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Text version

Figure 1-8

Site Location & O&M Areas

RMFLW-001RMFLW-001

COLOR INDEX

WATER-BEARING ZONES

PERCHED

DEEP CLAY SAND

DEEP

INTERMEDIATE / DEEP

INTERMEDIATE

SHALLOW

MNGR

PROJECTCHKDDRAWNCHKDINITIATOR

DATE

STARTING

AREA JOB NO. DRAWING NO. REV

A

12345678910111213

B

C

D

E

F

G s a m m c c a w le y lt m w p .d g n

:1

:4

A M

.0 f t in s e i_ t e x t s u b o n ly .t b l

P D

F w it h

L e v e ls .p lt

141516

H

I

J

K

L

M

X

YWRGW-054YWRGW-054

TNTGW-053DTNTGW-053D

RWRGW-049RWRGW-049

P13MW-003

P13MW-005

P13GRW-402

P13GRW-403

P13MW-003

P13MW-005

P13GRW-402

P13GRW-403

YWRGW-051D

RWRGW-053

RWRGW-055

TNTGW-052

RWRGW-048

RWRGW-051

YWRGW-051D

RWRGW-053

RWRGW-055

TNTGW-052

RWRGW-048

RWRGW-051

YWRGW-050

RWRGW-054

YWRGW-051

RWRGW-052

YWRGW-045

YWRGW-046

YWRGW-047

YWRGW-048

YWRGW-048D

YWRGW-049

YWRGW-049D

YWRGW-050D

RWRGW-050

YWRGW-050

RWRGW-054

YWRGW-051

RWRGW-052

YWRGW-045

YWRGW-046

YWRGW-047

YWRGW-048

YWRGW-048D

YWRGW-049

YWRGW-049D

YWRGW-050D

RWRGW-050

IWSLGW-002IIWSLGW-002I

IWSLGW-001S

IWSLGW-001I

IWSLGW-001S

IWSLGW-001I

TNTGW-054TNTGW-054

TNTGW-055TNTGW-055

N 700,500

N 703,500

N 706,500

E

,6

,0

,6

,0

,6

,0

,6

,0

,6

,0

KC S.DOWNEY

SCALE

1000 FEET 500

N 697,500

N 694,500

500112

CA SAM SAM

MASON COUNTY, WEST VIRGINIA

WEST VIRGINIA ORDNANCE WORKS

12MAY15

500112-LTM15-10

ACTIVE WELLS AT WVOW

FIGURE 2-9

LEGEND:

RWRGW-030

ZONES ARE ABSENT.

AGED BEDROCK OUTCROPS. WATER-BEARING

GENERALIZED AREAS OF PENNSYLVANIAN

POND & POND DESIGNATION

CREEK, RIVER, STREAM

RAILROAD

ROADS

TOPOGRAPHY

EXTRACTION WELL

MONITORING WELL

N 700,500

,6

,0

,6

,0

,6

,0

,6

,0

,6

,0

N 697,500

N 694,500

ACDGW-001

ACDGW-002

BGEGW-006

BGEGW-007

BGEGW-008

BGELW-002

BGELW-007

BGWGW-003

BGWGW-004

BGWLW-008

MCYGW-001

MCYGW-002MCYGW-002D

MZAGW-001

MZAGW-002

NGMW-001NGMW-002

NGMW-003

NPHGW-002NPHGW-002D

NPHGW-034 NPHGW-034D

P03GW-018

P13GW-022

P13GW-022D

P13GW-023I

P13GW-023S

P13GW-048D

P13GW-049

P13OB-004

PASGW-001

PASGW-002

PASGW-004

PASGW-005

PASGW-006

PASGW-007

PASGW-008

PCWGW-001

PCWGW-002

PCWGW-003

PCWGW-004

PCWGW-005

PCWGW-006

PCWGW-007

PCWGW-008

PCWGW-009

PCWGW-010

PPLGW-008

PPLGW-008D

PPLGW-009

PPLGW-009D

PPLGW-010

PPLGW-010D

PPLGW-011

PPLGW-011D

PPLGW-012 PPLGW-012D

PPLGW-013

PPLGW-013D

PPLGW-014

PPLGW-032PPLGW-032D

PPLLF-001

PPLLF-002

PPLLF-003

PPLLF-004

PPLLF-005

PPLLF-006

PPLLF-007

PPLLW-003D

PPWGW-002A

PPWGW-004

PPWGW-005

PPWGW-011

PPWGW-012

PPWGW-013

PWSGW-001

PWSGW-002

PWSGW-003

RWLGW-001D

RWLGW-001S

RWLGW-002D

RWLGW-002I

RWLGW-002S

RWLGW-024

RWLGW-026

RWLLW-004D

RWRDW-001

RWREW-101

RWREW-103

RWREW-105

RWREW-107

RWREW-109

RWRGW-002

RWRGW-003

RWRGW-003D

RWRGW-004

RWRGW-004D

RWRGW-005

RWRGW-029

RWRGW-030

RWRGW-031

RWRGW-033

RWRGW-045 RWRGW-045D

RWRGW-046

RWRGW-047

RWRMW-001

RWRMW-002

RWRPT-001

SAAGW-001D

SAAGW-002

SAAGW-005

SAAGW-042

TNTGW-005

TNTGW-009D

TNTGW-010

TNTGW-010D

TNTGW-011

TNTGW-013

TNTGW-014

TNTGW-015

TNTGW-016

TNTGW-017

TNTGW-019

TNTGW-020

TNTGW-021

TNTGW-037

TNTGW-043

TNTGW-045

TNTGW-048

TNTLW-005D

TNTLW-006

TNTLW-006D

TNTTW-002

TNTTW-002D

TNTTW-004

TNTTW-004D

TNTTW-006

TNTTW-007

TNTTW-009

TNTTW-010

TNTTW-011

TNTTW-012

W07GW-002

W21GW-003

YWLGW-025

YWLGW-025D

YWRGW-002

YWRGW-002D

YWRGW-027

YWRGW-027D

YWRGW-028

YWRGW-041

YWRGW-044

YWRMW-001A

TNTGW-049

TNTGW-050

TNTGW-051

PPWGW-003

TNTGW-047

P17GW-038

P13PT-001

TNTGW-012D

NAAGW-001

NAAGW-001D

RWLGW-001I

YWRDW-001

TNTTW-005

MCYGW-001

ACDGW-001

ACDGW-002

BGEGW-006

BGEGW-007

BGEGW-008

BGELW-002

BGELW-007

BGWGW-003

BGWGW-004

BGWLW-008

MCYGW-001

MCYGW-002MCYGW-002D

MZAGW-001

MZAGW-002

NGMW-001NGMW-002

NGMW-003

NPHGW-002NPHGW-002D

NPHGW-034 NPHGW-034D

P03GW-018

P13GW-022

P13GW-022D

P13GW-023I

P13GW-023S

P13GW-048D

P13GW-049

P13OB-004

PASGW-001

PASGW-002

PASGW-004

PASGW-005

PASGW-006

PASGW-007

PASGW-008

PCWGW-001

PCWGW-002

PCWGW-003

PCWGW-004

PCWGW-005

PCWGW-006

PCWGW-007

PCWGW-008

PCWGW-009

PCWGW-010

PPLGW-008

PPLGW-008D

PPLGW-009

PPLGW-009D

PPLGW-010

PPLGW-010D

PPLGW-011

PPLGW-011D

PPLGW-012 PPLGW-012D

PPLGW-013

PPLGW-013D

PPLGW-014

PPLGW-032PPLGW-032D

PPLLF-001

PPLLF-002

PPLLF-003

PPLLF-004

PPLLF-005

PPLLF-006

PPLLF-007

PPLLW-003D

PPWGW-002A

PPWGW-004

PPWGW-005

PPWGW-011

PPWGW-012

PPWGW-013

PWSGW-001

PWSGW-002

PWSGW-003

RWLGW-001D

RWLGW-001S

RWLGW-002D

RWLGW-002I

RWLGW-002S

RWLGW-024

RWLGW-026

RWLLW-004D

RWRDW-001

RWREW-101

RWREW-103

RWREW-105

RWREW-107

RWREW-109

RWRGW-002

RWRGW-003

RWRGW-003D

RWRGW-004

RWRGW-004D

RWRGW-005

RWRGW-029

RWRGW-030

RWRGW-031

RWRGW-033

RWRGW-045 RWRGW-045D

RWRGW-046

RWRGW-047

RWRMW-001

RWRMW-002

RWRPT-001

SAAGW-001D

SAAGW-002

SAAGW-005

SAAGW-042

TNTGW-005

TNTGW-009D

TNTGW-010

TNTGW-010D

TNTGW-011

TNTGW-013

TNTGW-014

TNTGW-015

TNTGW-016

TNTGW-017

TNTGW-019

TNTGW-020

TNTGW-021

TNTGW-037

TNTGW-043

TNTGW-045

TNTGW-048

TNTLW-005D

TNTLW-006

TNTLW-006D

TNTTW-002

TNTTW-002D

TNTTW-004

TNTTW-004D

TNTTW-006

TNTTW-007

TNTTW-009

TNTTW-010

TNTTW-011

TNTTW-012

W07GW-002

W21GW-003

YWLGW-025

YWLGW-025D

YWRGW-002

YWRGW-002D

YWRGW-027

YWRGW-027D

YWRGW-028

YWRGW-041

YWRGW-044

YWRMW-001A

TNTGW-049

TNTGW-050

TNTGW-051

PPWGW-003

TNTGW-047

P17GW-038

P13PT-001

TNTGW-012D

NAAGW-001

NAAGW-001D

RWLGW-001I

YWRDW-001

TNTTW-005

MCYGW-001

YWREW-502B

YWREW-502A

YWREW-502B

YWREW-502A

YWREW-501BYWREW-501B

YWREW-501AYWREW-501A

YWRPT-001YWRPT-001

P13MW-012P13MW-012

P13MW-011

P13MW-010

P13MW-011

P13MW-010

CB&I Federal Services LLC

RWREW-101

YWRGW-052YWRGW-052

YWRGW-053YWRGW-053

P13MW-004P13MW-004

P13MW-002P13MW-002

TNTGW-059TNTGW-059

TNTGW-060TNTGW-060

P13OB-003P13OB-003

TNTGW-058TNTGW-058

TNTGW-057TNTGW-057

TNTGW-056TNTGW-056

P13MW-009

P13MW-006

P13MW-008

P13MW-009

P13MW-006

P13MW-008

P13MW-007P13MW-007

Figure 9-10

Barricades North and South

Figure 11

Well Inspection Checklist Example

WVOW

Mowing Contract Figure 11

Well Inspection Checklist Example

Figure 12 a-c

Photographs

Flush Mount Well Standpipe with Bollards and Concrete base

Extraction Well with Bollards

Standpipe with Paint Removed Well Standpipe and Bollards with primer

WVOW

Mowing Contract

Figure 12a Photographs

Contract

Figure 12b Photographs

Red Water Reservoir RCRA Caps TNT Washer Flaker House Cap 6

TNT Washer Flaker House Cap 8 Burning Grounds Cap

Contract

Figure 12c Photographs

Main Access Road North of Yellow Water Treatment Building

Main Access Road leading to Red Water Reservoir

Red Water Reservoir Levy (winter) Red Water Reservoir Levy (summer)

Contract

Figure 12c Photographs

Example of a faded warning sign Main Access Road leading to Red Water Reservoir, mow and clear vertically all access roads and paths

Access road from Burning Grounds to Pond 30 Monitoring well prior to string trimming

Figure 13 a-d

Roads & Paths To Be Mowed

Contract

Figure 13a Roads &

Paths to be Mowed

Red Water Reservoir Area

Contract

Figure 13b Roads &

Paths to be

Yellow Water Reservoir Area and OU-11 Sellite Area

Contract

Figure 13c Roads &

Paths to be

Burning Grounds, TNT Manufacturing Area and ESI-8

Contract

Figure 13d Roads &

Paths to be

Wells near Mason County Airport

Figure 14-14a

Drainage Areas @ RWR To Be Mowed

Contract Figure 14 Drainage Areas @

RWR to be

Red Water Reservoir Drainage Ditches, See also Figure 14a

Contract

Figure 14a Drainage Areas @

RWR to be Mowed

Red Water Reservoir Drainage Areas

Underdrain at RWR Cap

RWR Pond

Figure 15-15a

YWR Outfall Ditch

Contract Figure 15

YWR

Outfall Ditch

Yellow Water Reservoir Outfall Ditch, See also Figure 15a

Treatment Building

Contract

Figure 15a

YWR

Outfall Ditch

Yellow Water Reservoir Outfall Ditch

YWR outfall

15 foot clearance on this side of ditch

Access road

GATE

Figure 16

Safety Inspection Checklist

Item Description Yes No N/A

1. Signature sheet

a. Includes the name, signature, and title of the Plan Preparer (Qualmed person, i.e. corporate safety staff person, QC)

b. Includes the name, signature,and tiUe of the Plan Approver {e.g.

owner, company president, regional vice presiden

c. Includes the name{s), signature(s), and title{s) for Plan Concurrence (provide concurrence of other applicable corporate and project personnel(contractor))

2.Background information

a. Includes the Contractor Name.

b. Includes the Contract Number.

c. Includes the Project Name.

d. Includes the Brief Project Description.

e. Includes the Location of the Project {map).

f. Includes a means to evaluate the work being done (see AHA requirements in 01.A.13) and associated hazards involved.

g. Addresses the identified hazards involved and the control measures to be taken.

3. Statement of Safety and Health Policy detailing their commitment to providing a safe and healthfulworkplace for all employees.

4.Responsibilities and Lines of Authorities a.Includes the identification and job responsibilities of personnel responsible for safety - at both corporate and project level - including their resumes.

b.Includes the lines of authority.

5. Training- new hire SOH orientation training at the time of initial hire of each new employee and any periodic retraining/recertification requirements 6.Procedures for job site inspections - assignment of responsibilities and frequency CESO Checklist A-01,Sep 14

U.S.Army Corps of Engineers Safety Inspection Checklist

Abbreviated Accident Prevention Plan

Inspector Name (Print) Inspector Signature

This checklist serves as a guide only. It does not replace or eliminate the need to comply with the requirements set forth in Engineering Manual 385-1-1, Safety and Health Requirements Manual, dated XX September 2014.The references Included In this checklist correspond to the applicablesections of EM 385-1-1.

If service, supply and R&D contracts with limited scopes are awarded, the contractor may submit an abbreviated Accident Prevention Plan. This APP shall address the following areas at a minimum. If other areas of the EM 385-1-1 are pertinent to the contract, the contractor must assure these areas are addressed as well.

Remarks (Any NO or N/A Item)

Date of Inspection

Location (Plant or Facility) Contract Number

Contractor Name Project Name

Date of Inspection

7.Procedures for reporting man-hours worked and reporting and investigating any accidents as soon as possible but not more than 24 hours afterwards to the Contracting Officer/Representative

(CO/COR).

8.Emergency Planning. Employees working alone shall be provided an effective means of emergency communication. This may be cellular phone, two-way radio or other acceptable means. The selected means of communication must be readily available and must be in working condition.

9.Drinking Water provisions, toilet and washing facilities.

10.First Aid and CPR training (at least two employees on each shift shall be qualified/certified to administer first aid and CPR) and provision of first aid kit (types/size).

11.Personal Protective Equipment

a. Work Clothing - Minimum Requirements. Employees to wear clothing suitable for the weather; minimum requirements for work shall be short-sleeve shirt, long pants (excessively long or baggy pants are prohibited) and leather work shoes. If AHA determines safety-toed (or other protective) footwear is necessary (i.e., mowing, weed eating, chain saw use, etc), they shall be wom.

b.Eye and Face Protection. Eye and face protection shall be worn as determined by an analysis of the operations being performed HOWEVER, all involved in chain saw use, chipping,stump grinding, pruning operations, grass mowing, weed eating and blowing operations shall be provided safety eyewear (Z87.1) as a minimum.

c. Hearing Protection. Hearing protection must be worn by all exposed to high noise activities {includes grass mowing/trimming, chainsaw operations, tree chipping, stump grinding and pruning) d.Head Protection. Hard hats shall comply with ANSIZ89.1 and shall be wom by all workers when a head hazard exists. At a minimum, hard hats shall be worn when performing activities identified in {b) above e.High Visibility Apparel shall comply with ANSI/ISEA 107, Class 2 requirements at a minimum and shall be worn by all workers exposed to vehicular or equipment traffic.

f.Protective Leg chaps shall be wom by all chainsaw operators.

g. Gloves of the proper type shall be worn by persons involved in activities that expose the hands to cuts,abrasions, punctures, bums and chemicalirritants.

h. If work is being performed around water and drowning is a hazard, PFD's must be provided and worn as appropriate.

12.Machine Guards and safety devices. Lawn maintenance equipment must have appropriate guards and safety devices in place and operational.

CESO Checklist A-01,Sep 14

U.S.Army Corps of Engineers Safety Inspection Checklist

Abbreviated Accident Prevention Plan Remarks (Any NO or N/A item)

Date of Inspection

13. Hazardous Substances. When any hazardous substances are procured, used, stored or disposed, a hazard communication program must be in effect and MSDSs shall be available at the worksite. Employees shall have received training in hazardous substances being used. When the eyes or body of any person may be exposed to corrosives, irritants or toxic chemicals, suitable facilities for quick drenching or flushing of the eyes and body shall be provided within 10 seconds of the worksite.

14. Traffic control shall be accomplished in accordance with DOrs

MUTCD.

15. Control of Hazardous Energy (Lockout/Tagout). Before an employee perfonns any servicing or maintenance on any equipment where the unexpected unergizing or startup of the equipment could occur, procedures must be in place to ensure adequate control of

16. Driving, working on (i.e., working with equipmenUmowers) while on slopes, working from/in boats/skiffs, etc shall also be considered and dealt with accordingly.

Other Remarks

CESO Checklist A-01,Sep 14

Remarks (Any NO or N/A Item)

U.S.Army Corps of Engineers Safety Inspection Checklist

Abbreviated Accident Prevention Plan

Figure 17

Quality Control Plan Example

EXAMPLE FOR CONTRACTOR’S USE

QUALITY CONTROL PLAN

FOR

MOWING OF VARIOUS LOCATIONS AND PERFORMING GROUNDWATER

MONITORING WELL INSPECTION AND REPAIR

FORMER WEST VIRGINIA ORDNANCE WORKS

POINT PLEASANT, MASON COUNTY, WEST VIRGINIA

CONTRACT NO. ______________________________

1.0 PURPOSE

The Contractor shall state the purpose of the Quality Control Plan (QCP). Basically describe the policy and specific actions that the Contractor shall implement to insure that high quality products are furnished to the Government. Specifically, the preparation, internal quality control review and revision, and revision following Government comments for all submittals that prepared for this project. The Contractor shall also state actions he shall implement to assure quality repair of the groundwater monitoring wells.

2.0 REFERENCES

The Contractor shall cite the following references:

• ER 1110-1-12 Quality Management, 1 June 1993

• CEORDR 1110-1-9, Quality Control and Quality Assurance, 3 March 1995

• CEORH Regulation No. 1110-2-4, Quality Management Plan

• CELRHR 5-2-7, Quality Management Plan,1 May 1999

• Appendix B, Engineering Sub plan; Paragraph 8, Contractor Quality Control Plan

• Applicable ISO 9001 processes developed for this type of work

The following website is provided to the Contractor to gain information on the Quality Control, Quality Management, and ISO 9001 requirements of the Huntington District:

http://www.lrh.usace.army.mil/Articles/index.cfm?id=2236&pge_prg_id=10438&pge_id=1284

3.0 GENERAL

Information shall be provided as to:

• Project type, e.g., DERP-FUDS program

• Project location, e.g., West Virginia Ordnance Works, Point Pleasant, WV

• Project customer, e.g., USACE, Huntington District

• General project description, e.g., mowing of various sites and performing groundwater monitoring well inspection and repair http://www.lrh.usace.army.mil/Articles/index.cfm?id=2236&pge_prg_id=10438&pge_id=1284

• Project objectives, e.g., perform maintenance and repair in accordance with the approved O&M Plan, February 2008, and per the contract scope of work.

4.0 TRAINING

List any special training that field personnel have that is applicable for this specific project.

Certifications and/or proof or training shall be referenced and attached in an appendix to the

QCP.

5.0 RESPONSIBILITIES/INTERNAL QUALITY CONTROL

Responsibilities. State the responsibilities of the various individuals who shall provide services for this project. At a minimum, responsibilities range from preparation and internal review of the submittals, performing the groundwater monitoring well inspection, preparing and submitting the groundwater monitoring well inspection report, and repairing the groundwater monitoring wells.

Internal Quality Control. The Contractor shall list all individuals performing the work as well as the individuals who shall oversee the work and review the submittals (the Internal Quality Control Team, IQCT) prior to submission to the Government. Tasks that shall be performed by these individuals shall also be noted. Quality control review checklists for each submittal shall be prepared and included in an appendix to the QCP. These checklists shall list the items of work that the IQCT member was responsible for reviewing. Example checklists are included in CELRHR 5-2-7, Quality Management Plan. Note: Individuals preparing the various reports or plans CANNOT be the same individual who performs the internal quality control review; IQCT members must be independent and not directly involved with the report and/or plan preparation.

6.0 PROJECT SCHEDULE

The proposed schedule of work shall be stated: planned timeframes for submittals, performing the mowing operations, performing the groundwater monitoring well inspection, and repairing the groundwater monitoring wells.

7.0 RESUMES

The Contractor shall provide abbreviated resumes for all individuals performing work and internal quality reviews for this project. These should be included in an appendix to the QCP.

Figure 18

Contract Discrepancy Report

Figure 19

Accident Investigation Report Form

H1EDDJTP

RFA RECORDABLE FIRST AID

NRI NONRECORDABLE INJURY

SOURCE OF INJURY NAME

Figure 20

Transmittal Form

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Figure 21

Pay Request/Estimate Form

Figures 1 - 15a - updated Oct 2015.pdf
2014 Figures 1-10 Final
Figure 11-15a
Slide Number 1
Slide Number 2
Slide Number 3
Slide Number 4
Slide Number 5
Slide Number 6
Slide Number 7
Slide Number 8
Slide Number 9
Slide Number 10
Slide Number 11
Slide Number 12
Slide Number 13
Figure 16 - CESO Checklist A-01 AbbrevAPPFINAL.pdf
Table 1
Figure 19 -Accident Report 3394.pdf
Untitled
Untitled
LOCATION:
CONTRACT NUMBER:
CONTRACTOR:
PROJECT:
INSPECTOR:
1: Off
2: Off
3: Off
t1:
4: Off
5: Off
6: Off
t2:
7: Off
8: Off
9: Off
10: Off
11: Off
12: Off
13: Off
14: Off
15: Off
16: Off
17: Off
18: Off
19: Off
20: Off
21: Off
22: Off
23: Off
24: Off
25: Off
26: Off
27: Off
28: Off
29: Off
30: Off
31: Off
32: Off
33: Off
34: Off
35: Off
37: Off
38: Off
39: Off
40: Off
41: Off
42: Off
43: Off
44: Off
45: Off
46: Off
t3:
t4:
t5:
t6:
t7:
t8:
t9:
t10:
t11:
t12:
t13:
t14:
t15:
DATE:
47: Off
48: Off
49: Off
t16:
50: Off
51: Off
52: Off
53: Off
54: Off
55: Off
56: Off
57: Off
58: Off
59: Off
60: Off
61: Off
62: Off
63: Off
64: Off
65: Off
66: Off
67: Off
68: Off
69: Off
70: Off
71: Off
72: Off
73: Off
74: Off
75: Off
76: Off
77: Off
78: Off
79: Off
80: Off
81: Off
82: Off
83: Off
84: Off
85: Off
t17:
t18:
t19:
t20:
t21:
t22:
t23:
t24:
t25:
t26:
t27:
t28:
86: Off
87: Off
88: Off
89: Off
90: Off
91: Off
92: Off
93: Off
94: Off
95: Off
96: Off
97: Off
t29:
t30:
t31:
t32:
t33:
Report Number:
EROC:
Civilian: Off
Military: Off
Injury: Off
Injury 2: Off
Fire Involved: Off
Fire Involved 2: Off
Motor Vehicle Involved: Off
Motor Vehicle Involved 2: Off
Motor Vehicle Involved 3: Off
Diving: Off
Diving 2: Off
Property Damage Other: Off
Property Damage OTher 2: Off
Contractor: Off
Public: Off
Fatal: Off
Name:
Job:
Other: Off
Age:
Sex: Male
On Duty: Off
TDY: Off
Off Duty: Off
EMP_STAT Army Active: Off
EMP_STAT Permanent: Off
EMP_STAT Temporary: Off
EMP_STAT Other: Off
EMP_STAT Army Reserve: Off
EMP_STAT Foreign National: Off
EMP_STAT Student: Off
Date of Accident:
Time of Account:
Location:
Prime:
Subcontractor:
Waste Other Specified:
Waste Other: Off
Waste DERP: Off
Waste Superfund: Off
Waste IRP: Off
Contract Type Other Specified:
Contract Dredge: Off
Contract Service: Off
Contract Construction: Off
Contract A/E: Off
Contract Other: Off
Contract Number:
Contract Civil Works: Off
Contract Military: Off
Contract Number Other: Off
Contract Other Specify:
Construction Activity: [ 0. N/A]
BPA: [ 1]
Severity of Illness: [NOI - NO INJURY]
Severity of Illness Code Number: [NOI]
Secondary Body PartsAffected: [ N/A]
Primary Body Part Code Num: [N/A]
Primary Body Parts Affected: [ N/A]
Secondary Body Part Code Num: [ N/A]
Nature of Illness: [ N/A]
Nature Code Num: [N/A]
Activity at Time of Accident: [ N/A]
Floation Yes: Off
Vehicle Pickup/Van 1: Off
Vehicle Pickup/Van 2: Off
Vehicle Automobile 1: Off
Vehicle Automobile 2: Off
Vehicle Truck 1: Off
Vehicel Truck 2: Off
Vehicle Other 1: Off
Vehicle Other 2: Off
Type of Vehicle Other Specified:
Collision Side Swipe: Off
Collision Broadside: Off
Collision Other: Off
Collision Head On: Off
Collision Roll Over: Off
Collision Other Specified:
Collision Rear End: Off
Collision Backing: Off
Name of Item 1:
Name of Item 2:
Name of Item 3:
Type of Vessel: [ N/A]
Vessel Code Num: [ N/A]
Estimated Days Lost: 00.00
Estimated Days Hospitalized: 00.00
Estimated Days Restricted Duty: 00.00
Type Injury: [ N/A]
Type Code Num: [ N/A]
Source Injury: [ N/A]
Source Code Num: [ N/A]
Floatation No: Off
Floatation NA: Off
Front Seat Belts Used: Off
Rear Seat Belts Used: Off
Front Seat Belts Not Used: Off
Front Seat Belts Not Available: Off
Rear Seat Belts Not Used: Off
Rear Seat Belts Not Available: Off
Ownership 1:
Ownership 2:
Ownership 3:
Amount of Damage 1:
Amount of Damage 2:
Amount of Damage 3:
Type of Collision: [ N/A]
Collision Code Num: [ N/A]
EMP_STAT Volunteer: Off
EMP_STAT Seasonal: Off
Employment Status Other Specified:
CONSTRUCTION EQ: [ 0. N/A]
Contract Code Num: [ N/A]
SSN:
GRADE:
Design Yes: Off
H_Factors No: Off
H_Factors Yes: Off
Factors No: Off
Factors Yes: Off
Practices No: Off
Practices Yes: Off
Procedures No: Off
Procedures Yes: Off
Condition No: Off
Maintenance No: Off
Condition Yes: Off
Maintenance Yes: Off
Design No: Off
Hazard Analysis No: Off
Hazard Analysis Yes: Off
Drugs Yes: Off
Protective Equiment Yes: Off
Drugs No: Off
Protective Equiment No: Off
Support Factors No: Off
Support Factors Yes: Off
Office Factors No: Off
Office Factors Yes: Off
Agent Factors No: Off
Agent Factors Yes: Off
Trinaing On Job: Off
Traingin Classroom: Off
Trained No: Off
Trained Yes: Off
Training Date:
Beginning Actions Date:
Completed Actions Date:
Org Identifier:
Office Symbol:
Date:
Management Review 1 Comments:
Management Review 2 Comments:
Concur 1: Off
Concur 3: Off
Concur 2: Off
Non Concur 3: Off
Non Concur 1: Off
Non Concur 2: Off
Saftery Office Comments:
Command Approval Comments:
Accident Description Continued:
Direct Cause Continued:
Indrirect Causes Continued:
Actions Taken etc:
Transmittal No:
TO:
FROM:
CONTRACT NO:
New Transmittal:
Resubmittal:
undefined_4:
undefined_5:
undefined_6: Off
undefined_7:
ITEM NO 1:
DESCRIPTION OF ITEM SUBMITTED 1:
MFG OR CONTR CAT CURVE DRAWING OR BROCHURE NO See instruction no 8 cRow1:
NO OF COPIES dRow1:
SPEC PARA NO eRow1:
DRA SHERow1:
Row1:
Row1_2:
Row1_3:
ITEM NO 2:
DESCRIPTION OF ITEM SUBMITTED 2:
MFG OR CONTR CAT CURVE DRAWING OR BROCHURE NO See instruction no 8 cRow2:
NO OF COPIES dRow2:
SPEC PARA NO eRow2:
DRA SHERow2:
Row2:
Row2_2:
Row2_3:
ITEM NO 3:
DESCRIPTION OF ITEM SUBMITTED 3:
MFG OR CONTR CAT CURVE DRAWING OR BROCHURE NO See instruction no 8 cRow3:
NO OF COPIES dRow3:
SPEC PARA NO eRow3:
DRA SHERow3:
Row3:
Row3_2:
Row3_3:
ITEM NO 4:
DESCRIPTION OF ITEM SUBMITTED 4:
MFG OR CONTR CAT CURVE DRAWING OR BROCHURE NO See instruction no 8 cRow4:
NO OF COPIES dRow4:
SPEC PARA NO eRow4:
DRA SHERow4:
Row4:
Row4_2:
Row4_3:
ITEM NO 5:
DESCRIPTION OF ITEM SUBMITTED 5:
MFG OR CONTR CAT CURVE DRAWING OR BROCHURE NO See instruction no 8 cRow5:
NO OF COPIES dRow5:
SPEC PARA NO eRow5:
DRA SHERow5:
Row5:
Row5_2:
Row5_3:
ITEM NO 6:
DESCRIPTION OF ITEM SUBMITTED Type size model numberetc bRow6:
MFG OR CONTR CAT CURVE DRAWING OR BROCHURE NO See instruction no 8 cRow6:
NO OF COPIES dRow6:
SPEC PARA NO eRow6:
DRA SHERow6:
Row6:
Row6_2:
Row6_3:
ITEM NO 7:
DESCRIPTION OF ITEM SUBMITTED Type size model numberetc bRow7:
MFG OR CONTR CAT CURVE DRAWING OR BROCHURE NO See instruction no 8 cRow7:
NO OF COPIES dRow7:
SPEC PARA NO eRow7:
DRA SHERow7:
Row7:
Row7_2:
Row7_3:
ITEM NO 8:
DESCRIPTION OF ITEM SUBMITTED Type size model numberetc bRow8:
MFG OR CONTR CAT CURVE DRAWING OR BROCHURE NO See instruction no 8 cRow8:
NO OF COPIES dRow8:
SPEC PARA NO eRow8:
DRA SHERow8:
Row8:
Row8_2:
Row8_3:
ITEM NO 9:
DESCRIPTION OF ITEM SUBMITTED Type size model numberetc bRow9:
MFG OR CONTR CAT CURVE DRAWING OR BROCHURE NO See instruction no 8 cRow9:
NO OF COPIES dRow9:
SPEC PARA NO eRow9:
DRA SHERow9:
Row9:
Row9_2:
Row9_3:
ITEM NO 10:
DESCRIPTION OF ITEM SUBMITTED Type size model numberetc bRow10:
MFG OR CONTR CAT CURVE DRAWING OR BROCHURE NO See instruction no 8 cRow10:
NO OF COPIES dRow10:
SPEC PARA NO eRow10:
DRA SHERow10:
Row10:
Row10_2:
Row10_3:
REMARKS:
Contractor Signature:
ENCLOSURES RETURNED:
undefined_9:

File details come from the government source that posted it. Updated .