Attachment_12_-_Hazardous_Material_Questionaire.doc

Attachment 12

28 Mar 13

Contractor's Hazardous Material Questionnaire 1.

Contractor’s Company Name:

Name of Contractor:

Phone Number:

Fax Number:

Address:

2. Contract Number:

3. Date, time and location of pre-performance conference meeting:

4. Project:

5. Quality Assurance Evaluator (QAE)/ Contracting Officer (CO)

________________________Phone#___________

6. Projected contract period:

Start Date: ________ End Date: _________

7. Will contractor be using any hazardous material (HAZMAT) during this contract?

a) If the answer is NO to the above question, sign and date below.

Contractor’s Name (print) Contractor’s Signature Date

b) If the answer is YES to the above question, sign and date below and complete item 8. Provide QAE/CO a chemical inventory and copies of all Material Safety Data Sheets (MSDS) 5 days prior to contract start date. Provide QAE/CO a monthly HAZMAT usage report (see Contractor’s Environmental Reporting Entry Form, Attachment 1) during the contract period no later than 5 days after the end-of-each month.

Contractor’s Name (print) Contractor’s Signature Date

8. Will the contractor be generating a potential waste or hazardous waste during the contract period? (Yes/No) If YES, contact the base Hazardous Waste Manager at (623) 856-6501 and/or the Pollution Prevention Chief at (623) 856-4166 for proper reporting and disposal procedures.

The point-of-contact for the HAZMO Office is Mr. Oscar Mabry, (623) 856-4748, Fax: (623) 856-4747, e-mail: oscar.mabry@us.af.mil