APPENDIX_D_2015_08_03.pdf

APPENDIX D

CONTRACT SPECIFIC FORMS

OPERATION MAINTENANCE PLAN (O&M PLAN)

PLATING FACILITY

ENVIRONMENTAL CONTROL EQUIPMENT

MAINTENANCE SERVICES

BLDG 3001

TINKER AFB OK

Contract Specific Forms. The following forms are available and managed through the QAP.

Any required modifications will be approved by the QAP prior to implementing. The Contract Manager shall ensure the following forms are completed in accordance with instructions provided by the QAP.

Form Number Date Title Applicable Contract Reference

Disposition

OC-ALC Form 141* Nov 2010 Pressure Drop Log for Compliance Monitoring 40 CFR 63, Subpart N – Chromium Electroplating

1.3.2., 1.3.3.1., 1.3.7.

Plating Shop Foreman required to retain for 5 years.

O&M Plan Form 002* Oct 2014 Packed Bed Srubber / Composite Mesh Pad System

(PBS/CMP)

Daily Maintenance: #202

1.3.3., 1.3.3.1., 1.3.7.

Plating Shop Foreman required to retain for 5 years.

O&M Plan Form 003* Oct 2014 Packed Bed Srubber / Composite Mesh Pad System

(PBS/CMP)

Weekly Maintenance: #202

1.3.4., 1.3.4.1., 1.3.7.

Plating Shop Foreman required to retain for 5 years.

O&M Plan Form 004* Oct 2014 Packed Bed Srubber / Composite Mesh Pad System

(PBS/CMP)

Monthly (30 Days) Maintenance: #202

1.3.5., 1.3.5.1., 1.3.7.

Plating Shop Foreman required to retain for 5 years.

O&M Plan Form 005* Oct 2014 Packed Bed Srubber / Composite Mesh Pad System

(PBS/CMP)

Quarterly Maintenance: #202

1.3.6., 1.3.6.1., 1.3.7.

Plating Shop Foreman required to retain for 5 years.

O&M Plan Form 006* Oct 2014 Packed Bed Srubber / Composite Mesh Pad System

(PBS/CMP)

Daily Maintenance: #204

1.3.3., 1.3.3.1., 1.3.7.

Plating Shop Foreman required to retain for 5 years.

O&M Plan Form 007* Oct 2014 Packed Bed Srubber / Composite Mesh Pad System

(PBS/CMP)

Weekly Maintenance: #204

1.3.4., 1.3.4.1., 1.3.7.

Plating Shop Foreman required to retain for 5 years.

O&M Plan Form 008* Oct 2014 Packed Bed Srubber / Composite Mesh Pad System

(PBS/CMP)

Monthly (30 Days) Maintenance: #204

1.3.5., 1.3.5.1., 1.3.7.

Plating Shop Foreman required to retain for 5 years.

O&M Plan Form 009* Oct 2014 Packed Bed Srubber / Composite Mesh Pad System

(PBS/CMP)

Quarterly Maintenance: #204

1.3.6., 1.3.6.1., 1.3.7.

Plating Shop Foreman required to retain for 5 years.

Periods of Excess Emissions form

Oct 2014 Periods of Excess Emissions form

1.3.8. Submitted to CEIE

(Base Air Quality)

Reports Form 001 Aug 2014 Monthly Materials and Parts Usage Report

1.3.7. COR retain

6 years 3 months

Corrective Action Report

(CAR)

Feb 2005 Corrective Action Report

(CAR)

1.8.1. COR retain

6 years 3 months

MXRIWRS Form 029 Jun 2005 Customer Complaint Record 1.8.1. COR retain 6 years 3 months

OC-ALC Form 152 Oct 2013 MSDS/SDS Information Sheet

1.16.2. COR submit to 72

ABW/CEIE for approval

AF Form 592 04 Sept

USAF Hot Work Permit 1.17.2. Contractor keep form with them at all times while working on site performing hot work

MXRIWRS FORM 32 Jun 2006 Contractor Tool Listing 1.19.3. COR retain 6 years 3 months

AFMC Form 496 14 Mar

Application for AFMC Identification Card

1.21.1. Contractor submits

to Pass and Registration

*Forms developed per NESHAP 40 CFR 63, Sub-part N and original equipment manufacturer’s (OEM’s) requirements

DEPARTMENT OF THE AIR FORCE

HEADQUARTERS OKLAHOMA CITY AIR LOGISTICS CENTER (AFMC)

TINKER AIR FORCE BASE OKLAHOMA

Pg. l of l

O&M Plan Form 002, Oct 2014

Operation and Maintenance Checklist Chrome Scrubber MAE, Bldg. 3001, Tinker AFB Chrome Electroplating

Control ID: 202 Tanks Serviced: 208, 210, 212, 214 Control System: Packed Bed Scrubber / Composite Mesh Pad System (PBS/CMP)

Daily Maintenance: #202 Date: _ / _ / -- _ / _ /

1. Inspect all plumbing, motors, and fans for excessive noise, vibration, and leakage

Findings:

Mon Tues Wed Thur Fri Sat Sun

Initials

2. Clear all scrubber alarms

3. Check scrubbers for leaks

4. Check alarm panel for proper operation

Pg. l of l DEPARTMENT OF THE AIR FORCE

O&M Plan Form 003, Oct 2014

Chrome Electroplating

Control ID: 202

Weekly Maintenance: #202

Date: _ / _ / _ Initials:

1. Check pressure drop stage # 1, stage #2, and stage #3

2. Inspect all scrubber fan belts. Tighten or replace as necessary

Pg 1 of 2 DEPARTMENT OF THE AIR FORCE

O&M Plan Form 004, Oct 2014

Monthly (30 Days) Maintenance: #202

Date: _ / _ / Initials:

1. Inspect scrubber nozzles. Nozzles should be present on the end of each distribution piping stub out, providing an even, full cone spray pattern. Clean or replace as necessary

2. Perform third stage wash down cycle

3. Check current reading on all electric motors ( fans, etc.)

4. Inspect traps for proper water level

Pg 2 of 2 DEPARTMENT OF THE AIR FORCE

O&M Plan Form 004, Oct 2014

Monthly (30 Days} Maintenance: #202 continuation

5. Exercise all valves to prevent seizures and ensure proper operation

6. Check scrubbers for proper water flow

Pg. 1 of 2 DEPARTMENT OF THE AIR FORCE

O&M Plan Form 005, Oct 2014

Quarterly Maintenance: #202 Work Practice Standards (40 CFR 63, subpart N, Table 1)

Date: _ / _ / _

Initials:

1. Visually inspect device to ensure there is proper drainage, no chromic acid buildup on the pads, and no evidence of chemical attack on the structural integrity of the device.

2. Visually inspect back portion of the mesh pad closest to the fan to ensure there is no breakthrough of chromic acid mist.

3. Visually inspect ductwork from tank or tanks to the control device to ensure there are no leaks.

Pg. 2 of 2 DEPARTMENT OF THE AI R FORCE

O&M Plan Form 005, Oct 2014

Quarterly Maintenance: #202 continued Work Practice Standards (40 CFR 63, subpart N, Table 1)

4. Inspect pressure line connections for degradation.

5. Check magnehelic pressure gauge for calibration. Calibrate annually per manufacturer's recommendation.

Pg 1 of 1

O&M Plan Form 006, Oct 2014

Operation and Maintenance Checklist: Chrome Scrubber

MAE, Bldg. 3001, Tinker AFB Chrome Electroplating

Control ID: 204 Tanks Serviced: 218, 220, 222, 224

Daily Maintenance: #204 Date: _ / _ / -- _ / _ /

1. Inspect all plumbing, motors, and fans for excessive noise, vibration, and leakage

2. Clear all scrubber alarms

3. Check scrubbers for leaks

4. Check alarm panel for proper operation

Pg 1 of 1 DEPARTMENT OF THE AIR FORCE

O&M Plan Form 007, Oct 2014

Control ID: 204

Weekly Maintenance: #204

1. Check pressure drop stage # l, stage #2, and stage #3

2. Inspect all scrubber fan belts. Tighten or replace as necessary

O&M Plan Form 008, Oct 2014

Control ID: 204

Monthly (30 Days) Maintenance: #204

1. Inspect scrubber nozzles. Nozzles should be present on the end of each distribution piping stub out, providing an even, full cone spray pattern. Clean or replace as necessary

2. Perform third stage wash down cycle

3. Check current reading on all electric motors ( fans, etc.)

4. Inspect traps for proper water level

O&M Plan Form 008, Oct 2014

Monthly (30 Days) Maintenance: #204 continuation

5. Exercise all valves to prevent seizures and ensure proper operation

6. Check scrubbers for proper water flow

O&M Plan Form 009, Oct 2014

Operation and Maintenance Checklist: Chrome Scrubber

Chrome Electroplating

Control ID: 204

Control System: Packed Bed Scrubber I Composite Mesh Pad System (PBS/CJ\.1P)

Quarterly Maintenance: #204 Work Practice Standards (40 CFR 63, subpart N, Table I)

Date: _ / _ / Initials: ----

l. Visually inspect device to ensure there is proper drainage, no chromic acid buildup on the pads, and no evidence of chemical attack on the structural integrity of the device.

2. Visually inspect back portion of the mesh pad closest to the fan to ensure there is no breakthrough of chromic acid mist.

3. Visually inspect ductwork from tank or tanks to the control device to ensure there are no leaks.

O&M Plan Form 009, Oct 2014

Quarterly Maintenance: #204 continued Work Practice Standards (40 CFR 63, subpart N, Table I)

Date: _ / _ / Initials:

4. Inspect pressure line connections for degradation.

5. Check magnehelic pressure gauge for calibration. Calibrate annually per manufacturer’s recommendation.

Pg 1 of 1

In the event of any exceedance, contact CEIE as soon as practical at 734-7071 ext so that an Excess Emission report can be submitted to ODEQ/AQD NLT than 4:30 p.m. the next working day.

PERIODS OF EXCESS EMISSIONS:

EQUIP ID: _______ DATE: _______

EQUIP ID: _______ DATE: ______

START

TIME: _______ STOP

TIME: _______ START

TIME: _______ STOP

TIME: ______

CORRECTIVE ACTION TAKEN: _______ CORRECTIVE ACTION TAKEN: _______

INITIALS: _______ INITIALS: _______

TIME: _______ STOP

TIME: _______ START

TIME: _______ STOP

TIME: ______

CORRECTIVE ACTION TAKEN: _______ CORRECTIVE ACTION TAKEN: _______

TIME: _______ STOP

TIME: _______ START

TIME: _______ STOP

TIME: ______

CORRECTIVE ACTION TAKEN: _______ CORRECTIVE ACTION TAKEN: _______

MONTHLY MATERIAL AND PARTS USAGE REPORT

Part Number Description

(Note as CAP from purchase or CAP from inventory)

Quantity Consumed (Equip ID#)

Total Cost of Parts

Comments

Reports Form 001, Aug 14

CORRECTIVE ACTION REPORT (CAR)

(If more space is needed, use reverse and identify by number)

1. CONTRACTOR

2. CONTRACT NUMBER

3. TYPE OF SERVICES

4. FUNCTIONAL AREA

5. SUSPENSE DATE

6. CONTROL NUMBER

7. DEFICIENCY MAJOR MINOR

FINDING:

FINDING IMPACT:

Please respond with a written corrective action plan that details the corrective action of the cited deficiency, the cause of the deficiency, and actions taken to prevent recurrence by Suspense Date in Block 5. If date was not entered in Block 5, the contractor is not required to provide a response.

8. QUALITY ASSURANCE PERSONNEL (QAP)

TYPED NAME AND GRADE

SIGNATURE AND DATE

9. ISSUING AUTHORITY

TYPED NAME AND GRADE

SIGNATURE AND DATE

10. QAP RESPONSE TO CONTRACTOR CORRECTIVE ACTION AND ACTION TAKEN TO PREVENT RECURRENCE

11. QAP DETERMINATION

ACCEPTED REJECTED

12. CLOSE DATE

Corrective Action Report (CAR) Template, Feb 05 (SAF/AQCP)

CORRECTIVE ACTION REPORT (CAR)

Continuation Sheet

(Number to correspond with applicable Item Number on reverse)

Corrective Action Report (CAR) Template, Feb 05 (SAF/AQCP)

CUSTOMER COMPLAINT RECORD

DATE/TIME OF COMPLAINT

Date/Time Recd by the government Quality Assurance Evaluator (QAE)

SOURCE OF COMPLAINT

ORGANIZATION

BUILDING NUMBER INDIVIDUAL PHONE

NUMBER

Government Quality Assurance Evaluator (QAE) annotates the organization originating the complaint.

Government Quality Assurance Evaluator (QAE) annotates the Bldg #, post location, system # or other identifying data, if applicable.

Government Quality Assurance Evaluator (QAE) annotates the name of individual lodging complaint.

Government Quality Assurance Evaluator (QAE)annotates the phone number of complainant.

NATURE OF COMPLAINT

Government Quality Assurance Evaluator (QAE) describes complaint in detail.

Name Organization Telephone

CONTRACT REFERENCE

Government Quality Assurance Evaluator (QAE)annotates SOW paragraph reference that applies to the complaint.

VALIDATION

Government Quality Assurance Evaluator (QAE) annotates reference paragraph number stated in the SOW and/or other applicable directives that apply to the complaint.

DATE/TIME CONTRACTOR INFORMED OF COMPLAINT ESTIMATED DATE/TIME ACTION TAKEN TO CORRECT PROBLEM Government Quality Assurance Evaluator (QAE) annotates the Contractor annotates date/time action was taken to correct problem. If date/time and method used to notify the contractor of this complaint. corrective action cannot be taken within the time allowed, the contractor may provide the date corrective action will be taken.

ACTION TAKEN BY CONTRACTOR

Contractor annotates specific action to correct the problem.

PLANNED ACTION TO PREVENT RECURRENCE

Contract annotates specific plan of action to prevent recurrence of the complaint and/or findings.

SIGNATURE OF CONTRACTOR ANSWERING COMPLAINT

Signature of Contractor personnel answering the complaint.

RECEIVED/VALIDATED BY

Follow up by government Quality Assurance Evaluator (QAE) to validate corrective was taken.

MXRIWRS FORM 029 (June 2005)

(Sample Form)

CONTRACTOR TOOL LISTING

Date: _______________

Company Name:

Contract #: Estimated Departure Date:

Contract Representative: QAP:

Wing Work Site Location: Shop OPR:

Description of Tool Any particular identifying markings such as: color, brand name, individual or company name markings on the tool.

Qty

MXRIWRS FORM 32-1 (June 2006)

4. Check alarm panel for proper operation

4. Inspect pressure line connections for degradation. Findings: