HAZMAT_Worksheet.pdf

CONTRACTOR HAZARDOUS MATERIAL AUTHORIZATION AND USE1

1. PRIME CONTRACTOR/ORGANIZATION:

2. E-MAIL

3. PHONE

4. FAX

5. DATE

6. PRIME COTR/POC

7. PHONE

8. FAX

9. CONTRACT NUMBER

10. CONTRACTOR/ORGANIZATION POC

11. WORKPLACE/BLDG

12. SUB-CONTRACTOR

13. DELIVERY ORDER

14. CONTRACTING OFFICER/FAFB OPR

15. CONTRACTING OFFICER SIGNATURE

16. PHONE

17. FAX

18. DATE

19. OFFICE REQUESTING CONTRACT/OPR

20. SIGNATURE

21. PHONE

22. FAX

23. DATE

24. EXPECTED START DATE

25. EXPECTED END DATE

26. PROJECT/TASK DESCRIPTION

27. Will Air Force or Civil Service Personnel be exposed to these chemicals?

Product Name/Part Number Material Manufacturer2 Solid, Liquid or Gas

Amount & Unit of

Issue4

Contai ner

Type

Max Amount Onsite at any Time 5

Est.

Amount Used for Project

Actual Amount Used6

Process Type7

Remarks/Notes8

FOOTNOTES:

1. This form is used for initial approval of hazardous materials and to report subsequent usage.

Include all materials, which contain an EHS, TRI, CERCLA hazardous substance, toxic chemical, generates a hazardous waste after use, and/or requires a Material Safety Data Sheet.

2. Attach copy of MSDS for each line item.

3. Identify National Stock Number if known. If unknown, leave blank, and HMMP will complete.

4. Identify amount in container & the units item is measured in, i.e. gallon, ounces, lbs, etc.

5. Identify maximum amount present (stored and used) at any one time on Fairhcild AFB.

6. Report actual quantities used at the end of the project, by January if project extends beyond

Calendar Year, and/or when directed on reporting schedule on reverse (Block 27)

7. See Table 1—Process Types for appropriate codes.

8. Use the Remarks/Notes section to indicate specific process/product information, e.g. weight of each component in a kit, mix rations, disposal info, etc.) Government will also use this section to indicate authorization status.

CONTRACTOR HAZARDOUS MATERIAL AUTHORIZATION AND USE1

Product Name/Part Number Material Manufacturer2 Solid, Liquid, or Gas

Amount & Unit of Issue4

Contai ner

Type

Max Amount Onsite at any Time 5

Est.

Amount Used for Project

Actual Amount Used6

Process Type7

Remarks/Notes8

28. Usage Reporting Schedule TABLE 1—PROCESS TYPES

CODE PROCESS DESCRIPTION CODE PROCESS DESCRIPTION

A Asbestos removal and disposal R Fiberglass or composite applications

B Asphalt paving S Renovation, specify process

C Abrasive blasting; specify substrate, blast media and surface area cleaned

T Stationary internal combustion engines, gasoline; specify size, gallons of fuel burned, & hours of operation

D Adhesives U Stationary internal combustion engines, diesel; specify size, gallons of fuel burned, & hours of operation

E Brazing V Sanding, specify substrate and surface area sanded

F Chemical or physical analysis W Surface coating, brush or roller applications

G Cutting, oxy-fuel; specify substrate X Surface coating, spray applications in filtered enclosures

H Cutting, plasma arc; specify substrate Y Surface coating, HVLP spray applications in filtered enclosures

I Cutting, mechanical process, specify substrate Z Surface coating, airless spray applications in filtered enclosures

J Construction, specify process AA Surface coating, electrostatic spray applications in filtered enclosures

K Demolition, specify process BB Surface coating, thermal spray applications n filtered enclosures

L Degreasing operations using solvents CC Surface coating, spray applications outdoors

M Fuel combustion DD Surface coating, HVLP spray applications outdoors

N Grinding, specify substrate and surface area EE Surface coating, airless spray applications outdoors

O Industrial boiler operations FF Welding, oxy-fuel; specify substrate and filler material

P Natural gas combustion GG Welding, electric arc; specify substrate and filler material

Q Paint stripping, chemical HH Soldering, specify substrate and filler material

Monthly End of Contract

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