B01 Attachment 3 Appendices to PWS Updated.pdf

Appendix I

Electronic Invoicing Instructions for the USACE Finance Center

In lieu of submitting a hardcopy invoice to the USACE Finance Center (UFC) in Millington, TN via the United States Postal Service per the contract instructions in Block 18a, you may submit an electronic version via email per the instructions below:

1. Save or scan the invoice so that it is an electronic (pdf) file.

2. Circle the amount to be paid. See Attached Example.

3. File name of the INVOICE must be the obligation number. (ex: W911WN-00-X-0000).

4. Attach the Invoice (see # 3) to an email. Make sure the file name is the obligation number.

5. The subject line of the email should contain only the OBLIGATION number (same as the INVOICE file name)

6. Email the PDF file to: CEFC-H4 Invoices@usace.army.mil and CC your contracting POC as well as the USACE project POC to whom the goods or services were delivered to confirm receipt.

7. You can only submit 1 invoice per email to the UFC. If you need to submit 3 invoices then you must send 3 separate emails.

8. See below for a sample email submission to the UFC.

9. This process does not apply to ENG93 payments; i.e. Progress payments for construction and Architect/Engineer contracts.

Attachment 3: APPENDICES TO THE PERFORMANCE WORK STATEMENT

Items to Note:

1. Circle the dollar amount to be paid on the invoice

2. If you are sending multiple invoices to the Finance Center, each invoice must be sent down in a separate email. Only 1 invoice per email.

3. The attached invoice’s file name must be the obligation number.

4. The subject of the email to the UFC must also be the obligation number.

5. Email is sent to CEFC-H4 Invoices@usace.army.mil AND

6. CC the USACE contracting POC and the USACE Project POC to whom the goods or services were provided.

7. This new process does not apply to ENG93 payments; i.e. Progress payments for construction and Architect/Engineer contracts.

Appendix II

(Put on Company Letterhead)

QUALITY CONTROL PLAN

W911WN-21-D-X3XXX

Building and Grounds Maintenance Service Tionesta Lake

Tionesta, Pennsylvania

Brief statement describing your company’s management philosophy relative to its commitment to quality.

1. Describe inspection process for each section of the contract.

2. List names of inspectors.

3. Describe process to identify deficiencies in quality of services performed before the level of performance is unacceptable.

4. Describe process for retaining records of inspections and corrective actions taken.

5. Accident Prevention:

a. Policy Statement for accident prevention signed by the Contractor (program and enforcement)

b. Emergency phone numbers

c. Equipment inspections

d. Safety training

e. Personal protective equipment required

Signature of contractor Date: _______________

Approved by: Date: ________________

COR

1. SIGNATURE SHEET.

This Accident Prevention Plan was

Prepared By:

Name Title of corporate safety staff person

Approved By:

Name President

2. BACKGROUND INFORMATION

a. Contractor: Name Address City, State Zip

b. Contract Number W911WN-19-D-3###

c. Project Name: Mahoning Creek Lake

d. Project Description: Building and Grounds Maintenance Service

e. Name of Company’s recent accident history is included as Attachment #__ to this Accident Prevention Plan. Information included includes EMR, OSHA 200 Forms and corporate safety trend analyses.

f. The Major definable features of work are: ______________________________. An Activity Hazard Analysis (AHA) will be prepared for each Major Definable Feature of Work. AHAs will be prepared in accordance with the format shown on page 4 of EM 385-1-1 and will be presented

Appendix III

ACCIDENT PREVENTION PLAN

Building and Grounds Maintenance Services Mahoning Creek Lake

Contract Number Contractor Name and discussed at the Preparatory Phase Inspection for the applicable feature of work.

3. STATEMENT OF SAFETY AND HEALTH POLICY

Enter statement which describes the company‘s commitment to safety.

4. RESPONSIBILITIES AND LINES OF AUTHORITIES

a. Name - Describe responsibility and accountability of personnel responsible for safety at corporate level.

b. Name - Describe responsibility and accountability of personnel responsible for safety at project level.

c. Lines of authority - Describe lines of authority (as related to safety) for this project.

5. SUBCONTRACTORS AND SUPPLIERS.

a. The following subcontractors will be working on this project:

1. List

b. The CQC System Manger (if someone else, identify) will be responsible for controlling and coordinating subcontractors and suppliers.

c. All subcontractors and suppliers performing work on site will be expected to conform to the requirements of this Accident Prevention Plan and to the requirements of EM 385-1-1.

6. TRAINING.

a. Each employee will receive a safety indoctrination consisting of a thorough review of applicable AHA’s.

b. The following is a list of mandatory training and certifications which are applicable to this project:

1. Vehicle Operator

2. Personal Protective Equipment)

3. Other

c. The following identifies requirements for periodic retraining or recertification relating to item b above.

1. List

d. The following individuals shall be trained in the contents of the Emergency Response Plan discussed in Section 12 of this Accident Prevention Plan:

e. Weekly toolbox safety meeting will be conducted at TIME every ENTER DAY OF WEEK.

Each on site worker will be required to attend. Attendance will be documented. Name will be responsible for conducting these meetings.

7. SAFETY AND HEALTH INSPECTIONS.

a. Name will conduct site safety inspections on a daily basis. Any noted deficiencies will be identified on that day’s CQC Report. Deficiencies will be tracked using the table included as Attachment # __ to this Accident Prevention Plan.

b. The following external inspections/certifications are required for this project:

List or enter “None Required”.

8. SAFETY AND HEALTH EXPECTATIONS, INCENTIVE PROGRAMS, AND

COMPLIANCE

a. Provide a statement or statements describing the company's written safety program goals, objectives, and accident experience goals for this contract.

b. Provide a brief description of the company's safety incentive programs (if any). If none, so state.

c. Provide a discussion of the company’s policies and procedures regarding noncompliance with safety requirements (to include disciplinary actions for violation of safety requirements).

d. Provide written company procedures for holding managers and supervisors accountable for safety.

9. ACCIDENT REPORTING

a. Name will submit Monthly Manhour Exposure Reports to the Contracting Officer no later than the 5th work day of each month. The report encompasses on-site work including all hourly and salaried employees. The report will include all subcontractors working on this project.

b. Name will complete the report and submit it to the Contracting Officer within five (5) workdays.

c. Name will immediately notify the Contracting Officer and District Safety Officer of any incidents involving a fatality or permanent total disability, accidents in which three or more persons are hospitalized, accidents that result in property damage in excess of $100,000 or any accident regardless of the consequences, if it is suspected that it will result in unfavorable criticism of the Corps of Engineers..

10. MEDICAL SUPPORT

a. A list of emergency telephone numbers and a map of directions to the nearest hospital(s) is included in the Emergency Response Plan section of this Accident Prevention Plan.

b. First aid kits will be maintained on site as required in Section 3 of EM 385-1-1.

c. At least two employees on each shift will be qualified to administer first aid and CPR.

Individuals who are required to work alone in remote areas shall be trained in first aid. The following employees are certified in First Aid and CPR and a copy of their current certificates are included as Attachment # __ to this Accident Prevention Plan:

11. PERSONAL PROTECTIVE EQUIPMENT.

a. Outline procedures (who, when, how) for conducting hazard assessments and written certifications for use of personal protective equipment.

12. PLANS (PROGRAMS, PROCEDURES) REQUIRED BY THE SAFETY MANUAL (as applicable)

a. Hazard Communication (HAZCOM) Program (01.B.04)

Included as Attachment # __ to this Accident Prevention Plan is a written hazard communication program addressing as a minimum, the following: training (to include potential safety and health effects from exposure), labeling, current inventory of hazardous chemicals on site, and the location and use of Material Safety Data Sheets (MSDSs).

b. Emergency Response Plans (01.E.01, 01.E.05, 06.A.02, 19.A.04, 09.K.01 and 09.K.02)

An Emergency Response Plan is included as Attachment # __ to this Accident Prevention Plan. This Emergency Response Plan includes:

An Emergency Response Plan to ensure employee safety in case of fire or other emergency.

Emergency telephone numbers and reporting instructions for ambulance, physician, hospital, fire, and police. Also included is a map of directions to the nearest hospital(s). This list and map shall be conspicuously posted at the work site.

c. Respiratory Protection Plan (05.E.01)

Name of Company‘s Respiratory Protection Plan is included as Attachment # __ to this Accident Prevention Plan.

d. Health Hazard Control Program (06.A.02)

Activity Hazard Analyses (AHA’s) shall consider all substances, agents and environments that present a hazard and will recommend hazard control measures. Engineering and administrative controls shall be used to control hazards. In cases where engineering or administrative controls are not feasible, PPE may be used. The AHA shall serve as certification that a hazard assessment has been conducted.

e. Plan for Prevention of Alcohol and Drug Abuse (Defense Federal Acquisition Regulation Supplement Subpart 252.223-7004, Drug-Free Work Force)

Name of Company‘s plan for prevention of Alcohol and Drug Abuse is included as Attachment # __ to the Accident Prevention Plan. This plan meets the minimum requirements of

DFAR 252.223-7004.

13. Detailed site specific hazards and controls will be provided in the activity hazard analysis (AHA) for each phase of the operation (each Major Definable Feature of Work as defined by the Contractor Quality Control Plan). The AHA’s will provide information on how the requirements of major sections of EM 385-1-1 will be met. Particular attention shall be paid to excavations, scaffolding, medical and first aid requirements, sanitation, personal protective equipment, fire prevention, machinery and mechanized equipment, electrical safety, public safety requirements, and chemical, physical agent, and biological occupational exposure prevention requirements.

AHA’s will be prepared utilizing the format shown on page 4 of EM 385-1-1.

Attachments Attachment # - Accident History Attachment # - Safety Deficiency Tracking Table Attachment # - Emergency Response Plan Attachment # - First Aid and CPR certificates Attachment # - Hazard Communication (HAZCOM) Program Attachment # - Emergency Response Plan Attachment # - Plan for Prevention of Alcohol and Drug Abuse

Contract Number: W911WN Contract Name:

Prime Contractor: Roster of employees on predecessor contract provided to current KTR?

Month/Year: Contractor must maintain employee records per FAR 52.222-17.

Number of employees on contract: Number of new employees placed on contract in the last month:

Date of Monthly Safety Meeting:

Date of next Monthly Safety Meeting: COR is to be invited 7 days in advance Total Hours worked for the Month:

Contractor is to complete Sections a through m.

a b c d e f g h i j k l m n COR completes Section n.

Notification Actions Contractor Employee Name: Contract of hire Select

1 AT/OPSEC 1: All contractor employees, to include subcontractor employees, requiring access to Army installations, facilities, 2 controlled access areas, or require network access, shall complete AT Level I awareness training within 30 calendar days after 3 contract start date or effective date of incorporation of this requirement into the contract, whichever is applicable. Upon request, 4 the contractor shall submit submit certificate of completion for each affected contractor employee and subcontractor employee, 5 to the COR or to the Contracting Officer (if a COR is not assigned), within 5 calendar days after completion of training by all 6 employees and subcontractor personnel AT Level I awareness training is available at the following website:

7 https://jko.jten.mil/courses/atl1/launch.html; or it can be provided by the Contracting Officer Representative (COR) in presentation 8 form which will be documented via memorandum.

10 AT/OPSEC 2. The contractor and all associated subcontractors' employees shall comply with applicable installation, facility, and area 11 commander installation and facility access and local security policies and procedures (provided by the Government Representative).

12 The contractor shall also provide all information required for background checks to meet installation access requirements to be 13 accomplished by the installation the USACE Security Office. The contractor workforce must comply with all personal identity 14 verification requirements as directed by DoD, HQDA, and/or local policy. In addition to the changes otherwise authorized by the 15 Changes clause of this contract, should the Force Protection Condition (FPCON) at any individual facility or installation change, the 16 Government may require changes in contractor security matters or processes. The contractor must submit the full name, Social 17 Security Number, Date of Birth, and Place of Birth for all associated contractor or subcontractor employees to the USACE Security 18 Stephen Davidson, 412-395-7504, stephen.davidson@usace.army.mil. The District retains the right to deny any contractor and 19 subcontractor employee from working on one of its contracts based on final background investigation results.

21 AT/OPSEC 4. The contractor and all associated sub-contractors shall receive a brief/training (iWatch provided by the COR) on the local 22 suspicious activity reporting program. This locally developed training will be used to inform employees of the types of behavior to 23 watch for and instruct employees to report suspicious activity to the project manager, security representative, or law enforcement entity.

24 This training shall be completed within 30 calendar days of contract award and within 30 calendar days of new employees commencing 25 performance with the results reported to the COR NLT 5 calendar days after the completion of the training.

Subcontractors: AT/OPSEC 13. All contract employees, including subcontractor employees who are not in possession of the appropriate security clearance or access privileges, will be escorted in areas where they may be exposed to classified and/or sensitive materials and/or sensitive or

Solid Waste Subcontractor Name On Contract? restricted areas.

n/a

AT/OPSEC 15. The Contractor must pre-screen Candidates using the E-verify Program (http://www.uscis.gov/e-verify) website to meet NOTE: Only Solid Waste Subcontractor employees are exempt from the AT/OPSEC requirements the established employment eligibility requirements. The vendor must ensure that the candidate has two valid forms of Government issued identification prior to enrollment to ensure the correct information is entered into the E-verify system. An initial list of verified/eligible Candidates must be provided to the COR no later than 3 business days after the initial contract award.

Subcontractor Name

Subcontractor Name

Subcontractor Name Contact Name

Date Completed Y or N Y or N

Date of initial hire on predecesso r Date AT/O

PSE

C 1

AT/O

PSE

C 2

AT/O

PSE

C 4

AT/O

PSE

C 15

Fir st

Aid Combatt ing H uman Traffic kin g

U

SA

CE

C le ar ed

Cu rr en tly o n

Co nt ra ct

Sa fe ty M ee tin g at te nd an ce

AT/O

PSE

C 13

Contact Name Title Phone E-mail

Contact Name Title Phone E-mail

Contact Name Title Phone E-mail

Title Phone E-mail

Appendix IV Contract Overview Workbook

For more information on Activity Hazard Analyses, see USACE Safety Manual:

https://www.publications.usace.army.mil/Portals/76/Publications/EngineerManuals/EM_385-1-1.pdf To be completed by COR

Activity Analysis on File

Appendix IV

Required Submittals To be completed by COR

On File Notes 1 Quality Control Plan 2 Contractor Quality Control Inspector.

List of Quality Control Inspector(s) and contact information. See tab.

3 Contractor Representatives.

List of names of Contractor’s authorized representative(s) and contact information. See tab.

4 Accident Prevention Plan (APP).

A suggested outline for the Contractor’s Accident Prevention Plan is in Attachment 2. See Section C-1.9.b for APP requirements.

a. Accident History

b. Safety Deficiency Tracking Table

c. Emergency Response Plan

d. First Aid & CPR Certificates

e. Hazardous Material Communication Plan

f. Drug and Alcohol Abuse Prevention Program

5 Emergency Contacts.

A prioritized list, including phone numbers, of those persons (normally Contractor authorized representatives) to call in case of emergencies. See tab.

6 Certificates of Insurance Does insurance meet requirements in PWS C-1.32?:

Workers's Compensation & Employer's Liability: $100,000 (PA) and as legally required by the state (OH and WV) Comprehensive General Liabilty: Bodily Injury $500,000 per occurrence & Property Damage $100,000 Automotive Liabilty: Bodily Injury $200,000 per person/$500,000 per occurrence & Property Damage $20,000

7 Security Requirements See tab.

8 A letter of compliance and a signed release from the dump site property owner.

9 A letter from either the sewage plant accepting sewage or the state environmental agency approval of an alternate dump site. BASE OY1 OY2 OY3 OY4

10 Annual Pest Control Plan by 12/1 Date Submitted:

For more information on Material Safety Data Sheets/Safety Data Sheets, see USACE Safety Manual:

https://www.publications.usace.army.mil/Portals/76/Publications/EngineerManuals/EM_385-1-1.pdf To be completed by COR

Product/Material On file

Contractor Representatives.

List of names of Contractor’s authorized representative(s) and contact information.

To be completed by contractor.

Name Title Office Cell E-mail

Emergency Contacts.

A prioritized list, including phone numbers, of those persons (normally Contractor authorized representatives) to call in case of emergencies.

To be completed by contractor.

Name Title Office Cell E-mail

PWS C-1.9 Safety and Security Requirements requires the Contractor to comply with the Occupational Health and Safety Act and USACE Manual EM 385-1-1.

Per 01.A.17 of EM 385-1-1, The Contractor Site Safety and Health Officer (SSHO) is:

Contractor Quality Control Inspector.

List of Quality Control Inspector(s) and contact information.

To be completed by contractor.

Name Title Office Cell E-mail

Executive Order No. 11246, Equal Employment Opportunity, dated 24 September 1965, as amended; Section 503 of the Rehabilitation Act of 1973;

and Section 402 of the Vietnam Era Veterans Readjustment Assistance Act of 1974

Your contract, (see FAR Clause 52.212-5) also requires you to display in conspicuous places, available to employees, applicants for employment, and representatives of each labor union with which you have a collective bargaining agreement, a poster setting forth the provisions of the "Equal Opportunity", the "Equal Opportunity for Workers with Disabilities," and the Equal Opportuniy for Veterans clauses. Your service contract also requires you to display (see FAR Clause 52.222-41) the Employees Rights on Government Contracts poster, WHD1313

Business Union USACE Project - fill in where these are located.

Equal Opportunity Equal Opportunity for Workers with Disabilities Equal Opportunity for Veterans Employee Rights on Government Contracts poster WHD1313

Displayed Poster

ACTIVITY HAZARD ANALYSIS (AHA)

Activity: Date:

Project Location:

Prepared By:

Reviewed By: s e e

Notes:

y

Add Identified Hazards

Un1Aui■11'1ii.

JOB STEPS

(Recoanized/Anticipated)

X

X

X

Add Items

EQUIPMENT TRAINING

X

X

X

Involved Personnel:

PPE Required:

Version 1.0 December 2020

Overall Risk Assessment Code (RAC)

(Use highest code)

Risk Assessment Code Matrix

E = Extremely High Risk Probability

H = High Risk

M = Moderate Risk Frequent Likely Occasional Seldom

L= Low Risk

Catastrophic E E H H

Critical E H H M

Marginal H M M L

Negligible M L L L

CONTROLS (ACTIONS TO ELIMINATE OR MINIMIZE HAZARDS)

INSPECTION

CJ

Unlikely

M

L

L

L

RAC

Appendix V

ACTIVITY HAZARD ANALYSIS (AHA)

Acceptance Authority (digital signature): Date:

Approval authority based on the overall RAC:

Version 1.0 December 2020

Project:

NAME (Last, First Middle) DOB (mm/dd/yyyy) SSN (no dashes)

POC/COR:

Joe Bali Chief of Security 412-395-7162 joseph.m.bali@usace.army.mil

APPENDIX VI

AT OPSEC Information Sheet

Appendix VII

(For I REPORT NO. I EROC I UNITED ST ATES ARMY CORPS OF ENGINEERS I REQUIREMENT Safety CODE

ACCIDENT INVESTIGATION REPORT CONTROL SYMBOL:

Staff only) /For Use of this Form See Helo Menu and USACE Sunn/ to AR 385-40! CEEC-S-8(R2)

1. ACCIDENT CLASSIFICATION

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

GOVERNMENT

0 CIVILIAN □ MILITARY □ □

FIRE

□ OTHER □ □ INVOLVED

0 CONTRACTOR □ 0 FIRE

INVOLVED □ OTHER □ □

□ PUBLIC 0 FATAL 0 OTHER

2. PERSONAL DATA

a. Name (Last, First, Ml) b. AGE I

c. SEX d. SOCIAL SECURITY NUMBER l e.GRADE

□ MALE 0 FEMALE

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

□ ARMY ACTIVE □ ARMY RESERVE □ VOLUNTEER

0 ON DUTY □ TDY □ PERMANENT □ FOREIGN NATIONAL □ SEASONAL

□ TEMPORARY □ STUDENT

0 OFF DUTY □ OTHER (Specify)

3. GENERAL INFORMATION

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

(month/day/year) (Military time)

(1) PRIME:

hrs

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

ACTIVITY

CONSTRUCTION SERVICE

□ SUPERFUND □ DERP (2) SUBCONTRACTOR:

□ CIVIL WORKS 0 MILITARY □ A/E □ DREDGE

□ IRP □ OTHER (Specify)

□ OTHER (Specify) □ OTHER (Specify)

4. CONSTRUCTION ACTIVITIES ONLY /Fill in line and corresoondino code number in box from list - see helo menu/

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

I# I I#

5. INJURY/ILLNESS INFORMATION (Include name on line and corresoondino code number in box for items e f & o - see helo menu

a. SEVERITY OF ILLNESS/INJURY

e. BODY PART AFFECTED

PRIMARY

SECONDARY

f. NATURE OF ILLNESS/INJURY

6.

a. ACTIVITY AT TIME OF ACCIDENT

7.

b. ESTIMATED c. ESTIMATED

(CODE) DAYS LOST DAYS HOSPIT-

I# I

ALIZED

(CODE) g. TYPE AND SOURCE OF INJURY/ILLNESS

I# I

(CODE)

I# I TYPE

(CODE)

I# I

SOURCE

PUBLIC FATALITY /Fill in line and corresoondence code number in box - see helo menu/

I#

!CODE!

I

b. PERSONAL FLOATATION DEVICE USED?

0 YES O NO

MOTOR VEHICLE ACCIDENT

d. ESTIMATED DAYS

RESTRICTED DUTY

(CODE)

I#

(CODE)

I#

□ N/A

I

I

I

a. TYPE OF VEHICLE b. TYPE OF COLLISION c. SEAT BEL TS USED NOT USED NOT AVAILABLE

[I] PICKUP/VAN [I] AUTOMOBILE □ SIDE SWIPE □ HEAD ON 0 REAR END (1) FRONT SEAT

[I] TRUCK [I] OTHER (Specify) □ BROADSIDE □ ROLL OVER □ BACKING

□ OTHER (Specify) (2) REAR SEAT

8. PROPERTY /MATERIAL INVOLVED

a. NAME OF ITEM b. OWNERSHIP c. $ AMOUNT OF DAMAGE

(1)

(2)

(3)

9. VESSEL/FLOATING PLANT ACCIDENT /Fill in line and corresnondence code number in box from list - see heln menu/

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

I# I I#

10. ACCIDENT DESCRIPTION /Use additional oaoer if necessaNI

I

ENG FORM 3394, MAR 99 Version 2 EDITION OF SEP 89 IS OBSOLETE. Page 1 of 4 pages (Proponent: CESO )

Appendix VIII

CONTRACT DISCREPANCY REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER FOR THIS DISCREPANCY

3. TO (Contractor and Manager's Name) 4. FROM (Name of QAE)

5. DATES (YYYYMMDD)

a. PREPARED

I

b. RETURNED BY CONTRACTOR

I

c. ACTION COMPLETE

6. DISCREPANCY OR PROBLEM (Describe in detail. Include reference to PWS Directive; attach continuation sheet if necessary.)

7. SIGNATURE OF CONTRACTING OFFICER

Ba. TO (Contracting Officer) b. FROM (Contractor)

9. CONTRACTOR RESPONSE AS TO CAUSE, CORRECTIVE ACTION AND ACTIONS TO PREVENT RECURRENCE. (Cite applicable Q. C.

program procedures or new Q.C. procedures. Attach continuation sheet(s) if necessary.)

10. SIGNATURE OF CONTRACTOR REPRESENTATIVE b. DATE (YYYYMMDD)

11. GOVERNMENT EVALUATION (Acceptance, partial acceptance, reflection. Attach continuation sheet(s) if necessary)

12. GOVERNMENT ACTIONS (Reduced payment, cure notice, show cause, other)

13. CLOSE OUT

NAME TITLE SIGNATURE DATE (YYYYMMDD)

(1) (2) (3) (4)

a. CONTRACTOR

NOTIFIED

b. QAE

c. ACO

DD FORM 2772, SEP 1998 (EG) REPLACES MT FORM 352-R, WHICH IS OBSOLETE. Designed using Perform Pro, WHS/DIOR, Sep 98

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APPENDIX IX

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Appendix IX, Pesticide Application Record CELRP Form 1031