Att_10a_FA8903-17-R-0035_Exhibit_A.pdf

(COMPUTER GENERATED)

CONTRACT DATA REQUIREMENTS LIST

Public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Department of Defense, Washington Headquarters Services, Directorate forInformation Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302, and to the Office of Management and Budget, Paperwork Reduction Project (0704-0188), Washington, DC 20503. Please DO NOT RETURN your form to either of these addresses. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

(1 Data Item) Form Approved OMB No. 0704-0188

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY

TDP TM OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO. 2. TITLE OF DATA ITEM 3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE

7. DD 250 REQ

8. APP CODE

9. DIST STATEMENT 10. FREQUENCY

11. AS OF DATE

12.DATE OF FIRST SUBMISSION

13.DATE OF SUBSEQUENT

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

Draft Final Reg Repro

16. REMARKS

15. TOTAL

G. PREPARED BY H. DATE I. APPROVED BY J. DATE

17. PRICE GROUP 18. ESTIMATED TOTAL PRICE

DD Form 1423-1, JUN 90 PREVIOUS EDITIONS ARE OBSOLETE Page of Pages USAPPC V3.00

REQUIRED

SUBMISSION

0002 A MISC

MGT, CULTURAL SITES FA8903-17-R-0035 TBD

A001 SCIENTIFIC AND TECHNICAL REPORTS SAFETY & HEALTH REPORT

DI-MISC-80711A PWS PARA - 3.4.1 AFCEC/CZOW

LT

A B

ASREQ

DANIEL GARCIA, AFCEC/CZOW28-Jul-2017JENNIFER HOLGUIN

N/A

28-Jul-2017

AFCEC/CZOW 0 0 1

772 ESS/PKS 0 0 0

BASE POC 1

SEE BLOCK 16

NSP

BLOCK 16

BLOCK 16N/A

0 0 2

Blocks 12, & 13 : Submissions shall be upon any changes to key personnel and shall be submitted within 3 days of the changes.

Block 14: All deliverables shall be submitted by e-mail or on CD-ROM, as necessary. The government uses Microsoft Office Suite. E-mail addresses will be provided by the COR.

1 1

FOR OFFICIAL USE ONLY

FA8903-17-R-0035

Exhibit A

FA8903-17-R-0035

Public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Department of Defense, Washington Headquarters Services, Directorate forInformation Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302, and to the Office of Management and Budget, Paperwork Reduction Project (0704-0188), Washington, DC 20503. Please DO NOT RETURN your form to either of these addresses. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

(1 Data Item) Form Approved OMB No. 0704-0188

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY

TDP TM OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO. 2. TITLE OF DATA ITEM 3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE

7. DD 250 REQ

8. APP CODE

9. DIST STATEMENT 10. FREQUENCY

11. AS OF DATE

12.DATE OF FIRST SUBMISSION

13.DATE OF SUBSEQUENT

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

Draft Final Reg Repro

16. REMARKS

15. TOTAL

G. PREPARED BY H. DATE I. APPROVED BY J. DATE

17. PRICE GROUP 18. ESTIMATED TOTAL PRICE

DD Form 1423-1, JUN 90 PREVIOUS EDITIONS ARE OBSOLETE Page of Pages USAPPC V3.00

REQUIRED

SUBMISSION

0002 A MISC

MGT, CULTURAL SITES FA8903-17-R-0035 TBD

A002 SCIENTIFIC AND TECHNICAL REPORTS ORGANIZATIONAL CHART

DI-MISC-80711A PWS PARA - 3.4.2 AFCEC/CZOW

LT

N/A B

ASREQ

DANIEL GARCIA, AFCEC/CZOW28-Jul-2017JENNIFER HOLGUIN

N/A

28-Jul-2017

AFCEC/CZOW 0 0 1

772 ESS/PKS 0 0 0

SEE BLOCK 16

BASE POC 1

NSP

BLOCK 16

BLOCK 16N/A

0 0 2

Block 4: DID Tailoring: DID Block 6a is not applicable.

Blocks 12 & 13: Submit chart within 30 business days of contract award. Subsequent submittals shall be upon ay changes to the chart or key personnel and shall be submitted within 10 days of the changes.

Block 14: All deliverables shall be submitted by e-mail or on CD-ROM, as necessary. The government uses Microsoft Office Suite. E-mail addresses will be provided by the COR.

1 1

FOR OFFICIAL USE ONLY

FA8903-17-R-0035

Public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Department of Defense, Washington Headquarters Services, Directorate forInformation Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302, and to the Office of Management and Budget, Paperwork Reduction Project (0704-0188), Washington, DC 20503. Please DO NOT RETURN your form to either of these addresses. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

(1 Data Item) Form Approved OMB No. 0704-0188

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY

TDP TM OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO. 2. TITLE OF DATA ITEM 3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE

7. DD 250 REQ

8. APP CODE

9. DIST STATEMENT 10. FREQUENCY

11. AS OF DATE

12.DATE OF FIRST SUBMISSION

13.DATE OF SUBSEQUENT

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

Draft Final Reg Repro

16. REMARKS

15. TOTAL

G. PREPARED BY H. DATE I. APPROVED BY J. DATE

17. PRICE GROUP 18. ESTIMATED TOTAL PRICE

DD Form 1423-1, JUN 90 PREVIOUS EDITIONS ARE OBSOLETE Page of Pages USAPPC V3.00

REQUIRED

SUBMISSION

0002 A MGMT

MGT, CULTURAL SITES FA8903-17-R-0035 TBD

A003 REPORT, PRODUCTION OR DELIVERY PROBLEM(S) OSHA

DI-MGMT-81178 PWS PARA - 3.5.1 AFCEC/CZOW

LT

N/A B

ASREQ

DANIEL GARCIA, AFCEC/CZOW28-Jul-2017JENNIFER HOLGUIN

N/A

28-Jul-2017

AFCEC/CZOW 0 0 1

772 ESS/PKS 0 0 0

SEE BLOCK 16

BASE POC 0 0 1

NSP

BLOCK 16

BLOCK 16BLOCK 16

0 0 2

Block 4: DID Tailoring: DID Block 6a is not applicable.

Blocks 12 & 13: Submit copies of reports within 10 business days of OSHA submittals.

Block 14: The Contractor shall submit a letter to 772ESS/PKS stating the submittal has been made. All deliverables shall be submitted by e-mail or on CD-ROM, as necessary. The government uses Microsoft Office Suite. E-mail addresses will be provided by the COR.

1 1

FOR OFFICIAL USE ONLY

FA8903-17-R-0035

DATA ITEM DESCRIPTION OMO NO. o w l m

2. mu - t 1. IDENTIFIUTION NUMBER

REPORT, PRODUCTION OR DELIVERY PROBLEM(s) DI-UGUT- 81 178

I 3.1 The report is used to inform the procuring activity of crises which have developed, or are developing, and which have the potential to stop, interrupt or severely impact the production or delivery of contract end items.

I 7.2 This DID is applicable to the acquisition, of both hardware and softvare systems, subsystems, components and equipment. It may be applied to any contract covering the acquisition of arpplies/services, the delive'ky of vhich, if stopped I

(continued on page 2) -

I (continued on page 2) I

4. WPROVAL DATE

WMMOO)

910328

J

WPROVAL U M K A T O N )b. AM% NUMBER

86094

1 10.1 Fonat. The report shall be in contractor forut. I

7 . 4PPUCATK)N I INTERREUTIONSMIP

7.1 This data item description (DID) contains the format'md content preparation instructions for the data product generated by the specific and discrete task requirement as delineated in the contract.

I 10.2 Content. The report shall contain the folloving: I

6b. GIDEP REOUIRED 5. OFFICE OF PRIMARY RESPONSIBILITY (OPR)

N/SEA 06D32

1 10.2.1 Identification. The first page of the iceport shall contain the follaving: I

6a. OTlC REQUIRED

a. Identification of the ~stem/component/progrum/project/hull/activity involved.

b. Contract Number.

c. Preparing activity.

d. ~erial/identification number (assigned by the preparing activity), and the date.

e. Security classification, when required.

10.2.2 Body of Report. The report shall contain a complete, but concise, explanation as to the nature and cause of the crisis or problem and the current or potential impact on contract end item production, delivery, cost or scheduling.

In addition, the report shall include the folloving as applicable and appropriate:

I (continued on page 2) I DIS1RlBUTK)N STATEMENT I

Distribution Statement A: Approved for public release; distribution is limited.

L DO Form 1664. JUN a m * o y ~ d o o I--(. ~ u ; r or 2 PAGES

./PI 0102- '-0014641

88 -*I l-I.C.(.CIP I..* .a,. ,"*.,4.a:p

FA8903-17-R-0035

Block 3, DESCRIPTION/PURPOSE (continued)

3.2 Examples of such crises are: accidents, strikes, subcontractor or vendor difficulties or slippage, shortage of material, transportation tie-ups, or other potential bottlenecks vhich may impact contract end item production or delivery.

Block 7, APPLICATION/INTERRELATIONSRIP (continued) or interrupted, vill adversely.effect a military program, project or operation, or the construction, conversion, overhaul, alteration or maintenance of military ships, systems or equipment.

Block 10, PREPARATION INSTRUCTIONS (continued)

a. Action(s1 Taken. Describe contractor action(s) taken to remedy the crisis or problem. If no contractor action-has been taken, provide a brief explanation.

b. Action(s1 Required. Clearly indicate the action(s) required, the date by which the action is required, and the responsible party, e.g., contractor, procuring activity, other agency or activity.

c. Revised Data. Revised/updated production, delivery, cost or scheduling data should be provided, if available.

d. Contractor Recommendations. Delineate contractor recotmendation(s), if any, to solve the current crisis or problem, to prevent a recurrence, or for procuring activity follorup.

e. Appendices. Tables, references, charts or other descriptive material or information that will clarify the crisis or problem, or that will support the rationale for contractor recommendations, if any, should be provided as appendices. Each appendix ahall be identified and referenced in the appropriate area of the report.

10.2.3 Report Preparer. Name and telephone number of the person(8) preparing the report.

page 2 of 2 pages

FA8903-17-R-0035

Public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Department of Defense, Washington Headquarters Services, Directorate forInformation Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302, and to the Office of Management and Budget, Paperwork Reduction Project (0704-0188), Washington, DC 20503. Please DO NOT RETURN your form to either of these addresses. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

(1 Data Item) Form Approved OMB No. 0704-0188

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY

TDP TM OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO. 2. TITLE OF DATA ITEM 3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE

7. DD 250 REQ

8. APP CODE

9. DIST STATEMENT 10. FREQUENCY

11. AS OF DATE

12.DATE OF FIRST SUBMISSION

13.DATE OF SUBSEQUENT

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

Draft Final Reg Repro

16. REMARKS

15. TOTAL

G. PREPARED BY H. DATE I. APPROVED BY J. DATE

17. PRICE GROUP 18. ESTIMATED TOTAL PRICE

DD Form 1423-1, JUN 90 PREVIOUS EDITIONS ARE OBSOLETE Page of Pages USAPPC V3.00

REQUIRED

SUBMISSION

0002 A MGMT

MGT, CULTURAL SITES FA8903-17-R-0035 TBD

A004 TECHNICAL AND MANAGEMENT WORK PLAN WORK PLAN

DI-MGMT-81117 PWS PARA - 4.7.1 AFCEC/CZOW

LT

A B

ONE/R

DANIEL GARCIA, AFCEC/CZOW28-Jul-2017JENNIFER HOLGUIN

N/A

28-Jul-2017

AFCEC/CZOW 1 1 1

772 ESS/PKS 0 0 0

SEE BLOCK 16

BASE POC 1 1 1

NSP

BLOCK 16

N/AN/A

2 2 2

Block 12: Draft plan shall be submitted within 45 days of task order award. The government shall require up to 30 days for review of draft. The contractor shall incorporate government comments and submit final within 15 days of receipt of government comments/approval.

Block 14: All deliverables shall be submitted by hard-copy, e-mail or on CD-ROM, as necessary. The government uses Microsoft Office Suite. E-mail addresses will be provided by the COR.

1 1

FOR OFFICIAL USE ONLY

FA8903-17-R-0035

DATA ITEM DESCRIPTION .

7 . 2 This DID may be used on any contract which is delivery order oriented.

Form P l E r n * d OYI ~a 0 7 w r u 8

I. APPROVAL wc Cvr-I

901219

10.1.1 -. Tha plan shall identify the contractor@s m e contract number, t i t l e and number of #e delivery or task ,order, security classification of the plan, name o f contract uonitor, an8 t h e Government office irauing the: tasking. .

, n u

TECHNICAL AND W A G E H E N T WORK PLAN

- '. U F W A T K ) n : W T E R 4 U 1 ~

7.1 his Data Item Description (DID) contains the format and content preparation instructions for the data product generated by the specifi and discrete task requirement as delineated in the contract.

s. c ;WE OF mm*rrr asmwmrun mm

X0.1.2 -material. The plan shall include descriptive matariaX, isyetem diagrams, sNtchee, photographs, tablea, forms, graphs, worksheets, char-, drawings, eto., a6 required. l0.r -. The plan shall be typewritten or printed on 8 1/2 11 ch paper. The pages &all be sequentially numbered and securely bound together. As nrceooary, graphic material may be one-way foldouts. A l 1 attachment6 shall be identified and referenced in khe text. Each sectfon and paragraph 8hall be numbered.

10.1.4 Tablg. plans of more than 30 pagea in

length shall contain a table of conkmts.

I. IDWWIUTON N U H ~ E ~

Dl-Mm-81117

9k *rrK NUlJlu

A6003

L UM0u.L UMlTAWM

( ~ o n t h u e d on Page :

1. DLSaiPrKIMlhlRmLE

3,1 The Technical and Hanagement Work Plan describes the contractor's plan to implement.the Statement of Work (SOW) tasking provided via delivery order or tasl order.

4#. OX UIUL~BLC

la rwutam wgtlstrnosa

10.1 -. The plan shall be subm%tted in a contractor devised and Government approved format w h i c h conforass to the following:

hu.rrPuwcrHIIIM5

I I . OtLlWuMW RATSMEW

DISTRIBUTION STATEMZNT A: approved for public release; distribution j unl hi ted .

WWDCC ACCUCAUE

FA8903-17-R-0035

Block lo, preparation Instructions (Continued)

10.1.5 s e a i b i l a . The document s h a l l be legible and reproducible.

10.2 C ~ n t e n t . The plan shall include information necessary to substantiate the-.contractor's approach t o completing the delivery or task order and information necessary f o r the Government to assess the soundness Of the contractor's approach. The plan shall contain the following:

10.2.1 -at- structw. The plan sha l l include a d e ~ c r i p t i a n of the contractor8s organizational structure and assignment of functions, duties, and respons ib i l i t i es which vill be assigned i n Support of the tasking. Additionally, the plan s h a l l ident i fy the contractorrs procedures, policies, and raport5ng requirements established t o i n i t i a t e , monitor, control, complete, and report on a c t i v i t i e s required of the delivery or tack order.

10 .2 .2 m a t f o t l a l interfaces. The plan sha l l describe a l l interfaces between the contrackor and the Government and between the contractor and other contractors or subcontractors which are necessary to complete the asmigned tasking. This shall include a descr ipt ion Of the applicable respons ib i l i t i es and functional re la t ionships betveen those organizations.

10.7 .3 pethod01 . The plan s h a l l include a narra t ive descr ipt ioh c lear ly d e f i n i n g z e t a c h n i a l approach (or method) Including toole, standards, and procedures to be wed by the contractor t o accomplish the delivery or task order, All d-antation, ac t iv i ty , or decisions required from the Government or ather GaverrrsPent contractor shall ha identified.

10.2.4 perso-. .The plan s h a l l identify the nmas and types of persome1 assigned to acconrpliah the delivary or.'LPsk order, .The plan shall show how the conbination of people assigned t o each task provides a su f f i c i en t knowledge or' experience base for that task. This includolu identifying any spec ia l education, training, experience, or skilla of these individwlci. Also, any spacial a&d.nistrative support requlrwnents oha l l be ident i f ied.

10.2.5 Securitu. The plan ohall identify any special or unique secur i ty requirements resulting from the delivery o r task order.

10,Z.L Sched . me plan ~bl l include a milastone chart(8) graphically d 3 c t i n g the schedule of eveintc aseooiateid with tbe delivery or task order, 'l!b lwel of d e t a i l s h a l l be eufficient to clearly show h w each eubtaok shall be pcrfozmod. his inoludee:

Page 2 of 3 Pages

FA8903-17-R-0035

Block lo, Preparation Instructions (Continued)

a. contractor activities.

b. Contractor deliverances (interim and final], including briefings (if required).

c, Other program milestones as appropriate (including Government input in 10.2.3 above).

dm Periodic milestones to allow adequate Government review of contractor progress.

10.2 7 The plan shall include a resources chart that graphically and numerically identifies the contractor's total planned manhour level of effort (WE) and LoE by month for each subtask identified in the delivery or task order. Proposed monthly aubtask manhour6 mhall be br~ken out by labar m ate gory in support of the dolivery or task order.

10.2.8 a The plan shall include a list of the travel requirements that shall include the following for each trip:

a. Company ar Govemnmt agency visited.

b. Location.

c, Number of travellers by labar category.

Trip dust ion.

10.2,9 contract= reauested data. Tbe plan shall include the contractor's best assessment of any additional data required by the contractor. This liet shall be as detailed as-poaarible and shall include document titles, respansible Government organizatione, anB reeponsjble Gavernment contractors. The criticality of each data required ahall be identified.

1D.2.10 Pelfverables. The plan shall include a brief description of the content8 of eacb deliverable to be provided as a result af the delivery or task order.

Page 3 of 3 Pages

FA8903-17-R-0035

Public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Department of Defense, Washington Headquarters Services, Directorate forInformation Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302, and to the Office of Management and Budget, Paperwork Reduction Project (0704-0188), Washington, DC 20503. Please DO NOT RETURN your form to either of these addresses. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

(1 Data Item) Form Approved OMB No. 0704-0188

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY

TDP TM OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO. 2. TITLE OF DATA ITEM 3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE

7. DD 250 REQ

8. APP CODE

9. DIST STATEMENT 10. FREQUENCY

11. AS OF DATE

12.DATE OF FIRST SUBMISSION

13.DATE OF SUBSEQUENT

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

Draft Final Reg Repro

16. REMARKS

15. TOTAL

G. PREPARED BY H. DATE I. APPROVED BY J. DATE

17. PRICE GROUP 18. ESTIMATED TOTAL PRICE

DD Form 1423-1, JUN 90 PREVIOUS EDITIONS ARE OBSOLETE Page of Pages USAPPC V3.00

REQUIRED

SUBMISSION

0002 A ENVR

MGT, CULTURAL SITES FA8903-17-R-0035 TBD

A005 ENVIRONMENTAL HEALTH AND SAFETY PLAN (HSP) N/A

DI-ENVR-81375 PWS PARA - 4.7.2 AFCEC/CZOW

LT

A B

ONE/R

DANIEL GARCIA, AFCEC/CZOW28-Jul-2017JENNIFER HOLGUIN

N/A

28-Jul-2017

AFCEC/CZOW 1 1 1

772 ESS/PKS 0 0 0

SEE BLOCK 16

BASE POC 1 1 1

NSP

BLOCK 16

N/AN/A

2 2 2

Block 12: Draft plan shall be submitted within 45 days of task order award. The government shall require up to 30 days for review of draft. The contractor shall incorporate government comments and submit final within 15 days of receipt of government comments/approval. Shall be submitted in conjunction with the Work Plan, CDRL A004.

Block 14: All deliverables shall be submitted by e-mail or on CD-ROM, as necessary. The government uses Microsoft Office Suite. E-mail addresses will be provided by the COR.

1 1

FOR OFFICIAL USE ONLY

FA8903-17-R-0035

DA'PA ITEM DESCRIPTION

I Environmental Health and Safety Plan (HSP) I Dl-ENVR-81375

I

3. DESCRIPTION l PURPOSE

1 3.1 The plan describes the Conuactor's procedures for ensuring health and safety standards. I

I 3.2 The plan serves as the basis for validation of the health aria safety standards to be Rnpkmented in acoDrdance with1 29 Combined Federal Regulation (CFR) 1910.120. I

7.1 This Data Item Desaiption (DID) contains the f o m t and content preparation instructions for the data product generated by the spatic and d i task requirement as delineated in the contracL 72 This DID is applicable when contractors are msponsibb for the ckwqment of p r o d u n s for health and safety requiremnts.

7.3 U.S. Environmental Protec!ion Agency (EPA) G u i i for Conducbng Remedial Investigations and Feasibility Shrdies Under Comprehensive Environmental Rcsponsc, Compensation, and Liobli Ad (CERLCA) can be obtained from: U.S. EPA, Omee of Emergency and Remedial Response. Washington DC 20460.

10.1 -. The applicable hrue of um documem ded herein. indudi Mi apprrnral dates and dates of any applicable amendments. nokes and rarision. $hall bs as specmod in the centrad I

10.3 Cantent. The HSP shall amt i n the folknring (addbnal informetion can bs obtained frwn U.S. EPA W i n e for Cnnducbng Remedial Investgations and FeasWty Studi Under CERCLA): I

4 APPROVALDATE

m ( - I

931216

a. IdernimbIl oi tite bcotiorr.

b. Sumw9ncs of r ; i h i .

C. &lWX$bS~ E'~B B ? d d .

d. FbnrCd aChi&s.

DD Fom 1564, APR 89 (EF) J tarm chvplrr.dylb~~~--. p.9.10l3pgl m.

7 APPUUllON I INTERREUllONtnIP

00 GlMPAPPLlCABLE 5 OFFICE OF P W Y RESPONSBIUW (OPR)

FIAFCEE-ESK

6m DnC APPLICABLE

FA8903-17-R-0035

Block 10, Preparation Instruchons (Continued)

10.3.2 -. The organization required to support the health and Safety function shall include:

a. Descnptlon of the program and project safety organization Structure

b. Identification of safety program members.

c. Description of tesponsibilitres of the safety program members.

d. Telephone number for each safety pmgrarn member.

10.3.3 Skrna~2. The plan shall include a site map to depict all details relevant to heam and Safety:

a. ldentrfy zones of exclusion.

b. ldentrfy work staging areas.

c . ldentrfy decontamination areas.

d. Idenbfy location of alarms.

e. ldenbfy emergency response equipment locations.

f. Identify site entrances and exits.

g. ldentrfy evacuation routes.

h. Location of telephones.

10.3.4 -. Identification of potential heatth and safety risks for each task and operation includtng:

a. Site amtaminants and hazardous materials that ere planned for ort4te use.

b. An appendix referencing material safety data sheets for sach chemical hazard.

10.3.5 w. The plan shall indude a statement of each mwkefs Occupational Safety and Heah Administration (OSHA) mining status under 29 CFR 1 B1 (F12O.

a. Identification of the lime, bcation, and subject matter of aita vdcer mining sessions.

b. A schedule fo r th pre-entry briefings held p* to initiating on-site activities.

10.3.6 -. An identification of the pcnonal pmkbw equipment to be used by on-site employees for each protection level that shall be requid including:

a. Equipment tern pmcedums and f r e q w .

b. Decontamination procedums and frequency.

10.3.7 Mcd,eal. Desmibe the medical wdUance program to be impbmetnted to sown and monitor site personnel.

10.3.8 m. Identify the mitoring procedums to ensure the safety of sibb personnel and ths public including:

a. The frequency of, and methods to be used to monibx ambient air, site personnel. and environmental media.

b. lmmentation, talibration, and qbliility conW pradkes.

c. Action kvels 8swSatd with cack monibDmd parameter.

d. Informstion to support the action level sektud.

Page 2 a13 Pages

FA8903-17-R-0035

Block 10, Preparation InsWctions (Continued)

10.3.9 Site Identify the procedures for controlling access to restricted areas and prevent"% wntarnrnatron of clean areas and srte personnel ~ncludng.

a. Areas that require the use of personal pt~tective equipment on a site map.

b. The steps to be taken to ensure safe worlong condibons and communicabon among Site personnel.

c. Confined space entry procedures.

10.3.10 m. The safety prahces, preparedness procedures, emergency telephone numbers and emergency response and follow-up for each site hazard identified in the HSP tncludrng:

a. The response action appropriate to all potential emergencies, spills, or contaminant releases.

b. Lecation and use of emergency response equipment, personnel, and sewices as well as the system for contacting response personnel in event of emergency.

c. Identification of all regulatory agenues nequiring notification of an emergency response including me system used for contacting regubtory authorities in the event of an emergency.

d. Outline of the emergency response documentation requirements necessary in the event of an emergency.

FA8903-17-R-0035

Public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Department of Defense, Washington Headquarters Services, Directorate forInformation Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302, and to the Office of Management and Budget, Paperwork Reduction Project (0704-0188), Washington, DC 20503. Please DO NOT RETURN your form to either of these addresses. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

(1 Data Item) Form Approved OMB No. 0704-0188

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY

TDP TM OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO. 2. TITLE OF DATA ITEM 3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE

7. DD 250 REQ

8. APP CODE

9. DIST STATEMENT 10. FREQUENCY

11. AS OF DATE

12.DATE OF FIRST SUBMISSION

13.DATE OF SUBSEQUENT

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

Draft Final Reg Repro

16. REMARKS

15. TOTAL

G. PREPARED BY H. DATE I. APPROVED BY J. DATE

17. PRICE GROUP 18. ESTIMATED TOTAL PRICE

DD Form 1423-1, JUN 90 PREVIOUS EDITIONS ARE OBSOLETE Page of Pages USAPPC V3.00

REQUIRED

SUBMISSION

0002 A MISC

MGT, CULTURAL SITES FA8903-17-R-0035 TBD

A006 SCIENTIFIC AND TECHNICAL REPORTS SUMMARY REPORT

DI-MISC-80711A PWS PARA - 5.2 AFCEC/CZOW

LT

A B

QRTLY

DANIEL GARCIA, AFCEC/CZOW28-Jul-2017JENNIFER HOLGUIN

N/A

28-Jul-2017

AFCEC/CZOW 1 1 1

772 ESS/PKS 0 0 0

SEE BLOCK 16

BASE POC 1 1 1

NSP

BLOCK 16

N/ABLOCK 16

2 2 2

Block 4: DID Tailoring: DID Block 6a is not applicable.

Blocks 12 & 13: Submit report as directed by the COR.

Block 14: All deliverables shall be submitted by e-mail or on CD-ROM, as necessary. The government uses Microsoft Office Suite. E-mail addresses will be provided by the COR.

1 1

FOR OFFICIAL USE ONLY

FA8903-17-R-0035