Contractor's Environmental Reporting Entry Form Attch 6.doc

Attachment 1 (Revised 3 Jan 06)

Contractor's Environmental Reporting Entry Form

HAZMO Office, Bldg. 927, Phone: (623) 856-4748, Fax: (623) 856-4747.

Contractor’s Signature: ________________________________________________ Date: _________________

Brought on Base

See reverse side of form for instructions.

1. Contractor Number

2. Contractor Name

3. HAZMAT Storage Location: Building number & location/room in building. If multiple locations please list. If stored off base please indicate.

4. Date of reporting month

(Note: For items 5 – 10 List HAZMAT information in columns provided)

5. Product Name being reported (e.g. latex gloss paint, walnut wood stain) or locally assigned Material Stock Number (MSN)

6. Manufacturer of product

7. Amount of material brought on base

8. Unit of issue (e.g. 10 each 16 oz aerosol cans, 5 each 3 oz tubes)

9. Application process/method: How product will be applied to process?

10. Balance remaining on base at the end of month The Federal Government has targeted the following chemicals for reductions in use. This includes DOD contractor use. Please avoid the use of these items plus any confirmed human carcinogens, sensitizers, teratogens, mutagens or extremely toxic materials when possible.

Benzene Cadmium (and compounds) Carbon Tetrachloride Chloroform Chromium (and compounds) Cyanides Dichloromethane or Methylene Chloride Lead (and compounds) Mercury (and compounds) Methyl Ethyl Ketone Methyl Isobutyl Ketone Nickel (and compounds) Toluene Tnonicroethane Tnchloroethylene Xylene Tetrachlorcethylene Terchicroethylene.

PAGE

a