CONTRACTOR CERTIFICATION REGARDING SAFETY AND ENVIRONMENTAL.docx
DOCX document 14 KB Posted
- Attached to
- Z2DZ--Modernize Generator Project
- Solicitation number
- 36C26126R0031
About this file
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.
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Text version
CONTRACTOR CERTIFICATION REGARDING SAFETY AND ENVIRONMENTAL
Contractor Certification: Project 459-24-001, Modernize Generators
| 2023 |
| 2024 |
| 2025 |
| 2026 |
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 .