9-09 - RFP 3906 Contractors CalOSHA.pdf
PDF 2 MB Posted
- Attached to
- FIRE HYDRANT PAINTING
- Solicitation number
- RFP-NH-3906
- Issued by
- Riverside County, California
About this file
This is a Cal/OSHA Compliance History form for RFP #3906, a fire hydrant painting services contract issued by the City of Murrieta, California. The form requires contractors to disclose their Standard Industry Code, California State Contractor's License number, and contact information. Contractors must answer two compliance questions: whether they have been cited by Cal/OSHA or any regulatory agency for safety or environmental violations within the past seven years, and whether they have experienced serious incidents or fatalities on job sites within the past ten years. If contractors answer affirmatively to either question, they must provide detailed information about the incident(s) and corrective actions taken to prevent recurrence, with additional documentation available as needed.
The form includes a signature line for the contractor's representative and a date field, along with a section designated for Elsinore Municipal Water District (EMWD) Risk Management review and approval. Risk Management is required to review the submission, document the review date, and indicate approval or denial status with a signature. This compliance documentation must be submitted as part of the complete proposal package for the fire hydrant painting contract, which covers painting services for 1,071 fire hydrants and blow-off valves in the City of Murrieta.
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Text version
CONTRACTOR’S CAL/OSHA COMPLIANCE HISTORY AND SIC CODE
(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: Date:
FOR EMWD USE ONLY: Purchasing to forward to Risk Management for review
Date:
(Risk Management) Approved: No Yes
Reviewed by (Risk Management) (signature required)
| Date_6: |
| 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_7: |
| Text1: RFP #3906 |
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