12-RFP 3936 Exhibits Contractors CAL OSHA Compliance History.pdf
PDF 345 KB Posted
- Solicitation number
- RFP 3936
- Issued by
- Riverside County, California
About this file
Contractor's CAL/OSHA Compliance History Exhibit for RFP #3936
This is a contractor compliance and safety disclosure form submitted as an exhibit to RFP #3936 by the Eastern Municipal Water District in California. The form requires contractors to disclose their Standard Industry Code, California State Contractor's License number, and contact information. Contractors must answer two critical safety and regulatory compliance questions: whether they have been cited by Cal/OSHA or any regulatory agency for safety or environmental violations within the past seven years, and whether they have experienced a serious incident or fatality on a job site within the past ten years. The form applies to the asphalt rehabilitation project for the Operations and Maintenance Center and Administration Center parking lots, which involves removal and replacement of asphalt, grinding, saw cutting, application of slurry and sealants, and line striping.
The form requires contractors to provide detailed explanations and supporting documentation if they answer affirmatively to either compliance question, including specific information about incidents and corrective actions taken to prevent recurrence. The contractor's representative must sign and date the submission. Upon receipt, the Eastern Municipal Water District's purchasing department forwards the completed form to Risk Management for review and approval. Risk Management personnel must review the submission and indicate approval or disapproval status with a signature and date. This document serves as a prerequisite screening mechanism to evaluate contractor safety performance and regulatory compliance history prior to contract award.
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Text version
CONTRACTOR’S CAL/OSHA COMPLIANCE HISTORY AND SIC CODE
RFP #3936
(This document is to be submitted with the proposal package) (rev. 10/08/18)
Date:
Contractor’s Standard Industry Code:
Contractor’s Name:
California State Contractor’s License #:
Address:
Contact Person:
Phone No:
Please answer the following questions:
1. Has the contractor been cited by Cal/OSHA or any regulatory agency for a violation related to safety or environmental issues within the past seven (7) years?
No Yes
2. Within the past ten (10) years has the contractor had a serious incident or fatality on a job site?
No Yes
* If yes to # 1 or #2, please provide information specific to the incident(s) and action(s) taken to ensure that there is not a repeat violation, or incident(s) (attach additional sheets if needed)
Contractor’s Representative signature:
FOR EMWD USE ONLY: Purchasing to forward to Risk Management for review
(Risk Management)
Approved: No Yes
Reviewed by (Risk Management)
(signature required)
| Date_11: |
| Contractors Standard Industry Code: |
| Contractors Name: |
| California State Contractors License: |
| Address_9: |
| Contact Person: |
| Phone No: |
| or environmental issues within the past seven 7 years: Off |
| Within the past ten 10 years has the contractor had a serious incident or fatality on a job site: Off |
| Please answer the following questions 1 Has the contractor been cited by CalOSHA or any regulatory agency for a violation related to safety or environmental issues within the past seven 7 years No Yes 2 Within the past ten 10 years has the contractor had a serious incident or fatality on a job site No Yes If yes to 1 or 2 please provide information specific to the incidents and actions taken to ensure that there is not a repeat violation or incidents attach additional sheets if neededRow1: |
| Please answer the following questions 1 Has the contractor been cited by CalOSHA or any regulatory agency for a violation related to safety or environmental issues within the past seven 7 years No Yes 2 Within the past ten 10 years has the contractor had a serious incident or fatality on a job site No Yes If yes to 1 or 2 please provide information specific to the incidents and actions taken to ensure that there is not a repeat violation or incidents attach additional sheets if neededRow2: |
| Please answer the following questions 1 Has the contractor been cited by CalOSHA or any regulatory agency for a violation related to safety or environmental issues within the past seven 7 years No Yes 2 Within the past ten 10 years has the contractor had a serious incident or fatality on a job site No Yes If yes to 1 or 2 please provide information specific to the incidents and actions taken to ensure that there is not a repeat violation or incidents attach additional sheets if neededRow3: |
| Please answer the following questions 1 Has the contractor been cited by CalOSHA or any regulatory agency for a violation related to safety or environmental issues within the past seven 7 years No Yes 2 Within the past ten 10 years has the contractor had a serious incident or fatality on a job site No Yes If yes to 1 or 2 please provide information specific to the incidents and actions taken to ensure that there is not a repeat violation or incidents attach additional sheets if neededRow4: |
| Please answer the following questions 1 Has the contractor been cited by CalOSHA or any regulatory agency for a violation related to safety or environmental issues within the past seven 7 years No Yes 2 Within the past ten 10 years has the contractor had a serious incident or fatality on a job site No Yes If yes to 1 or 2 please provide information specific to the incidents and actions taken to ensure that there is not a repeat violation or incidents attach additional sheets if neededRow5: |
| Date_12: |
| Date Risk Management: |
| Approved No: |
| Yes_5: |
| Reviewed by Risk Management: |
| signature required: |
| Signature3_es_:signer:signature: |
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