CONTRACTOR CERTIFICATION REGARDING SAFETY AND ENVIRONMENTAL.docx
DOCX document 14 KB Posted
- Solicitation number
- 36C26125R0012
About this file
This is a contractor certification form for safety and environmental compliance related to Project 570-22-219 Consolidate Sterile Supply Rooms at the Department of Veterans Affairs. The form requires contractors to disclose any OSHA and EPA violations (serious, willful, or repeat) from the past three years, with explanations required for any violations. Four serious violations, one repeat violation, or one willful violation automatically disqualifies a contractor. The form also requires contractors to provide their current Insurance Experience Modification Rate (EMR) supported by a signed letter from their insurance carrier on company letterhead.
The form is associated with VA solicitation number 36C26125R0012 for consolidating sterile supply rooms under the Veterans Integrated Service Network 21. It includes spaces for the contractor's signature, typed name, and title.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| 36C26125R0012 RFI_3.docx | DOCX document | |
| 36C26125R0012 0006.docx | DOCX document | |
| 36C26125R0012 0005.docx | DOCX document | |
| 36C26125R0012 RFI_2.docx | DOCX document | |
| 36C26125R0012 0004.docx | DOCX document | |
| SOW Consolidate Sterile Supply Rooms_Jan 22 .pdf | ||
| 36C26125R0012 0003.docx | DOCX document | |
| 36C26125R0012 RFIs.docx | DOCX document | |
| 52.209-5 CERTIFICATION REGARDING RESPONSIBILITY MATTERS.docx | DOCX document | |
| 36C26125R0012 0002.docx | DOCX document | |
| Site Visit Log_01-08-2025.pdf | ||
| 36C26125R0012 0001.docx | DOCX document | |
| 570-22-219 Construction Specifications.pdf | ||
| Large Business Subcontracting Plan Template.docx | DOCX document | |
| 570-22-219 Construction Drawings -.pdf | ||
| Price Breakdown.xlsx | XLSX spreadsheet | |
| RFI Form - 36C26125R0012.docx | DOCX document | |
| Wage Determination CA20240018 Oct 18 2024.pdf | ||
| 36C26125R0012_1.docx | DOCX document |
Show all 19
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
CONTRACTOR CERTIFICATION REGARDING SAFETY AND ENVIRONMENTAL
Contractor Certification: Project 570-22-219 Consolidate Sterile Supply Rooms
| 2021 |
| 2022 |
| 2023 |
| 2024 |
Number of serious, willful, or repeat violations from OSHA within the last 3 years. Please attach explanation for any violations.
Number of serious, willful, or repeat EPA violations within the last 3 years. Please attach explanation for any violations.
(Four serious, one repeat, or one willful violation disqualifies the contractor.)
Company’s Current Insurance Experience Modification Rate (EMR) = _____________ (Note: Contractor must support the EMR with a signed letter from Insurance Carrier on their letterhead.)
Signature: ______________________________________________
Typed Name: ______________________________________________________
Title: ______________________________________________________
File details come from the government source that posted it. Updated .