Attachment D - Specialized Experience Form.pdf

ATTACHMENT D - SPECIALIZED EXPERIENCE

“BPAS FOR ASBESTOS AND LEAD-BASED PAINT PRE-ALTERATION

ASSESSMENT, IH SURVEILLANCE AND AIR MONITORING SERVICES”

FEDERAL BUILDINGS THROUGHOUT THE COUNTIES OF LOS

ANGELES AND ORANGE, CA

PBS - REG 9

RFQ # 47PK0521N0001

Note: The offeror shall complete this form in its entirety and submit as part of their proposal. Make additional copies as necessary and complete one form for each reference.

ALL INFORMATION REQUESTED ON THE FORM MUST BE COMPLETED.

1. OFFEROR (COMPANY NAME)

3. PROJECT STATUS AND TYPE

CURRENT GOVERNMENT

PREVIOUS NON-GOVERNMENT

4. PROJECT NAME AND LOCATION (CITY, STATE)

REFERENCE TYPE (PAST PERFORMANCE, SPECIALIZED EXPERIENCE, OR BOTH COMBINED)

5A. REFERENCE CONTACT PERSON/PROJECT MANAGER 5B. REFERENCE CONTACT PHONE NUMBER

5C. REFERENCE CONTACT FAX NUMBER 5D. REFERENCE CONTACT E-MAIL ADDRESS

6. CONTRACT NUMBER (IF FEDERAL GOVERNMENT CONTRACT) 7. VALUE OF CONTRACT

7B. PERCENTAGE OF W ORK

PERFORMED BY OFFEROR

8. TYPE OF FACILITY (office, hospital, manufacturing, school, etc.) 9. SIZE OF PROJECT (SQUARE FOOTAGE)

10A. IS SERVICE COMPLETE?

YES NO

10B. START DATE 10C. COMPLETION DATE 10D. NUMBER OF DAYS

21 DESCRIPTION OF W ORK, PROBLEMS ENCOUNTERED AND CORRECTIVE ACTIONS TAKEN

SENSITIVE BUT UNCLASSIFIED (SBU)

PROPERTY OF THE UNITED STATES GOVERNMENT

FOR OFFICIAL USE ONLY

Do not remove this notice

Properly destroy or return documents when no longer needed