DI-ENVR-82091_CHMI-DID.pdf

DATA ITEM DESCRIPTION

Title: CONTRACTOR HAZARDOUS MATERIAL INVENTORY REPORT

Number: DI-ENVR-82091 Approval Date: 20161208

AMSC Number: N9751 Limitation: N /A

DTIC Applicable: No GIDEP Applicable: No

Preparing Activity: SH Project Number: ENVR-2017-001

Applicable Forms: PSNS&IMF form 5090/132

Use/Relationship: Contractor Hazardous Material Inventory Report will be used to identify hazardous materials needing for approval by the government for use on the Naval Installation.

This DID contains the format and content preparation instructions for the data product generated by the discrete task requirement as delineated in the contract.

Requirements:

1. Format. The Hazardous Material Inventory Report shall be presented on PSNS&IMF form

5090/132 in this DID.

2. Content. The report shall contain all of the information specified in PSNS&IMF 5090/132.

End of DI-ENVR-82091

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DI-ENVR-82091

CONTRACTOR HAZARDOUS MATERIAL INVENTORY (CHMI)

Ref: NAVSEA Standard Items 009-97 and 009-02 NWRMC Local Standard Item 099-04NW

Document No.

CONTRACTOR – INITIAL REQUEST1 (Before moving any hazmat onto this Federal facility) **Refer to instructions on last page**

PRIME CONTRACTOR (KTR) (POC) SUB-CONTRACTOR (If Applicable) PRIME KTR CERTIFICATION SIGNATURE (sign or submit electronically) Print & sign

PHONE

Mr KTR NA Signature on File 555-232-2222

CONTRACT NUMBER PROJECT NAME2 WORKSITE LOCATION3 PROJECT EXECUTION START

DATE

PROJECTED

END5

N4523A-12-D-0003 USS Michigan Dry Dock 2 12/14/2015 04/03/2016

ENVIRONMENTAL, SAFETY, AND HEALTH (ESH) GOVERNMENT REPRESENTATIVE

CONTRACT OFFICE AGENCY (i.e., C/400, AIT)

ESH GOVERNMENT REPRESENTATIVE NAME PHONE FAX SUBMITTAL

DATE C/400/106.2 ESH SBS 360-535-2222

CODE 106.31 HAZARDOUS MATERIAL PROCESS MANAGEMENT BRANCH

106.31 NAME & INITIALS RECEIPT DATE REVIEW DATE

Trade Name6

Name on product & MSDS must match

For kits, list kit name, then list kit components individually

Manufacturer7

Name on product & MSDS must match

Process Code Number8

Use provided flow chart

Container Size & Type9

Enter size

SHIPYARD MSDS

Number10 (As assigned by Code 106.31)

SHIPYARD Assigned Stock Number (Assigned by Code 106.31)

Speclt SSPR 6PK Marking Fluorescent Green Spray Paint, #1989830

Rust-Oleum Corp. ID0507 11 oz AER See Attached SDS

CONTRACTOR HAZARDOUS MATERIAL INVENTORY (CHMI) CODE 106.31 Document No. Page 2 of 2

CONTRACTOR – INITIAL REQUEST (Before moving any hazmat onto this Federal facility)

Trade Name6

Name on product & MSDS must match

For kits, list kit name, then list kit components individually

Manufacturer7

Name on product & MSDS must match

Process Code Number8

Use provided flow chart

Container Size & Type9

Enter size

SHIPYARD MSDS Number10 (As assigned by Code 106.31)

SHIPYARD Assigned Stock Number ( assigned by Code 106.31)

PSNS & IMF 5090/132 (Rev. 04-13)

INSTRUCTIONS

Contractor: Fill out each section under the heading “CONTRACTOR” per the following instructions and footnotes. List all hazardous material (HM) that you, as the contractor, anticipate transporting from offsite onto the Federal property located at the Bremerton Naval Complex (BNC). Do not list HM obtained inside the BNC that has been labeled with the facility’s salmon colored supplemental barcode label. Use as many additional sheets as necessary to include all HM that you anticipate transporting onsite. Provide the most current MSDS for each product listed in the CHMI. If you are using a “Non-Road” engine do not forget to submit an O&M plan to Code 106.31 Air Department. For all marine coatings, provide a Volatile Organic Compound (VOC) certification sheet for each batch. If you have a Marine Coating that is

General Use and the VOC’s are above 340g/l you must submit separate paperwork to Code 106.31 Air department. All HM must be approved by the Code 106.31 before bringing material onsite. Low Use

Exempt materials may also be processed on this form. Upon completion of all Contractors required items submit the completed CHMI form to your Government Environmental, Safety, and Health representative.

* Prime Contractor Certification Statement: I hereby certify that the submitted information contained in the attached document(s) is true, complete and accurate, and all material listed has been approved by

Code 106.31.

Designated Government Environmental, Safety, and Health Representative: Complete Designated Government ESH section. Submit completed CHMI to Code 106.31 for review and approval.

FOOTNOTES

This is for the initial request. Use the Receipt & Monthly Usage Form to report monthly HM usage by the 5 th calendar day of the following month. Negative usage reports are required. If no usage, enter 0 in applicable field or leave blank and submit report.

Identify Project (e.g. – ship hull number or name, etc).

Identify Worksite Location (e.g. – Hull number, bldg. 431 5th floor, Dry

Dock 2, Pier D, etc).

The date that the contractor is to start work on the project.

The planned (best estimation) completion date for work on the project.

Provide a separate line for each product and/or container size that will be used. When reporting kits, list each component on separate lines. If part numbers are included in the Trade Name block, it will be helpful in processing the CHMI faster.

Reference example below.

Trade Name Manuf acturer

Container

Size & Type

MSDS

Stock

Number

Buff Base Part

A PPG 0.8 gal CN

Converter Part

B PPG 0.2 gal CN

Welding electrodes 7018 ESAB 10lb

Table 1 – Container Type

Descripti on

Aeros ol Can

Ba g

Bottle Bo x

Cartri dge

Can Contain er

Cylind er

Drum

Code AER BG BT B

X

CA CN CO CY DR

Descripti on

Each Jar Package Ki t

Rod Spool Tank Tube

Code EA JR PG K

T

RD SP TK TU

Manufacturer, product name on container and company name must all match.

To determine the proper Process Code Number use the attached Hazardous Material Process Code Selection Flow Chart.

Report container size(s) in quantifiable units (e.g., weight or volume) such as a 3 lb. jar or a 16 fl oz bottle. For compressed gas cylinders, report the quantity of gas in cubic feet or units such as pounds (e.g., 150 cu-ft or 100 lb cylinder). For bulk material (e.g., diesel fuel) or material without a specific container size (e.g., welding rod or wire), use the units in which the material is commonly sold to consumers (e.g., use gallon for diesel fuel or pound for welding rod or wire). For kits, list both the kit size and each individual component size. Reference Footnote 6 for reporting kits. See Table 1 for the applicable container type. Enter container type code.

Provide the Shipyard approved Material Safety Data Sheet (MSDS) number (if known) or include a MSDS for each product (Code

400 projects only). Sending a Technical Data Sheet with the MSDS will be helpful in processing the CHMI faster. When sending an MSDS ensure that it is no older than 5 years old, the MSDS must be a representative of the material being used.

For Usage remember you are reporting for the size requested and it is listed on the form. When reporting round up to the nearest tenth, use percentages (i.e. do not use: 3 gal of a 10 gal container, use: .3

When Reporting Partial Usage, Use Decimals to Represent the Fraction of Container Used.

EXAMPLE:

Use 0.8 to indicate 3/4 usage of a container

Do Not Enter as Lbs, Gallons, Ounces etc.

Round Up to Nearest Tenth.

Use 0.3 to indicate 1/4 usage of a container Use 0.8 to indicate 3/4 usage of a container

PSNS 5090/132 (Rev. 04-13)