Appendix_L_HAZMAT_Usage_Report_30July13_(1).pdf
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- Attached to
- Replace Chiller Pumps & Piping Bldg 4196 Federal contract opportunity
- Solicitation number
- FA301618R0068
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Appendix L - GC HazMat Usage Report (SDS)
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JBSA Contractor Hazardous Materials Usage Report Contractor Instructions:
1. List any hazardous material and supporting documentation on the HAZARDOUS MATERIAL USAGE REPORT and provide a copy of the manufacturer-specific Safety Data Sheet (SDS) (formerly MSDS) prior to delivery for usage on the project (i.e., before the hazardous material is brought onto the installation).
2. Submit the completed Usage Report attached to the Contracting Officer (CO) Material Approval Form (AF Form 3000). Attach a
Compact Disc (CD) with a copy of the Usage Report (formatted in Microsoft Word© or Excel©) and the manufacturer SDSs
[formatted in Adobe© Portable Document Format (pdf)].
3. Submit the Form 3000 and Usage Report (with SDSs) to the CO by the 10th work day of each month. If there is a change or new material is added after the monthly report is submitted, then submit an updated Usage Report (with SDSs) no later than the same work day that the material is received on the installation.
Note: Hazardous Material is defined in Federal Acquisition Regulation (FAR) Clause 52.223-3 and the AF Instruction 32-7086
Contract Number:______________________________
Project Name: _________________________________________
Date of Report (Ex: 10Jun 2012):_______________________
Reporting Period (Ex: 10Jun2012 -30Jun2012):
Project Address: ________________________________________
Project Building #:_______________________________________
HAZMAT Location Address/Building# (if different from project):_______________________________________________
Contract Start Date: _______________________________
Contract End Date (Original date)____________________
Modified End Date (If Applicable):___________________
Contractor Business Name:___________________________________________________________________________________
Contractor POC for obtaining Hazardous Materials information Name: ________________________________________________
Phone:___________________________ Email: _________________________________
JBSA CO Name:________________________ Phone #:______________ Email:______________________________________
JBSA Shop Code(if known):_________________ Comments:____________________________________
Ref #
Process
(Brief description of the work being performed.)
Manufacturer
Name
Safety Data Sheet
(SDS) Manufacturer
Trade Name
Package
Part # or
Order #
Type of
Container
(e.g., drum, glass bottle, aerosol can, tube)
Size of
Containe r (e.g., oz, gal, lbs, volts)
Total Quantity brought on
Installation during reporting period
EESOH MSN (to be added by
JBSA HAZMAT
MGR)
Example: Cleaning Furniture in Bldg
S.C. Johnson & Son, Inc.
PLEDGE® Furniture Polish Revitalizing
Oil 498940
Trigger Spray Plastic bottle
16 fl oz.
1 case with 12 containers per case (total of
12)
(7930-01-381- 3491)
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