Exhibit_F_Attachments,_F7.0_revised_5.30.19.pdf

LA-UR-2189 8 SAVE PRINT

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Integrated Work Document (IWD) Part 2, FOD Requirements and Approval for Entry and Area Hazards and Controls

Form 2101

Non-Tenant Activity Form

IWD No./Work Request No: Revision #:

The Facility Operation Director (FOD) must determine the facility entry and coordination requirements and identify the Environment, Safety, Health (ESH)/Security and Safeguards (S&S) hazards and controls associated with the specific activity location.

FOD TA Bldg. Room Other Location

FOD Designated Facility Point-of-Contact

Name Phone Pager Email

Entry and Coordination Requirements (Check one or more of the following)

No Entry/Coordination Requirements FOD-designated facility Point-of-Contact must sign IWD Part 3

Plan of the Day/Plan of the Week (POTD/POTW) Check in at Start of Work Work-Area Training Required

Security Clearance Requirements Work must be Scheduled Check in Daily

Co-located Hazards/Concerns Other Security Requirements (ex.: Cellphone, No Foreign Nationals, etc.)

Check out at End of Work Quality Issues Check out Daily

Escort Required Review under Authorization Basis (AB)/Safety Basis/Unreviewed Safety Question (USQ)

Other Bounding Conditions:

Additional Comments

Instructions: In the block below, identify work-area hazards that could potentially affect the worker(s) or others. Avoid using the same Part 2, Form 2101 for multiple facilities. Ensure that work area hazards, specific to the facility or work location are identified and controlled. Specify the facility controls and preventive measures that must be implemented by the worker(s) to protect against the work area hazards, and also special training required.

ESH/S&S WORK AREA HAZARDS & CONTROLS

Work Area Hazards/Concerns

Identify site hazards and concerns that could potentially affect the worker(s) or others.

Work Area Hazard Present

Facility Controls/ Preventive Measures/ Bounding Conditions

Specify preventive measures, controls and bounding conditions for each site hazard

Reference Documents

List permits, operating manuals, and other reference procedures

Training and Qualification

List training requirements (P300, Integretated Work Management, Section 6.1)

No Work Area Hazards

Ionizing Radiation

Work in posted radiological areas, work with radioactive materials, or work on or near radiation producing devices.

Specify Hazard:

Yes No

Form 2101 (12/17) Page 1

PRINT SAVE

CLEAR FORM

Attachment F1-0

RFP-0000300

https://policy.lanl.gov/pods/policies.nsf/LookupDocNum/P300/%24file/P300.pdf https://policy.lanl.gov/pods/policies.nsf/LookupDocNum/P300/%24file/P300.pdf https://policy.lanl.gov/pods/policies.nsf/LookupDocNum/P300/%24file/P300.pdf

IWD No./Work Request No: Revision #:

ESH/S&S WORK AREA HAZARDS & CONTROLS

Work Area Hazards/Concerns

Identify site hazards and concerns that could potentially affect the worker(s) or others.

Work Area Hazard Present

Facility Controls/ Preventive Measures/ Bounding Conditions

Specify preventive measures, controls and bounding conditions for each site hazard

Reference Documents

List permits, operating manuals, and other reference procedures

Training and Qualification

List training requirements (P300, Integretated Work

Management, Section 6.1)

Worker Exposure

Working near non-ionizing radiation, beryllium, noise, chemicals, hazardous biological materials, lead, asbestos, temperature/humidity extremes, or high explosives.

Specify Hazards:

Yes No

Energized and Operative Systems

Working near energized electrical parts, pressure systems, steam lines; near unprotected belts, pulleys, chains or rotating equipment;

fuel fired equipment other than vehicles; or spark or flame producing operations.

Specify Hazards:

Yes No

Confined Spaces

Entry into tanks, manholes, cooling towers, sumps, or any other area with potentially low oxygen concentration or other hazards such as toxic vapors or engulfment.

Specify Hazards:

Yes No

Elevated Work Surface Elevated work when fall protection is not provided by conventional handrail systems or required per P101-20, Fall Protection Program

Yes No

Environmental Impact

Activities conducted in areas containing potential release site, contaminated soil, sensitive species, watercourse wetlands, floodplain, historical/archeological sites, or other work area condition that can be impacted by or can impact the environment.

Specify Hazards:

Yes No

Security Requirements Specify: Yes No

Other Hazards Specify:

Yes No

Form 2101 (12/17) Page 2

LA-UR-21898

I have verified that the hazards identified above adequately identify the area hazards and that the IWM process has been applied appropriately.

FOD or Representative (Signature/Z #/Date) Approval Required

Date Approval Expires:

SAVE PRINT CLEAR FORM

RFP-0000300

https://policy.lanl.gov/pods/policies.nsf/LookupDocNum/P300/%24file/P300.pdf https://policy.lanl.gov/pods/policies.nsf/LookupDocNum/P300/%24file/P300.pdf https://policy.lanl.gov/pods/policies.nsf/LookupDocNum/P300/%24file/P300.pdf https://policy.lanl.gov/pods/policies.nsf/MainFrameset?ReadForm&DocNum=P101-20&FileName=p101-20.pdf https://policy.lanl.gov/pods/policies.nsf/MainFrameset?ReadForm&DocNum=P101-20&FileName=p101-20.pdf

It is the policy of LANS that all work performed at LANL shall be conducted in a manner that protects workers, the public, and the environment. The objective of this policy is to establish a consistent site-wide approach to worker protection by incorporating safety and health into daily activities. To support the effective implementation of this policy, firms should have a demonstrated safety performance equal to or lower than the following standards:

Statistical Standards

Experience Modification Rate

The “EMR” is a number that is assigned to your company based on the insurance premium you pay and your loss statistics. Contact your insurance company for these numbers.

Maximum Allowable Average:

1.00

Total Recordable Injury/Illness Case Rate

(from Company OSHA 300 log)

Rate = Total Recordable Injuries/Illnesses x 200,000

Total Employee Hours Worked

Maximum Allowable Average:

3.2

DART Case Rate (Days Away From Work, Restriction, or Job Transfer) (from Company

OSHA 300 log)

Rate = Total Days Away/Restricted/Transferred Work Day Cases x 200,000 Total Employee Hours Worked

Maximum Allowable Average:

1.4

Firms must submit a properly executed Environment, Safety, and Health History Worksheet (Attachment F3-2) along with a letter from their Workman’s Compensation Insurance Carrier to certify the Experience Modification Rate (EMR) performance. If any of the above maximum allowable averages is exceeded, the firm shall provide information that clearly explains the excessive rate and that the anomaly causing that excess was not easily preventable using sound safety practice.

If a firm is a joint venture, association, consortia, or partnership that has fewer than three years of demonstrated safety and/or environmental performance, each entity comprising the joint venture, association, consortia, or partnership must submit a properly executed Environment, Safety, and Health History Worksheet (Attachment F3-2) along with a letter from their Workman’s Compensation Insurance Carrier to certify the Experience Modification Rate (EMR) performance.

Any response received from a firm which does not provide the ES&H History Worksheet(s), which exceeds any of the stated maximum allowable averages, or which has fewer than three years of demonstrated safety and/or environmental performance may, at LANS’ sole discretion, be considered unacceptable.

If a firm intends to use lower-tier subcontractors to perform elements of the subcontracted Scope of Work, such lower-tier subcontractors shall also meet the maximum allowable averages specified above. The firm to whom a subcontract is awarded (i.e., Subcontractor) shall be responsible for ensuring that all its lower-tier subcontractors meet the maximum allowable average safety performance eligibility requirements. When requested, Subcontractor must demonstrate to LANS’ satisfaction that its lower-tier subcontractors meet the maximum allowable average safety performance eligibility requirements. Any lower-tier subcontractor that does not meet one or more of the maximum allowable average safety performance eligibility requirements must be evaluated and approved by the Subcontractor and LANS.

LA-UR-21898 Page 1 of 1

Attachment F3-1 Safety Performance Eligibility Requirements

RFP-0000300

Attachment F3-2 Environment, Safety and Health Worksheet

Subcontractor Name:

Worksheet completed by:

Date:

Proposed LANS Subcontract Number:

1. Experience Modification Rate (EMR)

List your firm’s Interstate EMR for the past three (3) years and total hours worked.

Year: EMR:

Year: EMR:

Year: EMR:

3-year average:

If the state where the jobsite is located has an EMR rating system, provide the state EMR for the past three (3) years and the total hours worked.

Year: EMR:

Year: EMR:

Year: EMR:

3-year average:

2. Total Recordable Case (TRC) and Days Away/Restricted/Transferred Case (DART) Rates

List the cumulative injury statistics rates for the past three (3) years using the BLS formula to determine recordability.

Year: TRC: DART: Hours Worked:

Year: TRC: DART: Hours Worked:

Year: TRC: DART: Hours Worked:

3-year average TRC: DART:

Attach copies of the OSHA Annual Summary Logs (OSHA’s Form 300A) for the three most recent years and a current year OSHA 300 Log for the months during the period since the last annual report.

Any OSHA fine(s) over the past three (3) years? If yes, provide a written explanation on an attachment to this form.

3. Fatalities

Any fatalities within the last three (3) years? If Yes, list total number of fatalities: , and provide a written explanation for each fatality on an attachment to this form.

4. Bureau of Alcohol, Tobacco, and Firearms violations

Any Bureau of Alcohol, Tobacco, and Firearms violations within the last three (3) years?

If Yes, list the number: , and type of violations: .

5. For companies exempt from record keeping requirements per 29 CFR 1904.1 (ten or fewer employees), complete items 1 and 3 above and summarize the cause of the injuries/illnesses for the past three (3) years, including the current year, on a separate attachment to this form.

Additionally, include corrective actions taken to prevent re-occurrence.

6. Check your type of work for the most recent 3 year period:

Non-Residential Building, include dates:

Heavy (Non-Highway) Construction, include dates:

Mechanical, include dates:

Electrical, include dates:

Other (State type and date):

7. List key Safety and Health personnel planned for this project. Please list name and expected position.

NAME POSITION

8. List key Environmental personnel planned for this project. Please list name and expected position.

NAME POSITION

9. Environmental Record

Has your firm been subject to any environmental enforcement proceedings before a federal or state agency within the last five (5) years? If Yes, for each proceeding provide the name of the agency, the nature of the proceeding, the charge(s) and the result on an attachment to this form.

Has your firm violated or exceeded any federal or state environmental standard, requirement, regulation or statute within the last three (3) years? If Yes, for each violation give a brief description of the nature of the violation on an attachment to this form.

NOTE: This form is for evaluation purposes only and will not be a part of a Subcontract.

ES&H Professional / Specialist / Representative Qualification Form

Name: Z Number: Employer:

Certifications/Educational Experience/Equivalent

Board Certification(s) Organization:

1) ___________________

2)____________________

Certification / Certification Number:

2)

1)_____________________________________

Date Certification Expires:

1)

2)_______________________

Educational Institution From To Degree Major

Work/Applicable Experience (attach additional sheets as necessary)

Employer Job Title From To Credited Experience

Subject List Hours Course Description Date

Formal ES&H Training

(e.g., OSHA 500 / 501, Excavation Competent

Person, Erosion Control, Waste Mgt, etc.)

First Aid/CPR

Environmental

OSHA

HAZWOPER (40 hr / 24 hr / Supervisor)

Other (List)

Attachment F4-0 ES&H Personnel Qualification Form

ES&H Related Field

Experience

Activity Yes No # Yr Exper.

Safety

Drilling:

Excavation:

Heavy Equipment:

Other:

Environmental

Erosion Control:

Waste Mgt:

BMP:

Other:

Performing Hazards

Analysis

Chemical Agents:

Examples:

Biological Agents:

Examples:

Physical Agents:

Examples:

Developing / Implementing Health &

Safety Plans:

Site Safety Inspections:

Other (detail)

Attachment F4-0

Company Name:

Employee Name:

I have reviewed the qualifications for the above individual and have verified to the best of my ability that this individual meets N3B criteria to serve as: (Check all that apply) Environmental Safety & Health Professional / Specialist / Representative .

Employer Representative:

Print name then sign Title Date

N3B Project Field Execution Leader / N3B ESH Manager / IHS - Review and Approval:

Print name then sign Z # Date

N3B

Environmental Remediation Program N3B Environment, Safety & Health

Attachment F4-0

Attachment F6-1

Weekly Productive Man-Hour Report

Subcontract No.: Date:

SUBCONTRACTOR:

Sub-Tier Subcontractors:

FETL:

Note: Include all lower-tier subcontractors in reporting

Total Contract Productive Man-Hours for Week Ending

On-Site Hours Off-Site Hours

Non-Manual

Manual

Total Hours

1) OSHA 300 Log Report

Lost Workday Cases:

Restricted Cases or Job Transfer Cases:

Other Recordable Cases (i.e., medical treatment):

Total Recordable Cases:

(Cumulative for Project)

2) First Aids:

3) Incidents:

Definitions:

Non-Manual – Project Managers, Safety Representatives, Superintendents, Construction Managers, Engineers, Consultants, Drafters, Buyers, Cost Estimators, Schedulers, Clerks, etc.

Manual – Craft-type personnel (i.e., carpenters, welders, electricians, equipment operators, delivery personnel, etc.)

Incident – An unplanned event that may result in property damage, environmental release, vehicle damage or any undesired loss of resources.

Note: Only report productive man-hours. Do not include sick, vacation, etc.

****REPORT DUE TO FETL BY NOON EVERY MONDAY****

Initial Report Update Report Date of Original Report

COMPANY NAME:

Name of Employee: Employee Z Number Date of Injury

Incident Location:

Nature of Injury:

OSHA Classification

First Aid Recordable Restricted # Days

Lost-Time # Days For Information Only Undetermined

Case is an Upgrade in Classification Yes No

Home Address/Job Title of Employee Required if Case is Recordable, Restricted, or Lost-Time:

Address:

City: State: Zip Code:

Job Title:

Reason for Determination/Treatment:

Comments/Other information:

Name of Individual Completing Report: Title: Date of Submission:

INSTRUCTIONS:

1) First determine if the injury is work-related. If injury is work-related, complete this form along with Form 5484.

2) Indicate if this notification is an initial notification or an update to a previous notification. An update would be a change in medical condition or treatment of a previously reported injury. If this is an update, please indicate date of the previous notification.

3) Indicate company name, name of employee, Z number, and date of injury.

4) Indicate location of injury (i.e. TA-3, Building 1400, Room 200, sidewalk outside of TA-59, Building 3, etc.).

5) Briefly describe the nature of injury (i.e. Sprain to left knee, abrasion to right hand, etc.).

6) OSHA Classification:

a) Indicate if injury is First Aid, Recordable, Restricted, Lost-Time (according to

OSHA classification), For Information Only (i.e. drug test, no treatment, etc.), or Undetermined. If Restricted or Lost-Time, please indicate the known number of days. If Undetermined, further investigation will be required after this initial notification.

b) Indicate if this notification is an upgrade to a previous OSHA classification. For example, if this is an update to a previous notification is the update indicating an upgrade from a lower OSHA classification (i.e. First Aid to Recordable, Recordable to Lost-Time, etc.).

c) If this is a recordable, restricted, or lost-day injury please enter the employee’s home address and job title.

7) Briefly describe the reason for the OSHA classification determination or medical treatment. For example, “This is a recordable case because employee received prescription medication.”

8) Describe any additional comments that might be relevant to this case.

9) Indicate the name of the individual completing this form, job title and date of submission.

10) Submit both Form 5484 and 5484 Addendum to your appropriate Field Execution Technical Lead (FETL) or Requester.

Attachment D-7/Exhibit F Attachment F7-0, TA-21 DP West Slabs D&D and Remediation Project

* - Denotes that a corporate equivalent course may be substituted – proof of training required and curricula shall be available upon request.

RFP-0000300

Title / Description Requirement LANL Course No. Frequency Required for

General Employee Training (GET) LANL general 15503 Once All personnel

Environmental Management System (EMS) Worker Awareness LANL general 32461 52176

Once Every 2 years

All personnel

Beryllium: General Employee Overview LANL general 55173 Every 2 years All personnel

Preventing Sexual Harassment LANL general 16534 Every 2 years All personnel

Substance Abuse Policy and Procedure, IPP 732.0 LANL general 42095 Once All personnel

N3B Emergency Procedures and Protective Actions F11.1 10922 Annually All personnel

Radiological Worker II Training or DOE equivalent F49.0 20301 Annually All Personnel

Excavation/Soil Disturbance F28.2 31419 Annually On-site workers/management involved with excavation/soil activities

Electrical Safety for Electrical Workers F36.3 31083 On-site workers doing electrical verification

Electrical Facility Worker PPE Requirements for NFPA 70E F36.6 NFPA 70E* On-site workers doing electrical verification

Electrical Meter Demonstration of Proficiency F36.6 Self-study or video* On-site workers doing electrical verification

WCSF Training F39.0 WMC or FWMT briefing Once All personnel

Waste Generation Overview F39.0 23263 21464

Annually Superintendent and/or FWMT

RCRA Personnel Training F39.4 28582

Once Annually

Superintendent and/or FWMT

Integrated Work Management Overview F20.2 31881 Once On-site workers

Integrated Work Management: PIC F20.2 31884 Once PICs

Last Angry Words (video) G3.2 15869 Once All personnel

NES Access Control TA-21 NES access 53711 Annually Personnel who access NES areas

First Aid: Standard F4.0 3574* Every 3 years ES&H Professional and on-site

Safety Officer

CPR/AED: LANL Workplace F4.0 43562* Every 3 years ES&H Professional and on-site Safety

Officer

PPE Introduction F12.3 28886 * Once On-site workers

Thermal Stress Awareness F18.2 18649 * Once On-site workers

Asbestos Awareness F51.2 14727 * Once On-site workers

Lead Awareness F55.1 50318 * Once On-site workers

40 Hour Hazardous Waste Operations and Emergency Response

(HAZWOPER)

1910.120(a)(1)(i-v) N/A 8 Hour Yearly

Refresher On-site workers

DOT Job Specific Training 49 CFR 171 & 172 SME briefing Every 3 years On-site workers associated with packaging waste

Attachment F9-1

Samples of Inspection Checklist for Subcontractors

Note: Subcontractor shall provide a written report to the Contractor FETL

Project Title:

Subcontract No.

Subcontractor Name: Date:

Yes No N/A First Aid

1. Are first aid kit locations identified and accessible?

2. Are emergency eye wash/safety showers available and inspected monthly?

3. Are first aid kits inspected monthly?

4. Is a qualified first aid/CPR provider on site?

Personal Protective Equipment

1. Have levels of personnel protection been established?

2. Are respirators decontaminated, inspected, and stored according to standard procedures?

3. Have employees been fit-tested?

4. Is defected personal protective equipment tagged and taken out of service?

5. Does compressed breathing air meet CGA Grade “D” minimum?

6. Are there sufficient sizes and quantities of protective equipment?

7. At a minimum, are employees utilizing safety glasses, hard hats, and steel toe boots?

Fire Prevention

1. Are employees smoking only in designated outdoor areas?

2. Are fire lanes established and maintained?

3. Are flammable liquid dispensing systems bonded?

4. Are approved safety cans available for storage of flammable liquids?

5. Are fire extinguishers available and inspected monthly?

6. Are flammables and combustibles properly stored?

7. Are flammable storage cabinets available and used when needed?

Air Monitoring

1. Is required air monitoring being conducted?

2. Are air monitoring instruments calibrated daily?

3. Are air monitoring logs up to date?

4. Are instrument user manuals available?

5. Are instruments being maintained?

6. Are employees notified of personal sampling results within 5 days of receipt?

Welding and Cutting

1. Are fire extinguishers present at welding and cutting operations with designated fire watch?

2. Are confined spaces evaluated prior to and during cutting and welding operations?

3. Have Hot Work Permits been completed?

4. Are proper helmets, goggles, aprons, and gloves available for welding and cutting operations?

5. Are welding machines properly grounded?

6. Are oxygen and fuel gas cylinders stored a minimum of 20 feet apart?

7. Are only trained personnel permitted to operate welding and cutting equipment?

8. Are gas cylinders transported in a secured vertical position with caps in place?

Hand and Power Tools

1. Are defective hand and power tools tagged and taken out of service?

2. Is eye protection available and used when operating power tools?

3. Are guards and safety devices in place on power tools?

4. Are power tools inspected before each use?

5. Are non-sparking tools available when necessary?

6. Is the correct tool being used for the job?

Motor Vehicles

1. Are vehicles regularly inspected?

2. Are personnel licensed for the vehicles they operate?

3. Are unsafe vehicles tagged and reported to supervision?

4. Is vehicle safety equipment operating properly?

5. Are loads secured?

6. Are vehicle occupants using safety belts?

7. Are current insurance cards and blank accident report forms located in vehicles?

Emergency Plans

1. Are emergency telephone numbers posted?

2. Have emergency escape routes been designated?

3. Are employees familiar with the emergency signal?

4. Has the emergency route to the hospital been established and posted?

5. Is a vehicle on site that can transport injured employees to the hospital?

Materials Handling

1. Are materials stacked and stored to prevent sliding or collapsing?

2. Are tripping hazards identified?

3. Are semi-trailers chocked?

4. Are fixed jacks used under semi-trailers?

5. Are riders prohibited on materials handling equipment?

6. Are approved man lifts provided for the lifting of personnel?

7. Are personnel in man lifts wearing approved fall protection devices?

Fire Protection

1. Do employees know the location and use of all fire extinguishers?

2. Are fire extinguisher locations posted?

3. Are combustible materials segregated from open flames?

4. Have fire extinguishers been professionally inspected during the last year?

5. Are fire extinguishers visually inspected monthly?

Electrical

1. Is electrical equipment and wiring properly guarded and maintained in good condition?

2. Are extension cords kept out of wet areas?

3. Is damaged electrical equipment tagged and taken out of service?

4. Have underground electrical lines been identified by proper authorities?

5. Has a lockout/tagout system been established?

6. Are GFCIs being used on all temporary electrical systems and as needed?

7. Are extension cords being inspected daily (I.e., group pin in place, no unapproved splices)?

8. Are warning signs exhibited on high voltage equipment (250V or greater)?

9. Is adequate distance maintained from overhead electrical lines?

10. Are switches, circuit breakers, and switchboards installed in wet locations enclosed in weatherproof enclosures?

Cranes and Rigging

1. Are cranes inspected daily prior to use?

2. Are crane swing areas barricaded or demarked?

3. Is all rigging equipment tagged with an identification number and rated capacity?

4. Is rigging equipment inspection documented?

5. Are slings, chains, and rigging inspected before each use?

6. Are damaged slings, chains, and rigging tagged and taken out of service?

7. Are slings padded or protected from sharp corners?

8. Do employees keep clear of suspended loads?

9. Are rated load capacities and special hazard warnings posted on crane?

10. Are the records of annual crane inspection available?

11. Has accessible areas within the swing radius of the rear of the crane been barricaded?

12. Do crane operators have required training/certification?

Compressed Gas Cylinders

1. Are breathing air cylinders charged only to prescribed pressures?

2. Are cylinders stored in well ventilated areas?

3. Is smoking prohibited in cylinder storage areas?

4. Are cylinders stored secure and upright?

5. Are cylinders protected from snow, rain, etc.?

6. Are cylinders caps in place before cylinders are moved?

7. Are propane cylinders stored and used only outside of buildings?

Scaffolding

1. Is scaffolding placed on a flat, firm surface?

2. Are scaffold planks free of mud, ice, grease, etc.?

3. Is scaffolding inspected before each use?

4. Are defective scaffold parts taken out of service?

5. Have employees completed scaffold user training?

6. On scaffolds where platforms are overlapped, is planking overlapped a minimum of 12 inches?

7. Does scaffold planking extend over end supports between 6 to 18 inches (dependent upon platform length)?

8. Are employees restricted from working on scaffolds during storms and high winds?

9. Are all pins in place and wheels locked?

10. Is required perimeter guarding (top rail, mid rail, and toe board) present?

11. Has a competent person been designated to oversee scaffold construction?

12. Are employees prohibited from moving mobile scaffold horizontally while employees are on them?

13. Are all scaffolding components manufactured by the same company?

Ladders

1. Are ladders regularly inspected?

2. Are access ways, stairways, ramps, and ladders clean of ice, mud, snow, or debris?

3. Are ladders being used in a safe manner?

4. Are ladders kept out of passageways, doors, or driveways?

5. Are broken or damaged ladders tagged and taken out of service?

6. Are metal ladders prohibited in electrical service?

7. Are stairways and floor openings guarded?

8. Are safety feet installed on straight and extension ladders?

9. Is general housekeeping being maintained?

10. Are ladders tied off?

11. Are handrails and side rails installed along the unprotected sides of stairways having 4 or more risers or rising more than 30 inches?

Site Safety Plan

1. Is a site safety plan available on site and accessible to all employees?

2. Does the safety plan accurately reflect site conditions and tasks?

3. Have potential hazards been described to employees on site?

4. Is there a designated safety official on site?

5. Have all employees signed a safety plan acknowledgment form?

Site Posters

1. Are the following posters displayed in a prominent and accessible area?

A. Minimum Wage B. OSHA Job Protection C. Equal Employment Opportunity

2. Are all required state specific posters displayed?

Site Control

1. Are work zones clearly marked?

2. Are support trailers located to minimize exposure from a potential release?

3. Are support trailers accessible for approach by emergency vehicles?

4. Is the site properly secured during and after work hours?

5. Is an exclusion zone sign-in/sign-out log maintained?

6. Are only employees with current training and physicals permitted in exclusion zone?

Heavy Equipment

1. Is heavy equipment inspected as prescribed by the manufacturer?

2. Is defective heavy equipment tagged and taken out of service?

3. Are project roads and structures inspected for load capacities and proper clearances?

4. Is heavy equipment shut down for fueling and maintenance?

5. Are backup alarms installed and working on mobile equipment?

6. Have qualified equipment operators been designated?

7. Are riders prohibited on heavy equipment?

8. Are guards and safety appliances in place and used?

9. Are operators using the “three point” system when mounting/ dismounting equipment?

Excavation

1. Has a “competent person” been designated to oversee excavation activities?

2. Prior to opening excavations, are utilities located and marked?

3. Has a professional engineer evaluated all excavations greater than

20’ deep?

4. Is there rescue equipment on site and accessible to the excavation area?

5. Is excavated material placed a minimum of 24 inches from the excavation?

6. Are the sides of excavation sloped or shored to prevent cave ins?

7. Have excavations greater than 4 feet deep been monitored for hazardous atmospheres (i.e.,LEL/O2 deficiency)?

8. Are ladders or ramps used in excavations over 4 feet deep?

9. Are means of egress available so as to require no more than 25 feet or lateral travel?

10. Are barriers, i.e., guardrails or fences placed around excavations near pedestrian or vehicle thoroughfares?

11. Is excavation inspected daily by competent persons and documented?

Confined Spaces

1. Have employees been trained in the hazards of confined spaces?

2. Are confined space permits posted at entrance to confined space?

3. Is a copy of the confined space entry procedure available?

4. Has a rescue plan been established?

Attachment F10-1

Safety / Housekeeping Inspection Checklist

Safety / Housekeeping Inspection Checklist Subcontract No. / Location Supervisor (name) Date

Satisfactory Unsatisfactory Not Applicable

Personal Protective Equipment

Housekeeping

Flammable and Combustible Liquids

Welding and Cutting Operations

Electrical Installations

Floor and Wall Openings/Guarding

Ladders

Scaffolding

Temporary Heaters

Fire Protection and Prevention

Material Storage and Handling

Demolition Work

Concrete Construction

Steel Erection

Masonry Work

Excavation / Trench Shoring

Cranes / Hoists and Derricks

Power Tools

Hand Tools

Heavy Equipment

Motor Vehicles

Equipment Maintenance (Upkeep)

Accident Prevention (Warning) Signs and Tags

Barricades

Compressed Air Equipment

ALARA (Radcon)

OVERALL RATING Excellent Above Average Average Below Average Unsatisfactory

COMMENTS:

Attachment 15-1 Medical Surveillance For

Toxic and Hazardous Substance Requirements

Potential Carcinogens Metals Chemical CAS# Reference from:

29 CFR Requirement

Chemical CAS# Reference from:

29 CFR Requirement

2-Acetylamino-fluorine

CAS #53-96-3

1910.1014

1,3 Butadiene

CAS #106-99-0

1910.1051 American Conference of Governmental Industrial Hygienists Threshold Limit Values, 2005

Ethyleneimine

CAS #151-56-4

1910.1012 American Conference of Governmental Industrial Hygienists Threshold Limit Values, 2005

Methylene chloride

CAS #75-09-2

1910.1052 American Conference of Governmental Industrial Hygienists Threshold Limit Values, 2005

Beta-Propiolactone

CAS #57-57-8

1910.1013 American Conference of Governmental Industrial Hygienists Threshold Limit Values, 2005

Arsenic-Inorganic

CAS #7440-38-2

1910.1018 American Conference of Governmental Industrial Hygienists Threshold Limit Values, 2005

Acrylonitrile

CAS #107-13-1

1910.1045 American Conference of Governmental Industrial Hygienists Threshold Limit Values, 2005

Bis-Chloro-Methylether

CAS #542-88-1

1910.1008 American Conference of Governmental Industrial Hygienists Threshold Limit Values, 2005

Ethylene Oxide

CAS #75-21-8

1910.1047 American Conference of Governmental Industrial Hygienists Threshold Limit Values, 2005

Alpha-Naphthylamine

CAS #134-32-7

1910.1004 American Conference of Governmental Industrial Hygienists Threshold Limit Values, 2005

Chromium (VI)

CAS #1333-82-0

CAS #7738-94-5

1910.94(d)(9)(viii) American Conference of Governmental Industrial Hygienists Threshold Limit Values, 2005

Beryllium

10 CFR 850

American Conference of Governmental Industrial Hygienists Threshold Limit Values, 2005

4-Aminodi-phenyl

CAS #92-67-1

1910.1011 American Conference of Governmental Industrial Hygienists Threshold Limit Values, 2005

1,2-Dibromo-3- Chloropropane

CASE #107-13-1

1910.1044

Formaldehyde

CAS #50-00-0

1910.1048 American Conference of Governmental Industrial Hygienists Threshold Limit Values, 2005

Beta-Naphthylamine

CAS #91-59-8

1910.1009 American Conference of Governmental Industrial Hygienists Threshold Limit Values, 2005

Vinyl Chloride

CAS #75-01-4

1910.1017 American Conference of Governmental Industrial Hygienists Threshold Limit Values, 2005

Cadmium

CAS #7440-43-9

CAS #1306-19-0

1910.1027 American Conference of Governmental Industrial Hygienists Threshold Limit Values, 2005

Benzene

CAS #71-43-2

1910.1028 American Conference of Governmental Industrial Hygienists Threshold Limit Values, 2005

3,3’-Dichloro- Benzidine

CAS #91-94-1

1910.1007 American Conference of Governmental Industrial Hygienists Threshold Limit Values, 2005

Methylenedianiline

CAS #101-77-9

1910.1050 American Conference of Governmental Industrial Hygienists Threshold Limit Values, 2005

4-Nitrobiphenyl

CAS #92-93-3

1910.1003 American Conference of Governmental Industrial Hygienists Threshold Limit Values, 2005

Lead

CAS #74-39-1

1910.1025 Gen. Industry

1926.62 Construction

American Conference of Governmental Industrial Hygienists Threshold Limit Values, 2005

Fibers Physical & Biological Substances

Occupational Groups Required Certifications

Chemical CAS# Reference from:

29 CFR Requirement

Program Regulatory Driver

Program Regulatory Driver

Program Regulatory Driver

Asbestos

CAS #1332-21-4

1910.1001 1026.1101 American Conference of Governmental Industrial Hygienists Threshold Limit Values, 2005

Human Pathogens Blood-Borne Pathogens 1910.1030

Hazardous Waste/ Emergency Response 1910.120

(Also see NIOSH guide for hazardous waste site activities)

DOT Truck Driver

US DOT Federal Highway Admin, Federal Motor Carrier Safety Regs. 49 DFR 391.41

Silica 1910.1000 National Institute for Occupational Safety and Health, Criteria for a Recommended Standard:

Occupational Exposure to Crystalline Silica, DHEW (NIOSH) Publication No.

75-120, 1974 Table Z-3, permissible exposure limits for mineral dusts.

Noise

1910.95 and DOD Instruction 6055.12, DOD Hearing Conservation Program

American Conference of Governmental Industrial Hygienists Threshold Limit Values, 2005

Respiratory Protection 1910.134

Tower Climber (Hoisting & Rigging)

TSCM Operations Manual

DOE 0 471.2-4, 02-06-04

Chapter 3, Par lll E

American Conference of Governmental Industrial Hygienists Threshold Limit Values, 2005

Laser Use

ANSI Z136.1-2007

Crane Operator (Hoisting & Rigging)

Mobile or Pulpit Crane operator licensed by the State of New Mexico.

Licensing and training requirements conform to

29 CFR 1926.1427

Subpart CC

Deployable Teams

(ARG,BEST,JTOT,RAP)

DOE Order 151.1- Comprehensive Emergency Management System Centers for Disease Control, Health Information for International Travel

Attachment F16-1

Major Equipment Declaration

The following equipment will be used on Subcontract Number

EQUIPMENT MANUFACTURER SERIAL NO.

(Use Additional Sheets As Necessary)

All equipment listed above is properly serviced and maintained in accordance with each Manufacturer's recommendations and OSHA/ANSI/LANL requirements as applicable. All equipment listed above will be operated, inspected, and maintained by a competent person for the duration of the Subcontract.

Equipment will not be operated in an unsafe manner or condition. Equipment that cannot be repaired will be removed from the Los Alamos National Laboratory (LANL).

Documentation of all required certifications, inspections, and maintenance will be maintained by the Subcontractor's Representative on site, and available for review as requested.

Equipment leaking fluids will be immediately removed from service and the fluids will be contained to prevent absorption into surface areas or releases to the environment. Spill residues shall be cleaned up, containerized, characterized and managed in accordance with the Waste Management Plan or Waste Characterization Strategy Form (see Exhibit F39). If the Waste Management Plan or Waste Characterization Strategy Form does not include this type of waste stream, the SUBCONTRACTOR shall implement the requirements contained in Exhibit F39.3.

Before loading, unloading, and transporting self-propelled medium and heavy duty construction equipment LANL, read and complete the “Self-Propelled Equipment Loading, Unloading & Transport Safety Review Checklist”, pages 2 and 3 of this form.

All equipment listed above has the necessary permits(s) and/or relocation notices from NMED. Copies of permits and notices have been provided to FETL.

Signature of Company Representative Company Name

Submit one (1) copy to the Field Execution Technical Lead (FETL) before placing equipment in service.

MAJOR EQUIPMENT LISTING

Cranes (All Types) Front End Loaders Dozers Scrapers Light Plants

Finishing Machines Compactors/Rollers Backhoes Forklifts Power Shovels

Generators, Portable Spreading Machines Graders Gradalls Compressors

Aerial/Man Lifts Saws (Cut Off-Band-Table-Stone) Ditch Witches (Trenching Machines)

Wackers (Soil Compactors)

Tractors (Agricultural and Industrial) Trucks and Trailers (Excluding P/U’s)

Drilling Rigs Welding Machines (Gasoline or Diesel) Power Equipment/Fuel Burning Equipment

THIS LIST IS NOT ALL INCLUSIVE. CONTACT THE FETL CONCERNING ANY MAJOR EQUIPMENT TO

BE USED THAT MAY NOT BE LISTED

Self-Propelled Equipment Loading, Unloading & Transport Safety Review Checklist

The following items will be reviewed by the responsible work group supervisor prior to performing any activity involving the Loading, Unloading, and Transport of Self-propelled Medium or Heavy Construction Equipment (i.e. mobilization / demobilization). SUBCONTRACTOR will submit completed checklists to the responsible Field Execution Technical Lead (FETL). The intent of this checklist is to enhance personnel safety and does not alter the contractual relationship between CONTRACTOR and SUBCONTRACTOR.

Responsible Work Group Supervisor will assign the person in charge of loading, unloading, or transport activity.

Ensure trailer is positioned and secured properly, level, and on a surface sufficient to support the load.

Ensure that all proximity hazards have been identified and proper controls are established.

Inspect trailer and associated equipment to ensure they are in safe working condition.

Establish controls to restrict non essential personnel from the immediate proximity of loading/off loading activity.

Determine the need for and assign flagman when necessary.

Driver to determine loading alignment and position for transport.

Equipment Declaration submitted to FETL.

SUBCONTRACTORS Name Subcontract Number

To the best of my knowledge, I believe that this information is accurate and complete.

Print Name Date

Signature

Self-Propelled Equipment Loading, Unloading & Transport Safety Review Checklist

(continued)

Do:

If any condition changes unexpectedly or equipment malfunctions during loading or unloading, STOP WORK IMMEDIATELY, place in a safe condition and secure the area, and contact supervision.

Follow all manufacturer’s instructions and equipment operator manuals.

Contact the appropriate supervisor or PIC if original plans change or any questions arise during the work activity.

Always review the work area for potential hazards.

Follow established safety controls.

Maintain line of sight between flagman and operator.

Once the equipment is positioned on the transport vehicle, ensure the load is properly secured.

Contact FETL when necessary to notify an offsite vendor of malfunctioning equipment. Don’t:

Never place any part of your body within “THE LINE OF FIRE”. (i.e. Crush Points, Pinch Points, Rotating Structures, under suspended loads)

Never use equipment when it is unsafe

General Considerations

While offloading or loading equipment during inclement weather conditions the driver will take additional precautions to ensure control of the load. During icy conditions no loading or offloading will be performed.

Workers must never place any part of their bodies in a pinch or crush point.

At LANL, every worker has the right and duty to stop work if it appears unsafe to continue. While all employees are encouraged to thoughtfully comply with rules and job plan steps, they should not hesitate to stop work if they do not understand a rule or if compliance with it appears to be the wrong or unsafe thing to do.

Attachment F19-1

Environmental Reporting Data for EPA Annual Toxic Release Inventory Report

LANS Project Title Subcontractor:

LANS Subcontract Number:

FETL Name:

Form Completed by: Date

This data is due to FETL at the conclusion of project and by January 31 for multi-year projects.

Use additional sheets as needed.

Calendar Year:

All asphalt, lead or mercury used during this calendar year:

Amount (pounds)

Asphalt used

Lead used

Mercury used

All other chemicals stored or used in this calendar year in quantities greater than 100 pounds:

Chemical name CAS # Amount (in pounds)

For all wastes containing lead or mercury disposed in this calendar year:

Waste Description Amt (lbs)

Mercury or Lead Conc. In Waste (ppm) Disposal Site Name/Address

CERTIFICATION:

I certify that the information on this form is true, accurate and complete.

Signature of Subcontractor Representative Title Date

Form 2104

Integrated Work Document (IWD) Part 4, Feedback/Post Job Reviews

IWD #: Revision #:

Feedback of ongoing activities/post job review with the workers and Person in Charge (PIC) should include the following:

▪ identify inefficiencies, problems during the activity, coordination issues, unanticipated conditions, near misses; and

▪ develop recommendations for improvement.

A post-job review with the workers and PIC should include the following:

▪ verify that the activity is complete and make notifications in accordance with Facility Operations Director (FOD) requirements; and

▪ ensure that follow-through actions (e.g., clean-up, recycle, waste disposal, equipment removal, and secure storage) are completed.

Lessons learned; safety, security, and environmental issues; coordination issues; and unexpected conditions.

Suggested improvements to enter into the Job Hazard Analysis (JHA) Tool, FootPrints, or other Integrated Work

Control data bases supported by Lessons Learned.

Other recommendations for improvements to performing this activity. State the positive attributes of this activity.

Completion Statement

Name (print) of PIC/Z #: Signature Date

Form 2104 (3/12) Page 1 of 1

SAVE PRINT

Attachment F20-0 http://int.lanl.gov/scat/lessons_learned

Attachment F20-1 Integrated Work Document (IWD) - Form 2100

Attachment F20-1 Integrated Work Document (IWD) - Form 2100

Attachment F20-2

IWD Validation and Release Form 2102A Pre-Job Brief Content

What are the critical steps or phases of this activity?

How can we make a mistake at that point?

What is the worst thing that can go wrong?

What controls, preventive measures, and bounding conditions are needed?

What work permits are required and how will we meet their requirements?

What are the handoffs and coordination requirements among workers and multiple PICs?

Are there hold-points including those that require sign-offs?

What are the stop work responsibilities and expectations (e.g. for unanticipated conditions or hazards)?

How would we respond to alarms and emergencies?

Are there lessons learned from previous similar work?

Is other information needed to perform this activity in a safe, secure, and environmentally responsible manner?

Does everyone agree to the work tasks/steps, hazards, and controls and commit to follow them?

PRE-JOB BRIEF ATTENDANCE ROSTER

By signing below, I agree to the following:

I understand the work, the hazards, and the controls.

I agree to follow the work steps and implement the controls as written.

I agree to stop work when conditions or hazards change or when I encounter unexpected conditions during the execution of work, or when work cannot be performed as written, or instructions become unclear during execution.

I confirm that I am authorized, qualified, and, fit to perform the work.

Worker (Signature / Z # / Date) Required Worker (Signature / Z # / Date)

Worker (Signature / Z # / Date) Worker (Signature / Z # / Date)

Worker (Signature / Z # / Date) Worker (Signature / Z # / Date)

Worker (Signature / Z # / Date) Worker (Signature / Z # / Date)

Worker (Signature / Z # / Date) Worker (Signature / Z # / Date)

WORK RELEASE

By signing below, I have verified the following:

• I have jointly conducted a walkdown with workers to confirm the IWD can be performed as written, required initial conditions and other prerequisites are in-place.

• The assigned workers are authorized and are qualified to perform the work in a safe, secure, and environmentally responsible manner.

• I have conducted the pre-job briefing, and all workers have been briefed.

• I have ensured coordination as required by the FETL.

PIC (Signature / Z # / Date) Required

Alternate PIC Signatures when PIC authority is assumed the first time (Note: alternate PICs are required to sign only once, but formal handoff and employee notification are required for each PIC change).

Alternate PIC (Signature / Z# / Date) Required

Alternate PIC (Signature / Z# / Date) Required

Alternate PIC (Signature / Z# / Date) Required

Form 2102A

Fibers/Particulate ( potential for exposure to generated particulate (i.e. grinding or paint removal )

Attachment F20-3 COMPLETE THIS FORM IF WORK INVOLVES REMODEL, RENOVATION, AND/OR DEMOLITION

Identify site hazards and concerns (including legacy use) that could potentially affect subcontractors, support workers and collocated workers. See Section F61.0 for more information. The following checklist is to be used by the SUBCONTRACTOR to help specify training requirements, preventive measures, further hazard ID, exposure monitoring, controls and bounding conditions for each of the listed site hazards considered in the SUBCONTRACTOR’S - F20.0 Work Management - Form 2101 and the Site-specific ESH plan.

Fibers/Particulate ( potential for exposure to generated particulate (i.e. grinding or paint removal ) Asbestos (ACM) Refractory Ceramics-Fiberglass

Crystalline-Silica Plascite coating Epoxy coating Polyurethane

Lead based paint Metals ( potential for exposure to particulate or fume generation from D&D activity ( i.e. surface contamination or paint/surface removal, welding or cutting) Lead

Mercury Cadmium Chromium Nickle

Other Provide location and detail for any checked box:

Chemicals (potential for exposure to chemicals via contamination form historical use or current inventories of stored materials )

Attachment 20-3

Chemicals (potential for exposure to chemicals via contamination form historical use or current inventories of stored materials ) Acids/bases Perchlorates Peroxide formers Explosive residues Refrigerants PCBs Oils/Fuels Other Chemicals Biohazards ( potential for exposure to biohazards from existing contamination or from stored materials) Live animals/feces Sewage Mold, bacteria Other Electrical ( any uncontrolled electrical source or the potential for unidentified sources) Uncapped, Batteries Other Confined spaces Rad. Contaminated Structural issue Provide location and detail for any checked box:

PRINT

Work Statements

Attachment F22-1, Form 1563

Spark- Or Flame-Producing Operations Permit

Responsible Line Manager

I have reviewed the requirements on the back of this form and the work site meets those requirements. A fire watch is / is not (circle one) required. The fire protection system will / will not (circle one) be taken out of service or be potentially affected.

Name Signature Date

Fire Watch (if required)

Appropriate fire extinguisher equipment and emergency communications are available at the work site. I will monitor on-going operations for change that may affect operational safety and health, and stop work as appropriate. I will watch for fires during the operation and for 30 minutes after completion of the operation. I will inspect the operator’s apparel for the presence of hot slag and smoldering fabric before the operator leaves the area.

Name Signature Date

Operator

I am aware of the hazards of the operation and confirm that the controls required to perform the work safely are in place. I will monitor on-going operations for change that may affect operational safety and health, and stop work as appropriate. I will shut off and/or de-energize equipment before leaving the work area and during periods when the equipment is not in use. When I act as my own fire watch, I will watch for fires during the operation and inspect the work area for 30 minutes after completion of the operation/prior to leaving.

Name Signature Date

Reviews

Fire Protection Division Office (FP-DO)

Required if fire protection system will be taken out-of-service or potentially affected. Required if a fire watch has been determined not to be required. Required for exterior operations during issued wildland fire restrictions.

Name Signature Date

IHS Personnel

Required if operation is conducted in a confined space; if the operation is to be performed near a chlorinated solvent; if the operation involves the use of cleaning compounds or the use of materials containing cadmium, chromium, fluorine, zinc, lead, beryllium or mercury; or the operation involves drums, barrels, tanks, pipes, or other containers which have contained or been cleaned with flammable materials or substances which, when subjected to heat, produce flammable or toxic vapors, or flammable or explosive material, or the operation will be conducted in or on a filter plenum used to filter radioactive/hazardous materials.

Name Signature Date

Authorization

Responsible Line Manager and/or Facility Operations Director (FOD)

Name Signature Date

Name Signature Date

Use signagure continuation sheet on page 2 as needed for transfer of roles or multiple day operations.

Form 1563 (1/15) LA-UR-21898 Page 1 of 3

SAVE CLEAR FORM

Request Date Starting Date Expiration Date Integrated Work Document (IWD) Number Work Order Number

Responsible Line Manager Telephone Mail Stop Organization

Work Location:

Technical Area

Indoors

Outdoors

Building Room Work Area Building Construction:

Combustible Non-Combustible

Designated Spark- or Flame-Producing Area:

Yes No N/A Initial Issue Annual Renewal

Description of work to be performed and equipment to be used

Special Requirements/Controls

Low-Hazard (P300 Att B) Moderate-Hazard (P300 Att B) High-Hazard/Complex (P300 Att B)

Work Order # Operator (print name) Signature Date Fire Watch (print…