Attachment_23_-_CAFB_MAFR_Contractor_Env_Guide__Appendix_A_&_B_Forms_-_2_Jul_2015.pdf

Rev. 5 02 July 15

Cannon AFB & Melrose AFR Contractor Hazmat Worksheet

1. Contractor Information

Contractor Name:

Contract Number:

Project Number:

Estimated Start Date:

Estimated Completion Date:

Assigned Shop Code, if known:

2. Material Information

Material Name (from SDS):

Material Stock No. (MSN), or National Stock No. (NSN), or Local Stock No. (LSN), enter if known:

Container Type (circle one):

Box Bottle Can Drum Bag Tube Cartridge

Other (Specify):_

Container Volume or Weight (circle one):

Weight Oz. Pounds Tons Grams Kilograms

Fluid Oz. Pints Quarts Gallons Other (Specify):_

Total No. of Containers: Container Size: Total Hazmat

Quantity:

3. Process Information

Process Type:

Process Description:

4. Engineering Controls

Describe process engineering controls:

5. Personal Protective Equipment (PPE)

Describe process PPE:

6. Location Information

Process will be performed on/at (circle all that apply):

Existing Facility New Facility Equipment

Aircraft Outdoors Other (Specify):_

Physical location of process:

Staging location of hazmat:

Attachment 23 FA4855-18-R-0003

Signature Block

Contractor Title Phone Date

Printed Name Signature

7. Additional Information

Will a hazardous waste be generated (circle one)?

Yes No

TBD

Describe method(s) of waste manage-ment, transport, and disposal:

IAW FAR 52.223-3/AFI 32-7086 3.4.1; All HAZMAT brought onto an installation for use shall be authorized via the process described in this section.

NOTE: Manufacturer’s Safety Data Sheet (SDS) is required for every worksheet

Cannon AFB & Melrose AFR Contractor Hazmat Review

1. Project Information

Contractor:

Contract Number: Project Number:

Project Location: Shop Code (if known):

Form Turn-In Day / Frequency (Cannon AFB/ Melrose AFR will complete):

Day of Month and/or

End of project

2. Reporting Information Reporting Date:

Name:

3. Material Usage

Hazmat Name (SDS) MSN Container Size (w/ Unit of Measure) Containers Used This Period

4. Project Information

Contractor:

Contract Number: Project Number:

Project Location: Shop Code (if known):

Form Turn-In Day / Frequency (Cannon AFB/ Melrose AFR will complete):

Day of Month and/or

End of project

5. Reporting Information Reporting Date:

Name:

6. Material Usage

Hazmat Name (SDS) MSN Container Size (w/

Unit of Measurement)

Containers Used This Period

1. Contractor Information

Date:

Contractor Name:

Contract Number:

Project Number:

Assigned Shop Code:

2. Material Information

Material Name (from SDS):

MSN, NSN or LSN:

The Cannon AFB HAZMART has received and reviewed the attached:

1. Cannon AFB/ Melrose AFR Contractor Hazmat Information Worksheet

2. Cannon AFB / Melrose AFR Contractor Hazmat Usage Worksheet, and

3. Associated Safety Data Sheets.

The information submitted is complete. The hazmat noted above may enter Cannon AFB and/or Melrose AFR

The information submitted indicates that the material is not hazardous and may enter Cannon AFB and/or Melrose AFR

The information submitted is incomplete and/or erroneous. Please follow the instruction below and resubmit.

Problem If Checked

Description

The Contractor Hazmat Information Worksheet is incomplete. Missing information is highlighted or described:

The Contractor Hazmat Usage Worksheet is incomplete. Missing information is highlighted or described:

The SDS is illegible or outdated:

Other 1:

Other 2:

Other 3:

Other 4:

Cannon AFB & Melrose AFR Contractor Fuel Tank Approval Worksheet

1. Project Information Contract Number:

Project Number:

Project Name:

Project Coordinator (Name & Phone Number):

2. Tank Information Tank Location:

Dates the tank will be utilized on CAFB or MARF:

Tank Size:

Tank Content:

Does the tank have proper labeling?

Does the tank have a secondary containment?

Are the personnel trained on the Spill Response Procedures and Notifications as described in Appendix C of this guide?

Does the contractor have adequate spill supplies?

X Project Coordinator (Signature & Date)

Fire Department: Approve Disapprove

Comments: ___________________________________________________________________________

X Fire Department, Chief (Signature & Date)

Environmental Element: Approve Disapprove

Comments: ___________________________________________________________________________

X Environmental, Tank PM (Signature & Date)

Cannon AFB & Melrose AFR Contractor Solid Waste Disposal, Diversion, and Recycling Plan

Contract and Project Information Contract Number:

Project Number:

Project Name:

Project Waste & Recycling Coordinator(s):

Debris Disposal and Recycling Guidelines 1.

2.

3.

Material Total

Estimated Quantity

Recycling or Disposal Method Material Handling Procedure

Cannon AFB & Melrose AFR Contractor Solid Waste Disposal, Diversion, and Recycling Worksheet

Contract Number:

Project Number:

Project Name:

Project Waste & Recycling Coordinator(s):

Reporting Month:

Material

Monthly Volume, Weight, or Count Managed Project Totals To Date

Recycled Landfilled Recycled Landfilled

Appendix E – Environmental, Safety, and Occupational Health – Training Network Access and Registration Instructions