Attachment_13_-_Contractors_Environmental_Reporting_Entry_Form.doc

Attachment 13

Contractor's Environmental Reporting Entry Form

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

Date:

1. Contract Number:

2. Contractor Name:

Quantity by type of Construction and Demolition Debris removed/reused. Include facility name if recycled/disposed off-site.

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 (e.g. May 2012) (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. Application process/method: How product will be applied to process?

8. Unit of issue (e.g. 16 oz aerosol can, 3 oz tube, 5 gal pail)

9. Amount of material brought on base during reporting month (e.g. 3 cans, 2 tubes, 1 pail)

10. Amount of material used during reporting month

11. Remaining balance of product at the end of reporting 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