(Atch2)_PWS_Atch_E-5_Cannon_AFB_Contractor_Hazmat_Usage.pdf
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- Attached to
- Latrines and Pumping Service Federal contract opportunity
- Solicitation number
- FA4855-18-R-0029
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PWS Atch E-5
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ATTACHMENT E-5, Cannon AFB Contractor Hazmat Usage Instructions for Completing Attachment E-5
Complete one initial copy of Attachment E-5 for the contract. Submit the initial form to the Contracting Officer, who will route the form for review to the HMMP Team. The HMMP Team_will finalize the form and return it to the contractor. The contractor will complete the form monthly and/ or at the end of the project, indicating hazmat usage.
A. !nWiLCompletion Requirements (Prior to Starting Work)
1. Project Information -This block will be completed by the HMMP Team
Contractor Name Enter your contractor name.
Contract Number Enter your contract number.
Project Number Enter your project number.
Project Location Enter the project location.
Shop Code (if known) Enter your Cannon AFB Shop Code, if known. Otherwise, leave blank and the
HMMP Team will complete.
Form Turn-In Day/ Frequency Leave blank. The HMMP Team will complete.
2. Reporting Information
Reporting Date Leave blank. The HMMP Team will complete ..
Name Leave blank.
3. Material Usage
Hazmat Name (SDS) Enter the name of each hazmat on each line of the form, for all hazmats.
MSN
If known, enter the MSN, NSN, or LSN corresponding to the hazmat name.
Otherwise, leave blank. The HMMP Team will complete.
Container Size (w/ Unit of Enter the container size and unit of measure of the container, from Measure) Attachment A-1, Block 2.
Containers Used this Period Leave blank.
B. Periodic and End of project Completion Requirements
1. Project Information -This block will be completed by the HMMP Team
Contractor Name Previously entered.
Contract Number Previously entered.
Project Number Previously entered.
Project Location Previously entered.
Shop Code (if known) Previously entered.
Form Turn-In Day/ Frequency Previously entered.
2. Reporting Information
Reporting Date Enter the reporting date.
Name Enter the name of the person completing the form.
Contract: Pending Solicitation: FA4855-18-R-0029
LATRINE & PUMPING SERVICE
Performance Work Statement
Attachment E-5 7 June 2018
3. Material Usage
Hazmat Name (SOS) Previously entered.
MSN Previously entered.
Container Size (w/ Unit of Previously entered.
Measure)
Containers Used this Period Enter the whole number of containers used during the reporting period. For the final reporting period, round up any partial or fractional usage to a whole number.
Contract: Pending Solicitation: FA4855-18-R-0029
LATRINE & PUMPING SERVICE
Performance Work Statement
ATTACHMENT E-5, Cannon AFB Contractor Hazmat Usage
Instructions for Completing Attachment E-5
1. Project Information
Contractor: XYZ Contracting Company
Contract Number: FA4855-13-A-0001 Project Number: 123456789
Project Location: East of Building 9999 Shop Code {if known}: CXT-13-A-0001
Form Turn-In Day/ Frequency {Cannon AFB/ Melrose 15th Day of Month and/or
AFR will complete}: End of project
2. Reporting Information I
Reporting Date: 2014-08-15
Name: Xavier Y. Zelman, Owner
3. Material Usage
Hazmat Name (SOS) MSN Container Size (w/
Containers Used This Period Unit of Measure)
Spectracide Brand Bug Stop 6840PHfv100008182 32 Fl. Oz. 1
Insect Killer
Argon, Compressed 6830PHfv100007463 4 Cubic Feet 1
Gold Gas Shielding Gases 6830PHfv100042383 2 Cubic Feet 2
Oxygen 02 6830PHfv100050581 2 Cubic Feet 4
Alex Plus Clear 8030PHfv100001277 18 Wt. Oz. 5
EXAMPLE,,,.
Contract: Pending Solicitation: FA4855-18-R-0029
LATRINE & PUMPING SERVICE
Performance Work Statement
Contract: Pending Solicitation: FA4855-18-R-0029
LATRINE & PUMPING SERVICE
Performance Work Statement
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