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HomeMy WebLinkAboutRES 138 Draft 02 1992-1994COUNTY OF HAWAII STATE OF HAWAII RESOLUTION N0. `~'~ 93 (Draft 2) RESOLUTION AUTHORIZING THE MAYOR OF THE COUNTY OF HAWAII TO ENTER INTO A MEMORANDUM OF AGREEMENT BETWEEN THE UNITED STATES OF AMERICA AND THE COUNTY OF HAWAII FOR THE DESIGN AND REMEDIATION OF SUBSURFACE CONTAMINATION AT THE ALENAIO STREAM FLOOD CONTROL PROJECT, WHEREAS, the Hawaii County Council, in Resolution No. 284-91, resolved that it supported the construction of the Alenaio Stream Flood Control Project; and WHEREAS, the Hawaii County Council, in Resolution No, 377-91, resolved that the Mayor of the County of Hawaii is authorized to enter into a Local Cooperation Agreement for the Alenaio Stream Flood Control Project, a copy of which is marked as Exhibit "A" and attached hereto and made a part of this resolution; and WHEREAS, the Hawaii County Council, in Resolution No. 377-91, also resolved that if the project requires the expenditure of funds up until the 1993-94 fiscal year, such funds will be appropriated to the project; and WHEREAS, the Governor of the State of Hawaii has released appropriate and sufficient funds which will be used by the County of Hawaii for the design and remediation of subsurface contamination at the Alenaio Stream Flood Control Project; and WHEREAS, one of the requirements of the Alenaio Stream Flood Control Project is that the County of Hawaii, by its Mayor, execute a Memorandum of Agreement, which is in effect a contract binding the County of Hawaii for the design and remediation of subsurface contamination at the Alenaio Stream Flood Control Project, a copy of which agreement is marked as Exhibit "B" and attached hereto and made a part of this resolution; and WHEREAS, the aforementioned Memorandum of Agreement may require expenditures by the County of Hawaii of an amount not to exceed $500,000.00 based on the best current estimates during the County's fiscal year 1993-94; and WHEREAS, the aforementioned Memorandum of Agreement amends Article XVII of the previously referenced Local Cooperation Agreement; and WHEREAS, Section 46-7, Hawaii Revised Statutes, as amended, provides that the governing body or department of the County of Hawaii, with the consent of the County Council, may enter into agreements with the federal government respecting action to be taken pursuant to any of the powers granted to it by law and furnish, expend and receive any funds or other assistance in connection with projects being or to be undertaken pursuant to the powers; NOPl, THEREFORE, BE IT RESOLVED BY THE COUNCIL OF THE COUNTY OF HAWAII that the Mayor of the County of Hawaii is authorized to enter into the above-noted Memorandum of Agreement for the County of Hawaii. BE IT FURTHER RESOLVED that the Clerk of the County of Hawaii transmit copies of this resolution to the Honorable Stephen K. Yamashiro, Mayor of the County of Hawaii, and to the District Engineer, U.S. Army Engineer District in Honolulu. Dated at Hilo, Hawaii, this 22nd day of December , 1993. INTRODU E`` ~~ BY: ni i~ i"Y~~,((//""// ~ COUNCIL MEMBER, COUNTY OF HAWAII COUNTY COUNCIL ROLL CALL VOTE County of Hawaii Hilo. Hawaii I hereby certify that the fontgoinQ RE90LUTION wu by the vote indicated to the right haneof adopted by the ~OUNCIL of tha County of Hawaii on De c e mb e r 21 , 1 9 3 ATTEST: i 1 ~~ COU RK~ CHAIRMAN & PRESIDING OFFICER AYES NJES AIiS EX ARAKAKI X BDNIC-ABRAM90N X CHILDS DE LIlNA X DCMINC~J X HALE X RATH l3DSF~iILL SCHUTTE X 9 0 0 0 -~zet~3oe C-708/HS&PWC-73 I~LUZ•ZQV ~_ 138 :y3 (D£cAFT 2) LOCAL COOPERATION AGREEMENT BETWEEN THE DEPARTMENT OF THE ARMY AND THE COUNTY OF HAWAII FOR CONSTRUCTION OF THE ALENAIO STREAM FLOOD CONTROL PROJECT HILO, HAWAII THIS AGREEMENT, is entered April 19 92 by a (hereinafter referred to as the Assistant Secretary of the Army (hereinafter referred to as the the Mayor, WITNESSETH THAT: into this 27th day of id between the DEPARTMENT OF THE ARMY "Government"), acting by and through the (Civil Works), and the COUNTY OF HAWAII "Local Sponsor"), acting by and through WHEREAS; construction of the Alenaio Stream flood Control Project at Hilo, Hawaii (hereinafter referred to as the "Project" and defined in Article I.a. of this Agreement), was authorized by Section 401(a) of the Water Resources Development Act of 1986, Public Law 99-662, as amended; and, WHEREAS, modification of the Project was authorized by Section 102(k) of the Water Resources Development Act of 1990, Public Law 101-640, as amended; and, WHEREAS, Section 103 of the Water Resources Development Act of 1986, Public Law 99-662, as amended, specifies the cost-sharing requirements applicable to the Project; and, WHEREAS, Section 221 of the Flood Control Act of 1970, Public Law 91-611, as amended, provides that the construction of any water resources project by the Secretary of the Army shall not be commenced until each non-Federal interest has entered into a written agreement to furnish its required cooperation for the Project; and, WHEREAS, the Local Sponsor qualifies for a reduction of the maximum non-Federal cost share pursuant to the guidelines which implement Section 103(m) of the Water Resources Development Act of 1986, Public Law 99-662, published in 33 C.F.R. 241.1-241.6, entitled "Flood Control Cost-Sharing Requirements Under the Ability to Pay Provision"; and, EXHIBIT "~-°' ;, WHEREAS, the Local Sponsor has the authority and capability to furnish the cooperation hereinafter set forth and is willing to participate in cost-sharing and financing in accordance with the terms of this Agreement; NOW, THEREFORE, the parties agree as follows: ARTICLE I - DEFINITIONS AND GENERAL PROVISIONS For purposes of this Agreement: a. The term "Project" shall mean 1,787 feet of rectangular concrete channel, a 200-foot wedge-shaped concrete entrance transition, 832 feet of earth levee, 487 feet of concrete floodwall, 453 feet of cement-rubble-masonry (CRM) floodwall, four bridge replacements, removing one public, one business and six residential structures, incorporating flood plain management regulations on undeveloped areas, and an earth channel connecting the concrete channel to the existing Waiolama Canal, as generally described in the GENERAL DESIGN MEMORANDUM dated March 1990 and approved by the Chief of Engineers on 25 June 1990. b. The term "total project costs" shall mean all costs incurred by the Local Sponsor and the Government directly related to construction of the Project. Such costs shall include, but not necessarily be limited to: all Advanced Engineering and Design (AE&D) costs; Continuing Planning and Engineering (CP&E) costs incurred after October 1, 1985; all Preconstruction Engineering and Design (PED) costs; engineering and design during construction; actual construction costs; costs of relocations of railroad bridges and approaches thereto; supervision and administration costs; costs of contract dispute settlements or awards; and the value of lands, easements, rights-of-way, utility and facility alterations or relocations, and suitable borrow and dredged material disposal areas provided for the Project by the Local Sponsor, but shall not include any costs for betterments, operation, maintenance, repair, replacement, or rehabilitation. c. The term "period of construction" shall mean the time from the advertisement of the first construction contract to the time of acceptance of the Project by the Contracting Officer. d. The term "Contracting Officer" shall mean the U.S. Army Engineer for the Honolulu District, or his designee. e. The term "highway" shall mean any highway, thoroughfare, roadway, street, or other public road or way. f. The term "relocations" shall mean the preparation of plans and specifications for, and the accomplishment of, all alterations, modifications, lowering or raising in place, and/or new construction related to, but not limited to, existing: railroads, highways, bridges, railroad bridges and approaches thereto, pipelines, public utilities (such as municipal water and sanitary sewer lines, telephone lines, and storm drains), aerial utilities, cemeteries, and other facilities, structures, and improvements determined by the Government to be necessary for the construction, operation and maintenance of the Project. g. The term "fiscal year" shall mean one fiscal year of the United States government, unless otherwise specifically indicated. The Government fiscal year begins on October 1 and ends on September 30. h. The term "involuntary acquisition" shall mean the acquisition of lands, easements, and rights-of-way by eminent domain. i. The term "functional portion of the Project" shall mean a completed portion of the Project as determined by the Contracting Officer to be suitable for tender to the Local Sponsor to operate and maintain in advance of completion of construction of the entire Project. ARTICLE II - OBLIGATIONS OF THE PARTIES a. The Government, subject to and using funds provided by the Local Sponsor and appropriated by the Congress of the United States, shall expeditiously construct the Project (including relocations of railroad bridges and approaches thereto), applying those procedures usually followed or applied in Federal projects, pursuant to Federal laws, regulations, and policies. The Local Sponsor shall be afforded the opportunity to review and comment on all contracts, including relevant plans and specifications, prior to the issuance of invitations for bid. To the extent possible the Local Sponsor will be afforded the opportunity to review and comment on modifications and change orders prior to the issuance to the contractor of a Notice to Proceed. The Government will consider the comments of the Local Sponsor, but award of contracts, modifications or change orders, and performance of all work on the Project (whether the work is performed under contract or by Government personnel), shall be exclusively within the control of the Government. b. When the Government determines that the project or a functional portion of the Project is complete, the Government shall turn the completed Project or functional portion over to the Local Sponsor, which shall accept the Project or functional portion and be solely responsible for operating, maintaining, repairing, replacing, and rehabilitating the Project or functional portion in accordance with Article VIII hereof. c. As further specified in Article VI hereof, the Local Sponsor shall provide, during the period of construction, a cash contribution of 5 percent of total project costs. d. As further specified in Article III hereof, the Local Sponsor shall provide all lands, easements, rights-of-way, and suitable borrow and dredged material disposal areas, and perform all relocations (excluding railroad bridges and approaches thereto) determined by the Government to be necessary for construction of the Project. At its sole discretion, the Government may perform relocations in cases where it appears that the Local Sponsor's contributions will exceed the maximum non-Federal cost share set out in Article VI.f. e. If the value of the contributions provided under paragraphs c. and d. of this Article represents less than 25 percent of total project costs, the Local Sponsor shall provide, during the period of construction, an additional cash contribution in the amount necessary to make its total contribution equal to 25 percent of the total project costs. f. No federal funds may be used to meet the Local Sponsor's share of total project costs under this Agreement unless the expenditure of such funds is expressly authorized by statute as verified in writing by the Federal granting agency. with applicablehFederal floodopla9nemanagement~andaflood ansuranpey programs. h. No less than once each year the Local Sponsor shall inform affected interests of the limitations of the protection afforded by the Project. i. The Local Sponsor shall publicize flood plain information in the area concerned and shall provide this information to zoning and other regulatory agencies for their guidance and leadership in preventing unwise future development in the flood plain and in adopting such regulations as may be necessary to prevent unwise future development and to ensure compatibility with protection levels provided by the Project. j. At the request of the Local Sponsor, the Government may, on behalf of the Local Sponsor and in connection with the design or construction of the Project, design and/or construct a betterment or other work that is not a part of the Project. Prior to award of any Government contract involving such betterment or other work, the Local Sponsor shall provide to the Government a cash payment equal to 100 percent of the costs of such betterment or other work by delivering a check payable to "FAO, USAED, Pacific Ocean" to the Contracting Officer representing the Government. The Government shall draw on such payment as necessary to cover contractual and other Government fiscal obligations for such betterment or other work as such obligations are incurred. If at any time during the prosecution of such betterments or other work the Government determines that additional funds will be needed from the Local Sponsor to cover the costs of such betterment or other work, the Government shall so notify the Local Sponsor and the Local Sponsor, no later than 30 days after receipt of such notice, shall make a cash payment to the Government of the necessary amount. After the completion of any such betterment or other work, the Government will perform a final accounting. In the event the cash payment for such betterment or other work is less than the amount required to cover the costs of such betterment or other work, the Local Sponsor shall, no later than 30 days after receipt of written notice, make a cash payment to the Government of whatever sum is needed to cover all costs of such betterment or other work. In the event the cash payment exceeds the amount required to cover all costs of such betterment or other work, the Government shall return any excess cash to the Local Sponsor no later than 90 days after the final accounting. The Local Sponsor shall be responsible for all operation, maintenance, repair, replacement and rehabilitation associated with such betterment or other work in such a manner to insure proper functioning of the Project. The Local Sponsor shall hold and save the Government free from all damages arising from the construction, operation, maintenance, repair, replacement, and rehabilitation of such betterment or other work. ARTICLE III - LANDS, FACILITIES, AND PUBLIC LAW 91-646 RELOCATION ASSISTANCE a. The Local Sponsor shall furnish to the Government all lands, easements, and rights-of-way, including suitable borrow and dredged material disposal areas, as may be determined by the Government to be necessary for the construction, operation, and maintenance of the Project, and shall furnish to the Government evidence supporting the Local Sponsor's legal authority to grant rights-of-entry to such lands. The necessary lands, easements, and rights-of-way may be provided incrementally, but all lands, easements, and rights-of-way determined by the Government to be necessary for work to be performed under a construction contract must be furnished prior to the advertisement of the construction contract. b. The Local Sponsor shall provide or pay to the Government the cost of providing all retaining dikes, wasteweirs, bulkheads, and embankments, including all monitoring features and stilling basins, that may be required at any dredged material disposal areas necessary for construction of the Project. c. Upon notification from the Government, the Local Sponsor shall accomplish or arrange for accomplishment at no cost to the Government all relocations (excluding railroad bridges and approaches thereto) determined by the Government to be necessary for construction of the Project. d. The Local Sponsor shall comply with the applicable provisions of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970, Public Law 91-646, as amended by Title IV of the Surface Transportation and Uniform Relocation Assistance Act of 1987 (Public Law 100-17), and the Uniform Regulations contained in 49 CFR Part 24, in acquiring lands, easements, and rights-of-way for construction and subsequent operation and maintenance of the Project, and inform all affected persons of applicable benefits, policies, and procedures in connection with said Act. ARTICLE IV - VALUE OF LANDS AND FACILITIES a. The value of the lands, easements, and rights-of-way to be included in total project costs and credited toward the Local Sponsor's share of total project costs will be determined in accordance with the following procedures: 1. If the lands, easements, or rights-of-way are owned by the Local Sponsor as of the date of the first construction contract for the Project is awarded, the credit shall be the fair market value of the interest at the time of such award. The fair market value shall be determined by an appraisal, to be obtained by the Local Sponsor, which has been prepared by a qualified appraiser who is acceptable to both the Local Sponsor and the Government. The appraisal shall be reviewed and approved by the Government. 2. If the lands, easements, or rights-of-way are to be acquired by the Local Sponsor after the date of award of the first construction contract for the Project, the credit shall be the fair market value of the interest at the time such interest is acquired. The fair market value shall be determined as specified in Article IV.a.l. of this Agreement. If the Local Sponsor pays an amount in excess of the appraised fair market value, it may be entitled to a credit for the excess if the Local Sponsor has secured prior written approval from the Government of its offer to purchase such interest. 3. If the Local Sponsor acquires more lands, easements, or rights-of-way than are necessary for project purposes, as determined by the Government, then only the value of such portions of those acquisitions as are necessary for project purposes shall be included in total project costs and credited toward the Local Sponsor's share. 4. Credit for lands, easements, and rights-of-way in the case of involuntary acquisitions which occur within a one-year period preceding the date this Agreement is signed or which occur after the date this Agreement is signed will be based on court awards, or on stipulated settlements that have received prior written approval of the Government. 5. Credit for lands, easements, or rights-of-way acquired by the Local Sponsor within a five-year period preceding the date this Agreement is signed, or at any time after this Agreement is signed, will also include reasonable incidental costs of acquiring the interest, e.g., closing and title costs, appraisal costs, survey costs, attorney's fees, plat maps, and mapping costs, as well as the actual amounts expended for payment of any Public Law 91-646 relocation assistance benefits provided in accordance with the obligations under this Agreement. b. The costs of relocations which will be included in total project costs and credited toward the Local Sponsor's share of total project costs shall be that portion of the actual costs as set forth below, and approved by the Government: 1. Highways and Highway Bridges: Only that portion of the cost as would be necessary to construct substitute bridges and highways to the design standard that the State of Hawaii would use in constructing a new bridge or highway under similar conditions of geography and traffic loads. 2. Utilities and Facilities (including railroads): Actual relocation costs, less depreciation, less salvage value, plus the cost of removal, less the cost of betterments. With respect to betterments, new materials shall not be used in any alteration or relocation if materials of value and usability equal to those in the existing facility are available or can be obtained as salvage from the existing facility or otherwise, unless the provision of new material is more economical. If, despite the availability of used material, new material is used, where the use of such new material represents an additional cost, such cost will not be included in total project costs, nor credited toward the Local Sponsor's share. 3. For the second and subsequent fiscal years of project construction, the Government shall, no later than 60 calendar days prior to the beginning of the fiscal year, notify the Local Sponsor of the Local Sponsor's share of total project costs for that fiscal year. No later than 30 calendar days prior to the beginning of the fiscal year, the Local Sponsor shall make the necessary funds available to the Government through the funding mechanism specified in Article VI.b.2. of this Agreement. As construction of the Project proceeds, the Government shall adjust the amounts required to be provided under this paragraph to reflect actual costs. 4. If at any time during the period of construction the Government determines that additional funds will be needed from the Local Sponsor, the Government shall so notify the Local Sponsor, and the Local Sponsor, no later than 45 calendar days from receipt of such notice, shall make the necessary funds available through the funding mechanism specified in Article VI.b.2. of this Agreement. c. The Government will draw on the funds provided by the Local Sponsor such sums as the Government deems necessary to cover contractual and in-house fiscal obligations attributable to the Project as they are incurred, as well as costs incurred by the Government prior to the initiation of construction. d. Upon completion of the Project and resolution of all relevant claims and appeals, the Government shall compute the total project costs and tender to the Local Sponsor a final accounting of the Local Sponsor's share of total project costs. In the event the total contribution by the Local Sponsor is less than its minimum required share of total project costs, the Local Sponsor shall, no later than 90 calendar days after receipt of written notice, make a cash payment to the Government of whatever sum is required to meet its minimum required share of total project costs. e. In the event the Local Sponsor has made cash contributions in excess of 5 percent of total project costs and that result in the Local Sponsor's having provided more than its minimum required share of total project costs, the Government shall, no later than 90 calendar days after the final accounting is complete, subject to the availability of funds, return the said excess to the Local Sponsor; however, the Local Sponsor shall not be entitled to any refund of the 5 percent cash contribution required pursuant to Article II.c. of this Agreement. f. If the Local Sponsor's total contributions under this Agreement (including lands, easements, rights-of-way, relocations, and suitable borrow and dredged material disposal areas) exceed 36 percent of total project costs, the Government shall, subject to the availability of funds for that purpose, refund the excess to the Local Sponsor no later than 90 calendar days after the final accounting is complete. ARTICLE VII - DISPUTES Before any party to this Agreement may bring suit in any court concerning an issue relating to this Agreement, such party must first seek in good faith to resolve the issue through negotiation or ,other forms of nonbinding alternative dispute resolution mutually acceptable to the parties. ARTICLE VIII - OPERATION, MAINTENANCE, REPAIR, REPLACEMENT, AND REHABILITATION a. After the Government has turned the completed Project, or functional portion of the Project, over to the Local Sponsor, the Local Sponsor shall operate, maintain, repair, replace, and rehabilitate the completed Project, or functional portion of the Project, in accordance with regulations or directions prescribed by the Government. b. The Local Sponsor hereby gives the Government a right to enter, at reasonable times and in a reasonable manner, upon land which it owns or controls for access to the Project for the purpose of inspection, and, if necessary, for the purpose of completing, operating, maintaining, repairing, replacing, or rehabilitating the Project. If an inspection shows that the Local Sponsor for any reason is failing to fulfill its obligations under this Agreement without receiving prior written approval from the Government, the Government will send a written notice to the Local Sponsor. If the Local Sponsor persists in such failure 30 calendars days after receipt of the notice, then the Government shall have a right to enter, at reasonable times and in a reasonable manner, upon lands the Local Sponsor owns or controls for access to the Project for the purpose of completing, operating, maintaining, repairing, replacing, or rehabilitating the Project. No completion, operation, maintenance, repair, replacement, or rehabilitation by the Government shall operate to relieve the Local Sponsor of responsibility to meet its obligations as set forth in this Agreement, or to preclude the Government from pursuing any other remedy at law or equity to assure faithful performance pursuant to this Agreement. ARTICLE IX - RELEASE OF CLAIMS The Local Sponsor shall hold and save the Government free from all damages arising from the construction, operation and maintenance of the Project, except for damages due to the fault or negligence of the Government or its contractors. ARTICLE X - MAINTENANCE OF RECORDS The Government and the Local Sponsor shall keep books, records, documents, and other evidence pertaining to costs and expenses incurred pursuant to this Agreement to the extent and in such detail as will properly reflect total project costs. The Government and the Local Sponsor shall maintain such books, records, documents, and other evidence for a minimum of three years after completion of construction of the Project and resolution of all relevant claims arising therefrom, and shall make available at their offices at reasonable times, such books, records, documents, and other evidence for inspection and audit by authorized representatives of the parties to this Agreement. ARTICLE XI - GOVERNMENT AUDIT The Government shall conduct an audit when appropriate of the Local Sponsor's records for the Project to ascertain the allowability, reasonableness, and allocability of its costs for inclusion as credit against the non-Federal share of total project costs. ARTICLE XII - FEDERAL AND STATE LAWS The Local Sponsor, in acting under its rights and obligations hereunder, agrees to comply with all applicable Federal and State laws and regulations, including Section 601 of Title VI of the Civil Rights Act of 1964, Public Law 88-352, and Department of Defense Directive 5500.II issued pursuant thereto and published in Part 300 of Title 32, Code of Federal Regulations, as well as Army Regulation 600-7, entitled "Nondiscrimination on the Basis of Handicap in Programs and Activities Assisted or Conducted by the Department of the Army". ARTICLE XIII - RELATIONSHIP OF PARTIES The parties to this Agreement act in an independent capacity in the performance of their respective functions under this Agreement, and neither party is to be considered the officer, agent, or employee of the other. ARTICLE XIV - OFFICIALS NOT TO BENEFIT No member of or delegate to the Congress, or resident commissioner, shall be admitted to any share or part of this Agreement, or to any benefit that may arise therefrom. ARTICLE XV - CONVENANT AGAINST CONTINGENT FEES The Local Sponsor warrants that no person or selling agency has been employed or retained to solicit or secure this Agreement upon agreement or understanding for a commission, percentage, brokerage, or contingent fee, excepting bona fide employees or bona fide established commercial or selling agencies maintained by the Local Sponsor for the purpose of securing business. For breach or violation of this warranty, the Government shall have the right to annul this Agreement without liability, or, in its discretion, to add to the Agreement or consideration, or otherwise recover, the full amount of such commission, percentage, brokerage, or contingent fee. ARTICLE XVI - TERMINATION OR SUSPENSION a. If at any time the Local Sponsor fails to make payments required under this Agreement, the Assistant Secretary of the Army (Civil Works) shall terminate or suspend work on the Project until the Local Sponsor is no longer in arrears, unless the Assistant Secretary of the Army (Civil Works) determines that continuation of work on the Project is in the interest of the United States or is necessary in order to satisfy agreements with any other non-Federal interests in connection with the Project. Any delinquent payment shall be charged interest at a rate, to be determined by the Secretary of the Treasury, equal to 150 per centum of the average bond equivalent rate of the 13-week Treasury bills auctioned immediately prior to the date on which such payment became delinquent, or auctioned immediately prior to the beginning of each additional 3-month period if the period of delinquency exceeds 3 months. b. If the Government fails to receive annual appropriations for the Project in amounts sufficient to meet project expenditures for the then-current or upcoming fiscal year, the Government shall so notify the Local Sponsor. After 60 calendar days either party may elect without penalty to terminate this Agreement pursuant to this Article or to defer future performance hereunder; however, deferral of future performance under this Agreement shall not affect existing obligations or relieve the parties of liability for any obligation previously incurred. In the event that either party elects to terminate this Agreement pursuant to this Article, both parties shall conclude their activities relating to the Project and proceed to a final accounting in accordance with Article VI. of this Agreement. In the event that either party elects to defer future performance under this Agreement pursuant to this Article, such deferral shall remain in effect until such time as the Government receives sufficient appropriations or until either party elects to terminate this Agreement. ARTICLE XVII - HAZARDOUS SUBSTANCES a. After execution of this Agreement and upon direction by the Contracting Officer, the Local Sponsor shall perform, or cause to be performed, such environmental investigations as are determined necessary by the Government or the Local Sponsor to identify the existence and extent of any hazardous substances regulated under the Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA), 42 USC 9601-9675, on lands necessary for Project construction, operation, and maintenance. All actual costs incurred by the Local Sponsor which are properly allowable and allocable to performance of any such environmental investigations shall be included in total project costs and cost shared as a construction cost in accordance with Section 103 of Public Law 99-662. b. In the event it is discovered through an environmental investigation or other means that any lands, easements, rights-of-way, or disposal areas to be acquired or provided for the Project contain any hazardous substances regulated under CERCLA, the Local Sponsor and the Government shall provide prompt notice to each other, and the Local Sponsor shall not proceed with the acquisition of lands, easements, rights-of-way, or disposal areas until mutually agreed. c. The Government and the Local Sponsor shall determine whether to initiate construction, or if already in construction, to continue with construction of the Project, or to terminate construction of the Project for the convenience of the Government in any case where hazardous substances regulated under CERCLA are found to exist on any lands necessary for the Project. Should the Government and the Local Sponsor determine to proceed or continue with construction after considering any liability that may arise under CERCLA, the Local Sponsor shall be responsible, as between the Government and the Local Sponsor, for any and all necessary clean up and response costs, to include the costs of any studies and investigations necessary to determine an appropriate response to the contamination. Such costs shall not be considered a part of total project costs as defined in this Agreement. In the event the Local Sponsor fails to provide any funds necessary to pay for clean up and response costs or to otherwise discharge its responsibilities under this paragraph upon direction by the Government, the Government may either terminate or suspend work on the Project or proceed with further work as provided in Article XVI.a. of this Agreement. d. The Local Sponsor and the Government shall consult with each other under the Construction Phasing and Management Article of this Agreement to assure that responsible parties bear any necessary clean up and response costs as defined in CERCLA. Any decision made pursuant to paragraph c of this Article shall not relieve any party from any liability that may arise under CERCLA. e. The Local Sponsor shall operate, maintain, repair, replace, and rehabilitate the Project in a manner so that liability will not arise under CERCLA. ARTICLE XVIII - NOTICES a. All notices, requests, demands, and other communications required or permitted to be given under this Agreement shall be deemed to have been duly given if in writing and delivered personally, given by prepaid telegram, or mailed by first-class (postage pre-paid), registered, or certified mail, as follows: If to the Local Sponsor: Office of the Mayor 25 Aupuni Street, Room 213 Hilo, Hawaii 96720 If to the Government: District Engineer U.S. Army Engineer District, Honolulu Building 230 Fort Shafter, Hawaii 96858-5440 b. A party may change the address to which such communications are to be directed by giving written notice to the other party in the manner provided in this Article. c. Any notice, request, demand, or other communication made pursuant to this Article shall be deemed to have been received by the addressee at such time as it is personally delivered or seven calendar days after it is mailed, as the case may be. ARTICLE XIX - CONFIDENTIALITY To the extent permitted by the law governing each party, the parties agree to maintain the confidentiality of exchanged information when requested to do so by the providing party. ARTICLE XX - SECTION 902 PROJECT COST LIMIT The Local Sponsor has reviewed the provisions set forth in Section 902 of P.L. 99-662, as amended, and understands that Section 902 establishes maximum total project costs. For purposes of this Agreement, the Section 902 cost limit is $14,472,000 as calculated using March 1990 price levels and allowances for future inflation. This amount shall be adjusted to allow for appropriate increases for inflation and changes in total project costs as provided in Section 902. Should this cost maximum be reached, no additional funds may be expended on the Project until additional authority is obtained from Congress. IN WITNESS WHEREOF, the parties hereto have executed this Agreement, which shall become effective upon the date it is signed by the Assistant Secretary of the Army (Civil Works). THE DEPARTMENT OF THE ARMY THE COUNTY OF HAWAII BY: Y: c.c`x~~~. RA H V. LOCURCIO LORRAINE INOUYE Br' adier General, U.S. Army Mayor, County Hai+~aii Division Engineer DATE: 27 p,pplgg? DATE: ~ ~-7~ ~YPy For and on behalf of the Assistant Secretary of the Army (Civil Works) CERTIFICATE OF AUTHORITY I, Michael J. Matsukawa do hereby certify that I am the principal legal officer of the County of Hawaii, that the County of Hawaii is a legally constituted public body with full authority and legal capability to perform the terms of the Agreement between the Department of the Army and the County of Hawaii in connection with the Project, and to pay damages, if necessary, in the event of the failure to perform, in accordance with Section 221 of Public Law 91-611, and that the persons who have executed this Agreement on behalf of the County of Hawaii have acted within their statutory authority. IN WITNESS WHEREOF, I have made and executed this certification thi s a'7 day of ,A-P~Q/S 19 ~. MICHAEL J. MATSUKAWA Corporation Counsel CERTIFICATION REGARDING LOBBYING The undersigned certifies, to the best of his or her knowledge and belief that: (1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. (2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. (3) The undersigned shall require that the language of this Certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreement) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. / { ~ LORRAINE R. INOUY Mayor, County of Hawaii STATE OF HAWAII ) SS. COUNTY OF HAWAII ) On this °~~+h day of ~~n ~ 19 ~~- , before me personally appeared LORRAINE R. INOUYE, to me personally known, who, being by me duly sworn, did say that she is the Mayor of the COUNTY OF HAWAII, a municipal corporation of the State of Hawaii; that the seal affixed to the foregoing instrument is the corporate seal of the said County of Hawaii; that the foregoing instrument was signed and sealed in behalf of the County of Hawaii by authority given to said Mayor of the County of Hawaii by Section 5-1.3(g) of the County Charter, County of Hawaii (1991), as amended; and said LORRAINE R. INOUYE acknowledged said instrument to be the free act and deed of said County of Hawaii. Q~c~yn-. V ~-Fn.,na~r _ __ Notary P blic, State of IHawaii My commission expires:~~IiI93 _ MEMORANDUM OF AGREEMENT BETWEEN THE UNITED STATES OF AMERICA AND THE COUNTY OF HAWAII FOR THE DESIGN AND REMEDIATION OF SUBSURFACE CONTAMINATION AT THE ALENAIO STREAM FLOOD CONTROL PROJECT HILO, HAWAII This AGREEMENT is entered into by and between the United States of America, acting through the District Commander, U.S. Army Engineer District, Honolulu (hereinafter the "Government") and the COUNTY OF HAWAII, acting through the Mayor, County of Hawaii (hereinafter the "County"), WITNESSETH THAT: WHEREAS, construction of the Alenaio Stream Flood Control Project at Hilo, Hawaii (hereinafter the "Project"), was authorized by Section 401(a) of the Water Resources Development Act of 1986, Public Law 99-662, as amended; and, WHEREAS, modification of the Project was authorized by Section 102 (k) of the Water Resources Development Act of 1990, Public Law 101-640; and, WHEREAS, Section 221 of the Flood Control Act of 1970, Public Law 91-661, as amended, provides that the construction ~~~~~1 i eepn of any water resources project by the Secretary of the Army shall not be commenced until each non-Federal interest has entered into a written agreement to furnish its required cooperation for the Project; and, WHEREAS, on 27 April 1992, the County and the Government entered into a written agreement pursuant to Section 221 of the Flood Control Act of 1970, wherein the County agreed to furnish its required cooperation for the Project to include the provision of lands, easements and rights of way, and with regard to any case where hazardous substances regulated under the Comprehensive Environmental Response, Compensation and Liability Act (CERCLA), 42 U.S.C. 9601-9675, are found to exist on any lands necessary for the project, to be responsible for any and all necessary cleanup and response costs, including the costs of any studies and investigations necessary to determine an appropriate response to the contamination; and, WHEREAS, Engineer Regulation (ER) 1165-2-30, ACCEPTANCE AND RETURN OF REQUIRED, CONTRIBUTED, OR ADVANCED FUNDS FOR CONSTRUCTION OR OPERATION, allows acceptance by the Government of funds from the County for the purpose of conducting lands, easements, rights of way acquisitions or relocation activities, 2 required to be provided by and which are the obligations of local interests pursuant to the terms of local cooperation for the project; and, WHEREAS, by letter dated June 25, 1993, the County requested the Government to assist it in developing and executing a response plan to remediate subsurface contaminants regulated under CERCLA from certain lands which are part of the Project site and necessary to the Project; and, WHEREAS, by letter dated the County certified to the Government that it cannot procure the requested assistance reasonably or expeditiously through ordinary business channels; and WHEREAS, the County has the necessary funds to fully finance the requested assistance; NOW THEREFORE, the parties agree as follows: ARTICLE I - DEFINITIONS For the purposes of this Agreement, the term "Response Costs" shall mean all disbursements by the Government pursuant 3 to this Agreement. Such costs shall include, but not be limited to: labor charges, direct costs, overhead expenses, supervision and administration costs, contracts with third parties including termination and/or suspension costs, and any termination or suspension costs (ordinarily defined as those costs necessary to terminate ongoing contracts or obligations and to properly safeguard the work already accomplished) associated with this Agreement. ARTICLE II - OBLIGATION OF THE PARTIES a. The Government, using funds provided by the County, shall expeditiously prosecute and complete the response assistance substantially in compliance with ARTICLE III herein, and in conformance with applicable Federal, State, and local laws and regulations, and mutually acceptable standards of engineering and construction practice. The Government shall adhere to the schedule and work within the allotted schedule as much as practicable. b. The County, or the State of Hawaii on the County's behalf, shall deposit funds for developing and executing the response plan with the Government prior to commencement of work. Such deposit shall be made by cash or check made payable 4 to "FAO USAED, Pacific Ocean." These costs are currently estimated at $500,000 based on Appendix A, Scope of Work. The County shall pay the Government its actual costs incurred in developing and executing the response plan. In the event additional funds are required, the County shall provide such additional funds prior to the Government incurring any costs or performing any work in excess of the amount previously provided by the County. ARTICLE III - SCOPE OF WORK The Government will provide the requested response assistance to the County prior to and during construction of the Project in accordance with the scope of work attached hereto and incorporated herein as Appendix A. ARTICLE IV - RIGHTS OF ENTRY In the event that public access is not available, the County shall furnish to the Government any rights of entry to lands required for the development and execution of the response plan, together with evidence supporting the County's legal authority to grant such rights of entry. 5 ARTICLE V - DISPUTES Before either party to this Agreement may bring suit in any court concerning any issues relating to this Agreement, such party must first seek in good faith to resolve the issue through negotiation or other form of nonbinding alternative dispute resolution mutually acceptable to both of the parties. Pending final decision of a dispute hereunder, or pending suspension or termination of this Agreement under Article IX herein, the parties hereto shall proceed diligently with the performance of this Agreement. ARTICLE VI - CHOICE OF LAW This agreement and all rights and duties hereunder shall be interpreted in accordance with the applicable statutes, regulations, executive orders, and decisions of the United States of America, its branches, departments, agencies and instrumentalities. ARTICLE VII - MAINTENANCE OF RECORDS 6 The Government and the County shall keep books, records, documents and other evidence pertaining to costs and expenses incurred pursuant to this Agreement to the extent and in such detail as will properly reflect total response costs. The Government and the County shall maintain such books, records, documents and other evidence for a minimum of three years after completion of the remediation of subsurface contamination and resolution of all relevant claims arising therefrom, and shall make available at their offices at reasonable times, such books, records, documents, and other evidence for inspection and audit by authorized representatives of the parties to this Agreement. ARTICLE VIII - RELATIONSHIP OF THE PARTIES The parties to this Agreement act in an independent capacity in the performance of their respective functions under this Agreement, and neither party is to be considered the officer, agent, or employee of the other. ARTICLE IX - RELEASE OF CLAIMS The County will hold and save the Government, its officers and employees, free from all claims for damages 7 arising from the performance of the work done under this Agreement. ARTICLE X - OFFICIALS NOT TO BENEFIT No member of or delegate to the Congress, or Resident Commissioner, shall be admitted to any share or part of this Agreement, or to any benefit that may arise therefrom. No elected or appointed official of the County of Hawaii shall be admitted to any share or part of this Agreement, or to any benefit that may arise therefrom. ARTICLE XI - COVENANT AGAINST CONTINGENT FEES The County warrants that no person or selling agency has been employed or retained to solicit or secure this Agreement upon agreement or understanding for a commission, percentage, brokerage, or contingent fee, excepting bona fide employees or bona fide established commercial or selling agencies maintained by the County for the purpose of securing business. For breach or violation of this warranty, the Government shall have the right to annul this Agreement without liability or in its discretion to add to the Agreement or consideration, or 8 otherwise recover, the full amount of such commission, percentage, brokerage, or contingent fee. ARTICLE XII - TERMINATION OR SUSPENSION OF AGREEMENT Either party may terminate or suspend this Agreement without penalty upon a thirty day written notice to the other party. The termination or suspension shall be effective upon the thirtieth day following receipt of such notice, unless otherwise provided in the written notice, except that the Government's costs incurred through the termination or suspension effective date and those reasonably incurred in connection therewith shall be paid. ARTICLE XIII - NOTICES Any written notice required to be given by a party to this Agreement will be deemed to have been duly given if in writing and delivered personally, given by prepaid telegram or mailed by first class (postage prepaid) registered or certified mail as follows: 9 If to the County: Office of the Mayor County of Hawaii 25 Aupuni Street, Room 213 Hilo, Hawaii 96720 If to the Government: District Engineer United States Army Corps of Engineers Honolulu Engineer District Building 230 Fort Shafter, Hawaii 96858-5440 ARTICLE XIIZ - EFFECTIVE DATE This Agreement shall be effective immediately upon signature of both parties. FOR THE COUNTY: Date STEPHEN K. YAMASHIRO Mayor County of Hawaii State of Hawaii FOR THE GOVERNMENT: Date M. BRUCE ELLIOTT Lieutenant Colonel, USA District Engineer U.S. Army Engineer District, Honolulu l0 CERTIFICATE OF AUTHORITY I, Richard D. Wurdeman, do hereby certify that I am the principal legal officer of the County of Hawaii, that the County of Hawaii is a legally constituted public body with full authority and capability to perform the terms of the Agreement between the United States Army of America and the County of Hawaii, and that the person who executed the Agreement on behalf of the County of Hawaii has acted within his statutory authority. In Witness Whereof, Z have made and executed this Certificate this day of , 1993. RICHARD D. WURDEMAN Corporation Counsel County of Hawaii 11 STATE OF HAWAII ) SS. COUNTY OF HAWAII ) On this day of personally appeared STEPHEN K 1993, before me YA1~.ASHZRO, to me personally known, who, being by me duly sworn, did say that he is the Mayor of the County of Hawaii, a municipal corporation of the State of Hawaii; that the seal affixed to the foregoing instrument is the corporate seal of the said County of Hawaii; that the foregoing instrument was signed and sealed in behalf of the County of Hawaii by authority given to said Mayor of the County of Hawaii by Section 5-1.3(g) of the County Charter, County of Hawaii (1991), as amended; and said STEPHEN K. YAMASHIRO acknowledged said instrument to be the free act and deed of said County of Hawaii. Notary Public, State of Hawaii My commission expires: SCOPE OF WORK BIOTECHNOLOGY STIIDY FOR SIIBSIIRFACE CONTAMINATION ALENAIO STREAM FLOOD CONTROL PROJECT HILO, ISLAND OF HAWAII, HAWAII JIILY 28, 1993 (CONTRACT N0. DACA83-92-D-0011, Delivery Order 0015) 1. LOCATION. The study area is located on Figure 1, in Hilo, Island of Hawaii, Hawaii. 2. AIITHORITY. Not applicable. 3. PIIRPOSE. The purpose of this delivery order is to conduct a biotechnology study for the Alenaio Flood Control Project. The study shall focus on the fuel contaminated soil located within the project boundaries of the flood control project. This delivery order shall include developing a remediation work plan to cleanup the petroleum contaminated site using a cost effective method. The technology shall meet all Federal, State or Local laws and/or regulations. Consideration should be given to the use of bioremediation. 4. GENERAL WORK TASRS. a. The Contractor shall prepare a safety and health plan for remedial action phase of the project. b. The Contractor shall prepare a work plan. c. The Contractor shall implement the work plan. d. A draft and final report shall be prepared. 5. Detailed Work Tasks. a. The Contractor shall prepare a safety and health plan for remedial action phase of the project. The Contractor shall prepare and submit a site specific safety plan to the Contracting Officer for review and acceptance. No field work may be performed until the safety plan is reviewed and accepted by the Contracting Officer's Representative (COR) at least fourteen days before the implementation of the action. All work shall be performed according to the accepted plan. The safety plan shall be prepared in accordance with the requirements specified in Appendix A. b. The Contractor shall prepare a work plan. (1). Background. The Contractor shall prepare a work plan that details the cleanup process. The process ~lP°~IVDIX °'/~a°' shall consider using bioremediation as a cleanup technology for soil contaminated with petroleum product. Information about the soil contamination has been documented in a report prepared by Woodward-Clyde Consultants in 1992. The report estimates that two major areas of the site were contaminated. Area A encompasses the site of the former Hilo Gas Company where it is believed that there were uncontrolled releases of hydrocarbons. The contamination has been described as consisting of heavy and tar-like material with a distinct naphthalene odor. The contamination appears to be present from the soil surface to approximately 8 feet below ground surface (bgs) and consists of total hydrocarbon petroleum (TPH), BTEX (benzene, ethylene, toluene, and xylenes) and polycyclic aromatic hydrocarbons (PAH) One sample from that area is reported to have lead contamination of 150 milligrams/kilograms (mg/kg) The estimated volume of contaminated soil in this area is 4,300 cubic yards. Contamination in Area B is described as weathered diesel and does not appear to extend appreciably below the water table. Elevated BTEX were reported in a soil sample. The estimated volume of contaminated soil is 450 cubic yards. Area C also contains contamination and may also require remediation. (2). Work Plan. The work plan shall include the following: (a). A pilot study that addresses injection point and piezometer installation, groundwater flux estimate, soil analyses including lead, iron, COD (chemical oxygen demand), BOD (biochemical oxygen demand), TKN (total Kjeldahl nitrogen), TP (total phosphorus), and TOC (total organic carbons), pilot operation and data acquisition, data analyses, and a report. (b). A plan that details the process using maps, figures, and drawings. It shall consider using an in situ bioremediation approach without augmenting the contaminated soil with alien microorganisms to initiate the bioremediation process; tilling soils between 0 and 1.5 feet bgs in Areas A, B, and C periodically in place to deliver oxygen to the surficial soil to initiate microbial degradation of organic compounds; adding nutrients such as ammonia and phosphorus, if necessary with controlled-release nutrient pellets; installing a series of injection ports along the upgradient extent of soil contamination and injecting air into the subsurface for contaminated soils in areas A and C that are 1.5 feet to approximately 8 feet bgs; establishing a soil monitoring program to assess the performance of the two bioremediation systems; and detailing the regulatory concerns which may entail designating the contaminated areas of the project sites as a Corrective Action Management Unit (CAMU) if it is a RCRA (Resource Conservation and Recove^,~ Act) site. (c) work that details the permit process, mobilization, installation, startup and shakedown and demobilization. (d). Operation and monitoring activities that include performance sampling, soil disposal options, and any placement of residually affected soils on the in situ land treatment area, and off-site but on-island disposal. A draft work plan shall be submitted for review and comments. The final work plan shall be approved by the COR prior to its implementation. c. The Contractor shall implement the work plan. The Contractor shall follow approved work plan by the COR. Anv deviation or changes from the work plan shall be first approved by the COR prior to implementation. The levels of cleanup shall be in compliance with regulatory requirements. Any changes to the work plan shall be approved prior to any implementation. The Contractor shall notify the Government at least two weeks before this phase is implemented. d. Prepare Draft and Final Reports. The Contractor shall document the study phases by providing a written narrative of the action and shall contain the proper manifesting if appropriate. All reports shall be submitted to the U.S. Army Corps of Engineers, Pacific Ocean Division, ATTN: CEPOD-ED-E, Building 223, Fort Shafter, Hawaii 96858- 5440. Each final draft shall be accompanied by an original camera-ready copy but also one copy on Multimate or Microsoft WORD, MS-DOS compatible 5.25 inch floppy diskette. 6. PERIOD OF CONTRACT AND SCHEDDLE. The contractor shall use the following schedule: MAX CALENDAR ESTIMATED PROJECT DAYS AFTER WORlS COORDINATION MILESTONE NTP COMPLETED ACTION Submit Safety 30 10 Report health plan Submit draft 30 20 Report work plan Submit final 60 25 Report work plan Accept safety/health plan Implement biotechnology Complete biotechnology Submit draft report Submit final report 60 25 Letter 74 30 Conference, if needed 240 90 Study completed 270 95 Report 300 100 Report 7. EQIIIPMENT. Unless otherwise specified in the delivery order, all equipment and supplies shall be provided by the Contractor. 8. REPORT FORMAT. a. Draft Report. Ten (10) copies of the draft report shall be submitted to the Contract Monitor to allow for review of format, content, and compliance with applicable contract provisions. The draft report shall be returned to the Contractor for finalization. Photographs included in the draft EA need only be good quality photocopies. b. Final Report. Twenty (20) copies plus an original of the final report shall be submitted to the Government. The final report shall be on 8 1/2" X 11" page size and be suitable for bindings along the left hand margin. Stapling of the report shall not be acceptable. Text and line drawings shall be clean, clear, and easily reproducible. All maps shall contain a scale in feet. The original copy, including the photographs shall be suitable for reproduction and shall not be bound. Laser or color reproduction of photographs are permissible. c. The Government expects that the Contractor shall properly, appropriately, and adequately include and thoroughly investigate most areas and sources of information pertinent to an objective analysis and investigation as specified in the Scope of Work. The report and execution of the project shall be accomplished in an objective and dispassionate manner clearly delineating fact and opinion. All technical terms used in data, methods, and conclusions shall be based on professional judgments of recognized experts in the field. 9. MEETINGS AND COORDINATION. Conference shall be held between the Contractor and the Contracting Officer or his representatives to resolve contractual difficulties, to brief the Contracting Officer or his representative of significant environmental problems and to notify the Contracting Officer, immediately, if necessary. 10. SPECIAL CONDITIONS. a. Professional Qualifications. The Contractor must have expertise to perform the specified work tasks, analyze and report the results of the work tasks and be recognized in the community as an authority in hazardous/toxic wastes or environmental studies. The Contractor must be able to provide a principal investigator with the qualifications indicated below who shall conduct the study described in the Scope of Work and who shall be responsible for validity of the materials presented in his/her report. The following qualifications shall be required: (1) The principal investigator (PI) shall have at a minimum a masters degree in planning, biological or physical sciences, or engineering. (2) The principal investigator shall have at least five years of experience in the hazardous/toxic wastes and/or environmental sciences. b. The Contractor shall assure the Government that enough trained personnel to conduct field investigations, analyze data and prepare the reports are provided. A list of such personnel and brief descriptions of their expertise shall be provided to the Government. Any changes to key personnel shall be in writing to the Government. c. Safety. The Contractor shall assure the Government that all appropriate safety standards and regulations are complied with during the performance of the Scope of Work. The Contractor shall be responsible for sufficiently ensuring that no'safety hazards are caused by his/her actions. d. Spill Responsibility. (1). The Contractor is solely responsible for any and all spills or leaks during the performance of the contract and shall clean up such spills or leaks to the satisfaction of the COR. All spilled material and any contaminated materials resulting from the spill shall be disposed of by the Contractor at no expense to the Government. (2). The Contractor shall report all spills, regardless of quantity and all personnel exposures which arise out of the performance of this contract. Such spills and personnel exposures shall be reported first by telephone immediately following the incident and shall be followed up in writing no later than seven days after the initial telephonic report. When reporting a spill, the following information shall be furnished: (a). Item spilled (identification, quantity and manifest numbers, if any). (b). Whether amount spilled is EPA reportable, and if reported, a copy of the report. (c). Exact location of spill. procedures. (d). Containment procedures initiated. (e). Anticipated clean up and disposal (f). Disposal location of spill residue. e. The Contractor is responsible for assuring that all federal, state and/or local laws and requirements are met. Any unauthorized disposal shall be corrected at no cost to the Government. f. Down Time. Down time shall be defined as time when the equipment is broken down, or work is delayed by adverse weather conditions, shipping inadequacies, or insufficient coordination/support prevents continuous field operation. The Contractor shall not be compensated for down. time. Q. Inauraace. The Contractor shall have at least one million dollars per incident and two million dollars per aggregate of pollution liability insurance. h. Other Requirements. (1) During the progress of the work, the Contractor may be called upon by the Government to produce preliminary study data and information that is deemed necessary to satisfy Government needs. The Contractor shall provide data from this project to the extent that such requests do not detract from the contractual objectives of the study. (2). The Contractor shall be responsible for accuracy and validity of the data. In the event of controversy or court challenge of the report(s), the PI(s) may be placed under contract by the Government to testify on behalf of the Government in support of report(s) findings. (3). The Contractor shall be expected to properly, appropriately, adequately, and thoroughly investigate all areas and sources of information pertinent to the objective analysis of the work tasks specified in this Scope of work. The report and execution of investigation shall be done in an objective and dispassionate manner delineating fact and opinion. Interpretation shall be presented as arguments clearly identifying assumptions, premises, biases, and logic. Hypotheses shall be identified as such. All technical terms used in the report shall be defined. Concise, but ccmplete description detailing the data, methods, conclusions, and recommendations shall be based on professional judgments of recognized experts in their field of research. 11. PAY2~NTS. The Contracting Officer requires that Contractor billings be submitted by the 15th of each month and accompanied by a summary of work performed during the billing period. 12. CONTRACTOR RELEASE. The Contractor is required to submit his/her written and signed "Release of Claims" form to the Contracting Officer with his/her final bill for service rendered under the terms of this contract. 13. RELEASE OF INFORMATION. The information developed, gathered, and assembled in fulfillment of the contract required as defined in or related to the Scope of work shall not be released by the Contractor, his/her .consultants, his/her subcontractors or their associates without prior coordination and approval by the Contracting Officer or his/her designee. 14. IISE OF INFORMATION. The information developed, gathered, and assembled in fulfillment of the contract requirements as defined or related to the scope of Work will become the complete property of the Government and shall, therefore, not be used by the Contractor for any purpose at any time without the written consent of the Contracting Officer. 15. CONTRACT EXECIITION AND REPORTS. The Contractor is expected to develop an objective final product for fulfillment of the terms of the contract. The Government expects that the Contractor shall properly, appropriately, and adequately include and thoroughly investigate all areas and sources of information pertinent to the objective analyses of the areas specified in the Scope of Work. s-~ Haane~o~ _ . /. '.Il _ _'~ - - ' :pig,„ '-s=h _ - -~ .. 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I~ i I .* III F~} ~~ s \ ~ ~^~~~a...lh~ yV ~ t II u.~ / J ~ ~ r pEEt~ , LShbo~®~ ~ No ~' `a l 'c ~ ~ ? o, r H ~ ~ \ ~ ~ C o b ~~~~ o. . l ~ s~ .] 1 \tlp \ 0 10 ~ F l ~ I /1 ~ P ~ STREET ~ , / II I\ (~ PJ~ FLS~T 4NRULA ST Y ~i Y bP'a ~ 1 ~..'q -I-- ~I~ _ REBEAV CE P ~ ~.. ~ I II./~ V P ~~~~I CaI ge eo L ~ ~ _ ~~ ~ \ESti'' ~p 1 \o ~ BM 4 \~ ~ I II~ / / ~ 0' ~ / ~= • \ P -~ ~~ Baf.a oLH.waii ~ • ~ ~ o ( J Cam~tisl~ ~ ~ Y ~ `\ I ~~ ° ~ ~: ~ •~, to ~T .~ 1 p .. -~ .,,.. ~ ~ W W W ' Yom---~vakea H~g~ 2 41 ~ ~ ~;~ ~ mp~. ~ r- .0 7% ~ ~ -,R. ~ rwol yo i n /: nu Project No. ALENAIO STREAM SUBSURFACE 91C0499L HYDROCARBON INVESTIGATION PROJECT SITE LOCATION Fi¢ure _WOODWARD-CLYDE CONSULTANTS 1 APPENDIX A SAFETY, HEALTH AND EMERGENCY RESPONSE 1. N,!?A,. The most important consideration to be regarded throughout all aspects of the activities to be performed is the safety and health of all on-site personnel and the surrounding community. Accordingly, the Contractor shall review all information provided and develop the necessary documents which contain the safety and health criteria, procedures, and practices sufficient to protect on-site personnel, the environment, and the potential off-site receptors from the chemical, physical and biological hazards particular to any site. 1.1 The Contractor shall utilize the services of a Certified Industrial Hygienist (CIH) experienced in hazardous waste site operations and remediation to oversee the development and implementation of the health and safety documents required by this section. On-site implementation and continual enforcement of the safety and health documents may be delegated to a qualified Site Safety and Health Officer who is responsible to the CIH and Contractor. 1.2 If the information made available is insufficient to allow the Contractor to develop these documents, a description of all additional information required shall be prepared and submitted to the Contracting Officer (CO). 1.3 If explosive contamination or unexploded ordnance is discovered at any time during work operations at the site, the Contractor shall mark the location, immediately stop operations in the affected area, and notify the CO. 2. REGULATORY REQUIREMENTS. All safety and health documents required by the scope of work shall comply with and reflect the following regulations and appropriate guidance publications, as a minimum: 2.1 Federal Acquisition Regulation, F.A.R. Clause 52.236-13: Accident Prevention. 2.2 U.S. Army Corps of Engineers (USAGE) Safety and Health Requirements Manual, EM 385-1-1 (latest revision). 2.3 Occupational Safety and Health Administration (OSHA), Construction Industry Standards, 29 CFR 1926, and General Industry Standards, 29 CFR 1910; especially 29 CFR 1910.120 - "Hazardous Waste Site Operations and Emergency Response". 2.4 NIOSH/OSHA/USCG/EPA, "Occupational Safety and Health Guidance Manual for Hazardous Waste Site Activities", October 1985. 2.5 Other applicable Federal, State, and local safety and health requirements. 2.6 Where conflicts arise between requirements of the above list, the most restrictive of the requirements shall be followed. 3. DOCUMENTS. The Contractor shall develop a Safety and Health Program for all work under the contract and a Site Specific Safety and Health Plan for each delivery order involving site investigations or remediation. Avoid providing materials of a general nature and not specifically related to this project. Information readily available in standard texts shall be repeated only to the extent necessary to make the document self sufficient. 3 . 1 SAFETY Aim HFAT TH pR0('R r^, Contractors performing on-site activities at hazardous waste sites are required by regulation to develop and maintain written Safety and Health Program in compliance with OSHA standard 29 CFR 1910.120(b)(1) through (b)(4). All subcontractors shall comply with the prime contractor's Safety and Health Program (SHP) Written certification that such a program has been prepared and implemented shall be submitted to the CO as a preface to required site specific Site Safety and Health Plans. The Safety and Health Program shall be made available in its entirety to the CO upon request. 3.2 S'TTF SPFC'TF T(' SAFFTY T~ F'FAT TF pr AT~T (SSHP) A SSHP shall be prepared by the Contractor as required by 29 CFR 1910.120(b)(4) and submitted to the CO for review and approval prior to commencement of any site activities. The SSHP shall describe the health and safety procedures, practices, and equipment to be implemented and utilized in order to protect affected personnel from the potential hazards associated with the tasks to be performed. The level of detail provided in the SSHP shall be tailored to the type of work, complexity of operations to be accomplished, and hazards anticipated. All topics required by OSHA standard 1910.120(b)(4), and those described below shall be addressed in the SSHP. Where the use of a specific topic is not applicable, it shall be so noted in the plan, and a brief justification made. The SSHP shall include the elements outlined below, as a minimum: 3 .2 . 1 STTE DFS('RrPTTON nnm rO~rTz,n TNATrn i C'N~R ~C'TFRT7 z~TTnnr 3.2.1.1 Describe the site location, topography, approximate size of the site, the on-site jobs/tasks to be performed, and the duration of planned site activities. 3.2.1.2 Compile a complete list of the contaminants found or known to be present in site areas to be impacted by the work to be performed. This list shall be ,based on results of previous studies. If previous studies are not available, select the likely contaminants based on site history and prior site uses or activities. Include chemical names, concentration ranges, media in which found, locations on site,and estimated quantities/volumes to be impacted by the work. Copies of Material Safety Data Sheets (MSDS) for each known suspected contaminant shall be included in the SSHP. 3.2.2 j~ZARD ASSFS4MF1\rT Ait RTST. nnrA `STS Identify the chemical, physical, biological, and safety hazards of concern for each site task and/or operation to be performed. Selection of chemicals as indicators of hazard shall be based on media concentrations, toxicity, volatility or potential for air entrainment at hazardous levels, and frequency of detection. Describe chemical and physical properties of selected contaminants, sources and pathways of employee exposures, anticipated on and off-site exposure level potentials, and regulatory (including Federal, State and local) or recommended protective exposure standards. Specify and justify "action levels" based upon airborne exposure hazards and direct skin contact potentials for upgrades/downgrades in levels of personnel protection; for implementation of engineering and/or work practice controls; for emergency evacuation of on-site personnel; and for the prevention and/or minimization of public exposures to hazards created by site activities. Air monitoring/sampling shall be performed in accordance with Paragraph 3.2.8 below and resulting data compared with established action levels, and appropriate corrective actions initiated as necessary. 3.2.3 ACCT NT PRFt~Ft~rmT ~r~, The SSHP will serve as the Accident Prevention Plan (APP) and Activity Hazard Analyses (AHA), required by F.A.R. Clause 52.236-13, and Paragraphs O1.A.03 through O1.A.06 and Appendix Y of USACE EM 385-1-1. Thus a separate APP is not necessary for those topics required in Paragraphs 3.2.1 through 3.2.16 in this scope of work. 3.2.3.1 Any additional topics required by EM 385-1- 1, but not specifically covered in Paragraphs 3.2.1 through 3.2.16 of this scope of work, shall be addressed in the Accident Prevention section. A copy of the Accident Prevention Plan (POD Form 248- R) is provded as Enclosure 1. Appendix Y of USACE EM 385-1-1 contains a format for an Activity Hazard Analysis _(AHA) A copy of the AHA format (POD Form 184-R) is provided as Enclosure 2. The AHA describes each step in a phase of work, the chemical and/or physical hazard(s) associated with that action and methods to control the hazard. 3.2.3.2 Material Safety Data Sheets (MSDS). MSDS for each known suspected contaminant shall be included in the SSHP. MSDS for OSHA Hazardous Chemicals shall also be included in the SSHP. 3.2.3.2 The Contractor shall conduct daily safety and health inspections to determine if operations are being conducted in accordance with the SSHP, USACE and OSHA regulations, and contract requirements. 3.2.3.3 In the event of an accident/incident, the contractor shall immediately notify the COR. The contractor shall furnish the Safety Office Immediate Report of Accident to the COR within 24 hours. A copy of the Safety Office Immediate Report of Accident (POD Form 265) is provided at Enclosure 3. 3.2.3.4 Within two (2) working days of any reportable accident the contractor shall complete and submit to the COR an Accident Report on ENG Form 3394 in accordance with AR 385-40 and the USACE Supplement 1 to that regulation. The ENG Form 3394 shall be submitted any time there is: (1) an occupational illness/injury resulting in a lost work day, excluding the day of injury; (2) a fatality, permanent disability, or five (5) or more persons hospitalized; (3) $2,000.00 or more property damage; or, (4) when directed by the CO. A copy of ENG Form 3394 is provided at Enclosure 4. 3 .2 .4 ST?.FF rR , 1iT ~1mTON O Tnr TFr~nmTrlnrc nnm RESPONSIBILITIES. Discuss the organizational structure, including lines of authority, and overall responsibilities of the contractor, subcontractors, supervisors and employees for site activities. The operational and safety and health responsibilities and qualifications of each key person shall be identified and summarized. Specifically: 3.2.4.1 A Certified Industrial Hygienist (CIH) with experience in hazardous waste site operations shall be responsible for the development, implementation, and oversight of the Safety and Health Program and the Site Safety and Health Plan. All Site Safety and Health Plans shall be signed and dated by the CIH prior to submittal. 3.2.4.2 ~: fully trained and experienced Site Safety and Health Officer (SSHO), responsible to the contractor and the CIH, may be delegated to implement and continually enforce the Safety and Health Program and site-specific plan elements on- site. The SSHP shall provide evidence of related safety and health training received by the SSHO which qualifies him/her as a competent person.. 3.2.4.3 At least two individuals certified in first aid/CPR by the Red Cross, or equivalent agency, shall be present on site during all on-site operations. 3.2.5 TRAINING. All personnel performing on-site activities shall have completed applicable training in accordance and compliance with 29 CFR 1910.120(e). In addition, site-specific training covering site hazards, procedures, and all contents of the approved SSHP shall be conducted by the SSHO for on-site employees and visitors prior to commencement of work or entering the site. The type (including initial, supervisory, refresher, site- specific, and first aid/CPR), duration, and dates of all employee training performed shall be listed by employee name and certified in the SSHP. Copies of training certificates may be submitted in place of the listing. 3.2.6 PERSONAL PROTE TTV EO rpMENT (PPE). A written Personal Protective Equipment (PPE) program which addresses all the elements listed in 29 CFR 1910.120 (g)(5) and 29 CFR 1910.134 is required. Describe the minimum PPE ensembles (including respirators) and specific materials from which PPE components are constructed for Pa h s;ra-~„A~;F;.- task/on r ;on to h n rm d, based upon the hazard/risk analysis performed above. Components of levels of protection (A,B,C,D and modifications) must be relevant to site-specific conditions, including heat stress potential and safety hazards. Include site-specific procedures for PPE selection, fit-testing, cleaning, maintenance and storage, inspection, and determinations of program effectiveness. 3.2.6.1 For air supplied respirators, specify if the air compressor is oil-lubricated or oil-free. Follow carbon monoxide and thermal alarm requirements as outlined in EM 385-1-1 Section 07.B.10. Provide the COR with a copy of certification of analysis indicating that breathing air meets Type 1, Grade D as described in the Compressed Gas Association Commodity Specification for Air. 3.2.7 MEDICAL S RV T AN~r. All personnel performing on-site activities shall be participants in an ongoing medical surveillance program meeting the requirements of 29 CFR 1910.120 and ANSI Z-88.2 All medical surveillance protocols and examination results shall be reviewed by a licensed physician who is certified in Occupational Medicine by the American Board of Preventative Medicine, or caho, by necessary training and experience, is Board- eligible. In consultation with such an occupational physician, the contractor shall specify the minimum content and frequencies of necessary medical test/examination/consultations-based upon probable site conditions, potential occupational exposures and required protective equipment to be utilized. Certification of participation in the medical surveillance program, the date of last examination, and name of reviewing occupational physician shall also be included for each affected employee. The written medical opinion from the attending physician required by 29 CFR 1910.120 (f)(7) shall be made available upon request to the CO for any site employee. 3.2.8 F.XPOSURF MONITORING/AIR S A"P TNr pR0 RAr`. (Personal and Environmental). Where it has been determined that there may be employee exposures to and/or off-site migration potentials of hazardous airborne concentrations of hazardous substances, appropriate direct-reading (real-time) air monitoring and integrated [time-weighted average (TWA)] air sampling shall be conducted in accordance with applicable regulations (OSHA, EPA, State). Both types of air monitoring must accurately represent concentrations of air contaminants encountered on and leaving the site. 3.2.8.1 Sampling and analytical methods following NIOSH (for on-site personnel and site perimeter locations) and/or EPA (for site perimeter or off- site locations) criteria shall be appropriately utilized. Personnel samples shall be analyzed only by laboratories successfully participating in and meeting the requirements of the American Industrial Hygiene Association's (AIHA) Proficiency Analytical Testing (PAT) or Laboratory Accreditation programs. Meteorological monitoring shall be performed on-site as needed and used as an adjunct in determining perimeter and any off-site monitoring/sampling locations. 3.2.8.2 Where perimeter monitoring/sampling is not deemed necessary, provide a suitable justification for its exclusion. 3.2.8.3 Noise monitoring and radiation monitoring (alpha, beta, gamma) shall be conducted as needed, depending on the site hazard assessment. 3.2.8.4 All monitoring/sampling results shall be compared to "action levels" established pursuant to Paragraph 3.2.2 above to determine acceptability and need for corrective action. 3.2.8.5 M~nitorina EQ7;DmPn A list of the field instruments to be used by the Contractor specifying manufacturers, models, accessories, frequency of use, etc., with the procedures used for calibration and frequency of checks shall be included in the SSHP. The Contractor shall calibrate field monitoring equipment each day prior to commencement of work and after work is completed. 3.2.9 H AT/ OLD TRESS MONTTORrN~. Heat and/or cold stress monitoring protocols shall be specified and implemented, as appropriate. Work/rest schedules shall be determined based upon ambient temperature, humidity, wind speed (wind chill), solar radiation intensity, duration and intensity of work, and protective equipment ensembles. Minimum required physiological monitoring protocols which will affect work schedules shall be developed. In cases where impervious clothing is worn (full-body), the NIOSH/OSHA/USCG,EPA "Occupational Safety and Health Guidance Manual for Hazardous Waste Site Activities" protocol for prevention of heat stress shall be followed, and heat stress monitoring shall commence at temperatures of 70 degrees Fahrenheit and above. Where impervious clothing is not worn, the most current published ACGIH heat stress standard (TLV) shall be used. At locations where ambient temperatures fall below 40F cold stress monitoring shall reference and use standards in the most current ACGIH TLV and BEI Booklet. 3 .2 .10 STA?~TDARD OP RATTNC' 4AF°TY PRO D iRFS FNC'TNFERTN(' C'ONTR ~ N ti RK PRA, `7'Tr~S. The performance of project-specific work tasks shall implement applicable criteria of Paragraph 2 (Regulatory Requirements) to protect personnel from safety and health hazards and exposure to hazardous substances. 3.2.10.1 Address the following elements as appropriate for project-specific work tasks: (1) Site rules/prohibitions (buddy system, eat/drinkJsmoking restrictions, etc.); (2) Material handling procedures (soils, liquids, radioactive materials); (3) Drum/container handling procedures and precautions (opening, sampling, overpacking); (4) Confined space entry procedures; (5) Hot work, sources of ignition, and electrical safety (ground- fault protection, overhead power line avoidance, etc.); (6) Excavation safety; (7) Machine guarding; (8) Fall protection; (9) Hand/power tools; (10) Machinery and mechanized equipment; (11) Marine operations; (12) Engineering controls; (13) Disposal of hazardous waste; (14) Illumination; and (15) Sanitation. 3.2.10.2 Where work phases or tasks, hazards and controls have been addressed using the Activity Hazard Analyses format described in paragraph 3.2.3.1, duplication under this paragraph is not required. 3.2.11. SITE CONTROL MEA R 4, Include a site map, work zone identification and access points. Describe on and off-site communications, security (physical and procedural), and general site access. 3.2.12 PERSONA HYCT N ND D ONT MTNATTON, Specify necessary facilities and their locations. Detail procedures, frequencies, supplies and materials to accomplish decontamination of site personnel. The Contractor shall be responsible for proper disposal of all decontamination water. 3.2.13 EOtirorgFMrT DF ONTAMrniATTON. Specify necessary facilities, equipment and their locations. Detail procedures, frequencies, supplies and materials, and methods to determine adequacy for the decontamination of equipment used on-site. The Contractor shall be responsible for proper disposal of all decontamination water. 3.2.14. EMER(; N Y FOtirpM NT ism FrR T Arn REOtiTRFMF.NTS. The following items, as a minimum and appropriate shall be immediately available for on- site use: (1) First aid equipment and supplies approved by the consulting physician; (2) Emergency eyewashes/showers which comply with ANSI Z-358.1; (3) Emergency-use respirators (worst case appropriate); (4) Spill control materials and equipment; and (5) Fire extinguishers (specify type, size, and locations in SSHP). 3.2.15 EMERGENCY RESDONSE PLitiJ z~riD ODiTIDT EN Y PROCEDURES ( N-SITE A_niD OFF SITE). The Contractor shall contact local fire/police/rescue authorities having jurisdiction and nearby medical facilities that would be utilized for emergency treatment of injured personnel in order to notify them of upcoming site activities and potential emergency situation; to ascertain their response capabilities; and to obtain a response commitment. 3.2.15.1 An Emergency Response Plan, which complies with 29 CFR 1910.120 (1), shall be developed and implemented which addresses the following elements, as a minimum: (1) Pre-emergency planning and procedures for reporting incidents to appropriate government agencies for potential chemical exposures, personal injuries, fires/explosions, environmental spills and releases, discovery of radioactive materials; (2) Personnel roles, lines of authority, communications; (3) Posted instructions and list of emergency contacts: physician/nearby medical facility, fire and policy departments, ambulance service, state/local/federal environmental agencies, CIH, Contracting Officer; (4) Emergency recognition and prevention; (5) Site topography, layout, and prevailing weather conditions; (6) Criteria and procedures for site evacuation (emergency alerting procedures/employee alarm system, emergency PPE and equipment, safe distances, places of refuge, evacuation routes, site security and control); (7) Specific procedures for decontamination and medical treatment of injured personnel; (8) Route maps to nearest pre-notified medical facility; (9) Criteria for initiating community alert program, contacts, and responsibilities; and (10) Critique of emergency responses and follow-up. 3 . 2 , 16 T O ,S RFPnRmc nnm pFrnvnvro~-••~ The following logs, reports and records shall be developed, retained and made available to the COB and entitled regulatory agencies upon request (unless otherwise noted in previous sections): (1) Training logs including employees printed name and signature in addition to training subject and date, or copy of applicable training certificate: (2) Daily safety inspection logs (may be part of Daily QC Reports): (3) Employee/visitor register; (4) Medical opinions/certifications; (5) Environmental and personal exposure monitoring records; (6) Phaseout reports (final decontamination verification certificates, summary of air monitoring data, etc.). All personnel exposure and medical monitoring records shall be maintained in accordance with applicable OSHA standards, 29 CFR 1910 and 1926. 4. CO-APPROVED VISITOR . 4.1 Government visitors. All USACE contractors shall continuously maintain on-site a minimum of two (2) sets of protective equipment (except for air- purifying respirators, prescription safety glasses, and safety shoes) for government visitor usage. These ensembles shall include all PPE specified in the SSHP Paragraph 3.2.6. 4.2 Other visitors. The Contractor shall ensure that other site visitors are approved by the CO and comply with requirements of the SSHP. ACCIDENT PREVENTION PROGRAM ADMINISTRATIVE PLAN WILLINGNESS TO CORRECT SAFETY HAZARDS DETECTED BY THE CORPS JS COMMENDABLE, BUT A POOR SUBSTITUTE FOR A POSITIVE PP THAT PREYENTS OR DETECTS AND CORRECTS HAZARDS. I. CCN TRACTOR 2. CONTRACT NAME AND N0. 3. DATE a c. . 7ROJECT SUPERINTENDENT: 5. SNlFTS/DAY $a. nWgi/SHIFT $D. ~AZIMUM ENPLO7E E/SHIFT SuPER1nTEN0ENT'S TRAINING IX CORPS' SAFETY 0.EOUIRE}E NT S. 6a. SUDERINTENOEXT'S PREYIP_5 EKPERIENCE YITN CORPS 7. o. l. MAJOR UNITS OF EQUIPMENT COlRRALTOR .Ill USE 7a. MAJ00. UNITS OF EWIPMENT SUBCONTRACTOR PILL USE naME OF PERSON(S) YXO PILL INSPECT EQUIDMENT 8a. INSPECTOR'S QUALIFICATIONS BD. 1NSDECT1pN FREQ UEN CT .u( aF :EVSOn1sl v[s-MStELE voa ovEPAras• vNrslxs ID. LOCATION OF SAFETY.RELATEO RECORD 11. OAT Af/0 MOU0. YEEKLT SAF Y MEe iNG :2. i::, tiAME OF DERSON(S) RESPONSIBLE FOR ENPLOTEE SAFETY TRAINING nM1E OF PERSON(S) RESPONSIBLE FOR DAILY CLEAN UP AND HOUSEKEEPING 17. NAME OF PERSON(S) MFfO PILL ORIENT NEY EMDLOT EES 15. MMERE YILL DRINKING WTER BE OBTAINED ANO NOY MILL IT BE DISPENS 16. MA77E OF PERSON(S) YNO YILL INVESTIGATE ACCI0ENT5 17, NAME pF vERSON(5) RESPpIS ISLE FOR DROYIDING PERSONAL PROTEC7IYE EpUlt NAME ANO TELEPHONE N0. OF DOCTORS, HOSPI i TALS AND AMBULANCE SERVICES KITH WHOM ARRANGEMENTS HAVE BEEN MADE FOR THIS CONTRAI 18. DOCTOR 1Ba. HOSPITAL ~ 18N. AMBULANCE IBC . YNAT cnow nc rn.n~~.~....,.. •,... ,.. ...._ __ _ .___.. .. _._ _.___ __ __ __ ,r ~~ iu tlE ustU, YHERE ExACTIY IS IT LOCATE07 POD form 248-R (Rev) 1 Feb 85 En~.l 2 i. ~uei m [ERiIf 1E0 F10.ST AIO ANO C70. 4i"FEYOAIRS 19A. ttvE Of CE0.TIf[UTE, ISSUI116 AGENCY MO EIVIRATICN GATE 19c, MMES OF U.S.C.o. L.CFNSED E6AT GFEMT90.S 11 vE L1CEJ15E AIID EIII0.ATIOM OA iE. :, f10.E FIGIRIM6 EOUIFMEKT 22. FI0. 5T Ai0 11T 27. WISN FACIU TIES b. I1I/E E0.ICAL MTING ttvE (yATEN ,C02 qIT CXFJI) SiECI Fit IOGTION 1q. ttvE (16U1I TS 0.FOU IRE01 Iq, TTVE MO LO4T1011 2t. 70ILET5 ry0, ttvE ANO LOU7IOM --• ~~~~~ ~~~~•~+~~~ ~n wncwuo~c u~wErs un ugsts WILL BE ON JOB SITE (BLOCKS ZS b 26 SHOULD COINCIDE WITH BLOCK 7)? cc, wMERE HILL FLAMMABLES AND COMBUSTIBLES BE STORED? WHAT KIND OF CONTAINERS WILL BE USED? 21, NAVE OF PERSON(S) RESPONSIBLE FOR INSPECTION ANO MAINTENANCE OF FIRE FIGNTING EOUIPMEHT IF THE COMPANY HAS A PUBLISHED STATEMENT OF SAFETY POLICY, PLEASE RETURN A COPY WITH YOUR ACCIDENT PREVENTION PROGRAM ON A SEPARATE SHEET SUBMIT YOUR PROPOSED LAYOUT OF TEMPORARY BUILDINGS ANO FACILITIES (INCLUDING SUBCONTRACTORS) AND TRAFFIC PARTERNS INCLUDING ACCESS ROADS, HAUL ROADS, RAILROADS, UTILITIES, ETC. 28. THE MILL PURSUE A POSITIVE PROGRAM OF TRAINING, INSPECTIONS AHD HAZARD CONTROL THROUGHOUT THE TERM OF THIS CONTRACT. MR/MS HAS THE RESPONSIBILITY AND AUTHORITY FOR ENFORCING THEM. N SATE- . . . . -6ATt~ 8 ail W W W O O l ~, -~ ~ ~, -., a °~ .'~'' J~ .,~ U1 J~-~ E O y ~ a °~ ~ a z° ~ ,~' .~' ~ ~ ~ ~ a ai v .Q, O N .ti n b _ ~ h W O G - - -~--~--1--+-~-~- a - - - - x ~~ ~~ o '~ oO N W G,~( a ----------- I ~ ~ ~-- _'~_""1__f_-I_-~--1--~- -~-~-~--1.-1. -'~ - --~ . ~; L I W O J-1 t N - -t - --f - ---i . --~---I--{--{_~_'~_---I_ _____________ ~ i ~ I I I ~ a I ~ ~~ ', u ~~ O N [+~ N O . • C~D-SO E~LtTI7J IIJGZ?IEIIt .DISTRICT SAFETY OFFICE a'='gaTnmc ~` OF ACCIIgSTI' Orate Recd: Time Reed: ~~ Fes' CAT£: 1. Name of Per<.~rn Reporting: 2. location of Accident: 3. Date and Time of Accident: 4. Nye of Injured (if any); 5. Nature of Injury: 6. ociatpation (Injured Person) 7. Age (Injured Person): 8. Estimated Lost Time• 9. Estimated Damage: 10. CcrttraGtar i CYrttract No. 11. Board of Investigatim: Yea Q No Q 12. Desc:riptirn of Accident: (cont;n+e on back if needed) (Fd'iere, Ydsat, F3iy, Fiow it K~ppened) signature o! Person Making Report: Title of Person Making Report: Location of Pp_tscn Making Report POD FCiaS 265 1 NOV 90 c~nc(3 r^ UNITED STATES ARMY C RPS C' ~ - c,~,L;. sJ/ery ~ JGINEENS ACCIDENT INVESTIGATIOA' 7RT REOUIHErntr+T { S(ah only) Use of rnrs form See Arcacned In svucrrorrs dne ` Suool to AR JBS-col C ONTROL SvmanL: CEEC-5-8 R21 ACCIDENT CLA$$I FICATION PERSONNEL CLASSIFICATION INJURY~ILLNESS/FATAL PHOPERN DAMAGE MOTOR VEHICLE INVOLVED D GOVERNMENT IVING ^ CIVILIAN ^ MILITARY ^ FIRF_ ^ INVOLVED ^ OTHER ^ ^ ^ CONTRACTOR ^ ^ ^ OTHER I INVOLVED ^ ^ PUBLIC ^ FATAL ^ OTHER a NAME (LasLFirsGMll PEq$ONAL DATA b. AGE c SEX . d. SOCIAL SECURITY NUMBER e GRADE ^ MALE ^ FEMALE / I JOB SERIES/71TLE y DUTY STATUS AT TIME OF ACCIDENT h. EMPLOYMENT STATUS AT TIME OF ACCIDENT _ ^ ARMY ACTIVE ^ ARMY RESERVE ^ ^ VOLUNTEER ON DUTY ^ TDV ^ PERMANENT ^ FOREIGN NATIONAL ^ SEASONAL ^ TEMPORARY ^ STUDENT ^ OFF DUTY ^ OTHER (SpecityJ G NERAL INFORMATI N a. DATE OF ACCIDENT b. TIME OF ACCIDENT c EXACT LOCATION OF ACCIDENT (mon M/de y/year) (Military time)) d. CONTRA CTOR'S NAME r / 111 PRIME. o CONTRACT NUMBER I. TYPE OF CONTRACT y HAZARDOUS/TOXIC WASTE ^ CONSTRUCTION. ACTIVITY ^ SERVICE ^ CIVIL WORKS ^ MILITARY 121 SUBCONTRACTOq- ^ A/E ^ SUPERFUNO ^ DERP ^ DREDGE ^ IRP ^ OTHER (SpuulyJ ^ OTHER ($pgci/y) ^ OTHER (SpeCity) 'I CONSTRUCTION ACTIVITIE ONLY Frll m Lnp and tortes ondarr cede nurrrfmr ur O b a CONSTRUCTION ACTIVITY ux orn by - suu ursvwlnniS b TYPE OF CONSTRUCTION EOUIPMEN7 IGODE) ~~ (CODE) ~~ IN Y IL NE INF RMATI N L ' n~ r n lv r r ~ r n I ~ a. SEVERITY OF ILLNESS / INJURY r r r l r r r r b. ESTIMATED c. ESTIMATED (CODEI DAYS LOST DAYS HOSPIT~ d. ESTIMATED DAYS. RESTRICTED DUTY ALIZED a. 80DY PART AFFECTED (CODE) PRIMARY y TYPE AND SOURCE OF INJURY/ILLNESS O (C ODE) SECONDARY II~~~ -- ~~ (CODE) L-.J TYPE 1. NATURE OF ILLNESS /INJURY (CODEI (CODEI C~ SOURCE ~~ 6 PUBLIC FATALITY fill m Irne and Corte :nunr0no nndw n h a. ACTIVfTY AT TIME OF ACCIDENT urn wr yr hnx - aew me'Iru[Irnrre' fCODE b PERSONAL FLOATATION DEVICE USED? ~ ^ YES ^ NO ^ N/A MOTOR VEHICLE ACCIDENT a TYPE OF VEHICLE m PI h. TYPE OF COLLISION c. SEAT BELTS USED NOT USED NOT AVAILABLE CKUPNAN m AUTOMOBILE ^ SIDE SWIPE ^ HEAD ON ^ REAR END m TRUCK m OTHER (Specify) ^ BROADSIDE ^ ROLL OVER ^ BACKING (I I FRONT SEAT ^ OTHER (SpecrtyJ (2) REAR SEAT PROPERTV/MATERIAL INVOLVED a. NAME OF ITEM b OWNERSHIP c. E AMOUNT OF DAMAGE I 2 (~) ' VESSEL /FLOATING PLANT ACCIDENT Frll m I~ni~ mrJ tunas wn~~•~.; ..;, ~.. ,....,,n.., ,,; ~.,,. r, ,,. ° a TYPE OF VESSEUFLOATING PLANT , , ~ ~ °"e unlrucrm"' ICODEI b. TYPE OF COLLI$ONIMISHAP (CODE) ~~ 10 ACCIDENT DESCRIPTION 5e d c rbOnd le let r ne' S -tr ENGFORM uy EDITION OF JUL Btl IS OBSOLETE Peye I ur L Veyes IPouWnem CEM r{~ (.~ L rSAL i'AClr: RjS ._..s.....- ~,~ a~ IExp/am AYES answers m tlem 1~) ~ YES NO a. (CONTIrJUE0) YES NO DESIGN' Was devgn of faoliry.workplace or ^ ^ egwpmem a 1dC10!? CHEMICAL AND PHYSICAL AGL +CTOPS. Did e. WSUre l0 chem¢al agems, such as dusl.lumes. misls,vd Wrs nr I5 SUCYI a3 n p y d ^ . , piStl.ra(Jia110geIL.,WnlnbUlH lO CldL'nl? dO ^ INSPECTION/MAINTENANCE: Ware inspection 8 mainten- ^ ^ erica procedures a captor? OFFICE FACTORS. Did pll¢e selling such as, hllinq olhce lurnrture carrymgsloupin t ^ ^ PERSON'S PHYSICAL CONDRION. In your opinion, was the physical COndtliOn 1 th 1 7 ^ ^ , g,e a.conuibwe to the accident? 0 e W40n a aG101 SUPPORT FACTORS. Were ina VPropnalC 10015/re50U1ces promdero to properly Wrlorm Ih > ^ ^ OPERATING PROCEDURES Were operating procedures ^ ^ a taclor? ¢ activity/lask PERSONAL PROTECTIVE EQUIPMENT Did the im ro pc ' selecoon pl , e use ar maintenance o1 1xarsonal pmlechv¢ Wui m CONnDule to the accitlenl? p ^ ^ JOB PRACTICES. Were any jOb salety/health pract¢es nut IolluwN when Ine accident occurred ~ ~ DRUGS/ALCOHOL I n your opimm~,was drugs or alcohol a lactpr l0 me acudem? ^ ^ HUMAN FACTORS: Dld any human tatters such as sze or ~ suenglh of person, elc.,canurbule l0 dccWem7 ~ 6. WAS A WRITTEN JOB/ACTIN ITV HAZARD ANALYSIS COM PLETED ENVIRONMENTAL FACTORS Drd heal, cold, dull, sun, ^ ^ glare, ¢Ip., conlnbule l0 the accident? FOR TASK BEING PERFORMED nT TIME OF ACCIDENT? ^ ^ VES (Il yes, dlfdch a cpp y.) NO 12 TRAINING a WAS PERSON TRAINED TO PERFORM ACTIVITY?ASK? b. TYPE OF TRAINING. p. DATE OF MOST RECENT FORMAL TRAINING. ^ VES ^ NO ^ CLASSROOM ^ ON JOB / / (MOnlh) (Orly) (Y0a/) l3. FULLY E%PLAIN WHAT ALLOWED OR CAUSED THE ACCIDENT; INCLUDE DIRECT AND INDIRECT CAUSES (See mstruclron ror da DnrLOn of tlvect and mdvecf causes.) (Use addmonal a er, d necessa a. DIRECT CAUSE b. INDIRECT CAUSE(S) Id. ACTION(S) TAKEN ANTICIPATED OR RECOMMENDED TO ELIMINATE CAUSE(S). DESCRIBE FULLY: 15. DATES FOR ACTIONS IDENTIFIED IN BLOCK ld. a. BEGINNING (MOOMIOa ylYear) / / b. ANTICIPATED COMPLETION (MOnINDa ylYearJ l / c. SIGNATURE AND TITLE OF SUPERVISOR COMPLETING REPORT d DATE (MOIDaIYr) e. ORGANIZATION IDENTIFIER (Div, Br Secp t. OFFICE SYMBOL CORPS / CONTRACTOR / 16. MANAGEMENT REVIEW (tsp. a. ^ CONCUR b. ^ NON CONCUR c. COMMENTS SIGNATURE TITLE DATE t 7. MANAGEMENT REVIEW (2nd - Chiel Operations, Consvucbon, Engineering, eft.) a. ^ CONCUR U ^ NON CONCUR c. COMMENTS SIGNATURE TITLE DATE 18. SAFETY AND OCCUPATIONAL HEALTH OFFICE REVIEW a. ^ CONCUR p, ^ NON CONCUR c. ADDITIONAL ACTIONS/COMMENTS. SIGNATURE TITLE DATE 1B. COMMAND APPROVAL COMMENTS COMMANDER SIGNATURE DATE u! ENG Form 7]9~) Pagu 2 ul 2 Vages A us.c a o rses~ a16-11] -~ GENFiRAL. Complete a separate ~ _ parson who was injured. caused, or contributed to the t (excluding urnnju red personnel antl witnesses). Use of this dr reporting USACE employee lirsl-aid type injuries riot submni~tl to the OILCe of Workers' COmpensauon Programs (OWCP) Shall be al the descrClion 01 the FOA commander. Please type or print legibly. Appropriate items shall b0 marked with an "X" in box(es). II atldrtional space is needed, provide the inlormalion on a separate sheet and attach to the compleletl loan. Ensure that these instructions are forwartlOd with the completed report to the tlesignated management remewers indicated in sections t 6. antl t7. INSTRUCTIONS FOR SECTION 1 -ACCIDENT CLASSIFICATION. (Mark An Boxes Thar Are Appncable ) a. GOVERNMENT. Mark "CIVILIAN" box if accident involved government civilian employee; mark "MILITARY" box if accident involved U.S. military personnel. (1) INJURY/ILLNESS/FATALITY-Mark if accident resulletl in any government civilian employee injury, illness, or fatality that requves the submission of OWCP Forms CA-1 (injury), CA-2 (illness), or CA-6 (Ialahryl to OWCP; mark i( accdent resulted in milaary personnel lost-time or lalal injury or illness. (2) PROPERTY DAMAGE-Mark the appropriate box if accident resulted in any damage of $7000 or more to government properly (including motor vehicles), (3) VEHICLE INVOLVED-Mark if accident involved a motor vehicle, regardless of whether "INJURY/ILLNESS/FATALITY" or "PROPERTY DAMAGE" are marked. (4) DIVING ACTIVITY-Mark if the accitlent involved an in-hove USACE diving activity. b. CONTRACTOR. (1) INJURY/ILLNESS/FATALITY-Mark if accident resulted in any contractor lost-time injury/illness or fatality. (2) PROPERTY DAMAGE-Mark the appropriate box if accident resulted in any tlamage of 57000 or more to contractor properly (including motor vehicles). (3) VEHICLE INVOLVED-Mark if accident involved a motor vehicle, regardless of whether "INJURY/ILLNESS/FATALITY" or "PROPERTY DAMAGE" are marked. (4) DIVING ACTIVITY-Mark if the accitlent involved a USACE Contractor diving acnvrty. c. PUBLIC. (1) INJURY/ILLNESS/FATALITY-Mark if accitlent resulted in public latahry or permanent total disability. (The "OTHER" box will be marked when requested Dy the FOA to report an unusual non-latal public accitlent that could result in claims against the government or as otnerwise dvected by the FOA Commander). (2) VOID SPACE-Make no entry. (3) VEHICLE INVOLVED-Mark if accident restated in a fatality to a member of the public antl involved a motor vehicle, regardless of whether "INJURY/ILLNESS/FATALITY" is marked. (4) VOID SPACE-Make no entry. INSTRUCTIONS FOR SECTION 2-PERSONAL DATA a. NAME-(MANDATORY FOR GOVERNMENT ACCIDENTS. OPTIONAL AT THE DISCRETION OF THE FOA COMMANDER FOR CONTRACTOR AND PUBLIC ACCIDENTS). Enter last name, first name, middle initial of person involvetl. b. AGE-Enter age. c. SEX-Mark appropriate box. d. SOCIAL SECURITY NUMBER-(FOR GOVERNMENT PERSONNEL ONLY) Enter the social security number (or other personal identification number if no social security number issued). e. GRADE-(FOR GOVERNMENT PERSONNEL ONLY) Enter pay grade. Example: O.6; E-7; WG-8; WS-t 2; GS-1 t; etc. I. JOB SERIE --For government cwban employees enter 'he pay plan, h ,number, and lob idle, eg. GS-0810;Gvi1 Engineer. Fu. ..;tary personnel enter the primary military occupational speoany (PMOS), eg., ISA30 or nG50. For contractor employees enter the lob rile assigned to the inlu red person, e.g. carpenter, laborer, surveyor. etc.. DUTY STATUS-Mark the appropriate box. (1) ON DUTY-Person was at duly station tlunng duty hours or person was away Irom tluty siauon tlunng duty hours but on oilicial business at time of the accident. (2) TDY -Person was on official business, away horn the tlury station and with travel orders at time of accitlent. Line-of-duty investigation requvetl. (3) OFF DUTY -Person was not on official business al lime of accitlent h. EMPLOYMENT STATUS-(FOR GOVERNMENT PERSONNEL ONLY) Mark h~e most appropriate box. I; "OTHER" is marked, specify the employment status of the person. INSTRUCTION FOR SECTION 3-GENERAL INFORMATION a. DATE OF ACCIDENT-Enter the month, day, and year of accident. b. TIME OF ACCIDENT-Enter the local time of accident in military time. Example: 1430 firs (not 2:30 p.m.). c. EXACT LOCATION OF ACCIDENT-Enter facts needed to locate the accident scene. (installation/project name, building number, street, direction and distance from closest lantlmark, etc.,). d. CONTRACTOR NAME (1) PRIME-Enter the exact name (title of firm) of the prime contractor. (2) SUBCONTRACTOR-Enter the name of any subcontractor involved in the accitlent. e. CONTRACT NUMBER-Mark the appropriate box to itlentiry if contract is civil works, military, or other: if "OTHER" is marked, specify contract appropriation on line provided. Enter complete contract number of prime contract, e.g., DACW 09-85-C-0100. f. TYPE OF CONTRACT-Mark appropriate box. A/E means architecVengineer. If "OTHER" is marked, specify type of contract on line provided. g. HAZARDOUSlTOXIC WASTE ACTIVITY (HTW)-Mark the boz to identity the HTW activity being pedormetl at the time of the accitlent. For Supertund. DERP, and Installation Restoration Program (IRP) HTW acnvilies include accitlenis that occurred during inventory, predesign, design, and construction. For the purpose of accitlent reposing, DERP Formerly Used DoD Site (FUDS) activities antl IRP activities will be treated separately. For Civil Works O&M HTW activities mark the "OTHER" Dox. INSTRUCTIONS FOR SECTION 4-CONSTRUCTION ACTIVITIES a. CONSTRUCTION ACTIVITY-Select the mos( appropriate construction activity being performed at time of accident Irom the list below. Enter the activity name antl place the corresponding cotle number identified in the box. CONSTRUCTION ACTT VITV LIST 1. MOBILIZATION 2. SITE PREPARATION 3. E%CAVATIONRRENCMING 4. GRADING (EARTHWORK) 5. PIPING/UTILITIES 6. FOUNDATION 7. FORMING O. CONCRETE PLACEMENT 9. STEEL ERECTION 10. ROORNG 11. FRAMING 12. MASONRY 13. CARPENTRY 14. ELECTRICAL i6. SCAFFOLDING/ACCESS 16. MECHANICAL 17. PAINTING 19. EQUIPMENT/MAINTENANCE 19. TUNNELING 20. WAREHOUSING/STORAGE 21. PAVING 22. FENCING 23. SIGNING 29. LANDSCAPING/IRRIGATION 25. INSULATION 26. DEMOLITION b. TYPE OF CONSTRUCTION EU~r -Select the equipment involved m the accident from the liz Enter the name and place the corresponding code numb. .nified in the box. II equipment i5 not included below, use code 24, 'OTHER', and write in specific type of equipment. CONSTRUCTION EQUIPMENT 1. GRADER 2. DRAGLINE 3. CRANE ION VESSELIBARGE) d. CRANE (TRACKED( 5. CRANE (RUBBER TIRE( 6. CRANE (VEHICLE MOUNTED) 7. CRANE (TOWER) B. SHOVEL 9. SCRAPER 10. PUMP TRUCK (CONCRETE) n. TRUCK (CONCRETE/TRANSIT MIXER) 12. DUMP TRUCK (HIGHWAY) 13. DUMP TRUCK (OFF HIGHWAY) iq. TRUCK IOTHERI 15. FORKLIFT 16. BACKHOE 17. FRONT-END LOADER 19. PILE DRIVER 19. TRACTOR (UTILITY) 20. MANLIFT 21. DOZER 22. DRILL RIG 23. COMPACTORNIBRATORV ROLLER 2d. OTHER INSTRUCTIONS FOR SECTION 5-INJURY/ILLNESS INFORMATION a. SEVERITY OF INJURY / ILLNESS ~ Reference para 2-i0 of USACE Suppl t to AR 385<0 and enter code and descnp0on from Iis1 below. NOI NO INJURY FAT FATALITY PTL PERMANENT TOTAL DISABILITY PPR PERMANENT PARTIAL DISABILITY LWD LOST WORKDAY CASE INVOLVING DAYS AWAY FROM WORK NLW RECORDABLE CASE WITHOUT LOST WORKDAYS RFA RECORDABLE FIRST AID CASE NRI NON-RECORDABLE INJURY b. ESTIMATED DAYS LOST-Enter the estimated number of workdays the person will lose from work. c. ESTIMATED DAYS HOSPITALIZED-Enter the esnmatetl number of workdays the person will be hospitalized. d. ESTIMATED DAYS RESTRICTED DUTY-Enter the estimaletl number of workdays the person, as a result of the accident. will not be able to pertorm all of their regular tlulres. e. BODY PART AFFECTED-Select the most appropriate primary and when applicable, secondary body part affectetl from the list below. Enter body pan name on line and place the corresponding code letters identitying that body pan in the box. GENERAL BODY AREA CODE BODY PART NAME ARMNJRIST AB ARM AND WRIST AS ARM OR WRIST TRUNK, EXTERNAL 07 SINGLE BREAST MUSCULATURE B2 BOTH BREASTS B3 SINGLE TESTICLE 84 BOTH TESTICLES BA ABDOMEN BC CHEST BL LOWER BACK BP PENIS BS SIDE BU UPPER BACK BW WAIST BZ TRUNK OTHER HEAD. INTERNAL C1 SINGLE EAR INTERNAL C2 BOTH EARS INTERNAL C3 SINGLE EYE INTERNAL Cd BOTH EYES INTERNAL CB BRAIN CC CRANIAL BONES CD TEETH CJ JAW CL THROAT, LARYNX CM MOUTH ELBOW FINGER TOE HEAD, EXTERNAL KNEE LEG. HIP, ANKLE. BUTTOCK HAND FOOT TRUNK. BONES SMOULDER THUMB TRUNK. INTERNAL ORGANS CN NOSE ^ CR THROAT, OTHER CT TONGUE CZ HEAD OTHER INTERNAL ER BOTH ELBOWS ES SINGLE ELBOW Ft FIRST FINGER F2 80TH FIRST FING ER$ F3 SECOND FINGER Fd BOTH SECOND FINGERS Fs rHIRD FINCEa F6 BOTH THIRD FINGERS F7 FOURTH FINGER FB BOTH FOURTH FINGERS GI GREAT TOE G2 BOTH GREAT TOES G3 TOE OTHER G4 TOES OTHER Ht EvE EXTERNAL H2 BOTH EYES EXTERNA! H3 EAR EXTERNAL H4 BOTH EARS EXTERNA! HC CHIN HF FACE HK NECKrTHROAT HM MOUTH/LIPS HN NOSE HS SCALP KB BOTH KNEES KS KNEE L8 BOTH LEGSrHIPSf ANKLES/BUTTOCKS LS SINGLE LEGi HIP ANKLE!BUTTOCK MB BOTH HANDS MS SINGLE HAND PB 90TH FEET PS SINGLE FOOT Rt SINGLE COLLAR BONE R2 BOTH COLLAR BONES R3 SHOULCER BLADE R4 BOTH SHOULDER BLADES RB RIB RS STERNUM (BREAST BONE RV VERTEBRAE (SPINE: D!SC RZ TRUNK BONES OTHER SB BOTH SHOULDERS SS SINGLE SHOULDER TB BOTH THUh1BS TS SINGLE THUMB V7 LUNG, SINGLE V2 LUNGS. BOTH V3 KIDNEY, SINGLE V4 KIDNEYS, BOTH VH HEART VL LIVER VR REPRODUCTIVE ORGANS VS STOMACH VV INTESTINES VZ TRUNK. INTERNAL, OTHER (, NATURE OF INJURY/ILLNESS -Select the most appropnato nalur,~ of In)ury /illness from the list below. This nature of injury /illness shall correspond to the primary body pan selected in 5e, above. Enter the nature of injury /illness name on the line antl placo Vx: corresponding CODE letters in the box providetl. - ,C4vc Sv U:;CE i:F INJURY NAMC 0200 ENVIRONMENTAL CONL 0210 TEMPERATURE EXTREME ~OQR) 0220 WEATHER (ICE, RAIN. HEAT, ETC.) 0230 FIRE, FLAME, SMOKE (NOT TOBACCO) 0240 NOISE 0250 RADIATION 0260 LIGHT 0270 VENTILATION 0271 TOBACCO SMOKE 0260 STRESS (EMOTIONAL) 0290 CONFINED SPACE 0300 MACHINE OR TOOL 0310 HAND TOOL (POWERED: SAW, GRINDER, ETC.) 0320 HAND TOOL (NONPOWERED) 0330 MECHANICAL POWER TRANSMISSION APPARATUS 0340 GUARD, SHIELD (FIXED, MOVEABLE, INTERLOCK) 0350 VIDEO DISPLAY TERMINAL 0360 PUMP, COMPRESSOR, AIR PRESSURE TOOL 0370 HEATING EQUIPMENT 0380 WELDING EQUIPMENT CODE S'. )F INJURY NAME 1000 ,JAL PROTECTIVE EQUIPMENT 1010 Ph~rECTIVE CLOTHING. SHOES, GLASSES, GOGGLES 1020 RESPIRATOR, MASK 1021 DIVING EQUIPMENT 1030 SAFETY BELT, HARNESS 1060 PARACHUTE INSTRUCTIONS FOR SECTION 6 -PUBLIC FATALITY a. ACTIVITY AT TIME OF ACCIDENT-Select the activity being performed at the time of the accident tram the list below. Enter the activity name on [he line and the corresponding number in the box. If the activity performed is not identified on the list. select from the most appropriate primary activity area (water related, non-water related or other activity), the code number for "Other", and write in the activity being perormed at the time of the accident. WATER RELATED RECREATION Od00 VEHICLE 1. Sailing 9. Swimming/Cesignated area 0411 AS DRIVER OF PRIVATELY OWNED/RENTAL VEHICLE 2. Boating-powered 10. Swimmingrother area 0412 AS PASSENGER OF PRIVATELY OWNED/RENTAL VEHICLE 3. Boating-unpowered 1 t. Underwater activities (skin Giving, 0421 DRIVER OF GOVERNMENT VEHICLE 4. Water skiing scuba, etc) 0422 PASSENGER OF GOVERNMENT VEHICLE 5. Finning from boat 12. Wading Od30 COMMON CARRIER (AIRLINE, BUS. ETC.) 6. Fishing Irom bank dock or pier 13. Attempted rescue 0440 AIRCRAFT (NOT COMMERCIAL) 7. Finning while wading 14. Hunting Irom boat 0450 BOAT, SHIP, BARGE e. Swimming/supervised area 15. Other 0500 MATERIAL HANDLING EQUIPMENT 0510 EARTHMOVER (TRACTOR, BACKHOE, ETC.) 0520 CONVEYOR (FOR MATERIAL AND EQUIPMENT) 0530 ELEVATOR. ESCALATOR, PERSONNEL HOIST 0540 HOIST, SLING CHAIN, JACK 0550 CRANE 0551 FORKLIFT 0560 HANDTRUCK, DOLLY 0600 DUST, VAPOR, ETC. 0610 DUST (SILICA, COAL, ETC.) 0620 FIBERS 0621 ASBESTOS 0630 GASES 0631 CARBON MONOXIDE 0640 MIST, STEAM. VAPOq, FUME 0641 WELDING FUMES 0650 PARTICLES (UNIDENTIFIED) 0700 CHEMICAL, PLASTIC, ETC. 0711 DRV CHEMICAL-CORROSIVE 0712 DRV CHEMICAL-TOXIC 0713 DRV CHEMICAL-EXPLOSIVE 0714 DRV CHEMICAL-FLAMMABLE 0721 LIQUID CHEMICAL-CORROSIVE 0722 LIQUID CHEMICAL-TOXIC 0723 LIQUID CHEMICAL-EXPLOSIVE 0724 LIQUID CHEMICAL-FLAMMABLE 0730 PLASTIC 0740 WATER 0750 MEDICINE NON-WATER RELATED RECREATION 16. Hiking and walking 17. Climbing (general) 18. Camping/picnicking authorized area 19. Camping/pcnicking unautnorizetl area 20. Guitled tours 21 Huntng 22. Playgrountl equipment 23. Sports/Summer (baseball, football, etc.) 24. SportsAVinter (skiing, Sledding, snowmobiling etc.) 25. Cycling (oicycle, motorcycle. scooter) 26. Gliding 27. Parachuting 28. Other non-water related OTHER ACTIVITIES 29. Unlawful acts (tights, riots, vantlabsm, etc) 30. Footl preparation/serving 31. Food consumption 32. Housekeeping 33. Sleeping 34. Pedestrian struck by vehicle 35. Petlestrmn other acts 36. Suicide 37. "Other" acBvities b. PERSONAL FLOTATION DEVICE USED-If fatality was water- related was the victim wearing-a person flotation device? Mark the appropriate box. INSTRUCTIONS FOR SECTION 7-MOTOR VEHICLE ACCIDENT a. TYPE OF VEHICLE-Mark appropriate box for each vehicle involved. If more than one vehicle of the Same type i5 involved, mark both halves of the appropriate box. USACE vehicle(s) involved shall be marked in left half of appropriate box. 0800 INANIMATE O&IECT 0810 BO%, BARREL. ETC. 0820 PAPER 0830 METAL ITEM, MINERAL 0831 NEEDLE 0840 GLASS 0850 SCRAP, TRASH 0860 WOOD 0870 FOOD OBBO CLOTHING. APPAREL. SHOES 0900 ANIMATE OBJECT 0911 DOG 0912 OTHER ANIMAL 0920 PLANT 0930 INSECT 0940 HUMAN (VIOLENCE) 0950 HUMAN (COMMUNICABLE DISEASE) 0960 BACTERIA, VIRUS (NOT HUMAN CONTACT) b. TYPE OF COLLISION-Mark appropriate boz. c. SEAT BELT-Mark appropriate box. INSTRUCTIONS FOR SECTION 8-PROPERTY/ MATERIAL INVOLVED a. NAME OF ITEM-Describe all property involved in accident. Property/material involved means material which is damaged or whose use or misuse contributed to the accident. Include the name, type, model; also include the National Stock Number (NSN) whenever applicable. b. OWNERSHIP-Enter ownership for each item listed. (Enter one of the following: USACE; OTHER GOVERNMENT,' CONTRACTOR PRIVATE) c. S AMOUNT OF DAMAGE-Enter the total estimated tlollar amount of damage (parts and labor), if any. ' The .njury or condition selected below mug '.used by a specific incident or event which occurred dunng a ork day or shift. GENERAL NATURE NATURE OF INJURY CATEGORY CODE NAME 'TRAUMATIC INJURY OR TA AMPUTATION DISABILITY TB BACK STRAIN. TC CONTUSION; BRUISE; ABRASION iD DISLOCATION TF FRACTURE TH HERNIA TK CONCUSSION TL LACERATION, CUT TP PUNCTURE TS STRAIN, MULTIPLE TU BURN, SCALD. SUNBURN TI TRAUMATIC SKIN DISEASES/ CONCITIONS INCLUDING DERMATITIS TR TRAUMATIC RESPIRATORY DISEASE TO TRAUMATIC FOOD POISONING TW TRAUMATIC TUBERCULOSIS TX TRAUMATIC VIROLOGICAU INFECTIV E;PARASITIC DISEASE Tt TRAUMATIC CEREBRAL VASCULAR CONDITION,~STROKE T2 TRAUMATIC HEARING LOSS T3 TRAUMATIC HEART CONDITION T4 TRAUMATIC MENTAL DISORDER; STRESS: NERVOUS CONOiTION T6 TRAUMATIC INJURY -OTHER (EXCEPT DISEASE, ILLNESS) "A nontraumatic physiological harm or loss of capacity produced by systemic infection; continued or repeated stress or strain; exposure to toxins, poisons, fumes, etc.; or other continued and repeated exposures to conditions of the work environment over a long periotl of time. For practical purposes, an occupational illness/disease or Disability is any reported condition which doses not meet the definition of traumatic injury or disability as described above. GENERAL NATURE NATURE OF INJURY CATEGORY CODE NAME "NON-TRAUMATIC ILLNESS/DISEASE OR DISABILITY RESPIRATORY DISEASE RA ASBESTOSIS RB BRONCHITIS RE EMPHYSEMA RP PNEUMOCONIOSIS RS SILICOSIS R9 RESPIRATORY DISEASE. OTHER VIROLOGICAL, INFECTIVE VB BRUCELLOSIS 8 PARASITIC DISEASES VC COCCIDIOMYCOSIS VF FOOD POISONING VH HEPATITIS VM MALARIA VS STAPHYLOCOCCUS VT TUBERCULOSIS V9 VIROLOGICAUINFECTIVE/ PARASITIC-OTHER DISABILITY, OCCUPATIONAL DA ARTHRITIS, BURSITIS DB BACK STRAIN, BACK SPRAIN DC CEREBRAL VASCULAR CONDITION; STROKE DD ENDEMIC DISEASE (OTHER THAN CODE TYPES R8S) DE EFFECT OF ENVIRONMENTAL CONDITION DH HEARING LOSS DK HEART CONDITION DM MENTAL DISORDER, EMOTIONAL STRESS NERVOUS CONDITION OR RADIATION DS STRAIN, MULTIPLE DU ULCER DV OTHER VASCULAR CONDITIONS D9 DISABILITY, OTHER GENERAL NATURE NATURE OFINJURY ' CATEGORY :ODE NAME SKIN DISEASE SB BIOLOGICAL OR CONDITION SC CHEMICAL S9 DERMATITIS. UNCLASSIFIED g. TYPE AND SOURCE OF INJURY/ILLNESS (CAUSE) -Type antl Source Codes are used to describe what caused the incideni The Typo Code stands for an ACTION and the Source Code for an OBJECT or SUBSTANCE. Together, They form a bnel tlescrippon of how the modem occurred. Where (here are two different sources, code Ine impaling source of the madenl (see example t, bebw). Ezamples (1) An employee tripped on carpet antl struck his head on a desk. TYPE 2t0 Pell on same level) SOURCE: Ono (walklrtg/working sudacel NOTE'This example woultl NOT be codetl 120 (struck agains0 and 0140 Ournilure). (2) A Park Ranger contracted dermatitis from contact with poison rvy/ oak. TYPE: 510 (contact) SOURCE: 0920 (plant) (3) A lock and dam mechanic punctured his linger with a metal sliver while grinding a turbine blade. TYPE: 410 (puncturetl by) SOURCE: 0830 (metal) (4) An employee was driving a government vehicle when II was sVUCk by another vehlcle.. TYPE: B00 (traveling in) SOURCE: 0421 (government-owned vehicle, as dnver) NOTE The Type Code 900,'Traveling In"is different Irom fhe other type codes in that rts Junction Is not to itlentiiy lectors contributing to the injury or fatality, Dut rather :o collect data on the type of vehicle the employee was operating or traveling in at the time of the matlent. Select the most appropriate TYPE and SOURCE identifier Irom the list below and enter the name on the line antl the corresponding code in the appropriate box. CODE TYPE OF INJURY NAME STRUCK Otto STRUCK BV 0111 STRUCK BY FALLING OBJECT 0120 STRUCK AGAINST FELL, SLIPPED, TRIPPED 0210 FELL ON SAME LEVEL 0220 FELL ON DIFFERENT LEVEL 0230 SLIPPED, TRIPPED (NO FALL) CAUGHT 0310 CAUGHT ON 0320 CAUGHT IN , 0330 CAUGHT BETWEEN PUNCTURED, LACERATED 0410 PUNCTURED BY 0420 CUT BV 0430 STUNG BV 0440 BITTEN BV CONTACTED 0510 CONTACTED WITH (INJURED PERSON MOVING) 0520 CONTACTED 8V (OBJECT WAS MOVING) EXERTED 0610 LIFTED, STRAINED BY (SINGLE ACTION) 0620 STRESSED BV (REPEATED ACTION) EXPOSED 0710 INHALED 0720 INGESTED 0730 ABSORBED 0740 EXPOSED TO 0600 TRAVELING IN CODE SOURCE OFINJURYNAME 0100 BUILDING OR WORKING AREA 0110 WALKINGNJORKING SURFACE (FLOOR, STREET, SIDEWALKS. ETC) 0120 STAIRS, STEPS 0130 LADDER 01 d0 FURNITURE, FURNISHINGS. OFFICE EQUIPMENT 0150 BOILER, PRESSURE VESSEL 0160 EQUIPMENT LAYOUT (ERGONOMIC) 0170 WINDOWS. DOORS 0160 ELECTRICITY FiJSTRF:C"IONS FUH ScCTIU' VESSEU BOATING PLANT ACCIDEN-, a. TYPE OF VESSEUFLOATING PLANT-Select the most appropriate vesseVfloating plant from list below. Enter name and place corresponding number in box. II item is not listed below, enter rtem number for "OTHER" and wale in specific type of vessel/ floating plant. VESSEUFLOATING PLANTS 1. ROW BOAT 7. DREDGE3DIPPER 2. SAIL BOAT 6. DRE DG 6CLAMSHELL. BUCKET 3. MOTOR BOAT 9. OREDG EIPIPE LINE a. BARGE t0. DREDGE/DUSTPAN 5. DREDGE/HOPPER t t. TUG BOAT 6. DREDGE/SIDE CASTING 12. OTHER b. COLLISION/MISHAP -Select from the list below the object(s) that contributed to the accident or were damaged in the accident. COLLISION/MISHAP t. COLLISION W/OTHER VESSEL 7. HAULAGE UNIT 2. UPPER GUIDE WALL 8. BREAKING TOW 3. UPPER LOCK GATES 9. TOW BREAKING UP a. LOCK WALL ib. SWEPT DOWN ON DAM 5. LOWER LOCK GATES 1 t. BUOY;DOLPHIwCELL 6. LOWER GUIDE WALL 72. WHARF OR DOCK 13. OTHER INSTRUCTIONS FOR SECTION 10-ACCIDENT DESCRIPTION DESCRIBE ACCIDENT-Fully describe the accident. Give the sequence of events that describe what happened leading up to and including the accitlent. Fully identify personnel antl equipment involved and their role(s) in the accident. Ensure that relationships between personnel and equipment are clearly specitietl. Continue on blank sheets it necessary and attach to this report. INSTRUCTIONS FOR SECTION 11 -CAUSAL FACTORS a. Review thoroughly. Answer each question by marking the appropriate block. If any answer is yes, explain in item t 3 below. Cgnsider, as a minimum, the following: ( 7) DESIGN-Did inadequacies assocated with the building or work site play a role? Would an improved design or layout of the equipment or facilities reduce the likelihood of similar accidents? Were the tools or other equipment designed and intended for the task at hand? ( 2) INSPECTION/MAINTENANCE-Did inatlequatety or improperly maintained equipment, tools, workplace, etc. create or worsen any hazards that contributetl to the accitlent? Would better equipment, facility, work site or work activity inspections have helped avoitl the accident? (3) PERSON'S PHYSICAL CONDITION-DO you feel that the accident would probably not have occurred if the employee was in "good" physical condition? If the person involved in the accident had been in better physical condition, woultl the accident have been less severe or avoided altogether? Was over exertion a factor? ( 4) OPERATING PROCEDURES-Did a lack of or inadequacy within established operating procedures contribute to the accident? Did any aspect of the procedures introduce any hazard to, or increase the risk associated with the work process? Would establishment or improvement of operating procedures reduce the likelihood of similar accidents? ( 5) JOB PRACTICES-Were any of the provisions of the Safety and Health Requirements Manual (EM 385-1-t) violated? Was the task Deing accomplished in a manner which was not in compliance with an established job hazard analysis or actrvily hazard analysis? Did any established job practice Oncluding EM 385-1.1) tail to adequately address Ine task or work process? Would better job practices improve the safety of the task? ( 6) HUMAN PS-Was ;he person under undue s!ress (either in. ,r external to Lne lob)? Cip the task tend tcward overloading the capabilities of the person, i.e., did the lob require tracking antl reacting to many external inputs such as tlisplays, alarms. or signals? Did the arrangement of the workplace tend ;o interfere with efficient task per!ormance? Did the task require reach, strength, entlurance, agility, etc., at or beyond the capabilities of the employee? Was the v:ork environment ill-adapted to the personr DIC the person need more trotting, experience, or practice in doing the task? Was the person inadequately rested ;o perform safely? ( 7) ENVIRONMENTAL FACTORS-Did any tanors such as moisture. humitlity, rain, snow, sleet, hatl. ice, log, cold, heat, sun, temperature Changes, wing titles, hoods, currents, dust, mud, glare, pressure changes, lightning, etc., play a part in the accident? ( 8) CHEMICAL AND PHYSICAL AGENT FACTORS-Did exposure to chemical agents (either single shift expesure or long-term exposure) such as dusts, fibers (asbestos, etc.), silica, gases (carbon monoxide. chlorine, etc.,), mists, steam, vapors, fumes, smoke, other particulates, liquid or Cry chemicals that are corrosive, toxic, explosive or flammable, by- products of combustion or physical agents such as noise, ionizing radiation, non-ionizing radiation (UV radiation created during welding, etc.) contribute to the accidenVinadent? ( 9) OFFICE FACTORS-Did the fact that the accident occurred in an office setting or to an office worker have a beanng on its cause? For example, office workers tend to have less experience and training in pertorming tasks such as lifting office furniture. Did physical hazards within the office environment contribute to the hazard? (10) SUPPORT FACTORS-Was the person using an improper tool for the job? Was inadequate time available or mil¢etl to solely accomplish the task? Were less than atlequate personnel resources (in terms of employee skills, number of workers, and atlequate supervision) available to get the joD done properly? Was funding available, utilizetl, antl atlequate to provide proper tools, equipment, personnel, site preparation, etc? (1 f) PERSONAL PROTECTIVE EQUIPMENT-Did the person fail to use appropriate personal protective equipment Ieloves, eye protection, hard-toed shoes, respirator, etc.) for the task or environments Ditl protective equipment provided or worn tail to provide adequate protection from the hazard(s)? Did lack of or inadequate maintenance of protective gear contribute to the accident? (12) DRUGS/ALCOHOL-IS there. any reason to believe the person's mental or physical capabilities, judgement. etc., were impaired or altered by the use of tlrugs or alcohol? Consider the effects of prescription metlicine antl over the coumer medications as well as illicit tlrug use. Consider the effect of tlrug or alcohol inducetl "hangovers". b. WRITTEN JOB/ACTIVITY HAZARD ANALYSIS-Was a written Job/Activity Hazard Analysis completed for the task being performed at the time of the accident? Mark the appropriate box. Il one was peAOrmed, attach a copy of the analysis fo the report. INSTRUCTIONS FOR SECTION 12-TRAINING a. WAS PERSON TRAINED TO PERFORM ACTIVITV/TASK?-For the purpose of this section "trained" means the person has been provided the necessary information (either formal and/or on-the-job (OJT) training) to competently pertorm the ac6virynask in a sale antl heanhful manner. b. TYPE OF TRAINING-Mark the approprate box tnat best intlicates the type of [raining, IclasSroom or on-thegob) that the inJUred person rece rved be!ore the accident happened. c. DATE OF MOST RECENT TRAINING-Enter the month. day, and year of the last formal training completed that covered the ac;rviry- Iask being performed at the lime of the accitlent. INSTRUCTIONS FOR SECTI -CAUSES a. DIRECT CAUSES-The direct cause is Ihat single factor which most directly lead t0 the aCCident. See examples below. b. INDIRECT CAUSES-Indirect causes are (hose factors which contributed to but did not directly initiate the occurrence of the accident. Examples for section 13: a. Employee was dismantling scaffold and fell f2 feet from unguarded opening. Ovecr cause: failure to provide fall pr0leclion al elevation. /ndvecr causes: failure to enforce USACE safety requrements; improper training/mouvauon of employee (possibility that employee was not knowledgeable of USACE fall protection requirements or was lax in his attitude towards safety); failure to ensure provision of positive fall protection whenever elevated; falure to address fall protection during scattoltl dismantling in phase hazard analysis. b. Private citizen had stopped his vehicle at intersection for red light when vehicle was struck in rear by USACE vehicle. (note USACE vehicle was in proper/safe working condition). Direct cause: failure of USACE driver to maintain control of and stop USACE vehicle within sale distance. Indirect cause: Failure of employee to pay attention to driving (defensive driving). INSTRUCTIONS FOR SECTION 14-gCTION TO ELIMINATE CAUSE(S) DESCRIPTION-Fully describe all the actions taken, anticipated, antl recommended to eliminate the cause(s) antl prevent reoccurrence of similar accidents~llnesses. Continue on blank sheets of paper if necessary to fully explain and attach to the completed report form. INSTRUCTIONS FOR SECTION 15-DATES FOR ACTION a. BEGIN DATE-Enter the date when the corrective action(s) identified in Section 14 will begin. b. COMPLETE DATE-Enter the date when the corrective action(s) identified in Section 14 will be completetl. c. TITLE AND SIGNATURE-Enter the title antl signature of supervisor completing the accident report. For a GOVERNMENT employee accidenVillness the immediate supervisor will complete and sign the report. For PUBLIC accidents the USACE Protect Manager/Area Engineer responsible for the USACE property where the accident happened shall complete and sign the report. For CONTRACTOR accidents the Contractor's project manager snail complete and sign the report and provide to the USACE supervisor responsible for oversight of that contractor activity, This USACE Supervisor shall also sign the repon. Upon entering the information requiretl in 16.tl. 16.e and 16.f below, the responsible USACE supervisor shall forward the report for management review as intlicaletl in Section 16. d. DATE SIGNED-Enter the month, day, and year that the repon was signed by the responsible supervisor. e. ORGANIZATION NAME-For GOVERNMENT employee accidents enter the USACE organization name (Division, Branch, Section, etc.) of the injured employee. For PUBLIC accidents enter the USACE organization name for the person identified in block 16.c. For CONTRACTOR accidents enter the USACE organization name for the USACE office responsible for providing contract administration oversight. 1. OFFICE SY; -Enter the la!est complete USACE Office Symbol for the USACE organzation itlentAied ~n block 15.e- INSTRUCTIONS FOR SECTION 16-MANAGEMENT REVIEW (1st) 1ST REVIEW-Earh USACE FOA shall Cetermine v;ho will prov;de 1st management review. The responsible USACE suoerv~sor n section 15.c shall forward the completed repon to the USACE office designated as the 1st Reviewer by the FDA. Upon receipt, the Chief of the Office shall review the completed report. marR the appropriate box, provide substantive comments. s!gn, cafe. acd forward to the FOA Staff Chief (2nd revievq for review and comment. INSTRUCTIONS FOR SECTION 17-MANAGEMENT REVIEW (2nd) 2ND REVIEW -The FOA Staff Chief (i. e.. FOA Chief of Conslruuion, Operations, Engineering, planning, etc.) shall maC< Ine appropriate box, review the completed report, provide substantive comments, sign. date. and return to the FOA Safety and Occupational Health Office. INSTRUCTIONS FOR SECTION 18-SAFETY AND OCCUPATIONAL HEALTH REVIEW 3RD REVIEW-The FOA Safety and Occupational HeaRh Office shall review the completed report, mark the appropriate box, ensure that any inadequacies, discrepancies, etc, are rectified by the respons~Dle supervisor and management reviewers, provide substantive comments, sign, date and forwartl to the FOA Commander for review. comment, antl signature. INSTRUCTION FOR SECTION 19-COMMAND APPROVAL 4TH REVIEW-The FOA Commander sha!i fto include me per~c.° designatetl Acting Commander in his absence) review the camo;e;e~ report. comment it required, sign, date. and forwarC trio report ;o ,tie FOA Safety and Occupational Health Office. Signature authon;v sna. not be delegated.