3-RFP 3903 CONTRACTOR’S CAL OSHA.pdf
PDF 152 KB Posted
- Attached to
- Ammonia Chemical Feed Skid
- Solicitation number
- RFP # 3903
- Issued by
- Riverside County, California
About this file
This is a Contractor's Cal/OSHA Compliance History and SIC Code form required as part of the proposal package for RFP #3903 issued by the Eastern Municipal Water District (EMWD) for the purchase of a liquid ammonium sulfate and 12.5% sodium hypochlorite chemical dosing skid system in California. The form requires contractors to provide their standard industry code, California State Contractor's License number, company information, and contact details. Contractors must disclose 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 serious incidents or fatalities on job sites within the past ten years. If contractors answer affirmatively to either question, they must provide detailed information about the incidents and corrective actions taken to prevent recurrence.
The form includes a submittal checklist and requires contractor representatives to sign and date the document. All responses are subject to review and approval by EMWD's Risk Management department before contract award. Contractors must also confirm acceptance of the District's standard insurance requirements as outlined in the Insurance Requirements document dated May 2021, with any exceptions or modifications to be detailed separately. The document serves as a qualification screening tool to assess contractor safety and compliance history prior to selection for this chemical equipment procurement.
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Text version
RFP #3903
CONTRACTOR’S CAL/OSHA COMPLIANCE HISTORY AND SIC CODE
(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: Date:
FOR EMWD USE ONLY: Purchasing to forward to Risk Management for review
Date:
(Risk Management) Approved: No Yes
Reviewed by (Risk Management) (signature required)
| RFP #3903 PRICE FORM |
| LIST OF SUBCONTRACTORS |
| ADDITIONS, DELETIONS AND/OR EXCEPTIONS |
| District will issue an Agreement in its standard form to the successful firm(s) for the services contemplated herein; a copy of which is attached hereto and incorporated herein. Any deletion, exception, or modification taken to District contract terms... |
| ☐ Check here if you DO NOT accept terms and conditions as stated in the Insurance Requirements (05/2021). Detail all Exceptions in, Additions, Deletions and/or Exceptions Form. |
| (This document is to be submitted with the proposal package) (rev. 10/08/18) |
SUBMITTAL CHECK-OFF LIST
| Date_7: |
| Contractors Standard Industry Code: |
| Contractors Name: |
| California State Contractors License: |
| Address_7: |
| 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_8: |
| FOR EMWD USE ONLY: |
| Date Risk Management: |
| Approved No: |
| Yes_5: |
| Reviewed by Risk Management: |
| signature required: |
File details come from the government source that posted it. Updated .