doh 4204 attachment toscopeofwork .pdf
PDF 28 KB Posted
- Attached to
- Water and Wastewater Tesing
- Solicitation number
- 6923G521R0201
About this file
This document contains a New York State Department of Health form for designating a water operator in responsible charge along with details of a federal contract opportunity issued by the Saint Lawrence Seaway Development Corporation.
The contract opportunity solicits proposals for water and wastewater testing services at multiple SLSDC facilities located in Massena, New York. Services required include operation of potable water treatment systems in accordance with state regulations, wastewater testing and reporting per discharge permits, and responding to operational issues. The base period of performance is February 1, 2021 to September 30, 2021 with four optional one-year extensions. The solicitation was set aside for small businesses and was awarded on January 29, 2021 to Jeffrey Woods for $53,2092.00.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| StatementOfWork (1).docx | DOCX document | |
| NY0023035(Snell) (1).pdf | ||
| 6923G521R0201A0001.pdf | ||
| NY0023051(Eisenhower).pdf | ||
| WaterandWastewaterTestingBidScedule (1).xlsx | XLSX spreadsheet | |
| SCAWageDetermination15-4170 (1).txt | TXT text file | |
| NY0023078(Maintenance) (1).pdf |
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Text version
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Public Water Supply Protection Empire State Plaza - Corning Tower Room 1110 Albany, NY 12237
(518) 402-7712
Designation of Water Operator in Responsible Charge
INSTRUCTIONS
1. Type or Print - No pencil/felt tip pen.
2. Form must be completed in its entirety.
3. Form must be completed by system owner and designated operator in responsible charge.
4. Form must be signed and dated by both parties.
DOH-4204 (04/01: interim revision 01/10
V E R I F I C A T I O N
Note: Read carefully before signing
I certify that all information provided in this form for designation of operator in responsible charge for the above referenced water system is true. I understand that misstatement of material facts may result in a violation of Subpart 5-4 of the State Sanitary Code.
Signed _____________________________________________________ Date ________/________/________ (System Owner)
Signed _____________________________________________________ Date ________/________/________ (Operator in Responsible Charge)
5. Submit to the New York State Department of Health.
1. System Name: 2. Classification of System: 3. System Phone:
4. System Address: (Street) (City) (State) (Zip)
S Y S T E M I N F O R M A T I O N
5. Owner's Name: (Last) (First) (MI)
7. Owner's Address: (Street) (City) (State) (Zip)
6. Home phone:
Work phone:
O P E R A T O R I N R E S P O N S I B L E C H A R G E I N F O R M A T I O N
9. NYS DOH Certificate #
12. Home phone
Work phone ( )
( )11. ORC's Name: (Last) (First) (MI)
13. ORC's Address: (Street) (City) (State) (Zip)
10. Grade of CertificationDo not provide Social Security number
File details come from the government source that posted it. Updated .