CONTRACTOR CERTIFICATION REGARDING SAFETY AND ENVIRONMENTAL.docx

This is a Contractor Certification form regarding safety and environmental compliance for Project 662-23-111, a repair and weatherization project for Parking Structure 211 Elevator, issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 21. The form requires contractors to disclose the number of serious, willful, or repeat violations received from the Occupational Safety and Health Administration (OSHA) within the last three years, with attached explanations for any violations cited. Contractors must also report any serious, willful, or repeat violations from the Environmental Protection Agency (EPA) within the same three-year period, with documentation of explanations. The form establishes a disqualification threshold of four serious violations, one repeat violation, or one willful violation from either agency.

Additionally, contractors are required to provide their current Insurance Experience Modification Rate (EMR) and must support this rate with a signed letter from their insurance carrier on company letterhead. The form requires the contractor's signature, typed name, and title, serving as certification that all information provided is accurate and complete.