CONTRACTOR ENVIRONMENTAL & SAFETY REVIEW

PART 1. ACCEPTANCE & QUALIFICATIONS

I, , an authorized representative of
(OCWD PROJECT MANAGER)
OCWD have reviewed the Contractors Safety Guide with the contractor representative named below.

I, , an authorized representative of
(NAME OF CONTRACTOR REPRESENTATIVE)

, on
(COMPANY NAME) (DATE)
do agree to comply with all Federal, State, local, regulations and ordinances including OCWD safety and environmental
requirements (as defined in the Contractor Safety Guide). All personnel in my charge, including sub-contractors, will be
informed of the requirements contained therein before work is started. The OCWD representative will be provided with
required documents identified below, including any investigations of fatalities/serious injuries, citations, and violations over
the history of the “company”.

BRIEF DESCRIPTION OF PROJECT AND ANY SPECIAL REQUIREMENTS:

INTERNAL USE ONLY- REQUIRED DOCUMENTATION SUBMITTED:

 Contractor’s License (Current, On File & Reviewed Quarterly)
 Certificate of Insurance (Current, On File & Reviewed Quarterly)
 Experience Modification Rate XMOD or EMR Rating.
If >1.1 please document reasons for less than average rating
(<1.0 = BETTER THAN AVG; 1.0 = INDUSTRY AVG; >1.25 = LESS THAN AVG & TARGETED BY STATE OSHA)

 3 Years of OSHA 300A Annual Summary (REQUIRED IF >10 EMPLOYEES)

 3 Year Injury Frequency and Severity Rates
 Total Recordable Injury Rate (TRIR)
 Days Away, Restricted Duty, Transfers (DART)
 Safety Programs (Need Copies for review)
 IIPP
 Code of Safe Practices
 Lockout/Tagout (IF APPLICABLE)
 Confined Space (IF APPLICABLE)
 Electrical Space (IF APPLICABLE)
 Other applicable program(s):
 History of Regulatory Violations (REVIEW OSHA.GOV to ENSURE THERE ARE NO VIOLATIONS/CITATIONS FOR THE PAST 3 YEARS) If
violations are found please document specific reasons for violations/citations:

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 CONTRACTOR ENVIRONMENTAL & SAFETY REVIEW
PART 2: ENVIRONMENTAL CONSIDERATIONS:

Yes, No, NA Specify Details

AIR EMISSIONS:
Will new air emissions be produced or existing emissions be modified?
Is an air permit required for the process? (Federal, state, local) What type
of permit (Permit To Install, Permit To Operate, or both)?
Is a pollution control device required?

WATER USAGE/DISPOSAL:
Will water be used?
Does the water have to be treated prior to disposal?
Will new wastewater discharges be produced?
What waste will be discharged into the sanitary sewer?
Will wastewater discharges result in a permit or permit modifications?
Will the wastewater discharge cause an excursion or non-compliance with
the existing wastewater requirements?

RAW MATERIALS / CHEMICALS:

Are the raw materials being used hazardous or non-hazardous?
How much of the raw material will be stored on-site? (lbs)
Have you provided a Safety Data Sheets (MSDS) for all chemicals to the
Project Manager?

HAZARDOUS / NON-HAZARDOUS WASTE

GENERATION AND DISPOSAL:
How much waste will be generated during start-up, shut-down, and/or
process validation? (lbs) Reference the Waste Management Table I
below.
Can any of the waste be reused or recycled? If yes, please explain.

MISCELLANEOUS REQUIREMENTS:
Will there be any site vegetation clearance?
Will odors be generated and detectable beyond the facility property line?
Will noise be generated as a result of the project?
Will there be any impact to the surrounding environment (flora, fauna,
wildlife)
OTHER CONSIDERATIONS:
Please list any other environmental aspects and impact not considered
above?

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 CONTRACTOR ENVIRONMENTAL & SAFETY REVIEW

Table I: Waste Management (Generation and Disposal):

What waste will be generated? What are the methods of your waste disposal? Enter answers in the table below.
List all waste to be Type of waste The activity/process Expected Approved disposal method
generated as a result (hazardous, non- that will generate Quantity (recycled/reused, wastewater,
of your activities hazardous, bio- the waste of waste stormwater, fuel blended,
hazardous) (lbs) incinerated, or landfilled)

Contractor Evaluation:

The Project Manager shall complete the following section:

1. After full evaluation of the contractor’s proposed activities and services, if significant environmental aspects and impacts
are identified, list below:

2. List operational controls in place to mitigate environmental impacts:

3. Project Approved  / Not Approved .

If project not approved, please explain:

OCWD Project Manager Signature Date

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 CONTRACTOR ENVIRONMENTAL & SAFETY REVIEW

PART 3. POST AWARD CONTRACTOR SAFETY REVIEW

PRE-JOB Review

Project Name / Company Name (Please Print) Date of Meeting/ Representative Name (Please Print)

Project Start Date Estimated Completion Date

1. What equipment (if any) is needed for this project?

2. Estimate number of employees working on this project?

3. Name any hazardous materials you will need to bring on-site? (Attach copies of SDS)

4. Discuss potential hazards to OCWD or Contractor employees. Check all applicable hazards:
 Confined Spaces  Hazardous Waste
 Electrical & Mechanical Safety  Hot Work Permits
 Elevated Work  Cranes
 Fire Systems Impairments  Noise Control
 Hazardous Chemicals  Powered Actuated Tools
 Heavy Equipment/PIV  Trenching/Excavation
 Other (list)

Summary of Hazard Control Measures on this Job:

I acknowledge that I have reviewed and signed the “Contractor Acknowledgement of OCWD Rules” in Part- 4.

Contractor Signature Date

OCWD Project Manager or Risk & Safety Manager Signature Date

POST-JOB Review
1. Was the project completed satisfactorily? YES  NO 
2. What area of safety needs to be reviewed with this contractor?

3. Have all issues and concerns been discussed with contractor? YES  NO 

Contractor Signature Date

OCWD Project Manager or Risk & Safety Signature Date

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 CONTRACTOR ENVIRONMENTAL & SAFETY REVIEW

PART 4. ACKNOWLEDGEMENT OF OCWD RULES

Contractor Name: Company:

Project Manager or Risk & Safety: Date:

REQUIREMENTS Y N CORRECTIVE
ACTION
1. Safety Glasses/goggles worn in required areas (i.e. lab). Eye protection worn when working with
chemicals, and power tools.
2. Hard Hats are worn in construction areas and where there is a potential for falling objects.
3. Proper Attire worn – Long Pants and Safety Shoes in required areas (i.e. construction).
4. Hearing Protection worn in required areas or when noise is at or above 90 dB
5. All Emergency Equipment & Exits are accessible at all times.
6. Aisles and Floors are kept free of obstruction and debris that may cause a slip, trip, and fall hazard.
7. Tools are put away and stored properly after use.
8. Prior to bringing Chemicals on site, Risk & Safety Manager is provided with Safety Data Sheet(s).
9. Hazardous Materials are clearly labeled in compliance with the GHS requirements.
Safety Signs and Barriers are brought and used for construction areas.
11. Contractor ensures Protection of OCWD Property and Equipment.
12. Contractor Brings all required Housekeeping Equipment for cleanup after completion of work.
13. Contractor Obtains Permits where appropriate (i.e. Hot Works).
14. Electrical Work is reviewed with the Project Manager and Electrical Manager prior to start date.
15. Lockout/Tagout work reviewed with Project Manager to ensure compliance with OCWD Lockout
procedure.
16. Electrical Panels are De-Energized and Locked Out prior to performing electrical work.
Confined space permit and monitoring completed prior to entry into confined space.
18. Asbestos containing materials are not brought onsite.
19. Contractors are to report emergencies that occur on OCWD property immediately to the OCWD internal
emergency number by calling 714-378-3300.
20 Evacuation is required when the fire alarm sounds. Use the nearest safe exit, and proceed to
assembly area for roll call.
21. The Use of Portable Gasoline-Powered Equipment within and on the roofs of OCWD buildings is
Prohibited.
22. Self-Closing Safety Cans with flame arrestors must be used for 5 gallons or more Flammable liquids.
23. Understand that elevated work over 6 feet requires fall protection, or standard guardrails and 4-inch
toeboards.
24. Comply with Ladder Safety requirements to include pre-use inspection. NO Standing or working on the
top cap or the step below the top cap of a stepladder.

NOTE: Failure to comply with safety rules may result in dismissal from OCWD facilities.
I have read, understood, and will observe all requirements listed above while conducting contract work for OCWD.

_____________________________________
Contractor Signature Date

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 CONTRACTOR ENVIRONMENTAL & SAFETY REVIEW
PART 5: SAFETY VIOLATION DOCUMENTATION:
(Complete only if necessary)

Project Title: OCWD Supervisor:

Contractor Firm Name: Date of Violation:

Contractor Representative/Contact Date of Meeting:

Person:

Contractor Employee Name(s):

Description of Violation:

Action Taken:

Comments:

Contractor Representative OCWD Project Manager

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