A.03.09 Exhibits.pdf

Exhibits

A – Site Map

B – CELRH Form 2800

C – CESO Checklist A-01

Exhibit A

CELRH FORM 2800, MAY 2010 PREVIOUS EDITIONS ARE OBSOLETE. Page 1 of 4

VERSION 1.1

1. DATE OF INSPECTION (YYYYMMDD)

2. CORPS PROJECT

SECTION III - EQUIPMENT

CONTRACTOR EQUIPMENT AND SUPPLY INSPECTION

The proponent agency is CELRH-CT.

4. CONTRACTOR 5. CONTRACTOR PHONE3. CORPS INSPECTOR

6. FIRM OR CORPS REPRESENTATIVE 7. SOLICITATION NUMBER

CONTRACT SESSIONS: THE FOLLOWING CODES ARE TO BE USED IN SUBJECTIVELY EVALUATING THE APPARENT CONDITION AND

CONSIDERED UTILIZATION POTENTIAL OF CONTRACTOR EQUIPMENT, TOOLS ETC.

CONDITION CODES: (A) NEW, APPARENT CONDITION (B) USED, SERVICEABLE AND APPARENT GOOD CONDITION

(C) USED, SERVICEABLE (D) USED, UNSERVICEABLE (E) N/A NOT APPLICABLE

NOTE: DUE TO THE SIMILARITY IN SERVICES AND THE EQUIPMENT AND TOOLS USED TO PERFORM THESE SERVICES; SECTIONS II., V., VI., VII., VIII., X., XIII. AND XIV. HAVE BEEN COMBINED.

1. RIDING EQUIPMENT (e.g., Tractors, etc.)

a.

EQUIPMENT ITEM

b.

MODEL NUMBER

c.

SERIAL NUMBER

d. ROLLOVER

PROTECTION

e.

SEATBELTS

f.

PHOTO(s) g.

CONDITION

CODEYES NO YES NO YES NO

2. POWER LAWN MOWERS (Self-Propelled) g.

CONDITION

CODENOYES

f.

PHOTO(s)

NOYES

e.

BACK

GUARD

NOYES

d. GUARDS (discharge, belts, etc.)

3. POWER LAWN MOWERS (Push Type) a.

EQUIPMENT ITEM

b.

MODEL NUMBER

c.

SERIAL NUMBER

g.

CONDITION

CODENOYES

f.

PHOTO(s)

NOYES

e.

BACK

GUARD

NOYES

d. GUARDS (discharge, belts, etc.)

a.

EQUIPMENT ITEM

b.

MODEL NUMBER

c.

SERIAL NUMBER

Exhibit B

CELRH FORM 2800, MAY 2010 Page 2 of 4

4. TRIMMERS (String Type)

SECTION III - EQUIPMENT (Continuation)

6. PESTICIDE APPLICATION EQUIPMENT

5. HAND TOOLS (List hand tools displayed and describe their general condition) e.

CONDITION

CODENOYES

d. PHOTO(s)c.

SERIAL NUMBER

b.

MODEL NUMBER

a.

EQUIPMENT ITEM

7. COMMENTS

SECTION IV.

NOYES

d. PHOTO(s)b.

SERIAL NUMBER

(If applicable) c.

SAFETY FEATURES

(If applicable)

1a.

EQUIPMENT ITEM

2. COMMENTS

g.

CONDITION

CODENOYES

f.

PHOTO(s)

NOYES

e.

BACK

GUARD

NOYES

d. GUARDS (discharge, belts, etc.)

a.

EQUIPMENT ITEM

b.

MODEL NUMBER

c.

SERIAL NUMBER

NOTE: USE THIS SECTION TO EXPAND UPON OR TO PROVIDE FURTHER ELABORATION, THAT WILL AIDE THE DETERMINATION PROCESS AND IN THE UNDERSTANDING OF ANY CONCLUSION OR DETERMINATION (e.g., rating or condition codes selected) MADE ON THE ADEQUACY OF PROPOSED EQUIPMENT TO PROVIDE SERVICES REQUESTED UNDER SECTION III.

NOTE: USE THIS SECTION TO ELABORATE ON ANY OF THE FOREGOING OBSERVED ITEMS AND TO PROVIDE SUPPLEMENTARY INFORMATION THAT COULD ASSIST IN THE EVALUATION PROCESS. FOR EXAMPLE, SHOULD ANY ITEMS DEEMED NECESSARY TO PROVIDE THE SERVICES REQUIRED UNDER SECTION IV. (and noted in the "SPECS") NOT BE AVAILABLE FOR INSPECTION (e.g., expendable items such as brooms, brushes, toilet bowl swabs, etc.) NOTE HERE THE RESPONSE PROVIDE TO QUERIES INTO THE

PROPOSED ACQUISITION, ETC.

CELRH FORM 2800, MAY 2010 Page 3 of 4

SECTIONS II - V - VI - VII - VIII - X - XIII AND XIV

NOYES

d. PHOTO(s)c.

SAFETY FEATURES

(If applicable) b.

SERIAL NUMBER

(If applicable)

1a.

EQUIPMENT ITEM

e.

CONDITION

CODE

2. COMMENTS

SAFETY SECTION

NOTE: PROVIDE HERE COMMENTS ON PERSONAL PROTECTIVE EQUIPMENT AND ANY ITEMS TO TOPICS OF SAFETY NOT ADDRESSED IN THE PRECEDING SECTIONS. THE FOLLOWING IS A LIST OF SOME ITEMS THAT SHOULD BE ADDRESSED; USE THE COMMENTS SECTION TO PROVIDE EXPLANATORY STATEMENTS. FOR THOSE ITEMS OF PERSONAL EQUIPMENT (e.g., safety shoes) THAT ARE NOT NORMALLY OR REASONABLY EXPECTED TO BE SEEN FOR THIS INSPECTION, IT IS SUFFICIENT TO PROVIDE REMARKS ON

THESE ITEMS IN THE COMMENT SECTION.

NOYES

b. PHOTO(s) c.

CONDITION

CODE

1a.

EQUIPMENT ITEM

WELDING SAFETY EQUIPMENT

c.

CONDITION

CODENOYES

b. PHOTO(s)1a.

EQUIPMENT ITEM

LEG CHAPS

PERSONAL FLOTATION DEVICES

EAR PLUGS

BLAZE ORANGE SAFETY VEST

PROTECTIVE MASK

BREATHING APPARATUS

HARD HATS

EYE PROTECTION

GLOVES

SAFETY SHOES (Steel toe, spark proof)

PROTECTIVE CLOTHING

NOTE: USE THIS SECTION TO SHOW HOW THE FIRM OR CORPORATION REPRESENTATIVES PROPOSE TO ENSURE THE GOVERNMENT THEY HAVE ADEQUATE EQUIPMENT TO PERFORM THE SERVICES THAT MAY BE REQUIRED UNDER THESE SECTIONS. FOR EXAMPLE AND FOR ANY EQUIPMENT NOT OBSERVED ON THE DATE OF INSPECTION, DESCRIBE THE METHOD (e.g., rental, acquisition, etc.) PROPOSED OR EVIDENCE USED BY THE FIRM REPRESENTATIVE TO ENSURE THE AVAILABILITY OF SUCH

EQUIPMENT.

d. INSPECTOR'S SIGNATURE

CELRH FORM 2800, MAY 2010 Page 4 of 4

2. COMMENTS

SAFETY (Continued)

SUMMARY SECTION

1. PROVIDE HERE A WRITTEN SUMMARIZATION OF THE INSPECTION RESULTS TOGETHER WITH A FINAL RATING OF THE FIRM OR CORPORATION. INSPECTION RESULTS AND THIS SUMMARIZATION MUST SUPPORT A CONCLUSION MADE ON THE ADEQUACY OF

EQUIPMENT TO PROVIDE THE SERVICES UNDER THE REQUIREMENT CONTRACT.

b. NAME AND JOB TITLE (Last, First MI)

c. DATE OF INSPECTION (YYYYMMDD)

U.S. ARMY CORPS OF ENGINEERS PERSONNEL CONDUCTING THIS INSPECTION

1a. E-MAIL ADDRESS

2. OTHER DOCUMENTATION AND OR PHOTO(s) ARE ATTACHED

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

Exhibit C

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