Exhibit JC3 - Surveillance Forms 4pg.pdf

Exhibit JC3

EXHIBIT JC3

SURVEILLANCE FORMS

GSA FORM 1181A - CONTRACT CLEANING INSPECTION REPORT

This form shall be completed and submitted to the Contractor when deficiencies are found during the COR's inspections.

CONTRACT CLEANING INSPECTION REPORT

INSTRUCTIONS: Form is used for inspection of contract cleaning by inspectors to record results. The condition of area(s) inspected will be rated SATISFACTORY or UNSATISFACTORY. Explain unsatisfactory ratings in the REMARKS column and complete the QUANTITY column.

BUILDING REPORT NO. CONTRACT NO.

INSPECTOR (print name) INSPECTOR'S SIGNATURE DATE OF INSPECTION

TIME STARTED TIME COMPLETED

CONTRACTOR RECEIPT

CONTRACTOR (print name) CONTRACTOR'S SIGNATURE Time Date

WORK DESCRIPTION - Quantity Check One

LOCATION (Room no., (by measure REMARKS corridor, lobby, etc.) or count) SAT UNSAT

Room 3-5171 1 ea X Rust on toilet base around bolt

Room 3-5178 X

5th floor ladies' public toilet room X

5th floor mens' public toilet room 750 sf X Buildup on floor in corners around urinal

1st floor lobby drinking fountain 250 sf X Mineral buildup on bubbler

GENERAL SERVICES ADMINISTRATION GSA FORM 1181-A

QUALITY DEFICIENCY NOTICE

This form shall be completed and submitted to the Contractor when deficiencies are found during the COR's inspections.

QUALITY DEFICIENCY NOTICE

CONTRACTOR'S NAME: CONTRACTOR'S ADDRESS:

XXXX Cleaning Services 333 Smith Street, Suite, 201

San Francisco, CA 94102

CONTRACT NO. GS-09P-06-KSD-0000

A deficiency exists in your quality control system. The nature of thee deficiency is:

Continuous findings on 3rd floor men's toilet room 3-5171 - rust on toilet base around bolt.

Rust should be removed and toilet base should be clean.

Immediate action is required to correct the deficiency and the condition that caused it.

Failure to take acceptable corrective action on time may result in termination of your right to proceed with this contract.

Please provide a written response of corrective action taken to the CO or their designee within __________ workdays after receiving this notice.

CO OR DESIGNEE NAME ADDRESS DATE

Ima Boss, COR 450 Golden Gate Avenue, Suite 7

San Francisco, CA 94102 11/05/06

CO OR DESIGNEE SIGNATURE

RECEIPT ACKNOWLEDGED CERTIFIED RECEIPT NO.

Corrective action verified and found acceptable

Corrective action not acceptable and/or not implemented (Explain below).

This matter is being referred to the Contracting Officer for action. Direct further correspondence on this matter to the CO.

CO OR DESIGNEE SIGNATURE DATE

RECEIPT ACKNOWLEDGED DATE

QASP Monthly Inspection Report

BUILDING NAME & LOCATION: Phillip Burton Federal Building & US Courthouse

CONTRACT NO.: ______________GS-09P-06-KSD-0000__

CONTRACTOR NAME: ____XXX Cleaning Service____

Please report all deficiencies found during the previous month inspection(s). Attach copies of all GSA 3539 Forms submitted to the contractor with this form. If there were no deficiencies, please submit this form indicating there were no deficiencies reported for the month. This form will become a part of the official QA documentation.

DEFIENCIES & CORRECTIVE ACTIONS COMMENTS

Documented on the Contract Cleaning Inspection Reports

All Deficiencies Minor, Corrected by the Contractor

COR

Signature: _________________ Date: _________________

COR’s Checklist for Inspections

CUSTODIAL AND RELATED SERVICES COMMENTS

Submittals:

-a list of names and telephone numbers of on-site supervisors -security clearance documentation (current & new employees)

- work schedules

- floor maintenance schedules

- SDS documentation

- initial IPM inspection report

Quality Control Plan (QCP)

- description of training programs

- description of disciplinary procedures

- description of contingency plan for separation of employees

Inspection Reports

Service Call Logs

Tenant Reports

Integrated Pest Management (IPM) Quarterly Reports

Recycling and Solid Waste/Trash Hauling Reports

NOTE: This checklist does NOT represent an all-inclusive list of items that may be reviewed during an inspection. It is provide ONLY as guidance for the CO or their designee.