Attachment 3 - Green Procurement Form.pdf

UNCLASSIFIED

ATCH 5 (1 of 3)

RECOVERED MATERIALS DETERMINATION FORM

INSTRUCTIONS

This form is to be completed by the requiring activity when EPA-designated items are applicable to the requirement. For questions on whether the product counts as “EPA-designated” or what the required recycled content is, refer to product descriptions on EPA’s website at www.epa.gov/cpg/products. This form is not required for construction item purchases less than $2,000, or for other purchases less than $2,500. The completed form becomes part of the contracting office contract file.

PROCUREMENT TITLE: DBEH 21-1511, Maintain Airfield Markings

PROCUREMENT REQUEST NO.

PART 1: RECOVERED MATERIALS DETERMINATION

Part 1 shall be completed by the specifying authority when requesting a procurement action.

EPA-DESIGNATED ITEMS

(Place a check mark next to each product that applies to this procurement) Construction Products:

Building insulation Polyester carpet Carpet Cushion

Cement & concrete containing:

Coal fly ash Ground granulated blast furnace slag Cenospheres Silica fume Floor tiles (rubber & plastic) Flowable fill Latex paint Laminated paperboard Modular threshold ramps Nonpressure pipe Patio blocks Railroad grade crossings/surfaces Roofing materials Shower & restroom dividers/partitions Structural fiberboard

Landscaping Products:

Compost from yard trimmings or food waste Garden and soaker hoses Hydraulic mulch Lawn and garden edging Plastic lumber landscaping timbers and posts

Park & Recreation Products:

Park and recreational furniture Playground equipment Playground surfaces Running tracks Plastic fencing (snow or erosion control, safetybarriers) Non-paper Office Products:

Binders (paper, solid plastic or plastic covered)

Plastic clipboards Plastic file folders Plastic clip portfolios Plastic presentation folders Office furniture Office recycling containers Office waste receptacles Plastic desktop accessories Plastic envelopes Plastic trash bags Printer ribbons Toner cartridges

Paper & Paper Products:

Commercial/industrial sanitary tissue products Miscellaneous papers Newsprint Paperboard and packaging Printing and writing papers Tray liners

Vehicular Products:

Engine coolants Rebuilt vehicular parts Re-refined lubricating oils Retread tires

Transportation Products

Channelizers Delineators Flexible delineators Parking stops Traffic barricades Traffic cones

Miscellaneous Products:

Awards and plaques Bike racks Blasting grit Industrial drums Mats Pallets Signage Sorbents Strapping

GREEN PROCUREMENT FORMS

ATCH 5 (2 of 3)

PROCUREMENT TITLE: DBEH 21-1511, Maintain Airfield Markings

7.1 PROCUREMENT REQUEST NO.

PART 1: RECOVERED MATERIALS DETERMINATION (CONT’D)

FAR 11.002(d) requires the establishment of statements of work and specification requirements for the procurement of products containing recovered materials and environmentally preferable and energy-efficient products and services.

If no EPA designated items were checked on page 1, than check box A:

A. I hereby certify that no EPA designated guideline items are included in this procurement action

If any EPA designated items are checked on page 1, than mark box B or C:

B. I hereby certify that the EPA recycled content requirements have been specified for all of the designated guideline items in this procurement action

OR

C. I hereby certify that the EPA recycled content requirements have been specified for all but the following designated guideline items for which compliance with EPA standards is not attainable.

If Box C is checked, list each designated item and the corresponding justification number from the list below for each exemption being claimed. Attach the supporting documentation for each waiver.

The exemption being claimed for this purchase is:

1. The product is not available competitively (from two or more sources) within a reasonable time frame;

2. The product is only available at an unreasonable price (based on a life-cycle cost analysis);

3. The product does not meet appropriate performance standards (in accordance with National

Institute of Standards and Technology (NIST) guidelines.)

Designated Item Justification #

1.

2.

3.

4.

5.

5/24/2021

For/ Design/Specifying Agent Signature Date

5/24/2021

Requiring Organization’s Technical Representative Signature Date

WALLACE.BRIAN.K.1222107055 Digitally signed by WALLACE.BRIAN.K.1222107055 Date: 2021.05.24 11:03:11 -04'00'

GREEN PROCUREMENT FORMS

ATCH 5 (3 of 3)

PROCUREMENT TITLE: DBEH 21-1511, Maintain Airfield Markings

7.2

7.3 PROCUREMENT REQUEST NO.

7.4

7.5 PART 2: RECOVERED MATERIALS CERTIFICATION

Part 2 of this certification is to be completed upon receipt of the purchase goods and services. If EPA designated items were specified in this procurement action, the contractor/supplying agent shall complete Part 2 of this certification upon delivery of the products or services. Attach supporting documentation identifying percentage of recovered material content used in each designated item. NOTE: A designated item is specified if no exemptions were prepared and identified in Part 1.C of this form during the development of this procurement action.

Check the appropriate box:

A. EPA recycled content requirements have been met for all designated items specified in this procurement action.

OR

B. EPA recycled content requirements have been met for all but the following EPA designated guideline item(s) for which compliance with EPA standards was not attainable.

If Box B is checked, list each designated item and the corresponding justification number from the list below for each exemption being claimed. Attach the supporting documentation for each waiver.

The exemption being claimed for this purchase is:

1. The product is not available competitively (from two or more sources) within a reasonable time frame;

2. The product is only available at an unreasonable price (based on a life-cycle cost analysis);

3. The product does not meet appropriate performance standards (in accordance with National Institute of

Standards and Technology (NIST) guidelines.)

Designated Item Justification #

1.

2.

3.

4.

5.

Contractor/Supplying Agent Signature Date

Requiring Organization’s Technical Representative Signature Date