5100_2_Project_Management_Env-Safety_Review.pdf

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NSWCCORDIV 5100/2 (REV. 10-15)

PAGE of

NSWC CORONA

PREVIOUS EDITIONS ARE OBSOLETE

PROJECT MANAGEMENT ENVIRONMENTAL & SAFETY REVIEW

1. TYPE OF REQUEST (Please select one option per form):

Note: For this form to work correctly please click the button at the top in yellow "Enable all Features" and select the "Type of Request"

3. PROJECT MANAGER INFORMATION:

3. CONTRACTOR/VENDOR INFORMATION

This form must be completed by the prime contractor program manager or vendor to identify any anticipated hazards that may be encountered while executing the statement of work onboard the installation. This information will be used to specify project requirements. Prior to beginning work on-site, contractors/vendors may be required to submit a DETAILED SITE-SPECIFIC SAFETY PLAN to the Project Manager, Contracting Office Representative (COR) and the NSWC Environmental, Safety & Health (ESH) Office. This plan shall identify procedures and methods for controlling PROJECT-SPECIFIC environmental impacts and safety hazards throughout the scope of work. In addition, hazardous material Safety Data Sheets (SDS) and copies of the contractor's safety manual/safety programs must be submitted to the Project Manager, COR, and NSWC ESH Office, upon request.

6. POTENTIAL HAZARDS ASSOCIATED TO THE CONTRACT/WORK (Check all that apply):

7. EQUIPMENT OR MATERIALS USED (Check all that apply):

8. PERMITS/PLANS REQUIRED TO ACCOMPLISH PROJECT (Check all that apply):

9. PERSONAL PROTECTIVE EQUIPMENT REQUIRED FOR HAZARDS IDENTIFIED (Check all that apply):

NOTE: ALL CONTRACTOR OPERATIONS SHALL BE IN ACCORDANCE WITH THE US ARMY CORPS OF ENGINEERS EM 385-1-1 AND ALL FEDERAL, STATE, AND LOCAL REGULATIONS.

11. CONTRACTS OFFICE REPRESENTATIVE/SERVICE REQUESTOR REVIEW:

By submitting this document, I affirm that the contractor/vendor has been informed of the need to comply with the OSHA requirements related to the identified hazards. A detailed site-specific safety plan may need to be submitted to the ESH Office depending on the scope of work and associated hazards.

12. ENVIRONMENTAL, SAFETY AND HEALTH OFFICE REVIEW:

THIS IS A CAC SIGNED ELECTRONIC FORM AND THE RECORD COPY MUST BE MAINTAINED ELECTRONICALLY. CAC SIGNED PRINTED VERSIONS OF THIS FORM ARE NOT VALID RECORDS. IF THE FORM CANNOT BE CAC SIGNED, ALL SIGNATURES MUST BE PEN & INK. IF PEN & INK AND CAC SIGNATURES ARE MIXED ON THE FORM, THE FORM IS INVALID. RECORD COPIES OF THIS FORM WILL BE MAINTAINED BY CODE 102 IAW SECNAV M-5210.1.

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