Attachment_23_-_CAFB_and_MAFR_Civilian_Contractor_Environmental_Guide_Appendix_A_Forms_(2)_with_header.doc

Attachment 23 FA4855-13-R-0009

ATTACHMENT A-1

CAFB ESOH-MIS CONTRACTOR WORKSHEET

Contractor Name

Contract Number

Project Number

Estimated Start Date

Estimated Completion Date

Assigned Shop Code

(Leave shop code blank if not known)

Material Stock Number (MSN), National Stock Number (NSN), Local Stock Number (LSN), Or Part Number

Material Noun (Be Specific)

Size (Quantity)

Unit of Issue

Units Per Container

Other _______________

Will The Process Be Performed On: (Check All That Apply)

Existing Facility

Equipment

New Structure

Aircraft

Outdoors

Physical Location Of Process

Location Of Stored Materials

This Request Cannot Be Processed Without A Government Representative’s Signature

Printed Name

Signature

Printed Name

Signature

NOTE: Manufacturer’s Material Safety Data Sheet (MSDS) Required With Every Worksheet

ATTACHMENT A-2

CAFB CONTRACTOR HAZARDOUS MATERIAL REVIEW

TO: 27 SOCONS

FROM: 27 SOLRS/LGRMSH (HAZMART)

RE:

CONTRACT NUMBER: _____________________

PROJECT NUMBER: _____________________

DATE: _____________________

The CAFB HAZMART has received/reviewed the attached AF-EESOH-MIS Contractor Worksheets and associated Material Safety Data Sheets. Documents and the attached packet may require additional action. Please see below comments.

Comment 1:

Tagged MSDS(s) need replacing because it is illegible or outdated.

Comment 2:

No action required, these items do not require tracking in the EESOH-MIS Database.

______ Worksheets are incomplete, additional information required. See comments below.

______ EESOH-MIS Contractor Worksheets must be filled out for each attached MSDS.

Return worksheet and MSDS to the Contracting Office for input into the EESOH-MIS database to create a hazardous material tracking account.

______ The MSDSs that were submitted have been reviewed and information entered into the hazardous materials tracking data base. The attached hazardous materials list will be the items that the Hazardous Material Office will track on a monthly basis using the Contractor Hazardous Material Usage Data worksheet.

If any additional or different types of hazardous materials will be used on this or any future project, MSDSs must be submitted for review.

______ No action needed, documents are complete and will be entered into the hazardous materials tracking database.

Comment 3:

Other Comments.

Comment 1:

Comment 1a:

Comment 2:

ATTACHMENT A-3

CONTRACTOR HAZARDOUS MATERIAL USAGE DATA

Contractor:________________________ ESOH-MIS Shop Code:_____________________

Contract/Project Number: ______________________ Location:______________________ The following information is required for tracking of hazardous materials on-base. For contracts exceeding two months, this form is required to be filed out monthly and returned to the Government Representative, who will return it to the Hazmart/Hazardous Materials Program Manager office. This information is required in order to comply with Environmental Laws and Regulations. For purchase orders/contracts less than two months, this form is required at start and completion of work.

Print Name and Signature:

Contractor:_______________________________________________ Date:__________________________