Attachment_1-Appendix_A_27-JUL-2018.pdf

PDF 5 MB Posted May 9, 2019

Attached to: Replace Roof HVAC unit & Exhaust Fan Federal contract opportunity
Solicitation number: W91151-19-B-0019
Issued by: Department of the Army Materiel Command Mission and Installation Contracting Command Fort Hood

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

Attachment 1 A A

Directorate of Public Works Engineering Division

US Army, III Corps 4612 Engineer Dr.

Fort Hood, TX 76544

APPENDIX “A” TABLE OF CONTENTS

SECTION 1 – GENERAL

DESCRIPTION:

Sample Submittal Register Form 4025, Submittal Transmittal Sheet Contract Bi-Weekly Progress Report Form 1 Refrigeration Equipment Service Log EPA: Refrigeration Recovery Form Emissions Inventory Sheet Contractor Hazardous Materials Inventory and Consumption Log Landfill Permit Customer Service Inspection Certificate (CSI)

DPW-OMD Line Marking for Land Excavation Form Landscaping on Fort Hood Accident Investigation Report Sample-Contractor Quality Control Report Preparatory Phase Checklist Initial Phase Checklist Operation and Maintenance Training Fort Hood DPW Building Equipment Inventory Fort Hood Key SOP (Mechanical Keys and Electronic Keys)

SECTION 2 – NETWORK ENTERPRISE CENTER (NEC)

Information Infrastructure Installation Guidelines

SECTION 3 – AMERICAN WATER

American Water Design Guide

SECTION 4 – PRIVATIZED UTILITIES ON FT. HOOD

Ft. Hood Privatized Utility Policy Connection Charge Agreement

SECTION 1 - GENERAL

C E

M ak e M od el

N um be r

Se ria l N um be r

R ef rig er an t T yp e

C om pr es so r S er ia l N um be r

Lo ca tio n of L ea k on E qu ip m en t M ak e

U ni t R ef rig er an t C ha rg e

P er

C irc ui t

M od el

N um be r

R ef rig er an t R ec ov er ed

(l bs

.o z)

C irc ui t

Se ria l N um be r

R ef rig er an t A dd ed

(l bs

.o z)

C irc ui t

R ef rig er an t T yp e

Va cu um L ev el

A ch ie ve d (in ch es

H g)

Va cu um L ev el

A ch ie ve d (in ch es

H g)

*N et

L ea ka ge

(l bs

.o z)

R ef rig er an t A dd ed

(l bs

.o z)

*N et

L ea ka ge re fri ge ra nt a dd ed re fri ge ra nt re co ve re d

- a cc id en ta l l os s

R ef rig er an t R em ov ed (l bs .o

z) N ot es

M ak e M et ho d us ed fo r v er ifi ca tio n

M od el N um be r Le ak re pa ire d Ye s / N o Se ria l N um be r If no , a ct io n ta ke n

R ef rig er an t T yp e

R ef rig er an t A dd ed

(l bs

.o z)

M et ho d us ed fo r v er ifi ca tio n R ef rig er an t R em ov ed

(l bs

.o z)

Le ak re pa ire d

Ye s

/ N o

(l bs

.o z)

If no

, a ct io n ta ke n (T ec h w ill ad vi se R ea l P ro pe rty

R ef rig er an t C ha rg e pe r C irc ui t

N ot es

Si gn at ur e of

C er tif ie d Te ch ni ci an

Tu rn or D at e

R /M

H /D

Y Ty pe C he ck

Y R

C yl S er ia l # Pr in t N am e

(E C

Si gn at ur e (E

C O

Vi rg in

/R ec yc le d/ R ec ov er ed

Vi rg in /R ec yc le d/

R ec ov er ed Vi rg in

/R ec yc le d/ R ec ov er ed

Vi rg in /R ec yc le d/

R ec ov ed

Form Approved OMB No. 2060-0256

EPA regulations require establishments that service or dispose of refrigeration or air-conditioning equipment to certify that they have acquired recovery or recycling devices that meet EPA standards for such devices. To certify that you have acquired equipment, please complete this form according to the instructions and

Name of Establishment Street

(Area Code) Telephone Number City State Zip Code

Number of Service Vehicles Based at Establishment County

Identify the type of work performed by the establishment

Type A - Service small appliances Type B - Service refrigeration or air-conditioning equipment other that small appliances Type C- Dispose of small appliances Type D - Dispose of refrigeration or air-conditioning equipment other than small appliances

Name of Device(s) Manufacturer Model Number Year Serial Number (if any) Check Box if Self-Contained

1. G

2. G

3. G

4. G

5. G

I certify that the establishment in Part 1 has acquired the refrigerant recovery or recycling device(s) listed in Part 2, that the establishment is complying with Section 608 regulations, and that the information gives is true and correct.

Signature of Owner/Responsible Officer Date Name (Please Print) Title

INSTRUCTIONS

Please provide the name, address, and telephone number of the establishment where the refrigerant recovery or recycling device(s) is (are) located. Please complete one form for each location.

State the number of vehicles based at this location that are used to transport technicians and equipment to and from service sites.

Check the appropriate boxes for the type of work performed by technicians who are employees of the establishment. The term “small appliance” refers to any of the following products tat are fully manufactured, charged, and hermetically sealed in a factory with five pounds or less of refrigerant:

refrigerators, and freezers designed for home use, room air conditioners (including window air conditioners and packaged terminal air conditioners), packaged terminal heat pumps, dehumidifiers, under-the-counter ice makers, vending machines, and drinking water coolers.

For each recovery or recycling device acquired, please list the name of the manufacturer of the device, and (if applicable) its model number and serial number.

If more that seven devices have been acquired, please fill out an additional form and attach it to this one. Recovery devices that are self-contained should be listed first and should be identified by checking the box in the last column on the right. Self-contained recovery equipment means refrigerant recovery or recycling equipment that is capable of removing te refrigerant from an appliance without the assistance of components contained in the appliance. On the other hand, system-dependent recovery equipment means refrigerant recovery equipment that requires the assistance of components contained in an appliance to remove the refrigerant from the appliance.

If the establishment has been listed as Type B and/or Type D in Part 2, then the first device listed in Part # must be a self-contained device and identifies as such by checking the box in the last column on the right.

If any of the devices are homemade, they should be identified by writing “homemade” in the column provided for listing the name of the device manufacturer. Type A or Type B establishments can use homemade devices manufactured before November 15, 1993. Type C or Type D establishments can use homemade manufactured anytime. If, however, a Type C or Type D establishment is using homemade equipment manufactured after November 15, 1993, then it must not use these devices for service jobs.

Send your form to the EPA office listed under the state or territory in which the establishment is located.

Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont

CAA 608 Enforcement Contact: EPA Region I; Mail Code SEA; JFK Federal Building; One Congress Street, Suite 1100; Boston, MA 02114-2023

Arkansas, Louisiana, New Mexico, Oklahoma, Texas

CAA 608 Enforcement Contact: EPA Region VI; Mail Code 6EN-AA; 1445 Ross Ave., Suite 1200; Dallas, TX 75202

New York, New Jersey, Puerto Rico, Virgin Islands

CAA 608 Enforcement Contact: EPA Region II; Mail Code 2DECA-AC; 290 Broadway; New York, NY 10007-1866

Iowa, Kansas, Missouri, Nebraska

CAA 608 Enforcement Contact: EPA Region VII; Mail Code APCOARTD; 901 North Fifth Street; Kansas City, KS 66101

Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia

CAA 608 Enforcement Contact: EPA Region III-Wheeling Office; Mail Code 3AP12; 303 Methodist Building; 11th and Chapline Streets; Wheeling, WV 26003

Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming

CAA 608 Enforcement Contact: EPA Region VIII; Mail Code 8ENF-T; 999 18th

Street, Suite 500; Denver, CO 80202

Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee

CAA 608 Enforcement Contact: EPA Region IV; Mail Code APT-AE; 61 Forsyth Street, SW; Atlanta, GA 30303-8960

American Samoa, Arizona, California, Guam, Hawaii, Nevada

CAA 608 Enforcement Contact: EPA Region IX; Mail Code AIR-5; 75 Hawthorne Street; San Francisco, CA 94105

Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin

CAA 608 Enforcement Contact: EPA Region V; Mail Code AE-17J; 77 West Jackson Blvd.; Chicago, IL 60604

Alaska, Idaho, Oregon, Washington

CAA 608 Enforcement Contact: EPA Region X; Mail Code OAQ-107; 1200 Sixth Ave.; Seattle, WA 98101

Pr op os ed

P ro jec t E mi ss ion s I nv en tor y Q ue sti on na ire fo r N ew

S ou rce s

Th e

D ec is io n Su pp or t S ys te m p ro vi de s se ve ra l d oc um en ts li nk ed to ge th er to a id in th e

Ti tle

V a pp lic at io n an d re vi ew p ro ce ss

. T he se d oc um en ts in cl ud e

R ul e Te xt , R el at io ns hi p

En try

S cr ee ns

Fl ow ch ar ts a nd

H is to ric

R ul e O pi ni on s

(w he n ap pl ic ab le

M os t o f t he se d oc um en ts a nd th ei r s ub pa rts a re a va ila bl e in

P or ta bl e D oc um en t F or m at (P

D F)

. T o vi ew th e do cu m en ts in th is fo rm at , a fre co py o f A do be A cr ob at R ea de r w ill ha ve to b e in st al le d on y ou r c om pu te r.

Fo r b es t r es ul ts , i ns ta ll th e m os t c ur re nt v er si on o f A do be R ea de r.

G ui da nc e fo r u si ng th e D ec is io n

Su pp or t S ys te m

P ar t 5

- N at io na l V ol at ile O rg an ic C om po un d

Em is si on

S ta nd ar ds fo r C on su m er a nd C om m er ci al P ro du ct s

P ar t 6

- S ta nd ar d of P er fo rm an ce fo r N ew

S ta tio na ry S ou rc es (N

P ar t 6

- N at io na l E m is si on

S ta nd ar ds fo r H az ar do us A ir Po llu ta nt s

P ar t 6

- N at io na l E m is si on S ta nd ar ds fo r H az ar do us

A ir

Po llu ta nt s fo r S ou rc e

C at eg or ie s( a.

M ax im um A ch ie va bl e C on tro l T ec hn ol og y

P ar t 8

- P ro te ct io n of

S tra to sp he ric

O zo ne

C ha pt er s

, 1

-1

C on tro l o f A ir Po llu tio n

Ap pl ic ab ilit y

D et er m in at io n

In de x (A

D I)

Th e

A a ls o ha s a d at ab as e av ai la bl e on lin e th at c on ta in s m em or an da is su ed b y th e th e ag en cy o n ap pl ic ab ili ty a nd c om pl ia nc e is su es a ss oc ia te d w ith

S, N

A P an d

M A

C T

St an da rd s

Re qu es tor

Da te:

Ph on e:

_ P ro jec t #

Fa cil ity N am e /

B uil din g N um be r:

De sc rip tiv e N am e o f F ac ilit y:

Lo ca tio n o f F ac ilit y:

M Zo ne

Ho riz on tal

C oo rd ina te

Ve rtic al Co or din ate

Ind ica te pr op os ed em iss ion so ur ce ty pe an d c om ple te all ap pli ca ble fie lds fo r e ac h p ro ce ss

Co mp let e q ue sti on na ire sh ee t fo r e ac h p ro ce ss ty pe in th is fac ilit y.

S (I.

S, E

(C ov er ed by

6.5 an d 3

0 T

6.2

Ma ke

_ M od el_

S er ial

_ P ow er R ati ng

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P Fu el Ty pe

_ M

/JP

8/D ies el;

In teg ra ted F ue l T an k C ap ac ity

_g all on s

Ma ke

_ M od el_

S er ial

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_k w;

H or se po we r: _

P Fu el Ty pe

_ M

/JP

8/D ies el;

In teg ra ted F ue l T an k C ap ac ity

_g all on s

Ma ke

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_ P ow er R ati ng

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H or se po we r: _

P Fu el Ty pe

_ M

/JP

8/D ies el;

In teg ra ted F ue l T an k C ap ac ity

_g all on s

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P Fu el Ty pe

_ M

/JP

8/D ies el;

In teg ra ted F ue l T an k C ap ac ity

_g all on s

Ma ke

_ M od el_

S er ial

_ P ow er R ati ng

_k w;

H or se po we r: _

P Fu el Ty pe

_ M

/JP

8/D ies el;

In teg ra ted F ue l T an k C ap ac ity

_g all on s

Se pa ra te

Fu el

Ta nk

(s) : Y

/ N

O (ci rcl e o ne ) C om ple te Se pa ra te Qu es tio nn air e f or

E ac h T an k Se as on al Op er ati ng P er ce nta ge fo r T his E mi ss ion P oin t:

Sp rin g _

S um me r _

F all

W int er

N ot e:

To ta l M us t E qu al

No rm al Op er ati ng S ch ed ule : S tar t T im e_ ho ur s/d ay da ys /w ee k

_ w ee ks /ye ar

No rm al Op er ati ng R ate ga llo ns or C uF t/ y ea r

(C ov er ed by

5.4

, 3 0 T

6.4 an d 3

0 T

C ha p 1

Ma ke

Mo de l__

_S er ial

_ F ue l T yp e:

Ta nk V olu me

_g als ;T an k D im en sio ns

(f t):

D iam ete r _

Le ng th_

H eig ht_

Ma ke

Mo de l__

_S er ial

_ F ue l T yp e:

Ta nk V olu me

_g als ;T an k D im en sio ns

(f t):

D iam ete r _

Le ng th_

H eig ht_

Ma ke

Mo de l__

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Ta nk V olu me

_g als ;T an k D im en sio ns

(f t):

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H eig ht_

Ma ke

Mo de l__

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_ F ue l T yp e:

Ta nk V olu me

_g als ;T an k D im en sio ns

(f t):

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Le ng th_

H eig ht_

Ma ke

Mo de l__

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_ F ue l T yp e:

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_g als ;T an k D im en sio ns

(f t):

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Le ng th_

H eig ht_

Ta nk

T yp e:

Ab ov eg ro un d / U nd er gr ou nd (c irc le on e)

; V ap or C on tro l E qu ipp ed

: Y

/ N O

(ci rcl e o ne

Ro of Ty pe : H or izo nta l F ixe d R oo f /

Ve rtic al Fix ed R oo f /

Int er na l F loa tin g R oo f / Pr es su re T an k E xte rn al Flo ati ng

R oo f

Se as on al

Op er ati ng

P er ce nta ge fo r T his

E mi ss ion

P oin t:

Sp rin g _

S um me r _

F all

W int er

N ot e:

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0% No rm al

Op er ati ng

S ch ed ule

: S tar t T im e_ ho ur s/d ay da ys

/w ee k

_ w ee ks

/ye ar

No rm al

Op er ati ng

R ate ga llo ns /ye ar Ma xim um

O pe ra tin g R ate ga llo ns /ho ur

S (B oil er s, Ho t W ate r H ea ter s, Pr oc es s H ea ter

s) (C ov er ed by

6.1 an d 3

0 T

6.1

Fu el

Ty pe

: N atu ra l G as / D ies el

Ma ke

Mo de l__

_S er ial

In pu t R ati ng

_ M

He igh t o f S tac k:

; D iam ete r o f S tac k:

ft;

S tac k E xh au st Ve loc ity

_ft

/ s ec

Ma ke

Mo de l__

_S er ial

In pu t R ati ng

_ M

H He igh t o f S tac k:

ft ; D iam ete r o f S tac k:

ft;

S tac k E xh au st

Ve loc ity

_ft

Mo de l__

_S er ial

In pu t R ati ng

_ M

He igh t o f S tac k:

; D iam ete r o f S tac k:

ft;

S tac k E xh au st Ve loc ity

_ft

Mo de l__

_S er ial

In pu t R ati ng

_ M

H He igh t o f S tac k:

ft ; D iam ete r o f S tac k:

ft;

S tac k E xh au st

Ve loc ity

_ft

Se as on al

Op er ati ng

P er ce nta ge fo r T he se E mi ss ion P oin ts:

Sp rin g _

S um me r _

F all

W int er

N ot e:

To ta l M us t E qu al

0% No rm al

Op er ati ng

S ch ed ule

: S tar t T im e_ ho ur s/d ay da ys

/w ee k

_ w ee ks

/ye ar

N or ma l O pe ra tin g R ate

_g all on s/y ea r

S (C ov er ed by

6.4

Ma ke

Mo de l__

_S er ial

Mo de l__

_S er ial

Mo de l__

_S er ial

Mo de l__

_S er ial

Mo de l__

_S er ial

Mo de l__

_S er ial

Fu el

Ty pe

: M

/ D ies el / J

P- 8 /

O the r _ cir cle on e)

Di sp en sin g T yp e:

Re tai l / Bu lk (ci rcl e o ne

Va po r C on tro l E qu ipp ed : Y

/ N

O (ci rcl e o ne

Di sp en se r P um p r ate

_ g all on s/m inu te Se as on al Op er ati ng P er ce nta ge fo r T his E mi ss ion P oin t:

Sp rin g _

S um me r _

F all

W int er

N ot e:

To ta l M us t E qu al

No rm al Op er ati ng S ch ed ule : S tar t T im e_ ho ur s/d ay da ys /w ee k

_ w ee ks /ye ar

N or ma l Op er ati ng R ate ga llo ns

/ye ar

(C ov er ed by

6.4

, 3 0 T

6.4 or

6.1

At tac h a pp ro ve d M

S of ea ch co ati ng an d s olv en t u se d i n p ro ce ss

Pa rtic ula te Ma tte r C on tro l E ffic ien cy of B oo th:

Bo oth A ir F low

R ate

_s cfm

Tr an sfe r E ffic ien cy of

P ain t G un

Nu mb er of P ain t G un s:

As so cia ted

H ea ter : Y

/ N

O (ci rcl e o ne ) C om ple te Se pa ra te Qu es tio nn air e f or

E ac h H ea ter

As so cia ted

G un

C lea ne r:

/ N O

(ci rcl e o ne

) C om ple te

Se pa ra te

Qu es tio nn air e f or E ac h C lea ne r Se as on al Op er ati ng P er ce nta ge fo r T his E mi ss ion P oin t:

Sp rin g _

S um me r _

F all

W int er

N ot e:

To ta l M us t E qu al

No rm al Op er ati ng S ch ed ule : S tar t T im e_ ho ur s/d ay da ys /w ee k

_w ee ks /ye ar al Op er ati ng R ate ga llo ns

/ye ar

(e ac h c oa tin g a nd so lve nt)

, F

(C ov er ed by

6.1

Ma ke

M od el_

_S er ial

N o.

of co mp re ss or s:

Re frig er an tT yp e:

A mo un t o f C ha rg e:_

_lb s;

In itia l C ha rg e D ate

Ma ke

M od el_

_S er ial

N o.

of co mp re ss or s:

er an t T yp e:

A mo un t o f C ha rg e:_

_lb s;

In itia l C ha rg e D ate

Ma ke

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N o.

of co mp re ss or s:

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_lb s;

In itia l C ha rg e D ate

Ma ke

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N o.

of co mp re ss or s:

er an t T yp e:

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_lb s;

In itia l C ha rg e D ate

Ma ke

M od el_

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N o.

of co mp re ss or s:

er an t T yp e:

A mo un t o f C ha rg e:_

_lb s;

In itia l C ha rg e D ate

Se as on al

Op er ati ng

P er ce nta ge fo r T his

E mi ss ion

P oin t:

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S um me r _

F all

W int er

N ot e:

To ta l M us t E qu al

0% No rm al

Op er ati ng

S ch ed ule

: S tar t T im e_ ho ur s/d ay da ys

/w ee k

_w ee ks

/ye ar

(C ov er ed by

6.2

At tac h a pp ro ve d M

S of ea ch w eld ing ro d t yp e u se d i n p ro ss

Mo de l__

_S er ial

Mo de l__

_S er ial

Mo de l__

_S er ial ula te

Ma tte r C on tro l E ffic ien cy of ho od

(if av ail ab le)

Ex ha us t F an V en tila tio n R ate sc fm

Ac ety len e o n h an d:

lbs of ga s

Ox yg en on ha nd

_ l bs of ga s

Se as on al

Op er ati ng

P er ce nta ge fo r T his

E mi ss ion

P oin t:

Sp rin g _

S um me r _

F all

W int er

N ot e:

To ta l M us t E qu al

0% No rm al

Op er ati ng

S ch ed ule

: S tar t T im e_ ho ur s/d ay da ys

/w ee k

_w ee ks

/ye ar al

Op er ati ng

R ate

# o f r od s/y ea r

(C ov er ed by

6.2 an d 3 0 T

6.2

At tac h a pp ro ve d M

S of ea ch br ak e p ad ty pe us ed in pr oc es s Ma ke

Mo de l__

_S er ial

Mo de l__

_S er ial

Mo de l__

_S er ial ula te

Ma tte r C on tro l E ffic ien cy of ho od

(if av ail ab

le) : 1 st S tag e _

; 2 nd S tag e_

Ex ha us t F an V en tila tio n R ate sc fm

Se as on al

Op er ati ng

P er ce nta ge fo r T his

E mi ss ion

P oin t:

Sp rin g _

S um me r _

F all

W int er

N ot e:

To ta l M us t E qu al

0% No rm al

Op er ati ng

S ch ed ule

: S tar t T im e_ ho ur s/d ay da ys

/w ee k

_w ee ks

/ye ar al

Op er ati ng

R ate

# o f B ra ke s R ep air ed

/ye

Us e O nly F

, E

an d C

de ter mi na tio n c om es fr om

E mi ss ion s I nv en tor y G uid eli ne s

N-

F ac ilit y I de nti fic ati on N um be r;

N- E mi ss ion P oin t N um be r;

N- C on tro l Id en tifi ca tio n N um be r

Us e O nly Re ce ive d o n _

_ f or su bm itta l in

_ P er mi t

Au tho riz ed by

T itle

Si gn atu re

D ate

P Au tho riz ed by

T itle

Pr op os ed

P ro jec t E mi ss ion s I nv en tor y Q ue sti on na ire fo r N ew

S ou rce s

E C

O M

Y N

C O

N O

*C on tra ct or (s

) c er tif ie s th at th e ha za rd ou s m at er ia l(s ) r em ov ed fr om in st al la tio n w ill be u se d/ re us ed fo r i ts in te nd ed p ur po se

Su bm itt ed

B y:

Ph on e:

Fa x:

D at e:

Pr in te d

N am e

C on tra ct in g

O ffi ce r

Ph on e:

Fa x:

R ep re se nt at iv e

Pa ge of

C om pa ny

U si ng M at er ia l L is te d Ab ov e

C om pa ny

R ep re se nt at iv e' s Si gn at ur

E C

O M

Y N

C O

N O

Pa ge of

C on tin ua tio n

Sh ee t

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):

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.

I further certify that the following materials were used in the installation of the private water distribution facilities:

Service lines Lead __ Copper __ PVC __ Other __ �Solder Lead __ Lead Free __ Solvent Weld __ Other __

I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally responsible for the validity of the information I have provided.

Remarks:

Signature of Inspector Registration Number

Title Type of Registration

Date

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

COORDINATION FOR LAND EXCAVATION & WATER USE

(III Corps and FH Reg 200-1)

CONTROL NUMBER

TELEPHONE

NAME, RANK, TITLE, AND ORGANIZATION OF REQUESTER

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

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 200-X10

DPW-OMD LINE MARKING FOR LAND EXCAVATION FORM

LINE MARKING FOR LAND EXCAVATION FORM EXPIRES 14-DAYS AFTER UTILITY ASSETS HAVE BEEN MARKED

CONTROL NUMBER:

*This form may take 10-Business days to process and validate.

1. NAME, RANK, TITLE, AND ORGANIZATION OF REQUESTOR: 2. PHONE NUMBER:

3. PROJECTED DATES OF EXCAVATION:

4. LOCATION & DESCRIPTION OF LAND EXCAVATION: Requestor must include an attached map

5. SITE POC: 6. POC PHONE NUMBER:

7. REQUESTOR RESPONSIBILITIES AND GENERAL EXCAVATION STATEMENTS

8. SIGNATURE OF REQUESTOR: 9. DATE:

AW: I have marked the identified excavation site for AW owned utility assets.

AW SIGNATURE: DATE:

DE: I have marked the identified excavation site for DE owned utility assets.

DE SIGNATURE: DATE:

NEC: I have marked the identified excavation site for NEC owned utility assets.

NEC SIGNATURE: DATE:

I have marked the identified excavation site for DPW-OMD owned utility assets.

DPW-OMD SIGNATURE: DATE:

DPW-OMD:

I understand that once the approved dig or excavation permit is received, I must hand dig within three feet (36 in.) on either side of the ground markings indicating the presence of an underground utility.

Section III - DPW OFFICE USE ONLY

*Line Marking for Land Excavation Forms are valid until project is complete as long as utility location markings are maintained by the requestor and excavation is started within 14-days from all utility asset markings. Each requestor performing land excavation must obtain a valid Line Marking for Land Excavation Form for excavation within the identified and approved area. If excavation has not begun 14-days after approval, the form is no longer valid and the requestor will be responsible for submitting a new Line Marking for Land Excavation Form.

I understand that I am responsible for damages caused to persons or property as a result of my fault or negligence. If the exact location(s) of underground utilities are said to be unknown, I will perform whatever work is necessary to determine exact location(s) and avoid damaging utilities.

If archaeological resources (arrowheads, charcoal, bones, etc.) are discovered during excavation, I or my representative will notify DPW Cultural Resources at 287-1092 and suspend all digging activities pending further guidance from DPW-Cultural Resources.

I understand that it is my responsibility to review and comply with my contract requirements.

I understand that I must coordinate with external utility system owners by contacting them directly or by calling 811 for assistance.

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 understand that I cannot not dig or excavate without receipt of an approved excavation permit within Fort Hood Cantonment Areas.

Section I

*This DPW-OMD Line Marking for Land Excavation Form is required for coordination of land excavation. Upon receipt of a validated form, the requestor may proceed with coordination of land excavation IAW contractual and regulatory excavation requirements.

Section ll – REQUESTOR RESPONSIBILITIES

I understand this Line Marking for Land Excavation Form is required for coordination of land excavation and upon receipt of a validated form, I may proceed with coordination of land excavation IAW contractual and regulatory excavation requirements I propose to dig at the locations within Fort Hood cantonment areas depicted in the attached map and understand that G3 or DPTMS-Range Division is responsible for establishing excavation procedures and controlling access in maneuver and live fire training areas on the installation (AR 350-19).

*This form must be obtained and completed prior to the planned site excavation.

DIVING

b. AGE c. SEX e. GRADE

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

(1) PRIME:

PRIMARY

(CODE) (CODE)

(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)

(For Safety Staff only)

REPORT

NO.

EROC

CODE

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

GOVERNMENT

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

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

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

(Fill in line and corresponding code number in box from list - see instructions)

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

(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?

(Fill in line and correspondence code number in box - see instructions)

(2) (3)

b. TYPE OF COLLISIONa. TYPE OF VEHICLE

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

f. NATURE OF ILLNESS/INJURY (CODE)

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

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.

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

COMMANDER SIGNATURE DATE

c. ADDITIONAL ACTIONS/COMMENTS

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?

(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?

b. TYPE OF TRAINING

YES NO

CONCUR NON CONCUR

YES (If yes, attach a copy)

CLASSROOM ON JOB

10. ACCIDENT DESCRIPTION (Continuation)

Sample 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.)

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.

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?

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

Comments_____________________________________________________________________

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?

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

INITIAL PHASE CHECKLIST

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

I. Personnel Present:

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 _____________

(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

OPERATION AND MAINTENANCE

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.

FORT HOOD DPW EQUIPMENT INVENTORY INSTRUCTIONS

1 Header and Format. Final submission must be in Excel format. Please include building number and contract number in HEADER of all tabs. File name MUST EXCLUDE the following special characters: & . " ? < > # { } % ~ / \

2 Equipment Tab. Use only approved equipment categories in Column D.

Enter all Installed Building Equipment. Please include the following: The specific location of equipment items; Identify all equipment by item# i.e. "AHU-1"; provide a detailed description of the equipment i.e. "Air Handler"; Enter an equipment category from the specified list(Electrical, HVAC, Utilities, Mechanical, Roads, Vehicle Maintenance, Grounds, Structural, Force Protection); Enter the equipment manufacturer, model and serial number; Provide the equipment input, output, capacity and include the unit of measure; Provide the equipment manufacturer warranty start date, end date and duration; Provide manufacturer or supplier warranty contact information(Name, Phone#, Email, Address); Provide contact information for replacement parts(Name, Phone#, Email, Address). The Equipment tab includes Columns A through P.

3 Preventive Maintenance Tab.

Enter all Preventive Maintenance Requirements for installed building equipment. Please include the following: The specific location of the equipment; Equipment item number;

Equipment component; preventive maintenance required; Preventive Maintenance Schedule (Frequency or Cycle: Time Based, Usage Based, etc.); Equipment Specific Requirements or Information; Specify if water chemical treatment is required; filter size;

filter quantity; belt size; belt quantity; disconnect location ad label. The Preventive Maintenance tab includes Columns A through L.

4 Warranty Tab. Enter all Warranty and Extended Warranty Information. Please include the following:

Construction contract number; Construction warranty start date; Construction warranty end date(1year); COR/PM of project; Prime contractor company; Construction warranty point of contact, phone and email address; Enter extended warranty items such as roofs, windows etc.; Extended warranty start date and end date; Extended warranty point of contact, phone and email address. The Warranty tab includes Columns A thru N.

5 Equipment Category List: Description

Electrical All electrical, to include distribution.

HVAC All HVAC components.

Utilities Water/waste-water distribution; fire protection; plumbing; natural gas distribution;

irrigation; etc.

Mechanical All others (non-HVAC).

Roads Any horizontal features (e.g. sidewalks, parking lots, etc.)

Vehicle Maintenance Grounds Playgrounds, water features, trees under warranty, etc.

Structural All physical structural features.

Force Protection

Features funded via Force Protection vs. SRM (e.g. pop-up barriers, surveillance, Installation entry points, Entry Control Point components, Access Control Point components, etc.)

Installed Building Equipment Template

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STANDING OPERATING Directorate of Public Works PROCEDURE III Corps and Fort Hood, TX NO. MNT Fort Hood, TX 76544-5028

- 1 -

TAB C

PROCEDURE FOR INSTALLATION OF ELECTRONIC LOCKS

UTILIZING PLASTIC CARD KEYS

23 JUL 2015

PURPOSE: To outline the procedure to perform all installation of locking devices or duplicating, fabrication and issue of associated keys. The SOP applies for all types of Plastic card key locking systems used on Fort Hood Real Property facilities.

OBJECTIVE: To provide a simplified procedure to facilitate Plastic card key and electronic lock control at Fort Hood.

1. RESPONSIBILITIES:

a. Existing Facilities.

(1) Contractors, DPW personnel, and Corps of Engineers personnel will provide electronic locking devices SAFLOK model number 6000, or Stanley/Best series BASIS G, including Handheld Lock Programmer/Interrogator/Lab Top/Diagnostics Unit utilized by the system to operate exterior locks for all doors. Project lead will provide one (1) insertion encoder and all necessary software, approved by IASO. A two (2) year warranty will be provided on the system and all components and locksets, which will be of grade 1 quality approved by DPW, PPD that match the locking system and hardware in existing facilities.

(2) For contract orders, metal override keys will be supplied on all the locking systems for a facility. For marking the override keys, facility codes are to be obtained from Lock shop area by the COR in a written (email) request. 3 metal override keys per room – 2 facility manager keys and 1 DPW board key – are to be provided, unless otherwise designated.

(3) On existing facilities the contractor will provide blank key cards as follows:

a.) 100 locks or more - provide 2,000 blank key cards b.) 25 to 99 locks - provide 500 blank key cards c.) less than 25 locks - proved 100 blank key cards

(4) On existing facilities with SAFLOK - key cards have smart chip On existing facilities with BASIS G - key cards have magnetic strip

(5) Preventive maintenance will be performed by DPW Real Property as necessary.

(6). The project COR will be responsible for turning in all card keys/override keys, key

NO. MNT Fort Hood, TX 76544-5028

- 2 -

TAB C

Schedule, bitting codes with room number/location next to the bitting code, and 500 unused bitting codes to DPW Real Property before final payment is made to the contractor. Real

Property will forward blank card keys over to Housing project manager to be issued to the Barracks managers. Bitting codes obtained from the manufacturer will be sent via Registered

Mail for control/tracking purposes.

(7). Key designation shall be legible by eye, per paragraph 2, below.

b. New Facilities.

(1). Contractors, DPW personnel, and Corps of Engineers personnel will provide electronic locking devices by Stanley/Best, series BASIS G, in addition, provide handheld Lab Top/Diagnostics Unit to operate exterior locks for all doors. Project lead will ensure 10% extra locksets are provide as spares, and one (1) encoding station and all necessary software/licenses are approved by IASO. A Stanley/Best representative shall install the system, program all locksets, and make and label all keys so that this is a turnkey project. In addition, the representative shall provide two (2) separate 4-hour classes of training (to include training manuals) for all users to operate card encoding stations.

(2) A preconstruction meeting of contractors, DPW, Corps of Engineers and DPW Lock Shop personnel shall determine how locks shall be keyed or programed in sets or subsets as scheduled. Locks shall be furnished with the manufacturers’ standard construction key system. Patented cores will not be used for any locks.

(3). For new facilities the contractor shall provide a complete master keyed locking system with metal override keys.

This is the start of the file's text. The full file is on GovTribe.

File details come from the government source that posted it.