W91236-16-R-0004_Attachment_J-05_Sample_Forms.pdf

1 February 2016

ATTACHMENT 5

Sample Forms

The following forms are provided to help identify submittals and work required to support the preparation of those submittals required by the contract. The omission of forms from this attachment shall not relieve the contractor from submitting all forms required to support the contract. These forms are examples and can be adjusted to meet the contract requirements and may be submitted electronically. Referenced ENG electronic forms in pdf format are available for downloading at http://www.publications.usace.army.mil/.

Number Description

1. Visitor and Inspection Log

2. Gauge Readings, Dismal Swamp Canal

3. Gauge Readings, North Landing Bridge

4. Wicket Report, Dismal Swamp Canal

5. Monthly Fire Hydrant and Ring Buoy Checklist

6. Fire Extinguisher Report

7. Bridge and Lock Accident Report

8. Contractor Safety Meetings

9. Monthly Record of Work-Related Injuries and

Illnesses and Exposure Report (2 Pages)

10. Lake Drummond Visitor Log

MONTHLY FIRE HYDRANT AND RING BUOY CHECK

Date Inspected _________________ By: ________________________

Great Bridge Lock Hydrant Hose Twice Annual Flow and Reservation Testing

Hydrant No. 1

Hydrant No. 2

Hydrant No. 3 N/A

Hydrant No. 4 N/A

Hydrant No. 5 N/A

Hydrant No. 6 N/A

Hydrant No. 7 N/A

Location Ring Buoy Line Remarks

Per EM 385-1-1 Per EM 385-1-1

GBL #1 East Side

GBL #2 East Side

GBL #3 East Side

GBL #4 West Side

GBL #5 West Side

GBL #6 West Side

DCL #1 East Side

DCL #2 West Side

DCL #3 West Side

SML #1 East Side

SML #2 West Side

SML #3 West Side

LDR #1 SW By House

LDR #2 South Side

LDR #3 South Side

LDR #4 North Side

LDR #5 By Trolley Sign

LDR #6 Main Pier

LDR #7 Main Pier

FIRE EXTINGUISHER REPORT

ALL FACILITIES

Date Inspected __________________________ By: ___________________________

LOCATION NO. TYPE WEIGHT WEIGHED REFILLED HYDROSTAT

TESTED