<table style="width:100%;">
<colgroup>
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 6%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 4%" />
<col style="width: 11%" />
<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 9%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 9%" />
<col style="width: 0%" />
</colgroup>
<tbody>
<tr class="odd">
<td></td>
<td colspan="10"><strong>Initial Submittal</strong></td>
<td colspan="5" rowspan="2"></td>
<td colspan="9" rowspan="2"><p>First Quarter Nov 16 to Feb 15</p>
<p>Submit by Feb 15</p></td>
<td rowspan="2"></td>
<td colspan="7" rowspan="2"><p>Third Quarter May 16 to Aug 15</p>
<p>Submit by Aug 15</p></td>
<td></td>
<td colspan="3"><strong>Final Submittal</strong></td>
</tr>
<tr class="even">
<td></td>
<td colspan="10"><strong>Re-Submittal</strong></td>
<td rowspan="2"></td>
<td colspan="3" rowspan="2">Submit within 15 days after project
completion</td>
</tr>
<tr class="odd">
<td colspan="3">Rev. #</td>
<td colspan="7">     </td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="9"><p>Second Quarter Feb 16 to May 15</p>
<p>Submit by May 15</p></td>
<td></td>
<td colspan="7"><p>Fourth Quarter Aug 16 to Nov 15</p>
<p>Submit Nov 15</p></td>
</tr>
<tr class="even">
<td colspan="11"></td>
<td colspan="14"></td>
<td colspan="8"></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td colspan="2">Page</td>
<td colspan="3">1</td>
<td colspan="3">of</td>
<td colspan="6">    </td>
<td colspan="22"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="16">Prime Subcontractor Name:</td>
<td colspan="20">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="22">Project Name and Subcontract Number:</td>
<td colspan="14">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="10">Responsible Person:</td>
<td colspan="19">     </td>
<td colspan="3">Telephone No.:</td>
<td colspan="4">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="37"></td>
</tr>
<tr class="even">
<td colspan="2">Item #</td>
<td colspan="4">     </td>
<td colspan="12">Date On-Site:</td>
<td colspan="5">   /    /   </td>
<td colspan="4">Chemical Location (On-Site):</td>
<td colspan="4">     </td>
<td colspan="4">Date Product Taken Off-Site:</td>
<td>   /    /   </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="6">Product Name:</td>
<td colspan="19">     </td>
<td colspan="5">Manufacturer:</td>
<td colspan="6">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="37"></td>
</tr>
<tr class="odd">
<td colspan="7">Storage Codes:</td>
<td colspan="2"> </td>
<td></td>
<td colspan="3"> </td>
<td colspan="2"></td>
<td colspan="4"> </td>
<td></td>
<td colspan="4">Container Size:</td>
<td>     </td>
<td colspan="8">Quantity Brought On-Site This Period:</td>
<td colspan="3">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="4">End Use:</td>
<td colspan="32">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="13">Waste Disposal Location:</td>
<td colspan="23">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="7">Physical State:</td>
<td colspan="10"> Solid</td>
<td colspan="4"> Liquid</td>
<td colspan="7"> Gas</td>
<td colspan="5">Quantity Used This Period:</td>
<td colspan="3">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="37"></td>
</tr>
<tr class="even">
<td colspan="2">Item #</td>
<td colspan="4">     </td>
<td colspan="12">Date On-Site:</td>
<td colspan="5">   /    /   </td>
<td colspan="4">Chemical Location (On-Site):</td>
<td colspan="4">     </td>
<td colspan="4">Date Product Taken Off-Site:</td>
<td>   /    /   </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="6">Product Name:</td>
<td colspan="19">     </td>
<td colspan="5">Manufacturer:</td>
<td colspan="6">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="37"></td>
</tr>
<tr class="odd">
<td colspan="7">Storage Codes:</td>
<td colspan="2"> </td>
<td></td>
<td colspan="3"> </td>
<td colspan="2"></td>
<td colspan="4"> </td>
<td></td>
<td colspan="4">Container Size:</td>
<td>     </td>
<td colspan="8">Quantity Brought On-Site This Period:</td>
<td colspan="3">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="4">End Use:</td>
<td colspan="32">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="13">Waste Disposal Location:</td>
<td colspan="23">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="7">Physical State:</td>
<td colspan="10"> Solid</td>
<td colspan="4"> Liquid</td>
<td colspan="7"> Gas</td>
<td colspan="5">Quantity Used This Period:</td>
<td colspan="3">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="37"></td>
</tr>
<tr class="even">
<td colspan="2">Item #</td>
<td colspan="4">     </td>
<td colspan="12">Date On-Site:</td>
<td colspan="5">   /    /   </td>
<td colspan="4">Chemical Location (On-Site):</td>
<td colspan="4">     </td>
<td colspan="4">Date Product Taken Off-Site:</td>
<td>   /    /   </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="6">Product Name:</td>
<td colspan="19">     </td>
<td colspan="5">Manufacturer:</td>
<td colspan="6">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="37"></td>
</tr>
<tr class="odd">
<td colspan="7">Storage Codes:</td>
<td colspan="2"> </td>
<td></td>
<td colspan="3"> </td>
<td colspan="2"></td>
<td colspan="4"> </td>
<td></td>
<td colspan="4">Container Size:</td>
<td>     </td>
<td colspan="8">Quantity Brought On-Site This Period:</td>
<td colspan="3">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="4">End Use:</td>
<td colspan="32">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="13">Waste Disposal Location:</td>
<td colspan="23">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="7">Physical State:</td>
<td colspan="10"> Solid</td>
<td colspan="4"> Liquid</td>
<td colspan="7"> Gas</td>
<td colspan="5">Quantity Used This Period:</td>
<td colspan="3">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="37"></td>
</tr>
<tr class="even">
<td colspan="2">Item #</td>
<td colspan="4">     </td>
<td colspan="12">Date On-Site:</td>
<td colspan="5">   /    /   </td>
<td colspan="4">Chemical Location (On-Site):</td>
<td colspan="4">     </td>
<td colspan="4">Date Product Taken Off-Site:</td>
<td>   /    /   </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="6">Product Name:</td>
<td colspan="19">     </td>
<td colspan="5">Manufacturer:</td>
<td colspan="6">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="37"></td>
</tr>
<tr class="odd">
<td colspan="7">Storage Codes:</td>
<td colspan="2"> </td>
<td></td>
<td colspan="3"> </td>
<td colspan="2"></td>
<td colspan="4"> </td>
<td></td>
<td colspan="4">Container Size:</td>
<td>     </td>
<td colspan="8">Quantity Brought On-Site This Period:</td>
<td colspan="3">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="4">End Use:</td>
<td colspan="32">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="13">Waste Disposal Location:</td>
<td colspan="23">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="7">Physical State:</td>
<td colspan="10"> Solid</td>
<td colspan="4"> Liquid</td>
<td colspan="7"> Gas</td>
<td colspan="5">Quantity Used This Period:</td>
<td colspan="3">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="37"></td>
</tr>
</tbody>
</table>

If you need more line items please use Form 432.21A "Subcontractor
Reporting Form Chemical Inventory List -- Continuation Sheet:"

**[GENERAL INSTRUCTIONS]{.underline}**

Prime Subcontractor shall submit information for each chemical/product
brought on site including those proposed to be used by sub-tiers.
Material Safety Data Sheets shall be the source to provide the
information required by this form and the MSDS shall be submitted with
the initial submittal and for each item added by re-submittal. Updates
to previous submittals and Quarterly/Final updates do not require an
attached MSDS.

+-----------+----------------------------------------------------------+
| [Ini      | The initial request to utilize chemicals / products on a |
| tial:]{.u | given project.                                           |
| nderline} |                                                          |
+-----------+----------------------------------------------------------+
| [Re-Submi | Used to provide updates to a previous submittal, or for  |
| ttal:]{.u | any additional chemicals / products requested for        |
| nderline} | approval. Re-Submittals shall be complete with all       |
|           | previously submitted initial or revised information. The |
|           | item no. of additional products shall be identified on   |
|           | the Description section of the VDS Transmittal Form.     |
+-----------+----------------------------------------------------------+
| [Rev.     | After the initial submittal (rev 0), sequentially assign |
| #:]{.u    | a revision no., starting with #1 for each subsequent     |
| nderline} | submittal (re-submittal, quarterly, final).              |
+-----------+----------------------------------------------------------+
| [Quart    | Mark the correct quarter and submit the report at the    |
| erly:]{.u | end of the quarter to identify quantity used during the  |
| nderline} | quarter.                                                 |
+-----------+----------------------------------------------------------+
| [F        | The last submittal, after the subcontractors project is  |
| inal:]{.u | complete, to identify the date the chemical / product    |
| nderline} | was taken off-site. The Final Report will serve as the   |
|           | last Quarterly Report.                                   |
+-----------+----------------------------------------------------------+
| [Prime    | Enter the name of the Prime Subcontractor submitting the |
| Subc      | form for all products on the project used by the prime   |
| ontractor | and all sub-tier subcontractors.                         |
| Name:]{.u |                                                          |
| nderline} |                                                          |
+-----------+----------------------------------------------------------+
| [Project  | Enter designated project title and number.               |
| Name/N    |                                                          |
| umber]{.u |                                                          |
| nderline} |                                                          |
+-----------+----------------------------------------------------------+
| [Re       | The name of the individual and the company phone number  |
| sponsible | for the person responsible for the chemical submittal.   |
| Pe        |                                                          |
| rson]{.un |                                                          |
| derline}: |                                                          |
|           |                                                          |
| [Telep    |                                                          |
| hone]{.un |                                                          |
| derline}: |                                                          |
+-----------+----------------------------------------------------------+
| [Item     | Number each item in sequential order starting with       |
| #:]{.u    | number 1. Assign the next sequential number for each new |
| nderline} | product.                                                 |
+-----------+----------------------------------------------------------+
| [Date     | The initial date the product is ***scheduled to be       |
| On-       | brought on the job site***. This date should be accurate |
| Site:]{.u | to one week of the actual date the product comes on-site |
| nderline} | to ensure compliance to INL chemical tracking            |
|           | procedures.                                              |
+-----------+----------------------------------------------------------+
| [Loca     | Enter the nearest ***BUILDING NUMBER*** where the        |
| tion]{.un | chemical may be found. (i.e. CFA-696)                    |
| derline}: |                                                          |
+-----------+----------------------------------------------------------+
| [Date     | The date the product was taken off-site after the        |
| Product   | subcontractor has completed the job. (Final report only) |
| Off-      |                                                          |
| Site:]{.u |                                                          |
| nderline} |                                                          |
+-----------+----------------------------------------------------------+
| [Product  | Enter name of product **as listed on MSDS**.             |
| Name]{.un |                                                          |
| derline}: |                                                          |
+-----------+----------------------------------------------------------+
| [Manufact | Enter the name of the company **as on MSDS**. [BE        |
| urer]{.un | SPECIFIC]{.underline}.                                   |
| derline}: |                                                          |
+-----------+----------------------------------------------------------+
| [Storage  | Enter the three-part storage code that applies. See      |
| Code]{.un | example and table below. All storage codes are three     |
| derline}: | part, one letter (A-R), a number (1, 2, or 3), and       |
|           | another number (4, 5, 6, or 7).                          |
+-----------+----------------------------------------------------------+

Examples: Code: [**F 2 4**]{.underline} is an aerosol can (under
pressure), **[L 2 4]{.underline}** for a propane tank (under pressure).
**[R 1 4]{.underline}** (Other) for the following: Tank on a pickup
truck, Tube of caulk, A 5-gallon plastic bucket (normal pressure &
temperature). Tank Codes (A, B & C) for reporting purposes are
stationary containers, and do not apply to tanks mounted on a motor
vehicle. Drums Codes (D, E, & I) for reporting purposes are DOT
containers \>5 gallon & \<110 gallons. (typically 30, 55, or 85 gallon)
Tank Wagon--Code P is a tanker or wheeled vehicle with a tank built in,
pulled by a separate motor vehicle.

+-----------------+------------+-----------------+--------------------+
| **Container     |            | **Pressure      | **Temperature      |
| Storage Code**  |            | Storage Code**  | Storage Code**     |
|                 |            |                 |                    |
| (Part one of    |            | (Part two of    | (Part three of     |
| three parts)    |            | three)          | three)             |
+-----------------+------------+-----------------+--------------------+
| A = Above       | J = Bag    | 1 = Normal      | 4 = Container      |
| Ground Tank     |            | pressure        | stored at room     |
|                 |            | (ambient)       | temperature        |
|                 |            |                 | (ambient)          |
+-----------------+------------+-----------------+--------------------+
| B = Below       | K = Box    |                 |                    |
| Ground Tank     |            |                 |                    |
+-----------------+------------+-----------------+--------------------+
| C = Tank Inside | L =        |                 | 5 = Container      |
| Building        | Cylinder   |                 | stored at higher   |
|                 |            |                 | than room          |
|                 |            |                 | temperature        |
|                 |            |                 | (heated)           |
+-----------------+------------+-----------------+--------------------+
| D = Steel Drum  | M = Glass  | 2 = Contents of |                    |
|                 | Bottle     | container under |                    |
|                 |            | pressure        |                    |
+-----------------+------------+-----------------+--------------------+
| E = Plastic or  | N =        |                 | 6 = Container      |
| Non-Metal Drum  | Plastic    |                 | stored at lower    |
|                 | Bottle     |                 | than room          |
|                 |            |                 | temperature        |
|                 |            |                 | (refrigerated)     |
+-----------------+------------+-----------------+--------------------+
| F = Can         | O = Tote   |                 |                    |
|                 | Bin        |                 |                    |
+-----------------+------------+-----------------+--------------------+
| G = Carboy      | P = Tank   | 3 = Contents of | 7 = Container      |
|                 | Wagon      | container under | stored under       |
|                 |            | vacuum          | cryogenic          |
|                 |            |                 | conditions (frozen |
|                 |            |                 | at extremely low   |
|                 |            |                 | temperatures)      |
+-----------------+------------+-----------------+--------------------+
| H = Silo        | Q = Rail   |                 |                    |
|                 | Car        |                 |                    |
+-----------------+------------+-----------------+--------------------+
| I = Fiber Drum  | R = Other  |                 |                    |
|                 | (Specify)  |                 |                    |
+-----------------+------------+-----------------+--------------------+

+-----------+----------------------------------------------------------+
| *         |                                                          |
| *[GENERAL |                                                          |
| INS       |                                                          |
| TRUCTIONS |                                                          |
| (Con      |                                                          |
| t.)]{.und |                                                          |
| erline}** |                                                          |
+-----------+----------------------------------------------------------+
| [         | Enter size of product container (i.e., 46 oz., 2.5 lbs., |
| Container | or 2 fl. oz).                                            |
| Size]{.un |                                                          |
| derline}: |                                                          |
+-----------+----------------------------------------------------------+
| [Quantity | Total amount of product brought On-Site and stored on    |
| Br        | work vehicles or in work location facilities.            |
| ought]{.u |                                                          |
| nderline} |                                                          |
|           |                                                          |
| [On-Site  |                                                          |
| This      |                                                          |
| Pe        |                                                          |
| riod:]{.u |                                                          |
| nderline} |                                                          |
+-----------+----------------------------------------------------------+
| [End      | Enter the end use for the product; i.e., paint or        |
| Use:]{.u  | industrial coating, lubricant, adhesive, sealant,        |
| nderline} | concrete, fuel, abrasive blast, asphalt roofing, weld    |
|           | flux, insulation, cleaner, solvent etc.                  |
+-----------+----------------------------------------------------------+
| [Waste    | If waste is generated with the use of this product,      |
| Disposal  | indicate the disposal location: INL Landfill, Haz        |
| Loca      | Waste-Off Site TSD, Rad Waste-RWMC, ACM Waste-INL        |
| tion:]{.u | Landfill, other (explain).                               |
| nderline} |                                                          |
+-----------+----------------------------------------------------------+
| [Physical | Indicate whether chemical is in a solid, liquid, or      |
| S         | gaseous form, as applicable.                             |
| tate]{.un |                                                          |
| derline}: |                                                          |
+-----------+----------------------------------------------------------+
| **[For    |                                                          |
| Quarterly |                                                          |
| Reports   |                                                          |
| O         |                                                          |
| nly]{.und |                                                          |
| erline}** |                                                          |
+-----------+----------------------------------------------------------+
| [Quantity | Report the total quantity of product used in units of    |
| Used]{.un | weight or volume. (i.e., pounds, gallons, or cubic foot) |
| derline}: |                                                          |
+-----------+----------------------------------------------------------+