151119__Attachment_5-_Haz_Mat_Short_Term_Contractor_Usage_Report.pdf

Locally generated form – Laughlin AFB

Laughlin AFB Short Term Contractor Hazardous Materials Usage Report Contractor Instructions:

1. List any hazardous material and supporting documentation on the LAFB HAZARDOUS MATERIAL USAGE REPORT (attached) and provide a copy of the manufacturer-specific Safety Data Sheets (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 copy of the Usage Report and the manufacturer SDSs.

3. Submit the Usage Report 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 described in Federal Acquisition Regulation (FAR) Clause 52.223-3 and Air Force Instruction 32-7086, Hazardous Material Management.

Direct questions to the Contracting Officer.

Contract Number:

Project Name:

Date of Report (Ex: 10Jun 2012):

Reporting Period (Ex: 10Jun2012 -30Jun2012):

Project Address:

Project Building(s) #:

Where will HAZMAT be stored used and stored? Address/Building#:

Contract Start Date:

Contract End Date (Original date):

Modified End Date (If Applicable):

Contractor Business Name: Contractor POC for obtaining HM information:

Phone: Email:

LAFB Contracting Officer Name: Phone #: Email:

LAFB EESOH-MIS Shop Code: LAU0920 (Short Term Contractor)

Brief Description of Project

LAFB Hazardous Material Usage Report

Locally generated form – Laughlin AFB

LAFB Hazardous Material Inventory & Monthly Usage Report

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 Container (e.g., oz, gal, lbs, volts)

Total Quantity brought on installation during reporting period

47 CES/CEIE

HAZMO

Use Only

EESOH MSN (to be added by LAFB

HAZMAT MGR,

BLDG 75)

Example: “Polishing furniture in bldg 1000”

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)