5-RFP 3843 Contractors CAL OSHA Compliance History Form.pdf
PDF 242 KB Posted
- Attached to
- Roll-Up Door Replacement
- Solicitation number
- RFP 3843
- Issued by
- Riverside County, California
About this file
This document is a Cal/OSHA Compliance History and SIC Code form for RFP #3843, issued by EMWD (Eastern Municipal Water District), designed to be submitted as part of a proposal package. The form requires contractors to disclose their safety and environmental compliance history by answering two critical questions: whether they have been cited by Cal/OSHA or any regulatory agency for safety or environmental violations in the past seven years, and whether they have experienced a serious incident or fatality on a job site within the past ten years.
The form provides space for contractors to provide detailed information about any reported incidents and the corrective actions taken to prevent future violations. It also includes sections for the contractor's basic information such as name, address, contact details, and contractor's license number. The document is intended for internal review, with a section designated for EMWD Purchasing to forward the form to Risk Management for approval, ensuring that potential contractors meet safety and compliance standards before being considered for the project.
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Text version
CONTRACTOR’S CAL/OSHA COMPLIANCE HISTORY AND SIC CODE
RFP #3843
(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_15: |
| Contractors Standard Industry Code: |
| Contractors Name: |
| California State Contractors License: |
| Address_12: |
| 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_16: |
| FOR EMWD USE ONLY: |
| Date Risk Management: |
| Approved No: |
| Yes_5: |
| Reviewed by Risk Management: |
| signature required: |
| Signature2_es_:signer:signature: |
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