JA11- 01 57 19 Appendix C_EAFB Waste Determination Form.pdf

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Attached to
Maintain Boiler 4 Federal contract opportunity
Solicitation number
FA500422C0006
Issued by
Department of the Air Force Pacific Air Forces

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This document contains a hazardous waste determination form and information on a federal contract opportunity for boiler maintenance at Eielson Air Force Base in Alaska. The hazardous waste determination form provides a template for contractors to document waste characterization when working on-site. The related federal contract opportunity is an invitation for bid to repair and maintain Boiler 4 at the Central Heat and Power Plant on base. The project scope involves preparation of the site and performance of repair work. The performance period is 154 calendar days with an estimated value between $5 million and $10 million. A mandatory site visit will be held on April 21st and questions are due by April 25th. Bids must be submitted electronically by May 12th. The opportunity is a total small business set-aside for a contemplated firm fixed price contract requiring payment and performance bonds.

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HAZARDOUS WASTE DETERMINATION FORM

Hazardous Waste Determination Form #:

A. WASTE DESCRIPTION:

Generation Process:

Generation location and/or system: Total Quantity and/or Estimated Generation rate:

B. WASTE PROPERTIES, CHARACTERISTICS, and CONSTITUENTS:

pH: [ ] < 2 [ ] > 2 but < 12.5

[ ] N/A [ ] > 12.5

Physical [ ] Solid State: [ ] Solid w/freestanding or absorbed liquid

[ ] Liquid (If liquid, indicate if the liquid is:

[ ] Single Layer [ ] Multi-layer

[ ] Gas

Flashpoint: [ ] < 140 oF [ ] > 140 oF but < 200 oF

[ ] N/A [ ] > 200 oF Characteristics: Asbestos

Content:

PCB Content: Metal Content:

[ ] Antimony* [ ] Arsenic [ ] Barium [ ] Beryllium* [ ] Cadmium

[ ] Chromium [ ] Cobalt* [ ] Copper* [ ] Lead [ ] Mercury

[ ] Molybdenum* [ ] Nickel* [ ] Selenium [ ] Silver [ ] Thallium*

[ ] Vanadium* [ ] Zinc*

[ ] None

[ ] Corrosive [ ] Ignitable [ ] Reactive [ ] Radioactive [ ] Toxic

[ ] Friable [ ] Non-Friable

[ ] None

[ ] > 5 ppm [ ] < 5 ppm

[ ] None

*Check these metals (or metal compounds) only if they are in a friable, powdered, or finely divided state.

Composition (list all constituents, including debris, any absorbent, freestanding liquid, or absorbed liquid):

Constituent: Volume % (range): Constituent: Volume % (range):

C. REMARKS (Attach all applicable documentation describing the waste (e.g. process knowledge statement, MSDS, manufacturer's specifications, sample analysis, etc.):

D. REQUESTOR’S CERTIFICATION [By signing the form, the requestor certifies (based on process knowledge or certified records) that all information is complete and accurate to the best of his/her knowledge.]

REQUESTOR NAME/SIGNATURE: DEPARTMENT/GROUP: EXTENSION: DATE:

Upon completing Blocks A, B, C, and D above, the requestor will forward the form to the Contracting Officer who will in turn route the form to the Eielson Project Manager for processing through the Installation Environmental Office. The Installation Hazardous Waste Program Manager will complete Page 2 of the form and the form will be routed back to the PM and Contracting Officer. The Contracting Officer will provide the completed form back to the Contractor.

01 57 19 - APPENDIX

HAZARDOUS WASTE DETERMINATION FORM

For Installation Environmental Office Use Only

Hazardous Waste Determination Form #:

For Installation Hazardous Waste Program Manager Use Only

[ ] Sample Analysis Required (specify):

EPA Waste Codes: Hazardous Classification:

[ ] Non-Hazardous

[ ] RCRA Waste

[ ] Non-RCRA Waste (CA Haz Waste)

[ ] TSCA Waste

Remarks:

Installation Hazardous Waste Program Manager NAME/SIGNATURE: DATE:

01 57 19 - APPENDIX

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