9-Exhibits CAL OSHA Compliance.pdf

264 KB Posted

Attached to
MICROWAVE POINT-TO-POINT LINK
Solicitation number
RFP 3897
Issued by
Riverside County, California

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This document is a Cal/OSHA Compliance History and Standard Industry Code form for a Request for Proposal (RFP #3897) issued by EMWD (Eastern Municipal Water District). The form requires potential contractors to disclose their safety 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 is designed to assess a contractor's safety record and risk profile, with a section for detailed explanations if any violations or incidents have occurred. The document includes spaces for contractor information such as name, address, contact details, and contractor's license number. It also includes an internal review process where the Purchasing department will forward the completed form to Risk Management for approval, with designated signature lines for review and authorization.

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CONTRACTOR’S CAL/OSHA COMPLIANCE HISTORY AND SIC CODE

RFP #3897

(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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