Attachment 7 Recovered Materials Determination.pdf

Recovered Materials Determination Form Instructions

Project Name:

Project Number:

This form is to be completed by the procurement originator where the items or deliverables subject to Grissom ARB’s Affirmative Procurement Program for Recovered Materials are being procured from outside vendors. This form is not required for items requisitioned from established Federal supply sources.

1. The procurement originator checks off which items(s) apply to the procurement request, and signs and dates the bottom of the form.

2. The completed form becomes part of the contracting office contract file.

The Statement of Work/Specifications covering this procurement request is subject to Grissom ARB’s Affirmative Procurement Program for Recovered materials. The items being procured are:

Paper and Paper Products Transportation Products (Traffic Barricades or Traffic Cones, _____ Lubricating Oils Containing Parking stops, Delineators, Re-Refined Oil Flexible Delineators and

Channelizers Retread Tires

Landscaping Products _____ Shower and Restroom Dividers (Hydraulic Mulch or Compost, Garden and Soaker Hoses, and _____ Latex Paint Lawn and Garden Edging)

Plastic Fencing Office Recycling Containers or Office Waste Receptacles

Reclaimed Engine Coolants _____ Plastic Desktop Accessories

Building Insulation _____ Printer Ribbons

Structural Fiberboard Plastic Envelopes

_____ Laminated Paperboard Remanufactured or Recycled

_____ Pallets Toner Cartridges for Laser Printers, Photocopiers, Facsimile Machines, Cement and Concrete Containing or Micrographic Printers Fly Ash or Ground Granulated Blast Furnace Slag Plastic Trash Bags

Carpet Other Recycled-Content Items Not in EPA Guidelines, but Included in Grissom ARB’s Affirmative

Patio Blocks Procurement Plan _____ Floor Tiles (Describe item on reverse of form)

Binders Other

I hereby certify the Statement of Work/Specifications for the requisition of materials/services listed above complies with applicable Grissom ARB preference standards for recycled/recovered materials.

Procurement Originator's Signature Date

Text55: 21 March 2025