available from 2 or more sources. List the vendor name and contact information that is able to provide the alternative(s) to the HM:

[ ] Potential alternative(s) to the HM are only available at an unreasonable cost.

Cost of the Alternative to the HM: $ HM Cost:

Requestor Signature: Date:

Requestor’s Manager/Supervisor Signature: Date: