5._N3B-Form-2175_Beryllium_Inventory_Update_Form__DRAFT.pdf

N3B-Form-2175, R0 Page 1 of 2 Effective Date: xx/xx/xx Implementing Procedure: N3B-P101-21

N3B-Form-2175

Beryllium Inventory Update Form

Update Submitted By Name: Z No.: Org.: Phone: Date:

Area/Operation Knowledgeable Person (KP) and RLM Information KP: Z No.: Org.: Phone: Pager:

RLM: Z No.: Org.: Phone: Pager:

Update Details Reason for Submitting Update: New Entry Update Existing Entry Unsure If New/Existing Inspection FOD: TA: Bldg: Room(s):

Other Location: Inventory Rec ID (if known):

Approximate Size of Area: ft2 (see ARCHIBUS database) Approximate # of Workers Affected:

Area/Operation/Activity Description (NO PART NUMBERS; NO CLASSIFIED INFORMATION; check box if UCNI):

DC Review (as needed): UCNI Unclassified Z No./Signature/Date:

Applicable IWDs, procedures, etc. (Use comments field below if needed):

Hazard Assessment

Hazard assessment form completed? Yes No If yes, hazard assessment date:

QEA ID #: Other documents:

Latest Sampling Information (Check and complete those that apply)

Surface Wipes Date: CTS Survey ID#: Any results ≥ trigger levels? Yes No

Personal BZ Date: CTS Survey ID#: Any results ≥ action levels? Yes No

Area Air Date: CTS Survey ID#: Any results ≥ action levels? Yes No

Bulk Date: CTS Survey ID#: Any results ≥ 3.3 levels? Yes No

Designated Beryllium Area Type and Posting Requirement (Check one area type and one area status) Not a Designated Beryllium Storage Area Beryllium Contamination Area (also check below) Beryllium Airborne Regular Beryllium Area Accessible Inaccessible

Area/Operation/Activity Status:

Active Inactive Released Area Area Posted Yes No

Update/Inspection Comments (Use back or attach or reference other documents as needed)

Beryllium Program Only (Person making change to inventory) Name: Z No.: Org: Phone: Date:

DRAFT

RFP-0000297

N3B-Form-2175, R0 Page 2 of 2 Effective Date: xx/xx/xx Implementing Procedure: N3B-P101-21

Instructions for Completing the Beryllium Inventory Update Form

1. Update Submitted By – Enter identifying information and date form is completed.

2. Area/Operation Knowledgeable Person (KP) and RLM Information – Enter contact information for a person knowledgeable of the area/operation and the Responsible Line Manager (RLM) for the area/operation.

3. Update Details Reason for submitting update:

Indicate if this is a new entry, an update to an existing entry, or unsure of entry status.

If unsure if the entry is new or an update; first try to match to inventory report on the beryllium web-page. If still unsure, check the

“Uncertain if New/Existing” box.

“Inspection” box may be checked along with any one of the other boxes.

FOD, TA, Bldg., Rooms, Other:

Enter location information for the operation or area.

If the operation or area is moveable (e.g. a test vessel), provide details in the comment section.

Inventory Rec ID – If known, enter the beryllium inventory record ID number.

Approximate Size of Area – Measure or estimate the square footage of the area.

Approximate # of Workers Affected – Estimate the number of workers affected (i.e. those potentially exposed).

Area/Operation/Activity Description – Enter a brief description of the area and/or operation. Include enough detail to clearly identify the area or operation. Description should note any unusual conditions or hazards associated with the area. DO NOT enter part numbers or classified information. UCNI information may be entered if necessary to adequately describe the area or operation. Mark checkbox on form if UCNI is entered. If in a controlled area or you are uncertain, a review by a Derivative Classifier (DC) may be appropriate.

Applicable IWDs, procedures, etc. – List the IWDs, procedures, or other work control documents for the area or operation.

4. Hazard Assessment – Indicate if a hazard assessment has been completed for the area or operation. If yes, indicate date and reference the applicable hazard assessment documents. (Note: Hazard assessment details are covered in Form 2061.)

5. Latest Sampling Information – Provide date and survey ID# for the most recent sampling for the area or operation. Also indicate if any results exceeded applicable action levels.

6. Type of Designated Beryllium Area:

Indicate the type of designated beryllium area or if it is not a designated beryllium area. See P101-21 for definitions and requirements. The areas, in order of increasing hazard, are Storage, Inaccessible Contamination, Accessible Contamination, Airborne, and Regulated. Each beryllium area will be given one designation based on the highest hazard level. For example, it is expected that beryllium would be stored in and surface contamination would be present in an Airborne Beryllium Area. It would not require designation and postings for storage and contamination. The description or comments sections or an attachment can be used to provide information on non-designated beryllium areas (e.g. chemical hygiene plan area; beryllium articles only, etc.).

Area/Operation/Activity Status:

Active – Performed at least once per year; or an activity that is less frequent (e.g. specific maintenance), but the organization anticipates the need and is prepared to perform as needed. Note: A Beryllium Storage Area is active if any beryllium material is stored there.

Inactive – Not currently performed or is performed less than once per year, but the organization anticipates that it may be performed again. May require efforts to re-start (e.g. develop IWDs).

Former – No longer performed. No plans to perform in future.

Released – A former beryllium area or suspect legacy area that has been sampled to statistically determine that the area is not contaminated above release levels.

7. Beryllium Program Only – This section is reserved for the use of the beryllium inventory manager only.

8. Completed Form – Submit completed pdf form to the N3B Beryllium Program Lead

Additional Information and Comments

DRAFT

RFP-0000297