36C26318Q0548-001.docx

Sources Sought Notice Response Form for Leaking Underground Storage Tank (LUST) Remediation Services – VA Central Iowa Health Care System

Please fully complete each section of the form below.

Company Name: _____________________________________________________________ Company Address: ___________________________________________________________ DUNS Number: _____________________________________________________________ Point of Contact: ____________________________________________________________ Phone Number: _____________________________________________________________ Email Address: _____________________________________________________________

Socio-Economic Classification in Accordance with NAICS Code 562910 – Remediation Services (check all that apply) ☐ Small Business ☐ Service Disabled Veteran Owned Small Business (SDVOSB) ☐ Verified SDVOSB by www.vip.vetbiz.gov ☐ Veteran Owned Small Business (VOSB) ☐ Verified VOSB by www.vip.vetbiz.gov ☐ Small Disadvantage Business ☐ Women-owned Small Business ☐ Economically Disadvantaged Small Business ☐ HUBZone ☐ 8(a) Certified ☐ Other: _________________________________________________

Businesses desiring to do business with the Federal Government are required to be active and registered at System for Award Management (SAM) at https://www.sam.gov; is your business registered at this site? Yes ___No ____ If yes, please provide copy of SAM registration.

Detailed Information:

1. Please summarize your company’s ability to provide LUST remediation services as contained in Sources Sought Notice posted to https://www.fbo.gov:

2. What percentage of the contracted services can your company complete as the prime contractor? ______________%

3. What percentage of the contracted services would your company subcontract? ______________%

4. If solicitation is pursued after market research conducted, the Government will require that company have an Iowa Certified Groundwater Professional (CGWP), in accordance with 567 IAC Chapter 134 (http://www.iowadnr.gov/Environmental-Protection/Land-Quality/Underground-Storage-Tanks/Groundwater-Professionals)

a) Does your company have this certification? If so, please provide a copy of certification.

b) If does not, does company anticipate being able to obtain such certification if solicitation is contemplated by the Government? Please explain: