Exhibit M - Construction Environmental Safety Health Certification.pdf

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ATTACHMENT C – Construction Environmental, Safety, & Health Certification (CESHC)

INSTRUCTIONS

This Construction Environmental, Safety & Health Certification (CESHC) is required for each construction project at DOE’s Fermi National Accelerator Laboratory site (Fermilab). See Technical Specification 013100 for further information.

This document is a template for the CESHC designed to assist construction subcontractors in describing project conditions and developing project-specific hazards and controls information.

The CESHC template is available in electronic format to facilitate editing.

The prime subcontractor may either flow down this requirement to each of its subcontractors; or serve as a control and coordination point, requiring all subcontractors’ activities to be conducted under the prime subcontractor’s solitary CESHC.

Subcontractors must submit the completed CESHC to the FermiForward Procurement Office, which will distribute the document for review and concurrence by the FermiForward ES&H and Project Management teams prior to work commencing. The CESHC is intended to be a living document, which may be updated as necessary throughout a project as information changes or as the project progresses (e.g. – as additional Task/trade Hazard Analyses are developed, subcontractors added, etc.).

All of the sections in are required to be completed for each construction project, regardless of the size or complexity. Enter information in all of the fill-in blocks that are applicable. For those that are not applicable, enter “N/A” or other suitable explanation.

10 CFR 851 Acknowledgement

Because Fermilab is a Department of Energy site, your company must meet the Department of Energy requirements of Title 10, Code of Federal Regulations, Part 851, “Worker Safety and Health Program” (Link to 10 CFR 851). It is your responsibility to ensure you have read and understand the actual regulatory requirements. Specify medical surveillance and qualifications. This may include Occupational exposure monitoring.

https://www.gpo.gov/fdsys/granule/CFR-2012-title10-vol4/CFR-2012-title10-vol4-part851

Construction Environmental, Safety & Health Certification (CESHC)

ACKNOWLEDGMENT of 10 CFR 851

As a subcontractor to FermiForward, while your workers are physically located at Fermilab you must meet the requirements of Title 10, Code of Federal Regulations, “Energy”, Part 851, “Worker Safety and Health Program” (10 CFR 851). As such, you must be aware of, and comply with, the requirements of this regulation. (Link to 10 CFR 851)

Acknowledgment I, (the author of this CEHSC), certify that that I have read the requirements of 10 CFR 851 and attest that my firm and its sub-tier contractors will comply with the requirements of 10 CFR 851.

Yes No

MEDICAL SURVEILLANCE AND

QUALIFICATION

Occupational Medicine Will you have any employees that will work on-site at Fermilab for 30, eight-hour days in a 12-month period, or are enrolled for any length of time in a medical or exposure monitoring program required by federal, state, or local regulations (including hearing conservation, respiratory protection, lead exposure)?

Yes No

If yes, you will need to:

1. Comply with the occupational medicine requirements of 10 CFR 851, Appendix A

2. Provide your occupational medicine provider contact information

Clinic Information Clinic Name & Address: Enter telephone number: Enter e-mail address: (Optional)

Required Medical Surveillance Task-specific medical testing

DOT/Commercial Vehicle Blood Lead Hearing Conservation Respirator User Fit for Duty Other(s) List other(s) Substance Abuse Testing

List specific task(s) requiring medical surveillance:

Signature (Subcontractor) Dated Signature

(FermiForward) Dated https://www.gpo.gov/fdsys/granule/CFR-2012-title10-vol4/CFR-2012-title10-vol4-part851

FermiForward has identified five medical facilities. Please highlight the facility to be used or identify and provide a map of an alternate selected place. Annotate address for designated facility.

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