Appendix__A_Attachment_1.pdf

Headquarters III Corps, Fort Hood Directorate of Public Works (DPW)

Appendix “A”

Directorate of Public Works Engineering Division

US Army, III Corps 4612 Engineer Dr.

Fort Hood, TX 76544

APPENDIX “A” TABLE OF CONTENTS

PAGE NUMBER DESCRIPTION _

1‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ Form 4025, Transmittal Sheet

3 ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ Emissions Inventory Sheet

7 ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ Contractor Hazardous Materials Log

9 ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ Landfill permit

10 ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ ‐‐‐‐‐‐‐‐‐ Coordination for Land Excavation (Dig permit)

12 ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ Landscaping on Fort Hood

23 ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ Accident Investigation Report

27 ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ Sample Contractor Quality Control Report

29 ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ Preparatory Phase Checklist

32 ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ Initial Phase Checklist

Proposed Project Emissions Inventory Questionnaire for New Sources

TCEQ Title V Operating Permit Decision Support System

The Decision Support System provides several documents linked together to aid in the Title V application and review process. These documents include Rule Text, Relationship Entry Screens, Flowcharts and Historic Rule Opinions (when applicable). Most of these documents and their subparts are available in Portable Document Format(PDF). To view the documents in this format, a free copy of Adobe Acrobat Reader will have to be installed on your computer. For best results, install the most current version of Adobe Reader.

For information on installing or configuring the Adobe Acrobat Reader click here. Even if you have the Adobe Acrobat Reader installed, you may need to configure it to work as required (The hyperlinking capability will not work unless the reader opens up within the browser window).

Guidance for using the Decision Support System Decision Support System for:

40 CFR Part 59 - National Volatile Organic Compound Emission Standards for Consumer and Commercial Products 40 CFR Part 60 - Standard of Performance for New Stationary Sources(NSPS) 40 CFR Part 61 - National Emission Standards for Hazardous Air Pollutants (NESHAPS) 40 CFR Part 63 - National Emission Standards for Hazardous Air Pollutants for Source Categories(a.k.a. Maximum Achievable Control Technology (MACT)) 40 CFR Part 82 - Protection of Stratospheric Ozone 30 TAC Chapters 39, 101-122 - Control of Air Pollution

Applicability Determination Index (ADI)

The EPA also has a database available online that contains memoranda issued by the the agency on applicability and compliance issues associated with NSPS, NESHAP and MACT Standards

Requestor: ____________________________ Date: _____________ Phone: _____________ Project # _____________________________ Facility Name / Building Number: ____________________________ Descriptive Name of Facility: ______________________________________________ Location of Facility: UTM Zone: 14 Horizontal Coordinate _____________________E Vertical Coordinate ____________________N

Indicate proposed emission source type and complete all applicable fields for each process.

Complete questionnaire sheet for each process type in this facility.

http://www.tnrcc.state.tx.us/link.html http://www.adobe.com/ http://www.tnrcc.state.tx.us/permitting/airperm/opd/pdfhelp.htm http://www.tnrcc.state.tx.us/permitting/airperm/opd/dssgui.htm http://www.tnrcc.state.tx.us/permitting/airperm/opd/59/59hmpg.htm http://www.tnrcc.state.tx.us/permitting/airperm/opd/60/60hmpg.htm http://www.tnrcc.state.tx.us/permitting/airperm/opd/61/61hmpg.htm http://www.tnrcc.state.tx.us/permitting/airperm/opd/63/63hmpg.htm http://www.tnrcc.state.tx.us/permitting/airperm/opd/82/82hmpg.htm http://www.tnrcc.state.tx.us/permitting/airperm/opd/state/statehp.htm http://www.epa.gov/compliance/planning/data/air/adi.html

BOB.MILLENBACH

Typewritten Text

INTERNAL COMBUSTION UNITS (I.E. GENERATORS, ENGINE TEST CELLS)

(Covered by 30 TAC 106.511 and 30 TAC 106.261)

Make_________________ Model_____________ Serial #________________ Power Rating: ____kw; Horsepower: ___ HP Fuel Type: ________________ MUR/JP8/Diesel; Integrated Fuel Tank Capacity: __________gallons Make_________________ Model_____________ Serial #________________ Power Rating: ____kw; Horsepower: ___ HP Fuel Type: ________________ MUR/JP8/Diesel; Integrated Fuel Tank Capacity: __________gallons Make_________________ Model_____________ Serial #________________ Power Rating: ____kw; Horsepower: ___ HP Fuel Type: ________________ MUR/JP8/Diesel; Integrated Fuel Tank Capacity: __________gallons Make_________________ Model_____________ Serial #________________ Power Rating: ____kw; Horsepower: ___ HP Fuel Type: ________________ MUR/JP8/Diesel; Integrated Fuel Tank Capacity: __________gallons Make_________________ Model_____________ Serial #________________ Power Rating: ____kw; Horsepower: ___ HP Fuel Type: ________________ MUR/JP8/Diesel; Integrated Fuel Tank Capacity: __________gallons

Separate Fuel Tank(s): YES / NO (circle one) Complete Separate Questionnaire for Each Tank Seasonal Operating Percentage for This Emission Point:

Spring _____% Summer _____% Fall _____% Winter _____% Note: Total Must Equal 100% Normal Operating Schedule: Start Time_____ hours/day _____days/week _____ weeks/year____ Normal Operating Rate: _______________gallons or CuFt/ year

FUEL STORAGE TANKS (Covered by 30 TAC 115.473 , 30 TAC 106.478 and 30 TAC Chap 115)

Make__________________Model_________________Serial #______________ Fuel Type: _____________ Tank Volume: __________gals;Tank Dimensions (ft): Diameter _______Length_______ Height________ Make__________________Model_________________Serial #______________ Fuel Type: _____________ Tank Volume: __________gals;Tank Dimensions (ft): Diameter _______Length_______ Height________ Make__________________Model_________________Serial #______________ Fuel Type: _____________ Tank Volume: __________gals;Tank Dimensions (ft): Diameter _______Length_______ Height________ Make__________________Model_________________Serial #______________ Fuel Type: _____________ Tank Volume: __________gals;Tank Dimensions (ft): Diameter _______Length_______ Height________ Make__________________Model_________________Serial #______________ Fuel Type: _____________ Tank Volume: __________gals;Tank Dimensions (ft): Diameter _______Length_______ Height________

Tank Type: Aboveground / Underground (circle one); Vapor Control Equipped: YES / NO (circle one) Roof Type: Horizontal Fixed Roof / Vertical Fixed Roof / Internal Floating Roof / Pressure Tank External Floating Roof

Seasonal Operating Percentage for This Emission Point:

Spring _____% Summer _____% Fall _____% Winter _____% Note: Total Must Equal 100% Normal Operating Schedule: Start Time_____hours/day _____days/week _____weeks/year_____ Normal Operating Rate: _______________gallons/year Maximum Operating Rate: _______________gallons/hour

EXTERNAL COMBUSTION UNITS (Boilers, Hot Water Heaters, Process Heaters) (Covered by 30 TAC 106.102 and 30 TAC 106.183) Fuel Type: Natural Gas / Diesel Make__________________Model_________________Serial #___________________ Input Rating: __________ MMBTUH Height of Stack: __________ ft ; Diameter of Stack: __________ ft; Stack Exhaust Velocity: ______________ft / sec Make__________________Model_________________Serial #___________________ Input Rating: __________ MMBTUH Height of Stack: __________ ft ; Diameter of Stack: __________ ft; Stack Exhaust Velocity: ______________ft / sec Make__________________Model_________________Serial #___________________ Input Rating: __________ MMBTUH Height of Stack: __________ ft ; Diameter of Stack: __________ ft; Stack Exhaust Velocity: ______________ft / sec Make__________________Model_________________Serial #___________________ Input Rating: __________ MMBTUH Height of Stack: __________ ft ; Diameter of Stack: __________ ft; Stack Exhaust Velocity: ______________ft / sec

Seasonal Operating Percentage for These Emission Points:

Spring _____% Summer _____% Fall _____% Winter _____% Note: Total Must Equal 100% Normal Operating Schedule: Start Time_____ hours/day _____days/week _____ weeks/year____ Normal Operating Rate:

_______________gallons/year

FUEL DISPENSING UNITS (Covered by 30 TAC 106.412) Make__________________Model_________________Serial #___________________ Make__________________Model_________________Serial #___________________ Make__________________Model_________________Serial #___________________ Make__________________Model_________________Serial #___________________ Make__________________Model_________________Serial #___________________ Make__________________Model_________________Serial #___________________

Fuel Type: MUR / Diesel / JP-8 / Other ______________ (circle one) Dispensing Type: Retail / Bulk (circle one) Vapor Control Equipped : YES / NO (circle one) Dispenser Pump rate: __________ gallons/minute Seasonal Operating Percentage for This Emission Point:

Spring _____% Summer _____% Fall _____% Winter _____% Note: Total Must Equal 100% Normal Operating Schedule: Start Time_____ hours/day _____days/week _____ weeks/year____ Normal Operating Rate: _______________gallons/year http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=511 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=263 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=473 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=478 http://info.sos.state.tx.us/pls/pub/readtac$ext.ViewTAC?tac_view=5&ti=30&pt=1&ch=115&sch=C http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=102 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=183 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=412

BOB.MILLENBACH

SURFACE COATING OPERATIONS (Covered by 30 TAC 106.433 , 30 TAC 106.436 or 30 TAC 116.110)

Attach approved MSDS of each coating and solvent used in process Particulate Matter Control Efficiency of Booth: __________% Booth Air Flow Rate:___________scfm Transfer Efficiency of Paint Gun: __________% Number of Paint Guns: __________ Associated Heater: YES / NO (circle one) Complete Separate Questionnaire for Each Heater Associated Gun Cleaner: YES / NO (circle one) Complete Separate Questionnaire for Each Cleaner Seasonal Operating Percentage for This Emission Point:

Spring _____% Summer _____% Fall _____% Winter _____% Note: Total Must Equal 100% Normal Operating Schedule: Start Time_____hours/day _____days/week _____weeks/year____ Normal Operating Rate: _______________gallons/year (each coating and solvent)

REFRIGERATION EQUIPMENT (AIR CONDITIONING SYSTEM, FREEZER) (Covered by 30 TAC 106.103)

Make__________________ Model____________Serial#___________________ No. of compressors: ______ Refrigerant Type: __________ Amount of Charge:______lbs; Initial Charge Date:_____/_____/_____ Make__________________ Model____________Serial#___________________ No. of compressors: ______ Refrigerant Type: __________ Amount of Charge:______lbs; Initial Charge Date:_____/_____/_____ Make__________________ Model____________Serial#___________________ No. of compressors: ______ Refrigerant Type: __________ Amount of Charge:______lbs; Initial Charge Date:_____/_____/_____ Make__________________ Model____________Serial#___________________ No. of compressors: ______ Refrigerant Type: __________ Amount of Charge:______lbs; Initial Charge Date:_____/_____/_____ Make__________________ Model____________Serial#___________________ No. of compressors: ______ Refrigerant Type: __________ Amount of Charge:______lbs; Initial Charge Date:_____/_____/_____

Seasonal Operating Percentage for This Emission Point:

Spring _____% Summer _____% Fall _____% Winter _____% Note: Total Must Equal 100% Normal Operating Schedule: Start Time_____hours/day _____days/week _____weeks/year_____

WELDING OPERATIONS (Covered by 30 TAC 106.227)

Attach approved MSDS of each welding rod type used in process Make__________________Model_________________Serial #___________________ Make__________________Model_________________Serial #___________________ Make__________________Model_________________Serial #___________________

Particulate Matter Control Efficiency of hood (if available): __________% Exhaust Fan Ventilation Rate :___________scfm Acetylene on hand: __________lbs of gas Oxygen on hand: __________ lbs of gas Seasonal Operating Percentage for This Emission Point:

Spring _____% Summer _____% Fall _____% Winter _____% Note: Total Must Equal 100%

Normal Operating Rate: _______________# of rods/year

BRAKE REPAIR OPERATIONS (Covered by 30 TAC 106.261 and 30 TAC 106.262)

Attach approved MSDS of each brake pad type used in process Make__________________Model_________________Serial #___________________ Make__________________Model_________________Serial #___________________ Make__________________Model_________________Serial #___________________

Particulate Matter Control Efficiency of hood (if available): 1st Stage ________%; 2nd Stage_____% Exhaust Fan Ventilation Rate :___________scfm Seasonal Operating Percentage for This Emission Point:

Spring _____% Summer _____% Fall _____% Winter _____% Note: Total Must Equal 100%

Normal Operating Rate: _______________# of Brakes Repaired/year http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=433 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=436 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=116&rl=110 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=103 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=227 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=261 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=262

BOB.MILLENBACH

ENV Use Only FIN, EPN and CIN determination comes from Emissions Inventory Guidelines

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN- Facility Identification Number; EPN- Emission Point Number; CIN- Control Identification Number

ENV Use Only Received on __________ for submittal in _________ Permit

AUTHORIZATION TO PROCEED WITH CHANGE

Authorized by: ____________________ Title: ______________________ Signature: ________________________ Date: ______________________

AUTHORIZATION FOR STARTUP

Authorized by: ____________________ Title: ______________________

Proposed Project Emissions Inventory Questionnaire for New Sources http://www.tnrcc.state.tx.us/air/aqp/psei.html

BOB.MILLENBACH

Typewritten Text

BOB.MILLENBACH

PROJECT TITLE/LOCATION: ___________________________________________________________________

Material Name Manufacturer MSDS Number

State (i.e. Liquid, Solid, Gas)

Storage Quantity (container size-quantity of)

Average Max Daily Daily

Quantity (lbs/gals) used in CY [ ]

*Contractor(s) certifies that the hazardous material(s) removed from installation will be used/reused for its intended purpose.

Company Using Material Listed Above Company Representative's Signature

Submitted By: ________________________ Phone:_____ ______ Fax:_________________ Date:________________ Printed Name

Contracting Officer ________________________ Phone:________________ Fax:_________________ or Representative Page____of____

CONTRACTOR HAZARDOUS MATERIAL INVENTORY & CONSUMPTION LOG

(EPCRA/E.O. 13423)

PRIME COMPANY NAME: _______________________________ CONTRACT NO: _______________________

PROJECT TITLE/LOCATION: ___________________________________________________________________

Material Name Manufacturer MSDS Number

State (i.e. Liquid, Solid, Gas)

Storage Quantity (container size-quantity of)

Average Max Daily Daily

Quantity (lbs/gals) used in CY [ ]

*Contractor(s) certifies that the hazardous material(s) removed from installation will be used/reused for its intended purpose.

Company Using Material Listed Above Company Representative's Signature

Submitted By: ________________________ Phone:_____ ______ Fax:_________________ Date:________________ Printed Name

Contracting Officer ________________________ Phone:________________ Fax:_________________ or Representative Page____of___

LANDFILL PERMIT

DPW COR POC and telephone phone number: _______________________________________ Contract Name: ________________________________________________________________ Contract Number: _______________________________________________________________ Contract completion date or end of authorization date: __________________________________ Building or areas affected (i.e., Soldier's Development Center):

Prime Contractor's Name: ________________________________________________________ Contractor POC and phone (i.e. someone on site that can get immediate action):

Appendix D: Customer Service Inspection Certificate (30 TAC §290.47(d))

Customer Service Inspection Certificate Name of PWS _______________________________________PWS I.D.# ______________ Location of Service ______________________________________________________ Reason for Inspection:

New construction. __ Existing service where contaminant hazards are suspected __ Major renovation or expansion of distribution facilities __

I _____________________________, upon inspection of the private water distribution facilities connected to the aforementioned public water supply do hereby certify that, to the best of my knowledge:

(1) No direct connection between the Compliance Non-Compliance public drinking water supply and a potential source of contamination exists. Potential sources of contamination are isolated from the public water system by an air gap or an appropriate backflow prevention assembly in accordance with Commission regulations.

(2) No cross-connection between the public drinking water supply and a private water system exists. Where an actual air gap is not maintained between the public water supply and a private water supply, an approved reduced pressure-zone backflow prevention assembly is properly installed and a service agreement exists for annual inspection and testing by a certified backflow prevention assembly tester.

(3) No connection exists which would allow the return of water used for condensing, cooling or industrial processes back to the public water supply.

(4) No pipe or pipe fitting which contains more than 8.0% lead exists in private water distribution facilities installed on or after July 1, 1988.

(5) No solder or flux which contains more than 0.2% lead exists in private water distribution facilities installed on or after July 1, 1988.

BOB.MILLENBACH

COORDINATION FOR LAND EXCAVATION & WATER USE

(III Corps and FH Reg 200-1)

NAME, RANK, TITLE, AND ORGANIZATION OF REQUESTER

CONTROL NUMBER

TELEPHONE

PROJECTED DATES OF EXCAVATION OR WATER USE

PURPOSE AND DESCRIPTION OF EXCAVATION OR WATER USE (PROJECT NO./CONTRACT NO./TITLE, ETC.)

AREA OF LAND DISTURBANCE = _________ ACRES DPW Point Of Contact:_______________________________________

Note: Permit Expires After 30 Days of Approved Start Date

EXCAVATION

I propose to dig at the locations depicted in the attached map, sketch, or overlay (For military operations, plot digging locations on transparent overlays that include two grid register marks using standard 1:50,000 topographic maps).

I understand that the proposed digging or excavation is a requirement within the scope of work to be accomplished. I will not dig or excavate before receiving written approval from the Directorate of Public Works (DPW). I understand my responsibilities and obligations pursuant to safety, property damage, personal injury, and life-threatening hazards associated with digging in the vicinity of underground utilities (including utilities such as electrical cables and pipes containing natural gas, water, sewer, liquefied fuels, and refrigerants). Severe injuries, death, and extensive property damage may occur as a result of digging through underground utilities. I am responsible for damages caused to persons or property as a result of my fault or negligence. If the exact locations of underground utilities are unknown, I will perform whatever work is necessary to determine exact locations and avoid damaging utilities.

Unless otherwise permitted, I will not excavate within 50 meters of streams, natural drains, roads, and tank trails. I will not dig or deposit excavated spoil within 10 meters of trees.

If archaeological resources (arrowheads, charcoal, bones, etc.) are discovered during excavation, I or my representative will notify DPW, 287- 1092, and suspend disturbance of the finding until DPW issues guidance.

Upon completion, I will restore the excavation site including backfilling, reshaping, and seeding to conform to surrounding topography.

For construction activities that will result in land disturbance (clearing, grading or excavating) of one acre or more, or that are part of a larger common plan of development that will ultimately disturb one or more acres of land, I will comply with the provisions of the TPDES General Permit, TXR150000, to discharge storm water from construction sites, and I will coordinate with DPW-Environmental Division, 287-6499.

WATER USE

I propose to take surface water from the location depicted in the attached map, sketch, or overlay. Include dates and amounts of proposed water use.

I understand that the proposed water supply point is a requirement within the scope of work to be accomplished. I will not divert or draw any water before receiving written approval from the Directorate of Public Works (DPW).

I understand that in addition to this permit, a Temporary Water Use Permit may be required from TCEQ, depending on the proposed water use.

SIGNATURE OF REQUESTER DATE

FHT Form 200-X10, April 2004(DPW) Replaces FHT Form 420-X10

REVIEWED OR INSPECTED BY

(All blocks must be signed for Excavation permit. Natural Resources & Environmental Mgmt only for Water Use permit.)

NATURAL RESOURCES

Sprint ELECTRIC GAS RANGE DIVISION

ENVIRONMENTAL MGMT

CULTURAL RESOURCES DOIM TV CABLE WATER & SEWER

Approved under the following conditions

Disapproved for the following reasons

APPROVED BY (Range Division for Training Activities, Range Safety for Live Fire Activities, DPW for all other Activities)

DATE

FHT Form page 2 200-X1

DIVING

b. AGE c. SEX e. GRADE

a. DATE OF ACCIDENT (month/day/year)

(1) PRIME:

PRIMARY

(CODE) (CODE)

____________________ TYPE

(CODE)

c. SEAT BELTS USED NOT USED NOT AVAILABLE

(1) FRONT SEAT

(2) REAR SEAT

b. ESTIMATED DAYS LOST c. ESTIMATED DAYS

HOSPITALIZED

d. ESTIMATED DAYS

REST. DUTY

a. SEVERITY OF ILLNESS/INJURY (CODE)

1. ACCIDENT CLASSIFICATION

(For Safety Staff only)

REPORT

NO.

EROC

CODE

GO ACCIDENT INVESTIGATION REPORT

PERSONNEL CLASSIFICATION INJURY/ILLNESS/FATAL PROPERTY DAMAGE MOTOR VEHICLE INVOLVED

GOVERNMENT

2. PERSONAL DATA

a. NAME (Last, First, MI) d. SOCIAL SECURITY NUMBER

f. JOB SERIES/TITLE g. DUTY STATUS h. EMPLOYMENT STATUS AT TIME OF ACCIDENT

3. GENERAL INFORMATION

b. TIME OF ACCIDENT c. EXACT LOCATION OF ACCIDENT d. CONTRACTOR'S NAME

(military time) hrs

(2) SUBCONTRACTOR

e. CONTRACT NUMBER f. TYPE OF CONTRACT g. HAZARDOUS/TOXIC WASTE

e. BODY PART AFFECTED (CODE) g. TYPE AND SOURCE OF INJURY/ILLNESS

4. CONSTRUCTION ACTIVITIES (Fill in line and corresponding code number in box from list - see instructions)

a. CONSTRUCTION ACTIVITY (CODE) b. TYPE OF CONSTRUCTION EQUIPMENT (CODE)

5. INJURY/ILLNESS INFORMATION (Include name on line and corresponding code number in box for items e, f & g - see instructions)

a. ACTIVITY AT TIME OF ACCIDENT (CODE) b. PERSONAL FLOATATION DEVICE USED?

6. PUBLIC FATALITY (Fill in line and correspondence code number in box - see instructions)

(2) (3)

7. MOTOR VEHICLE ACCIDENT

b. TYPE OF COLLISIONa. TYPE OF VEHICLE

a. NAME OF ITEM b. OWNERSHIP c. $ AMOUNT OF DAMAGE (1)

8. PROPERTY/MATERIAL INVOLVED

f. NATURE OF ILLNESS/INJURY (CODE)

See attached page.

a. TYPE OF VESSEL/FLOATING PLANT (CODE) b. TYPE OF COLLISION/MISHAP (CODE)

10. ACCIDENT DESCRIPTION (Use Additional paper, if necessary)

9. VESSEL/FLOATING PLANT ACCIDENT (Fill in line and correspondence code number in box from list - see instructions)

CIVILIAN MILITARY

CONTRACTOR

PUBLIC FATAL OTHER

FIRE INVOLVED OTHER

FIRE INVOLVED OTHEROTHER

MALE FEMALE

ARMY ACTIVE

PERMANENT

TEMPORARY

OTHER (Specify)

ARMY RESERVE

FOREIGN NATIONAL

STUDENT

VOLUNTEER

SEASONAL

ON DUTY TDY

OFF DUTY

CIVIL WORKS

OTHER (SPECIFY)

MILITARY

CONSTRUCTION SERVICE

A/E DREDGE

OTHER (SPECIFY)____________

SUPERFUND

IRP

DERP

OTHER (SPECIFY)

# YES NO N/A

PICKUP/VAN

TRUCK

AUTOMOBILE

OTHER (Specify)

SIDE SWIPE

BROADSIDE

OTHER (Specify)

HEAD ON

ROLL OVER

REAR END

BACKING

BOB.MILLENBACH

YES NO a. (CONTINUED) YES NO

Month/Day/Year

a. DIRECT CAUSE

b. INDIRECT CAUSE(S)

DESCRIBE FULLY:

f. OFFICE SYMBOL

CORPS

CONTRACTOR

a. b. c. COMMENTS

SIGNATURE TITLE DATE

a. b. c. COMMENTS

SIGNATURE TITLE DATE

a. b.

SIGNATURE TITLE DATE

See attached page.

15. DATES FOR ACTIONS IDENTIFIED IN BLOCK 14

a. BEGINNING (Month/Day/Year) b. ANTICIPATED COMPLETION (Month/Day/Year)

19. COMMAND APPROVAL

COMMANDER SIGNATURE DATE

18. SAFETY AND OCCUPATIONAL HEALTH OFFICE REVIEW

c. ADDITIONAL ACTIONS/COMMENTS

17. MANAGEMENT REVIEW (2nd - Chief Operations, Construction, Engineering, etc.)

16. MANAGEMENT REVIEW (1st)

c. SIGNATURE AND TITLE OF SUPERVISOR d. DATE (Month/Day/Year) e. ORGANIZATION IDENTIFIER (Div,Br,Sect) maintenance of personal protective eqpt contribute to the accident?

contribute to the accident?

b. WAS A WRITTEN JOB/ACTIVITY HAZARD ANALYSIS

HUIMAN FACTORS: Did any human factors such as size or strength of accident?

DRUGS/ALCOHOL: In your opinion, was deugs or alcohol factor to the person, etc., contribute to accident?

ENVIRONMENTAL FACTORS: Did heat, cold, dust, sun, glare, etc.

condition of the person a factor?

exposure to chemical agents, such as dust, fumes, mists, vapors, or

INSPECTION/MAINTENANCE: Were inspection & maintenance procedures a factor?

PERSON'S PHYSICAL CONDITION: In your opinion, was the physical

OFFICE FACTORS: Did office setting such as, lifting office furniture, physical agents such as noice, radiation, etc. contribute to accident?

carrying, stooping, etc. contribute to the accident?

11. CASUAL FACTORS (Read Instructions Before Completing)

a. (Explain YES answers in item 13 DESIGN: Was design of facility, workplace or equipment a factor?

CHEMICAL AND PHYSICAL AGENT FACTORS: Did

SUPPORT FACTORS: Were inappropriate tools/resources provided

See attached page.

OPERATING PROCEDURES: Were operating procedures a factor?

JOB PRACTICES: Were any job safety/health practices not followed when the accident occurred?

to properly perform the activity/task?

PERSONAL PROTECTIVE EQPT: Did the improper selection, use or

a. WAS PERSON TRAINED TO PERFORM ACTIVITY/TASK? c. DATE OF MOST RECENT FORMAL TRAINING

See attached page.

COMMENTS

COMPLETED FOR TASK BEING PERFORMED AT TIME OF

ACCIDENT?

13. FULLY EXPLAIN WHAT ALLOWED OR CAUSED THE ACCIDENT: INCLUDE DIRECT AND INDIRECT CAUSES (See instruction for definition of direct and indirect causes.) (Use additional paper, if necessary)

14. ACTION(S) TAKEN, ANTICIPATED OR RECOMMENDED TO ELIMINATE CAUSE(S)

12. TRAINING

b. TYPE OF TRAINING

NO

YES NO

CONCUR NON CONCUR

CONCUR NON CONCUR

CONCUR NON CONCUR

YES (If yes, attach a copy)

CLASSROOM ON JOB

BOB.MILLENBACH

10. ACCIDENT DESCRIPTION (Continuation)

13a. DIRECT CAUSE (Continuation)

BOB.MILLENBACH

13b. INDIRECT CAUSES (Continuation)

14. ACTION(S) TAKEN, ANTICIPATED, OR RECOMMENDED TO ELIMINATE CAUSE(S) (Continuation)

BOB.MILLENBACH

Sample of typical Contractor Quality Control Report

CONTRACTOR'S NAME (Address)

DAILY CONSTRUCTION QUALITY CONTROL REPORT

Date: __________________ Report No. ____________ Task Order Number _____________________________________________________________ Description and Location of work:

WEATHER: (Clear) (P. Cloudy) (Cloudy);

Temperature:_________ Min. _________ Max;

Rainfall _________ inches.

Contractor/Subcontractors and Area of Responsibility with Labor Count for Each a.___________________________________________________________________________ b.___________________________________________________________________________ c.___________________________________________________________________________ d.___________________________________________________________________________

Equipment Data: (Indicate items of construction equipment, other than hand�tools, at the job site, and whether or not used.)

1. Work Performed Today: (Indicate location and description of work performed. Refer to work performed by prime and/or subcontractors by letter in Table above. If no work is performed, report the reason.)

2. Results of Surveillance: (Include satisfactory work completed, or deficiencies with action to be taken.)

a. Preparatory Inspection: ________________________________________________________

b. Initial Inspection: _____________________________________________________________

c. Follow-up Inspections: _________________________________________________________

3. Test Required by Plans and/or Specifications performed and Results of Tests:

4. Verbal Instructions Received: (List any instructions given by Government personnel on construction deficiencies, retesting required, etc., with action to be taken.)

BOB.MILLENBACH

5. Remarks: (Cover any conflicts in plans, specifications, or�instructions or any delay to the job.)

6. Results of Safety Inspection: (Include safety violations and�corrective actions taken.)

Contractor's Inspector

CONTRACTOR'S VERIFICATION: The above report is complete and correct and all material and equipment used and work performed during this reporting period are in compliance with the contract plans and specifications except as noted above.

Contractor's Quality Control Manager

NOTE: DO NOT LEAVE REPORT ITEMS BLANK

Items 1. through 6. must be reported every day. If there is no other report on an item, enter the work "none" in the reporting space. Reports with items left blank will be returned as incomplete.

BOB.MILLENBACH

PREPARATORY PHASE CHECKLIST

Task Order Number _________________ Date:_____________________ Definable Feature:_______________ Spec Section:_______________ Gov't Rep Notified ________ Hours in Advance Yes________ No_______ I. Personnel Present:

Name Position Company/Government 1.____________________________________________________________________________ 2.____________________________________________________________________________ 3.____________________________________________________________________________ 4.____________________________________________________________________________ 5.____________________________________________________________________________ 6.____________________________________________________________________________ 7.____________________________________________________________________________ 8.____________________________________________________________________________ 9.____________________________________________________________________________ 10.___________________________________________________________________________ (List additional personnel on reverse side)

II. Submittals

1. Review submittals and submittal register.

Have all submittals been approved? Yes_________ No_________ If no, what items have not been submitted?

a.____________________________________________________________________________ b.____________________________________________________________________________ c.____________________________________________________________________________

2. Are all materials on hand? Yes_________ No__________ If no, what items are missing?

a.____________________________________________________________________________ b.____________________________________________________________________________ c.____________________________________________________________________________

3. Check approved submittals against delivered materials. (This should be done as material arrives.)

Comments_____________________________________________________________________

BOB.MILLENBACH

III. Material storage

Are materials stored properly? Yes___________ No ____________ If No, what action is taken?_______________________________________________________

IV. Specifications

1. Review each paragraph of specifications.

2. Discuss procedure for accomplishing the work.

3. Clarify any differences.

V. Preliminary Work and Permits nsure preliminary work is correct and permits are on file. f not, what action is taken?

VI. Testing

1. Identify test to be performed, frequency, and by whom

2. When required?

BOB.MILLENBACH

3. Where required?______________________________________________________________________

4. Reviewing Testing Plan._________________________________________________________________________

5. Have test facilities been approved?_____________________________________________________________________

VII. Safety

1. Review applicable portion of EM 385-1- 1.____________________________________________________________________________ ____________________________________________________2. Activity Hazard Analysis approved? Yes ________ No ________

VIII. DPW comments during meeting.

CQC REP

BOB.MILLENBACH

INITIAL PHASE CHECKLIST

Task Order Number_________________ Date:_____________________ Definable Feature:_______________ Gov't Rep Notified ________ Hours in Advance Yes________ No_______

I. Personnel Present:

Name Position Company/Government 1.____________________________________________________________________________ 2.____________________________________________________________________________ 3.____________________________________________________________________________ 4.____________________________________________________________________________ 5.____________________________________________________________________________ 6.____________________________________________________________________________ 7.____________________________________________________________________________ 8.____________________________________________________________________________ 9.____________________________________________________________________________ 10.___________________________________________________________________________ (List additional personnel on reverse side)

II. Identify full compliance with procedures identified at preparatory. Coordinate plans, specifications, and submittals.

Comments

III. Preliminary Work. Ensure preliminary work is complete and correct. If not, what action is taken?

IV. Establish Level of Workmanship.

1. Where is work located?

2. Is a sample panel required? Yes ______ No ______

3. Will the initial work be considered as a sample? Yes _________ No _____________

BOB.MILLENBACH

(If yes, maintain in present condition as long as possible.)

V. Resolve any differences.

Comments

VI. Check Safety Review job conditions using EM 385-1-1 and job hazard analysis. Comments

CQC REP

BOB.MILLENBACH

OPERATION AND MAINTENANCE INSTRUCTIONS

Task Order Number _____________________________________________________________

DESCRIPTION ________________________________________________________________

LOCATION ___________________________________________________________________

DATE ________________________________________________________________________

Operation and maintenance instructions were conducted for__________________ (Type of Equipment) required by section______________, paragraph_____________ on __________________________ (Date).

The following personnel were present:

Instructions were given by________________________________________________________ (Contractor's Representative)

The personnel identified herein by their signatures certify that they have�been instructed in the operation and maintenance of the above-mentioned�equipment.

BOB.MILLENBACH