5-Exhibits Contractors CAL OSHA FORM.pdf

244 KB Posted

Attached to
Asphalt Repair Services at EMWD Facilities
Solicitation number
RFP 3888
Issued by
Riverside County, California

About this file

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This document is a Cal/OSHA Compliance History and Standard Industry Code form for Request for Proposal (RFP) #3853, issued by EMWD (Eastern Municipal Water District). The form requires contractors to disclose their safety compliance history by answering two critical questions: 1) whether they have been cited by Cal/OSHA or any regulatory agency for safety or environmental violations in the past seven years, and 2) whether they have experienced a serious incident or fatality on a job site in the past ten years.

The form is designed to be submitted with a proposal package and includes fields for contractor details such as name, address, contact information, state contractor's license number, and standard industry code. If a contractor answers "Yes" to either compliance question, they are required to provide specific details about the incident(s) and actions taken to prevent future violations. The document is intended for internal review by EMWD's Purchasing and Risk Management departments, who will assess the contractor's safety record as part of the evaluation process.

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CONTRACTOR’S CAL/OSHA COMPLIANCE HISTORY AND SIC CODE

RFP #3853

(This document is to be submitted with the proposal package) (rev. 10/08/18)

Date:

Contractor’s Standard Industry Code:

Contractor’s Name:

California State Contractor’s License #:

Address:

Contact Person:

Phone No:

Please answer the following questions:

1. Has the contractor been cited by Cal/OSHA or any regulatory agency for a violation related to safety or environmental issues within the past seven (7) years?

No Yes

2. Within the past ten (10) years has the contractor had a serious incident or fatality on a job site?

No Yes

* If yes to # 1 or #2, please provide information specific to the incident(s) and action(s) taken to ensure that there is not a repeat violation, or incident(s) (attach additional sheets if needed)

Contractor’s Representative signature:

FOR EMWD USE ONLY: Purchasing to forward to Risk Management for review

(Risk Management)

Approved: No Yes

Reviewed by (Risk Management)

(signature required)

Date_8:
Contractors Standard Industry Code:
Contractors Name:
California State Contractors License:
Address_4:
Contact Person:
Phone No:
or environmental issues within the past seven 7 years: Off
Within the past ten 10 years has the contractor had a serious incident or fatality on a job site: Off
Please answer the following questions 1 Has the contractor been cited by CalOSHA or any regulatory agency for a violation related to safety or environmental issues within the past seven 7 years No Yes 2 Within the past ten 10 years has the contractor had a serious incident or fatality on a job site No Yes If yes to 1 or 2 please provide information specific to the incidents and actions taken to ensure that there is not a repeat violation or incidents attach additional sheets if neededRow1:
Please answer the following questions 1 Has the contractor been cited by CalOSHA or any regulatory agency for a violation related to safety or environmental issues within the past seven 7 years No Yes 2 Within the past ten 10 years has the contractor had a serious incident or fatality on a job site No Yes If yes to 1 or 2 please provide information specific to the incidents and actions taken to ensure that there is not a repeat violation or incidents attach additional sheets if neededRow2:
Please answer the following questions 1 Has the contractor been cited by CalOSHA or any regulatory agency for a violation related to safety or environmental issues within the past seven 7 years No Yes 2 Within the past ten 10 years has the contractor had a serious incident or fatality on a job site No Yes If yes to 1 or 2 please provide information specific to the incidents and actions taken to ensure that there is not a repeat violation or incidents attach additional sheets if neededRow3:
Please answer the following questions 1 Has the contractor been cited by CalOSHA or any regulatory agency for a violation related to safety or environmental issues within the past seven 7 years No Yes 2 Within the past ten 10 years has the contractor had a serious incident or fatality on a job site No Yes If yes to 1 or 2 please provide information specific to the incidents and actions taken to ensure that there is not a repeat violation or incidents attach additional sheets if neededRow4:
Please answer the following questions 1 Has the contractor been cited by CalOSHA or any regulatory agency for a violation related to safety or environmental issues within the past seven 7 years No Yes 2 Within the past ten 10 years has the contractor had a serious incident or fatality on a job site No Yes If yes to 1 or 2 please provide information specific to the incidents and actions taken to ensure that there is not a repeat violation or incidents attach additional sheets if neededRow5:
Date_9:
FOR EMWD USE ONLY:
Date Risk Management:
Approved No:
Yes_5:
Reviewed by Risk Management:
signature required:
Signature2_es_:signer:signature:

File details come from the government source that posted it. Updated .