Attachment A - Consultant Qualification Questionnaire.pdf
PDF 188 KB Posted
- Attached to
- EOI: Webster County Landfill Closure Cap Design
- Solicitation number
- CEOI 0313 DEP1800000002 1
- Issued by
- Wayne County, West Virginia
About this file
This is a Consultant Qualification Questionnaire form issued by the West Virginia Department of Environmental Protection for firms seeking to provide consulting services on landfill closure projects. The questionnaire is designed to evaluate the qualifications, experience, and resources of consulting firms interested in performing work that may include solid waste landfill closure design, site characterization assessment and evaluation, construction inspection, aerial photography and contour mapping development, groundwater contamination evaluation, and closure cost estimating. Respondents must provide comprehensive information about their firm structure, personnel by discipline, principal officers, West Virginia registered professional engineers, joint venture partnerships, and anticipated sub-consultants. The form requires detailed documentation of the firm's specific experience in landfill-related work, including descriptions and the number of completed projects in each technical area.
The questionnaire requires firms to document the professional qualifications, experience, education, and registration credentials of key personnel responsible for landfill closure design, site characterization assessment, quality assurance/quality control, and heavy earth work construction projects. Applicants must list current and completed projects within the last five years where they served as the designated engineer of record or as a sub-consultant, including project names, locations, owners, construction costs, and completion status. Firms must also identify software and equipment available in their primary office that will be used for the project and provide any additional information supporting their qualifications. The form does not specify contract award dates, pricing terms, set-asides, funding sources, or contract renewal options, as it functions as a qualification evaluation tool rather than a formal bidding document.
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| File | Type | Posted |
|---|---|---|
| CEOI DEP1800000002.pdf | ||
| Final_CEOI_0313_DEP1800000002_1_CEOI_FORM.PDF |
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Text version
WEST VIRGINIA DEPARTMENT OF ENVIRONMENTAL PROTECTION
CONSULTANT QUALIFICATION QUESTIONAIRE
PROJECT NAME
DATE (DAY, MONTH, YEAR) FEIN
1. FIRM NAME
2. HOME OFFICE BUSINESS ADDRESS 3. FORMER FIRM NAME
4. HOME OFFICE TELEPHONE
5. ESTABLISHED
(YEAR)
6. TYPE OWNERSHIP
INDIVIDUAL,
CORPORATION,
PARTNERSHIP,
JOINT-VENTURE
6A. WV REGISTERED
DBE
(DISAVANTAGED
BUSINESS
ENTERPRISE)
YES NO
7. PRIMARY OFFICE: ADDRESS/ TELEPHONE/ PERSON IN CHARGE/ NO. (name particular type)
PERSONNEL EACH OFFICE
8. NAMES OF PRINCIPAL OFFICERS OR MEMBERS
OF FIRM
8a. NAME, TITLE, & TELEPHONE NUMBER-OTHER
PRINCIPALS
9. NUMBER OF PERSONNEL BY DISPLINE (Bold Lettering Indicates Minimum Design Team Members) Detailed information On Team To Be Included
_ ADNIMSIRATIVE _ ECOLOGISTS _ LANDSCAPE _STRUCTURAL
_ ARCHITECTS _ ECONOMISTS ARCHITECTS ENGINEERS
_ BIOLOGIST _ ELECTRICAL _ MECHANICAL _SURVEYORS
_ CADD OPERATORS ENGINEERS ENGINEERS
_ CHEMICAL ENGINEERS _ ENVIRONMENTALISTS _ MINING _OTHER
_ CIVIL ENGINEERS _ ESTIMATORS ENGINEERS
_ CONSTRUCTION _ GEOLOGIST _ PHOTOGRAMMETRISTS
INSPECTORS _ HISTORIANS _ PLANNERS: _TOTAL
_ DESIGNERS _ HYDROLOGISTS URBAN/REGIONAL PERSONNEL
_ DRAFTSMEN _ SANITARY
ENGINEERS
_ SOILS ENGINEERS
_ SPECIFICATION
WRITERS
TOTAL NUMBER OF WV REGISTERED PROFESSIONAL ENGINEERS IN PRIMARY OFFICE:
*RPEs other than Civil must provide supporting documentation that qualifies them to supervise and perform this type of work.
10. If submittal is by joint venture, list participating firms & outline specific areas of responsibility (including administrative, technical, & financial) for each firm. Each participating firm must complete a "Consultant Confidential Qualification Questionnaire".
10a. HAS THIS JOINT-VENTURE WORKED TOGETHER BEFORE? YES NO
11. OUTSIDE KEY CONSULTANTS/ SUB-CONSULTANTS ANTICIPATED TO BE USED.
NAME AND ADDRESS:
SPECIALTY: WORKED WITH BEFORE
YES NO
NAMEAND ADDRESS:
12. A. Is your firm experienced in (Solid Waste Landfill Closure Design)?
YES Description and Number of Projects:
NO
B. Is your firm experienced in Solid Waste landfill site characterization assessment and evaluation?
YES Description and Number of Projects:
NO
C. Is your firm experienced in landfill closure construction inspection?
YES Description and Number of Projects:
NO
D. Is your firm experienced in Aerial Photography and the Development of Contour Mapping?
YES Description and Number of Projects:
NO
E. Is your firm experienced in evaluating ground water contamination, such as may be associated with landfills?
YES Description and Number of Projects:
NO
F. Is your firm experienced in Landfill Closure cost estimating?
YES Description and Number of Projects:
NO
13. PERSONAL HISTORY STATMENT OF PRINCIPALS AND ASSOCIATES RESPONSIBLE FOR
LANDFILL CLOSURE DESIGN (describe project) (Furnish Complete data but keep to essentials) NAME& TITLE (Last, first, Middle Int.)
YEARS OR EXPERIENCE
YEARS OF (type)
EXPEIRENCE:
YEARS OF (type)
EXPEIRENCE:
YEARS OF (name type)
EXPEIRENCE:
Brief Explanation of Responsibilities:
EDUCATION (DEGREE, YEAR, SPECIALIZATION)
MEMBERSHIP IN PROFESSIONAL ORGANIZATIONS:
REGISTRATION (Type, Year, State)
13a.PERSONAL HISTORY STATMENT OF PRINCIPALS AND ASSOCIATES RESPONSIBLE FOR
SOLID WASTE LANDFILL SITE CHARACTERIZATION ASSESSMENT AND EVALUATION?
(name type of design or work) (Furnish complete data but keep to essentials) NAME & TITLE (Last, First, Middle Int.)
YEARS OF EXPEIRENCE
YEARS OF
EXPEIRCENE (name type):
YEARS OF
EXPEIRENCE (name type):
YEARS OF
EXPEIRENCE (name type):
Brief Explanation of Responsibilities:
EDUCATION (Degree, Year, Specialization)
MEMBERSHIP IN PROFESSIONAL ORGANIZATIONS
13b. PERSONAL HISTORY STATEMENT OF PRINCIPALS AND ASSOCIATES RESPONSIBLE FOR LANDFILL CLOSURE QA/QC (Furnish complete data but keep to essentials) NAME & TITLE (last, first, middle Int.)
YEARS OF EXPEIRENCE
YEARS OF EXPERIENCE
(name type):
YEARS OF EXPEIRENCE
(name type):
YEARS OR EXPEIRENCE
(name type):
Brief Explanation of Responsibilities:
13c. PERSONAL HISTORY STATEMENT OF PRINCIPALS AND ASSOCIATES REPONSIBLE FOR HEAVY EARTH WORK CONSTRUCTION PROJECTS (Furnish complete data but keep to essentials) NAME & TITLE (last, first, middle Int.)
(name type)
YEARS OF EXPERIENCE
(name type)
YEARS OF EXPERIENCE
(name type)
Brief Explanation of Responsibilities
14. PROVIDE A LIST OF SOFTWARE AND EQUIPMENT AVAILABLE IN THE PRIMARY OFFICE
WHICH WILL BE USED TO COMPLETE THIS PROJECT (name project)
15. CURRENT ACTIVITIES ON WHICH YOUR FIRM IS THE DESIGNATED ENGINEER OF
RECORD ASSOCIATED WITH OR RELATING TO LANDFILL CLOSURE OR CONSTRUCTION.
PROJECT
NAME,TYPE
AND
LOCATION
NAME AND
ADDRESS OF
OWNER
NATURE OF
YOUR FIRM'S
RESOPNSIBILITY
ESTIMATED
CONSTRUCTION
COST
PERCENT
COMPLETE
TOTAL NUMBER OF PROJECTS:
TOTAL ESTIMATED CONSTUCTION COSTS:
16. CURRENT ACTIVITIES ON WHICH YOUR FIRM IS SERVING AS A SUB-CONSULTANT TO
OTHERS RELATING TO LANDFILL CLOSURE AND CONSTRUCTION.
PROJECT
NAME,
TYPE, AND
LOCATION
NATURE OF
FIRMS
RESPONSIBILITY
NAME
AND
ADDRESS
OF OWNER
ESTIMATED
COMPLETION
DATE
ESTIMATED CONSTURCTION
COST:
ENTIRE
PROJECT
YOUR FIRMS
RESPONSIBILITY
17. COMPLETED WORK WITHIN LAST 5 YEARS ON WHICH YOUR FIRM WAS THE
DESIGNATED ENGINEER OF RECORD (List 5 to 7)
PROJECT NAME,
TYPE AND
LOCATION
NAME AND
ADDRESS OF
OWNER
ESTIMATED
CONSTRUCTION COST
YEAR CONSTRUCTED
(YES OR NO)
18. COMPLETED WORK WITHIN LAST 5 YEARS IN WHICHYOUR FIRM HAS BEEN A
SUBCONSULTANT TO OTHER FIRMS (INDICATE PHASE OF WORK WHICH YOUR FIRM WAS
RESPONSIBLE) LIST 5 TO 7.
PROJECT
NAME,
TYPE AND
LOCATION
NAME AND
ADDRESS
OF OWNER
ESTIMATED
CONSTRUCTION
COST OF YOUR
FIRM'S PORTION
YEAR CONSTRUCTED
(YES OR NO)
FIRM
ASSOCIATED
WITH
19. Use this space to provide any additional information or description of resources supporting your firm's qualifications to perform work for the WV Department of Environmental Protection.
20. The foregoing is a statement of facts
Signature:_______________________________ Title:___________________________________
Printed Name:__________________________________
Date:____________________________________
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