Technical_Exhibit_H_-__Hazardous_Material_Request_Form.pdf

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Page 1 of 2FORT HOOD FORM 200-19, APRIL 2013

HAZARDOUS MATERIAL AUTHORIZATION REQUEST

(For use of this form, see Fort Hood Regulation 200-1. The proponent of this form is DPW-ENV.)

SECTION l - REQUESTOR USE

1. NOMENCLATURE/TRADE NAME:

2. STOCK NUMBER (NSN, LSN, NCN, etc.): 3. PART NUMBER:

4. QUANTITY REQUESTED: 5. MONTHLY REQUIREMENT:

(estimate monthly usage or a one-time purchase)

6. UNIT OF ISSUE (each, gallon, can, etc.): 7. UNIT OF MEASURE (must be weight or volume):

8. UNIT OF USE 9. TYPE OF CONTAINER

(can, bottle, tube, plastic, metal, glass, aerosol, etc):(must be weight or volume, e.g., pounds, gallons, etc):

10. SUGGESTED SOURCE OF SUPPLY: 11. MANUFACTURE INFORMATION (complete if different than supplier):

a. COMPANY NAME: a. COMPANY NAME:

b. ADDRESS: b. ADDRESS:

c. TELEPHONE/FAX: c. TELEPHONE/FAX:

SECTION ll - WORK PROCESS

12. DESCRIBE THE WORK OR PROCESS IN WHICH THE MATERIAL WILL BE USED:

REPLACES FHT FORM 210-X19 (NOV 2006) WHICH IS OBSOLETE

13. LIST BUILDING OR AREA WHERE

MATERIAL WILL BE USED:

14. COST CENTER/DODAAC

AUTHORIZED TO USE THIS

MATERIAL:

15. PROCESS:

(check one):

NEW

CURRENT

16. TECHNICAL REFERENCE REQUIRING

SPECIFIC USE:

17. REQUESTER NAME AND

TELEPHONE NUMBER:

18. TECHNICAL POC AND

TELEPHONE NUMBER:

19. ORGANIZATION: 20. DATE REQUESTED:

SECTION lll - DPW ENVIRONMENTAL USE ONLY

21. HMMS

CONTROL

NUMBER:

22. SDS

SERIAL

NUMBER:

23. REMARKS (alternate material available?):

SECTION lV - ROUTING

PROGRAM REQUIRED DATE

REC'D

DATE ROUTED

TO

ROUTED

TO

APPROVAL

PROGRAM REMARKS

fedcba g

AIR

WATER

IH

PEST MGT

SAFETY

HAZMAT TEAM

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

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Page 2 of 2FORT HOOD FORM 200-19, APRIL 2013

INSTRUCTIONS

NOTE: Contractors are strongly encouraged to purchase hazardous materials at the Base Supply Center (BSC). On those rare occasions that short-term contractors use non-government furnished HAZMAT, they must use the Hazardous Material Authorization Request (Fort Hood Form 200-

19) to notify Fort Hood of HAZMAT usage and submit a Safety Data Sheet (SDS) for all materials. In these cases, SDS are used for tracking purposes and does not imply endorsement of any product by Fort Hood.

BLOCK DESCRIPTION INFORMATION REQUIRED

1 Nomenclature If not a government source NSN, enter a descriptive noun for the item you are purchasing, for example, SAE 30 oil, yellow spray paint, lead acid battery, etc.

2 NSN Enter NSN if item is from a government source of supply. If it is, skip to block 4.

3 Part Number Enter as appropriate, using the most specific information available.

4 Quantity Requested Make every effort to enter only how much you will need to sustain your process for 7-10 days. The only exceptions should be for those items where the smallest size procurable (UI) lasts longer in your process.

5 Monthly Requirement How much do you use per MONTH ? Enter a quantity and select the appropriate unit: FL OZ, Gallon, Gram, KG, LB, Liter, OZ, Pint, Quart, Troy OZ. An example would be using 5 qts to change oil in car.

6 Unit of Issue Unit of issue. Examples are EA, GAL, PT, OZ.

7 Unit of Measure Enter the quantity of the size and selet the appropriate measuring unit: Fluid OZ, gallon, gram, KG, LB, liter, OZ, pint, quart, Troy OZ.

8 Unit of Use If decanting, what unit will you issue/use?

9 Type Container Select the appropriate container description: bottle, box, can, cartridge, drum. If not listed, fill in the container type next to "other"

10 Suggested Source of Supply

Name of brand name or source of supply.

11 Manufacturer Information Enter the manufacturer information. This is very important to determine the correct SDS and chemical formulation.

You may also find this on the container.

12 Work or Process Description

A full description of the work activity and process in which the HAZMAT is used. More detail in this block enhances your chances of approval. For example, application method, such as hand, brush, spray gun/nozzle, or vapor condensation; type of industrial equipment, such as open tanks, closed tanks, vapor degreaser, spray booth mechanical equipment, or other system.

If the HAZMAT is transferred to industrial equipment, list the equipment number and specify whether the transfer will occur by pouring, pumping, or another method.

Explain what will happen to the HAZMAT in the process, such as heated in an oven, soldering iron, torch, or heated to facilitate parts washing, or even used to facilitate removal of other HAZMAT by wire brush, sander, or grinder.

The important thing is to be as specific as possible, which can shave days off the approval process: use additional paper if necessary and remember reviewers don't do your work; explain it so they can understand it.

13 Where is the product used?

Provide a building number or location.

14 DODAAC/Cost Center Enter your DODAAC for your unit/activity.

15 Process Circle the appropriate answer.

16 Technical Reference Where is the authorization to use this HAZMAT, for example, TM, LO, etc?

17 Requestor Name Your name.

18 Technical POC Who can answer questions about the process using the HAZMAT?

19 Organization Where do you come from?

20 Date Requested Date hazardous material authorization request (Fort Hood Form 200-19) complete.