5-Bid Item Key and Acceptance - NBCUA Contract No. 25-002 FINAL.pdf

BID ITEM KEY AND ACCEPTANCE

NORTHWEST BERGEN COUNTY UTILITIES

AUTHORITY

REMOVAL AND DISPOSAL OF RESIDUALS

FOR THE WASTEWATER TREATMENT PLANT

Contract No. 25-002 Solicitation Reference No. NBCUA-BID-25-002

TO THE NORTHWEST BERGEN COUNTY UTILITIES

AUTHORITY:

The undersigned Bidder proposes and agrees, if this Bid is accepted, to enter into an agreement with Owner in the form included in the Procurement Documents to perform the removal and disposal of residuals as specified or indicated in the Procurement Documents for the Contract Price and within the Contract Time indicated in this Bid and in accordance with the Procurement Documents.

It is understood that the Total Price for the entire contract stated by the undersigned in the Schedule is based on the unit prices bid in the awarding of the contract.

The quantities of residuals to be removed and disposed of under the proposed contract are set forth in the Bid Form. The estimated quantity of 550 tons per year is approximate only. No minimum quantity is guaranteed. The Owner does not expressly or by implication agree that any specific quantities will be generated, but reserves the right to have removed and disposed of all residuals as generated. The Contractor shall at no time make a claim for anticipated profit or loss of profits because of any difference between estimated quantities and actual quantities.

Bidder agrees that residuals removal and disposal services will be performed in accordance with the Period of Contract specified in the specifications (two years from date of notice to proceed). Bidder also accepts the provisions of the agreement as to liquidated damages in the event of failure to remove residuals within the time stipulated.

The terms used in this Bid have the meanings assigned to them in the General Terms and Conditions.

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BID TABLE: NBCUA CONTRACT NO. 25-002

BID FORM

TO BE COMPLETED ON EUNA PROCUREMENT PLATFORM (BERGENBIDS.COM)

Item# Description Unit Unit Cost

Estimated Annual

Quantity

Extended Cost

1 REMOVAL AND DISPOSAL OF

RESIDUALS (2 YEARS)

1-1 Removal and Disposal of Residuals Cost per Ton

$. 1,100 tons (2 years) $________.____

REMOVAL AND DISPOSAL OF

DEWATERED SLUDGE CAKE

RESIDUALS (2 YEARS)

2-1 Removal and Disposal of Dewatered Sludge Cake Residuals (15-25% solids)

Cost per Ton

$. As Needed $________.____

CONTRACT EXTENSION OPTIONS (Subject to Authority Approval)

Item# Description Unit Unit Cost

3 REMOVAL AND DISPOSAL OF RESIDUALS - YEAR 3

3-1 Removal and Disposal of Residuals (3rd year price) Cost per Ton $.

3-2 Removal and Disposal of Residuals (4th year price) Cost per Ton $.

3-3 Removal and Disposal of Residuals (5th year price) Cost per Ton $.

4 REMOVAL AND DISPOSAL OF DEWATERED SLUDGE

CAKE RESIDUALS - YEAR 3

4-1 Removal and Disposal of Dewatered Sludge Cake Residuals (3rd year price)

Cost per Ton $.

4-2 Removal and Disposal of Dewatered Sludge Cake Residuals (4th year price)

Cost per Ton $.

4-3 Removal and Disposal of Dewatered Sludge Cake Residuals (5th year price)

Cost per Ton $.

TO BE COMPLETED ON EUNA PROCUREMENT PLATFORM (BERGENBIDS.COM)

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EXPLANATION OF BID ITEMS

ITEM 1 – REMOVAL AND DISPOSAL OF RESIDUALS

1.1 Removal and Disposal of Residuals: This item covers the cost per ton for removal and disposal of screenings and grit classifier wastes generated from wastewater treatment facilities. Services include:

• Furnishing and delivering sufficient suitable containers (not to exceed 8 feet in total height above grade)

• Containers must have removable covers to control odors and secure contents during transport

• Removal of containers at least once every 7 days (approximately 104 hauls over 2 years)

• No more than two containers stored on site at any time

• Disposal at NJDEP-approved facility

• All transportation, tipping fees, taxes, permits, licenses, and registrations included in unit price

ITEM 2 – REMOVAL AND DISPOSAL OF DEWATERED SLUDGE CAKE

RESIDUALS

2.1 Removal and Disposal of Dewatered Sludge Cake Residuals: This item covers the cost per ton for removal and disposal of dewatered sludge cake (15-25% solids) on an on-call basis. Services include:

• Furnishing 30-40 cubic yard containers approved for this purpose

• Container removal every 8 hours when service is required

• No more than two containers stored on site at any time

• Disposal at NJDEP-approved facility

• All transportation, tipping fees, taxes, permits, licenses, and registrations included in unit price

• This service may or may not be required during the contract period

DESIGNATION OF DISPOSAL SITES:

Primary Disposal Site:

• Name: _____________________________________________

• Address: __________________________________________

Alternate Disposal Site (if applicable):

• Name: _____________________________________________

• Address: __________________________________________

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BASIS OF AWARD

The contract shall be awarded to the lowest responsible bidder based on the aggregate total of Items 1 and 2 for the initial two-year period. Extension year pricing (Items 1A-1C and 2A-2C) shall not be considered in the evaluation for contract award; however, the unit prices quoted for extension years shall be incorporated into the final contract and may be utilized at the discretion of the Owner if contract extensions are exercised. The Owner reserves the right to reject any or all bids in accordance with N.J.S.A. 40A:11-13.2, if such action is deemed to be in its best interest.

CONTRACT TERM

The initial contract term is Twenty-Four (24) Months from the date of Notice to Proceed. The Authority reserves the right to authorize up to three (3) one-year extensions, not to exceed a total contract life of five years, subject to the conditions specified in N.J.S.A. 40A:11-15(7).

BID GUARANTEE

• Bid Bond: Required (see Instructions to Bidders)

• Consent of Surety: Required (see Instructions to Bidders)

STATEMENT ON BID DOCUMENT SUBMISSION

CHECKLIST

For this procurement the Northwest Bergen County Utilities Authority is utilizing the Euna Procurement platform (BergenBids.com). When preparing your bid, the system will alert you to those documents which are labeled as "Mandatory Forms Which Shall Cause Your Submission to be Rejected" and "Other Requested Documents Due Before Contracting". The system will not allow you to submit your bid without including an attachment in each of the mandatory criteria or forms.

Therefore, it is the position of the Authority in consultation with the NJ Department of Community Affairs Division of Local Government Services that this format satisfies as a checklist properly delineating those documents needed to be returned at time of bid.

BUSINESS REGISTRATION CERTIFICATE

In accordance with P.L. 2009, C315, all business organizations doing business with any governmental agency (including the Northwest Bergen County Utilities Authority hereafter known as NBCUA) are required to be registered with the State of New Jersey and provide proof of registration before the NBCUA may enter into a contract. Therefore, all bidders must submit prior to the time of contract award a copy of the bidder's "BUSINESS REGISTRATION CERTIFICATE" issued by the

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Division of Revenue. Bidders can contact the Division of Taxation, Regulatory Services Branch, at 609-292-5995 for information on the required form.

Bidder's named subcontractors, at all levels, must also provide proof of registration to their contractors until they reach the direct contractor. The bidder has the obligation to obtain these certificates and file them with the NBCUA prior to the time of contract award. A "subcontractor" is described as a business organization that "knowingly" supplies goods or services to a contractor (bidder) in fulfillment of a contract with the NBCUA. "Knowingly" means the subcontractor has affirmative and clear knowledge that the specific goods or services being provided are for the

NBCUA.

NOTE: No subcontracting is permitted under this contract. All work must be performed by the successful Bidder/Contractor.

"NEW JERSEY BUSINESS REGISTRATION REQUIREMENTS"

Before final payment on the contract is made by the contracting agency, the contractor shall submit an accurate list and proof of business registration of each subcontractor or supplier used in the fulfillment of the contract, or shall attest that no contractors were used.

For the term of the contract, the contractor and each of its affiliates and a subcontractor and each of its affiliates (N.J.S.A. 52:32-44(g)(3)) shall collect and remit to the Director, New Jersey Division of Taxation, the use due tax pursuant to the Sales and Use Tax Act on all sales of tangible personal property is intended for a contract with a contracting agency.

A business organization that fails to provide a copy of a business registration as required pursuant to section 1 of P.L. 2001, c. 134 (C.52:32-44 et al.) or subsection e. or f. of Section 92 of P.L. 1977, c.

110 (c.5:12-92), or that provides false business registration information under the requirements of either of those sections, shall be liable for a penalty of $25 for each day of violation, not to exceed $50,000 for each business registration copy not properly provided under a contract with a contracting unit.

AMERICANS WITH DISABILITIES ACT OF 1990

Equal Opportunity for Individuals with Disability

The contractor and the OWNER do hereby agree that the provisions of Title II of the Americans With Disabilities Act of 1990 (the "Act") (42 U.S.C. S12101 et seq.), which prohibits discrimination on the basis of disability by public entities in all services, programs, and activities provided or made available by public entities, and the rules and regulations promulgated pursuant there unto, are made a part of this contract. In providing any aid, benefit, or service on behalf of the owner pursuant to this contract, the contractor agrees that the performance shall be in strict compliance with the Act. In the event that the contractor, its agents, servants, employees, or subcontractors violate or are alleged to have violated the Act during the performance of this contract, the contractor shall defend the owner in any action or administrative proceeding commenced pursuant to this Act. The contractor shall indemnify, protect, and save harmless the owner, its agents, servants, and employees from and against any and all suits, claims, losses, demands, or damages, of whatever kind or nature arising out

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The owner shall, as soon as practicable after a claim has been made against it, give written notice thereof to the contractor along with full and complete particulars of the claim. If any action or administrative proceeding is brought against the owner or any of its agents, servants, and employees, the owner shall expeditiously forward or have forwarded to the contractor every demand, complaint, notice, summons, pleading, or other process received by the owner or its representatives.

It is expressly agreed and understood that any approval by the owner of the services provided by the contractor pursuant to this contract will not relieve the contractor of the obligation to comply with the Act and to defend, indemnify, protect, and save harmless the owner pursuant to this paragraph.

It is further agreed and understood that the owner assumes no obligation to indemnify or save harmless the contractor, its agents, servants, employees and subcontractors for any claim which may arise out of their performance of this Agreement. Furthermore, the contractor expressly understands and agrees that the provisions of this indemnification clause shall in no way limit the contractor's obligations assumed in this Agreement, nor shall they be construed to relieve the contractor from any liability, nor preclude the owner from taking any other actions available to it under any other provisions of the Agreement or otherwise at law.

CERTIFICATION OF EQUAL EMPLOYMENT

OPPORTUNITY

The undersigned hereby agrees by the submission of this bid and in accordance with Executive Order No. 11246, Section 202, dated September 24, 1965, the bidder, offeror, applicant, or subcontractor certifies that he shall not discriminate against any employee or applicant for employment because of race, color, creed, or national origin. This obligation not to discriminate in employment includes, but is not limited to, the following:

HIRING, PLACEMENT UPGRADING, TRANSFER OR DEMOTION, RECRUITMENT,

ADVERTISING, OR SOLICITATION OF EMPLOYMENT, TRAINING DURING

EMPLOYMENT, RATES OF PAY OR OTHER FORMS OF COMPENSATION,

SELECTION FOR TRAINING INCLUDING APPRENTICESHIP, LAYOFF, OR

TERMINATION.

He further agrees that (except where he has obtained identical certifications from proposed subcontractors for specific time periods) he will obtain identical certifications from proposed subcontractors prior to the award of subcontractors exceeding $10,000, which are not exempt from the provision of Equal Opportunity clause: that he will retain such certifications in his files, and that he will post in a conspicuous place and forward Notice of Non-Discrimination to such proposed

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EXHIBIT A

MANDATORY EQUAL EMPLOYMENT OPPORTUNITY LANGUAGE

N.J.S.A. 10:5-31 et seq. (P.L.1975, c.127) N.J.A.C. 17:27 et seq.

GOODS, GENERAL SERVICES, AND PROFESSIONAL SERVICES

CONTRACTS

During the performance of this contract, the contractor agrees as follows:

The contractor or subcontractor, where applicable, will not discriminate against any employee or applicant for employment because of age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex. Except with respect to affectional or sexual orientation and gender identity or expression, the contractor will ensure that equal employment opportunity is afforded to such applicants in recruitment and employment, and that employees are treated during employment, without regard to their age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex. Such equal employment opportunity shall include, but not be limited to the following: employment, upgrading, demotion, or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship. The contractor agrees to post in conspicuous places, available to employees and applicants for employment, notices to be provided by the Public Agency Compliance Officer setting forth provisions of this nondiscrimination clause.

The contractor or subcontractor, where applicable will, in all solicitations or advertisements for employees placed by or on behalf of the contractor, state that all qualified applicants will receive consideration for employment without regard to age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex.

The contractor or subcontractor will send to each labor union, with which it has a collective bargaining agreement, a notice, to be provided by the agency contracting officer, advising the labor union of the contractor's commitments under this chapter and shall post copies of the notice in conspicuous places available to employees and applicants for employment.

The contractor or subcontractor, where applicable, agrees to comply with any regulations promulgated by the Treasurer pursuant to N.J.S.A. 10:5-31 et seq., as amended and supplemented from time to time and the Americans with Disabilities Act.

The contractor or subcontractor agrees to make good faith efforts to meet targeted county employment goals established in accordance with N.J.A.C. l7:27-5.2.

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The contractor or subcontractor agrees to inform in writing its appropriate recruitment agencies including, but not limited to, employment agencies, placement bureaus, colleges, universities, and labor unions, that it does not discriminate on the basis of age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex, and that it will discontinue the use of any recruitment agency which engages in direct or indirect discriminatory practices.

The contractor or subcontractor agrees to revise any of its testing procedures, if necessary, to assure that all personnel testing conforms with the principles of job related testing, as established by the statutes and court decisions of the State of New Jersey and as established by applicable Federal law and applicable Federal court decisions.

In conforming with the targeted employment goals, the contractor or subcontractor agrees to review all procedures relating to transfer, upgrading, downgrading and layoff to ensure that all such actions are taken without regard to age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex, consistent with the statutes and court decisions of the State of New Jersey, and applicable Federal law and applicable Federal court decisions.

The contractor shall submit to the public agency, after notification of award but prior to execution of a goods and services contract, one of the following three documents: Employee Information Report (AA-302) or Certificate of Employee Information Report, or proof of a federally approved Affirmative Action program (electronically provided by the Division and distributed to the public agency through the Division's website at: http://www.state.nj.us/treasury/contract_compliance).

The contractor and its subcontractors shall furnish such reports or other documents to the Division of Purchase & Property, CCAU, EEO Monitoring Program as may be requested by the office from time to time in order to carry out the purposes of these regulations, and public agencies shall furnish such information as may be requested by the Division of Purchase & Property, CCAU, EEO Monitoring Program for conducting a compliance investigation pursuant to N.J.A.C. 17:27-1.1 et seq.

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BID SUBMISSION FORMATS

Bid is submitted herewith if Bidder is:

AN INDIVIDUAL

BY

_____________________________________________________________________________(Seal (Individual's Name - Print or Type)

Doing Business As

Business Address:______________________________________________________________________

Phone No.:

(Signature)

A PARTNERSHIP

BY

_____________________________________________________________________________(Seal (Firm Name)

(General Partner - Print or Type)

Business Address:______________________________________________________________________

Phone No.:

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(Note: Address of bidder shall not be a post office box.)

A CORPORATION

(Corporation Name)

(State of Incorporation)

(Name of Person Authorized to Sign - Print or Type)

(Corporate Seal)

Attest:

(Secretary)

Business Address:

Phone No.

A JOINT VENTURE

BY_____________________________________________________________________________(S eal) (Name)

(Address)

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(Signature)

BY_____________________________________________________________________________

(Seal)

BY_____________________________________________________________________________

(Seal)

(Each joint venture must sign. The manner of signing for each individual, partnership, and corporation that is a part to the joint venture should be in the manner indicated above.)

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BID ACCEPTANCE

The undersigned hereby agrees to dispose of the residuals in the manner as indicated in the Specifications for a period from the date of notice from the Authority to proceed until two (2) year after such date. The Authority will determine the TOTAL BID PRICE by multiplying the unit cost per ton of residuals times the estimated quantity of tons of residuals stipulated herein for each Bid. It is understood that the award of the Bid will be based upon the lowest number arrived at by taking the total obtained by adding together the TOTAL BID PRICES for the disposal of existing accumulated residuals and future accumulated residuals. It is understood each unit price per ton of residuals is a firm price for the Contract, and includes the cost of suppling containers, removing, hauling, disposing of residuals, and any other cost to the Bidder, including necessary permits, licenses, registrations, fees, overhead and profit. No other allowance, addition or number of any nature will be permitted to enter into the calculation. Each Bidder must schedule a site inspection at the Authority’s Wastewater Treatment Plant. An acknowledgement that the Bidder has conducted a site inspection is included in the Bidder’s Affidavit.

Contractor shall cause a letter of approval by the New Jersey Department of Environmental Protection (NJDEP) to be addressed to the Contractor and to the Authority and a copy of same delivered to the Authority prior to being permitted to dispose of the residuals.

The undersigned agrees to haul the future accumulated residuals as often as practical, but in no case less than 104 hauls over a two year period, separated by not more than one (1) week between hauls and with the final haul not to be started prior to 720 consecutive calendar days from the date of execution of the Contract; and all Contract Work shall be completed within 730 consecutive calendar days from the date of execution of the Contract; and he further agrees that the Authority may retain from the moneys that are or which may become due, as liquidated damages, the payment of any and all fines levied by the State and which are caused in whole or in part by the Contractor’s failure to comply fully with the terms, conditions and other requirements of this Contract.

The undersigned agrees to haul the future accumulated dewatered sludge cake residuals, on an on call basis, as often as practical, but in no case less than every 8 hours over a two year period when this service is required, and all Contract Work shall be completed within 730 consecutive calendar days from the date of execution of the Contract; and he further agrees that the Authority may retain from the moneys that are or which may become due, as liquidated damages, the payment of any and all fines levied by the State

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Bidders are advised that an award, if any, will be made solely on the basis of the Unit Price Proposal and Unit Prices Bid only. The Authority reserves the right to award the Contract for the per Unit Prices Bid deemed to be in the best interest of the Authority, to waive any deficiencies in bids submitted as it sees fit, to reject any or all Proposals, or to otherwise act to promote what it, in its sole discretion, it deems to be in the best interest of the Authority.

Witnessed or Attested to By: By:

(Signature of Individual, Partner or

Officer signing the Proposal)

(Signature of Witness or Attestee)

Print Name and Title Print Name and Title

AFFIX SEAL:

(Required if Bidder is a corporation)

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FINANCIAL RESOURCES: That information relative to the Bidder’s financial resources can and may be obtained from the following: (Give name, business and address).

Upon request, the Bidder will be expected to amplify the foregoing statements as necessary to satisfy the Owner concerning his ability to successfully perform the Work in a satisfactory manner.

The undersigned Bidder submitting this Proposal or Bid certifies and affirms that its Bid is genuine and not collusive or sham; that said Bidder has not colluded, conspired, connived, or agreed, directly or indirectly, with any Bidder or person, to put in a sham Bid, or that such other person shall refrain from bidding, and has not in any manner, directly or indirectly sought by agreement or collusion, or communication or conference, with any person, to fix the Bid price of said Bidder or any other Bidder, or fix any overhead, profit, or cost element of said Bid price, or of that of any other Bidder, or to secure any advantage against the Northwest Bergen County Utilities Authority or any person interested in the proposed Contract; and that all statements contained in this Proposal (pages C1-C10), including all attachments) are true; and further, that such Bidder has not directly or indirectly submitted this Bid, or the contents thereof, or divulged information or data relative thereto to any association or to any member or agent thereof; and, none of the Authority’s Officials or Employees are interested, directly or indirectly, in the Bid or in any portion of the Bid nor in the Contract or any part of the Contract which may be awarded the undersigned on the basis of such Bid.

Signed this day of 20 .

Witnessed or Attested to By:

By:

Signature of Witness or Attestee (Officer signing the Proposal)

Print Name and Title Print Name and Title

AFFIX SEAL:

(Required if Bidder is a corporation)

If a partnership or corporation give the name of all partners or all officers of the corporation with the address of each.

NAME ADDRESS

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CERTIFICATION OF AUTHORITY OF FOREIGN CORPORATION TO

CONDUCT BUSINESS IN THE STATE OF NEW JERSEY

In accordance with the provisions of N.J.S.A. 14A:13-3, we

, President and

, Secretary of

Company, a corporation of the State of do hereby certify that said Company is authorized by the Secretary of the State of New Jersey to conduct business in that state. Furthermore, we certify that the

Company's New Jersey Secretary of State registration number is

BY: ______________________________________

President

Affix

Corporate

Seal BY: ____________________________________

Secretary

(This form must be completed if the Bidder is a Corporation of any state but New Jersey.)

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AFFIDAVIT OF NON-DISCRIMINATION IN EMPLOYMENT

(N.J.S.A. 10:2-1 through 10:2-4)

(This Affidavit is part of the Proposal and must be executed by all Bidders)

STATE OF ]

] S.S.

COUNTY OF ]

, being first duly sworn, deposes and says he is the (sole owner, a partner, president, secretary) of the party making the within Proposal, (the "Contractor"); that in the hiring of persons for the performance of work under this Contract or any subcontract hereunder, or for the procurement, manufacture, assembling or furnishing of any such materials, equipment, supplies or services to be acquired under this Contract, neither the Contractor, nor any person acting on its behalf, shall discriminate against any person by reason of race, creed, color, national origin, ancestry, marital status or sex who is qualified and available to perform the work to which the employment relates; that neither the Contractor, nor any person acting on its behalf, shall, in any manner, discriminate against or intimidate any employee engaged in the performance of work under this Contract, or any subcontract hereunder, or engaged in the procurement, manufacture, assembling or furnishing of any materials, equipment, supplies or services to be acquired under this Contract, on account of race, creed, color, national origin, ancestry, marital status or sex; that there may be deducted from the amount payable to the Contractor by the Northwest Bergen County Utilities Authority under this Contract, a penalty of $50.00 per person for each calendar day during which such person is discriminated against or intimidated in violation of the provisions of the Contract; and that this Contract may be canceled or terminated by the Northwest Bergen County Utilities Authority and all moneys due or to become due hereunder may be forfeited for any violation of these provisions.

(Signature of Affiant)

(Print Name and Title of Affiant)

Sworn to and subscribed before me this day of , 20__.

AFFIX CORPORATE SEAL

(Notary Public)

My Commission expires on:

(AFFIX NOTARY SEAL)

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CERTIFIED COPY OF RESOLUTION OF

BOARD OF DIRECTORS OF

(Name of Corporation)

"RESOLVED that _______________________________________ , _______________________________

(Person Authorized to Sign) (Title) of _________________________________________________________________ be authorized to sign and

(Name of Corporation) submit the Bid Proposal of this Corporation for the following project:

THE NORTHWEST BERGEN COUNTY UTILITIES AUTHORITY,

CONTRACT NO. 25-002 REMOVAL AND DISPOSAL OF RESIDUALS

The foregoing is a true and correct copy of the resolution adopted by

(Name of Corporation) at a meeting of its Board of Directors held on the day of , 20____.

By:

Title:

(SEAL OF CORPORATION)

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BIDDER'S AFFIDAVIT

NORTHWEST BERGEN COUNTY UTILITIES AUTHORITY

Contract No. 25-002

STATE OF _______________________)

) ss.

COUNTY OF ______________________)

________________________________ being duly sworn, deposes and says that he resides at and that he is the (Give Title) of who signed the above Bid acceptance, that he was duly authorized to sign and that the Bid is the true offer of the Bidder, that the seal attached is the seal of the Bidder and that all declarations and statements contained in the Bid are true to the best of his knowledge and belief.

He further deposes that he has submitted herewith a list of names and addresses of all stockholders and/or partners owning a 10 percent or greater interest therein in compliance with P.L. 1977, Chapter 33, effective March 8, 1977.

He further certifies that an authorized representative of the Bidder has visited the Location of the Work at the Authority's facilities.

Affiant

Subscribed and Sworn to before me this ______________ day of__________________, 20__.

X_________________________________ Notary Public

My commission expires: _________________

(AFFIX NOTARY SEAL)