CONTRACTOR CERTIFICATION REGARDING SAFETY AND ENVIRONMENTAL.docx

This is a Contractor Certification form regarding safety and environmental compliance for Project 459-24-001, the Modernize Generators project at Sparks M. Matsunaga VA Medical Center. The certification requires contractors to disclose the number of serious, willful, or repeat violations issued by OSHA within the last three years, with written explanations for any violations cited. Contractors must also report the number of serious, willful, or repeat EPA violations within the same three-year period and provide supporting documentation. A disqualifying threshold of four serious violations, one repeat violation, or one willful violation applies to both OSHA and EPA violations combined. Additionally, contractors must provide their current Experience Modification Rate (EMR) from their insurance carrier, supported by a signed letter on the carrier's letterhead. The form requires the contractor's authorized representative to sign and print their name and title, certifying the accuracy of the submitted information.