Construction_of_Homestead_Water_Supply_Well_No._7_Chlorination_ITB_Contractors_Forms.pdf

Construction of Homestead Water Supply Well No.7

A14-1-1 Revision Date: 08-20-2025

[Insert date]

Contractor Safety Qualification for Chlorine Process Areas

Dear applicants:

The Wittkop Park Water Treatment Plant (WTP) is subject to the Environmental Protection Agency’s Risk Management Program (volume 40 Code of Federal Regulations [CFR] part 68).

As part of the City of Homestead’s efforts to comply with this regulation and prevent the accidental release of chlorine, the City of Homestead requires all contractors who propose to work on or adjacent to the chlorine system to complete the attached Contractor Qualification Safety Form.

The completed form should be returned with the proposal package to:

Via OpenGov as part of your bid submittal package or mail to City of Homestead Procurement & Contract Services Department 450 SE 6th Avenue, Homestead, FL 33030

The information contained on this form will be evaluated as part of the overall selection process.

Initially the City of Homestead will disqualify contractors from work on or adjacent to the chlorine system under any one of the following conditions:

The contractor fails to complete and submit the Contractor Safety Qualification Form.

The contractor will then be considered non-responsive and will not be considered for the work.

The contractor reports a workman’s compensation experience modification ratio (EMR) greater than 1.0 on two or more consecutive years, unless the contractor substantiates that the factors that caused the high EMR ratio were outside of the contractor’s control.

The contractor cannot document that its employees have adequate training for working with chlorine.

The contractor has experienced a workplace fatality in the last three years, unless the contractor substantiates that the factors that caused the fatality were outside of the contractor’s control.

The remaining contractors will be further evaluated based on the information contained in the Contractor Safety Qualification Form.

Very truly yours, City of Homestead Public Works Department

Well No.7

A14-1-2 Revision Date: 08-20-2025

Contractor Safety Qualification Form

SECTION 1: COMPANY INFORMATION

Company Name:

Address 1:

Address 2:

City, State, Zip:

Telephone No.:

Fax No.:

SECTION 2: NAME(S) AND RELATIONSHIPS OF PARENT COMPANY, AFFILIATES, SUBSIDIARIES, PARTNERS

Company Name:

Address:

City, State, Zip:

Relationship:

Company Name:

Address:

City, State, Zip:

Relationship:

SECTION 3: INSURANCE COVERAGE

3.1 Please attach certificates showing the extent of coverage, exclusions and deductibles for the following:

General Business Liability Insurance Professional Liability Insurance

Contractors Pollution Liability Insurance Workman’s Compensation Insurance

3.2 How long have you been covered by your current provider of Workman’s Compensation Insurance?

3.3 List the Experience Modification Ratio (EMR) that has been applied to your company’s workman’s compensation insurance policy for the past five years:

Year Intrastate EMR Interstate EMR Comments

Well No.7

A14-1-3 Revision Date: 08-20-2025

Contractor Safety Qualification Form

3.4 List the contact information for an insurance broker who can verify your EMR’s:

Name:

Address 1:

Address 2:

City, State, Zip:

Telephone No.:

If you do not have an EMR, please explain:

SECTION 4: INJURY AND FATALITY INFORMATION

4.1 Please transfer the numbers and rates of injuries and illnesses from your firm’s OSHA No. 200 Logs to the table below:

Statistic

Year: Year: Year:

No. Rate No. Rate No. Rate

Lost Workday Cases

Restricted Workday Cases

Medical Treatment (not First Aid) Cases

Total Illness Cases

Total Recordable Cases

Fatalities

4.2 If your company has had fatalities in the past three years include location, cause, and corrective actions in the space below:

Well No.7

A14-1-4 Revision Date: 08-20-2025

Contractor Safety Qualification Form

SECTION 5: SAFETY MEETINGS

5.1 Do you require that documented safety meetings be held for:

Field Supervisors? � Yes � No Frequency:

Employees? � Yes � No Frequency:

New Hires? � Yes � No Frequency:

Subcontractors? � Yes � No Frequency:

SECTION 6: SAFETY AUDITS

6.1 Will a representative of your company audit safety practices on this job?

� Yes � No

Name: Title:

How frequently will the representative visit the project site?

SECTION 7: HEALTH AND SAFETY PROGRAM

7.1 Does the company have a health and safety program? If yes, please give details below. (The contractor is encouraged to attach a copy of the program to satisfy this requirement).

7.2 Please give the name and telephone number of your company’s health and safety officer, if any:

Name: Title:

Telephone No.:

SECTION 8: HEALTH AND SAFETY CITATIONS

8.1 Attach a list of any State or Federal Health and Safety citations received during the past three years.

SECTION 9: SIGNATURE OF COMPANY OFFICER

I certify that to the best of my knowledge, information, and belief formed after reasonable inquiry, the information submitted is true, accurate, and complete.

Name (print): Title:

Signature: Date:

Well No.7

A14-2-1 Revision Date: 08-20-2025

[Insert Date]

Contractor Safety Information Required Under Volume 40 Code of Federal Regulations (CFR) § 68.87 and Volume 29 CFR § 1910.119(h)

Dear [Insert Name]:

BACKGROUND

Any contractors performing maintenance, repair, turnaround, major renovations, or specialty work on or adjacent to the chlorine process at the Wittkop Park Water Treatment Plant (WTP) is subject to the contractor safety requirements of the Environmental Protection Agency’s Risk Management Program (volume 40 CFR § 68.87) and the Occupational Safety and Health Administration’s Process Safety Management Program (volume 29 CFR § 1910.119(h)). The owner and the contractor both have responsibilities under these regulations to ensure the safety of the contractor’s employees. The purpose of this letter is to summarize each party’s responsibilities and to support their compliance efforts.

OWNER’S REQUIREMENTS

The City of Homestead has specific requirements relative to contractor safety as outlined in volume 40 CFR § 68.87(b). These requirements are summarized as follows:

Selecting a Contractor:

When selecting a contractor, obtain and evaluate information regarding the contractor’s safety performance and programs.

Informing a Contractor:

Inform the contractor of the known potential fire, explosion, or toxic release hazards related to the contractor’s work and the regulated process.

Explain to the contractor the applicable provisions of the facility’s Emergency Action Plan (i.e., alarms, evacuation routes, etc.)

Inform the contractor of the facility’s safe work practices for operations such as:

o Confined space entry o Equipment/line opening o Lockout/tagout

Well No.7

A14-2-2 Revision Date: 08-20-2025 o Control over entry into regulated (i.e., hazardous) process areas

Evaluating a Contractor’s Performance:

Evaluate the contractor’s performance in fulfilling their requirements under this regulation.

CONTRACTORS’ REQUIREMENTS

Contractors have specific requirements relative to their safety programs and work practices as outlined in volume 29 CFR § 1910.119(h)(3), OSHA Compliance (CPL) 2-0.124, and volume 40 CFR § 68.87(c). These requirements are summarized as follows:

Assure that each of the contractor’s employees is trained in the work practices to safely perform his/her job. Also, document that each employee understood the training. The documentation will include the name of employee, date of training, and means used to verity that the employee understood the training.

Assure that each of the contractor’s employees are instructed in the known potential fire, explosion, or toxic release hazards related to his/her job and the process, and the applicable provisions of the Emergency Response Plan.

Assure that their employees follow the facility’s safety rules including safe work practices such as control over entry into chlorine process areas, lockout/tagout, equipment/line opening, and confined space safety.

Advise the facility owner of any unique hazard presented by the contractor’s work, or of any hazards found by the contractor.

OWNER’S SUBMITTALS

Facility owners are required to obtain and evaluate information regarding potential contractor’s safety performance and programs. Once contractor selection is complete, the owner must provide the contractor with specific facility safety information related to the chlorine process. To meet this requirement and assist the contractor in meeting their training requirements, the City of Homestead will provide the following:

Safety Data Sheet (SDS) for chlorine

Facility Emergency Response Plan overview and training

Facility Safe Work Practice Procedures

• Equipment/Line Opening Summary of Potential Hazards

The contractor should note that the City of Homestead will perform periodic evaluations of the contractor’s safety performance while working at the facility. Evaluations will be documented and will be used in evaluating the contractor for future work proposals involving the chlorine process.

Well No.7

A14-2-3 Revision Date: 08-20-2025

CONTRACTOR’S SUBMITTALS

The following summarizes the submittals that the contractor must make to the City of Homestead to document that the contractor is complying with their responsibilities under these regulations:

Receipt of Safety Information Checklist

The contractor shall complete the attached Receipt of Safety Information Checklist. The contractor shall then return the Receipt of Safety Information Checklist to the Superintendent Water and Wastewater Treatment prior to the commencement of work at the chlorine process.

Training Certification

Prior to work commencement, the contractor shall certify in writing to the Superintendent Water and Wastewater Treatment that those employees involved in work on or around the chlorine process at the Wittkop Park WTP have successfully completed training in accordance with volume 40 CFR § 68.87(c) and volume 29 CFR § 1910.119(h)(3). The contractor shall complete the enclosed Contractor’s Training Certification Form and return it to the Superintendent Water and Wastewater Treatment.

Furthermore, the contractor is required to maintain a record of those employees who successfully completed the training outlined above. These records must include the following information:

Name of employee

Contents of training

Date of training

Means used to verify that the employee understood the training

The contractor shall forward a copy of the training records of all employees involved in work on or around the chlorine process at the Wittkop Park WTP to the Superintendent Water and Wastewater Treatment.

Unique Hazard Statement

The contractor must provide a written statement to the Superintendent Water and Wastewater Treatment indicating whether the contractor’s work presents any unique hazards and, if so, a description of those hazards. The contractor shall complete the enclosed Contractor’s Unique Hazard Statement and return it to Superintendent Water and Wastewater Treatment.

ADDITIONAL RESPONSIBILITIES

The contractor must inform the Superintendent Water and Wastewater Treatment of all contract employee injuries or illnesses resulting from work performed on or around the chlorine process.

The contractor must immediately inform the Superintendent Water and Wastewater Treatment of any serious injuries resulting from any work at the facility.

Well No.7

A14-2-4 Revision Date: 08-20-2025

Contract employees will participate in an on-site contractor orientation, conducted by Wittkop Park WTP staff during the morning of the first day of work.

CONCLUSION

The City of Homestead is committed to a safe work environment for all the City’s employees and contract employees. If you have any questions, please feel free to contact me at 305-224-4772.

Very truly yours, Eliezer Thomas-Reyes Superintendent of Water & Wastewater Treatment Public Works Department

Attachments: (check as appropriate)

� SDS(s) � Receipt of Safety Information Checklist

� Facility Emergency Response Plan � Contractor’s Training Certification Facility Safe Work Practice Procedures

� Equipment/Line Opening

� Summary of Potential Hazards

� Contractor’s Unique Hazard Statement

� Other:

� Other:

� Other: