Event_40442_-_Roll-Off_Dumpster_Rental_Service.pdf

STATEMENT OF WORK

40 YARD ROLL OFF DUMPSTER SERVICE

1. STATEMENT OF WORK.

The contractor shall furnish professional services, labor, equipment, materials, tools, transportation, equipment insurance, permits and fees and licenses necessary to provide two (2) forty (40) yard roll off dumpster rentals for general trash and to perform non-hazardous waste removal services at the National Guard facility located at 100 Armory Dr., San Francisco, California 94132 for a total of 30 days.

2. CONTRACTING OFFICER'S REPRESENTATIVE.

Wherever in these specifications the abbreviation CM is referenced, it shall be the same as if the term Contracting Manager is referenced.

3. CONTRACTOR'S RESPONISIBILITIES.

The contractor is not required to visit the work site but nothing contained in these specifications shall relieve the contractor from the responsibility of visiting the site, accurately measuring the work or otherwise ensuring that the quantities used in preparing the bid are the actual quantities of the work to be accomplished under the contract. Contractor shall provide two (2) forty-yard dumpsters for a period of 30 days. Contractor shall provide pick up and dispose of all refuse collected after 30 days. Contractor is responsible for disposing and transporting all refuse in accordance with all laws and regulations including but not limited to San Francisco Environment and Health Codes.

4. PICK UP DAYS AND HOURS.

A. Contractor shall provide delivery of two dumpsters,, transportation, final pickup, and disposal of all waste collected in dumpsters at the end of the 30-day period. Contractor will coordinate with the CM on pick up. The Contractor will not receive payment for any additional pick ups not expressly authorized by the CM.

B. Contractor will be responsible for all costs associated with providing the services outlined in this Scope of Work.

5. SPECIFIC REQUIREMENTS.

The specific requirements of the refuse service are as follows:

Service Address Container Size (Cubic Yards)

Quantity Frequency of Service

Billing

100 Armory Drive San Francisco, CA 94132

40 Yard Roll Off 2 One (1) Pickup Final at 30 days.

One-time

6. GENERAL CONDITIONS

A. All containers shall comply with San Francisco Environment Code Section 1906. Contractor will maintain containers in complete, serviceable condition at all times. CMD reserves the right to inspect all delivered containers upon delivery and prior to acceptance. Containers shall be clean, structurally sound, fully operational, and conform to the specifications identified in this Scope of Work, including required container size and type. Rejected containers shall be removed and replaced by the Contractor within one day of notification by the CM. Replacement containers shall meet all requirements of the Scope of Work. The CMD shall not be responsible for payment for rejected containers or any costs associated with the replacement due to nonconforming equipment.

Containers will be placed in the designated location identified in Appendix A.

B. The CM is not typically on-site during periods of service. The CM will designate a local site representative(s) for the contractor to coordinate with for the drop off and pick-up site access and services. Containers will be dropped off within five days of receiving the Notice to Proceed.

Contractor agrees to contact the local representative(s) first for site access, followed by the CM, in those successive orders. If the contractor is unable to gain access to provide service but fails to conduct proper coordination and leaves a detailed voice messages on the provided phone numbers/emails, the contractor agrees to return to the site on a later date/time to complete required service at no additional cost to the CMD.

C. Contractor is solely responsible for any injuries, losses, and damages caused by Contractor, its employees, or its agents.

D. In the event that any CMD property is damaged as a result of the actions of Contractor, or its employees, Contractor shall repair, at its sole expense, the damage which has occurred as a direct result of Contractor, or its employees.

E. CMD and its employees or agents are not responsible for any injury, loss, or damage that may occur to Contractor, its employees, vehicles, equipment, tools, or materials.

7. WORKMANSHIP

Work shall be executed in a careful, neat, proficient manner and in compliance with generally accepted trade practices by personnel skilled in the work to be done. If a site is not left in a clean and orderly condition, Contractor shall be called back to correct the condition at no extra charge to CMD.

8. SAFETY.

The contractor shall be responsible for safety management and shall enforce all safety requirements of California Division of Occupational Safety and Health (Cal/OSHA) and other required safety regulations in connection with the performance of the services as necessary to provide a safe environment for Contractor's employees and any other personnel in the service area.

9. SCHEDULING AND INSPECTION

The contractor shall work directly with the CM on the scheduling of work and inspection procedures prior to starting any work and throughout the contract term. Local site representative(s) will be designated and identified with contact information provided by the CM when the Contractor contacts the CM within five

(5) calendar days after receipt of the Notice to Proceed.

END OF STATEMENT

APPENDIX A

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SECTION 1 (SERVICES)

REQUEST FOR PROPOSAL

1-01. The State of California Military Department shall accept proposals until October 1, 2026 at 2:00PM, from qualified proposers offering to provide equipment, materials, labor, licenses, bonds and insurance required for the Roll Off Dumpster Service in San Francisco, CA on or around October 19, 2026 through November 20, 2026 in accordance with the terms and conditions, and requirements of this Request for Proposal (RFP).

All questions regarding this RFP must be submitted in writing to Ash Erickson at bids@cmd.ca.gov no later than September 25, 2026 at 2:00PM. If an addendum is necessary it will be issued prior to September 28, 2026 at

2:00PM.

a. Basis of award of this contract will be the lowest responsive proposal from a qualified, responsible contractor.

b. In the event of a tie between two proposals, the Military Department Contracting Officer shall conduct a coin toss to determine award. The coin toss shall be witnessed by a minimum of two personnel from the Purchasing and Contracting Branch.

c. Proposers are not required to visit the worksite. Contractors are responsible for satisfying themselves as to the local conditions, to accurately measure area and insure the actual area of work for the preparation of their bid. Contractors providing a proposal without visiting the worksite, do so at their own risk. Contractors can schedule a worksite visit by contacting Ash Erickson at bids@cmd.ca.gov.

1-02. The State is seeking a single proposal, not to exceed, to be inclusive of all contract's costs involved in performing the full scope of this service.

a. Proposal MUST be submitted for the entire work described therein. Any deviation from the specification will not be considered and will be cause for rejection of your proposal.

b. The Military Department reserves the right to reject any or all proposals.

c. If applicable for the work being performed, contractors must pay the State prevailing wage rate for each discipline as specified by the Department of Industrial Relations.

1-03. Contractor shall provide qualified and trained personnel during the contract period. Personnel skilled in the work to be done shall execute in a careful, neat, proficient manner, and in compliance with acceptable trade practices.

a. Specific schedule and definition of level of service will be found in the Technical Specifications of this RFP.

b. All services called for in this RFP and the resulting contract will be performed in accordance with the specific requirements and schedule of performance found in the technical specifications.

c. Costs of developing and submitting proposals are entirely the responsibility of the firm and shall not be chargeable to or paid by the State of California.

d. The Prime Contractor shall perform all work under the contract with its own organization. The Prime Contractor shall provide at all times sufficient competent labor, materials, and equipment to properly carry on the work and to ensure completion within the time agreed. The use of subcontractors is not permitted for this contract.

1-04. Questions regarding this RFP, worksite conditions, and/or contractor responsibilities shall be directed as follows: Please email CA Military Department personnel who initiated this solicitation (Ash Erickson at bids@cmd.ca.gov) between 8:00 am and 3:00 p.m. Monday through Friday.

1-05. The use of the proposal forms provided in this RFP is mandatory (or a xerox copy of the attached forms).

1-06. Withholding on Independent Contractors doing business with the State:

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a. Pursuant to California Revenue and Taxation Code Section 18806.1, independent contractors may be subject to one (1) percent State Income Tax Withholding.

b. An independent contractor as defined in the Black's Law Dictionary is: "one who, in the exercise of independent employment, contracts to do a piece of work according to their own methods and is subject to their employer's control only as to the end product or final result of work."

1-07. Contract Standard Clauses - Contractor awarded a contact pursuant to this RFP will be required to sign contract documents containing the following provisions:

a. The General Terms and Conditions (02/2025) of the State of California.

b. The Contractor agrees to indemnify and save harmless the Military Department, the State, its officers, agents and employees from any and all claims and losses accruing or resulting to any and all contractors, subcontractors, material men, laborers and any other person, firm or corporation furnishing or supplying work, services, materials or supplies in connection with the performance of this contract, and from any and all claims and losses accruing or resulting to any person, firm or corporation who may be injured or damaged by the contractor in the performance of this contract.

c. The Contractor, and the agents and employees of Contractor, in the performance of this agreement, shall act in an independent capacity and not as officers or employees or agents of the State of California.

d. The State may terminate this agreement and be relieved of the payment of and consideration to the Contractor should Contractor fail to perform the covenants herein contained at the time and in the manner herein provided. In the event of such termination the State may precede with the work in any manner deemed proper by the State. The cost to the State shall be deducted from any sum due the contractor under this agreement and the balance, if any, shall be paid the Contractor upon demand.

e. Without the written consent of the State, This agreement is not assignable by Contractor either in whole or in part.

f. Time is of the essence in this agreement.

g. No alteration or variation of the terms of this contract shall be valid unless made in writing and signed by the parties hereto, and no oral understanding or agreement not incorporated herein, shall be binding on any of the parties hereto.

h. The consideration to be paid Contractor, as provided herein, shall be in compensation for all of Contractor's expenses incurred in the performance hereof, including travel and per diem, unless otherwise expressly provided.

i. Contractor swears under penalty of perjury that no more than one final unappealable finding of contempt of court by a Federal Court has been issued against the Contractor within the immediately preceding two-year period because of the Contractor's failure to comply with an order of the National Labor Relations Board.

j. This contract may be amended during the period of contract performance, subject to the mutual agreement of parties.

k. This contract shall be subject to and construed in accordance with the laws of the State of California, whether or not specifically cited herein (including but not limited to Government Code § 927).

l. This agreement contains all the terms and conditions agreed to by all parties. No other understanding, oral or otherwise, regarding the subject matter of this agreement, shall be deemed to exist or to bind any of the parties hereto.

m. The contractor agrees to recognize the mandatory standards and policies relating to the energy efficiency in the

State Energy Conservation Plan Title 23, California Code of Regulations, as required by the U.S. Energy Policy and Conservation Act (Public Law 94-165).

https://www.dgs.ca.gov/-/media/Divisions/OLS/Resources/GTC-Updates/GTC-225-February-2025.pdf

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n. Contractor shall not enter into any subcontracts for the performance of the principle services to be rendered under this agreement without the express consent in writing of the State. Any subcontractors authorized to provide such services MUST meet and comply with all requirements set forth in this agreement.

o. All Contracting parties shall be subject to the examination and audit of the Auditor General for a period of three years after final payment under the contract (Government Code Section 10532) should the contract amount exceed $10,000.

p. Contractor agrees that the Military Department or its delegatee will have the right to review, obtain, and copy all records pertaining to performance of the contract. Contractor agrees to provide the Military Department with any relevant information requested and shall permit the Military Department access to its premises, upon reasonable notice, during normal business hours for the purpose of interviewing employees and inspecting and copying such books, records, accounts, and other material that may be relevant to a matter under investigation for the purpose of determining compliance with Public Contract Code Section 10115 et. seq. and Title 2, California Code of Regulations, Section 1896.60 et. seq. and for the purpose of determining compliance with the State requirements for M/WBE and DVBE. Contractor further agrees to maintain such records for a period of three (3) years after final payment under the contract.

q. This agreement is valid and enforceable only if sufficient funds are made available by the Budget Act for each

Fiscal Year of this agreement for the purposes of this contract. This contract is further subject to any additional restrictions, limitations, or conditions enacted by the Legislature and contained in the above Budget Bills or any statute enacted by the Legislature which may effect the provisions, terms, or funding of this or any subsidiary contract in any manner.

1-08. Cancellation, Modification, and Waiver: The Military Department reserves the right to cancel or modify this RFP, in whole or in part. The Military Department may reject any or all proposals for cause, and may waive any immaterial deviation or defect in a proposal. The Military Department's waiver of a deviation or defect shall in no way modify the IFB documents, or excuse the contractor from full compliance with the RFP specifications if awarded the contract.

1-09. Drug-Free Workplace Certification: Senate Bill 1120, Chapter 1170, Statutes of 1990, requires state contractors to maintain a "drug-free workplace”:

a. Every contractor MUST comply with the following:

(1) Certify that the individual or organization "will provide a drug-free workplace" (Government Code Section 8355).

(2) Publish a statement notifying employees that company policy prohibits specified activities involving controlled substances, and defining actions to be taken for violating the policy (Government Code Section 8355(a)).

(3) Establish a drug-free awareness program to inform employees about specified topics (Government

Code Section 8355 (b)).

(4) Provide the drug-free statement to each employee working on a state contract and require that these employees agree to abide by the terms of the statement (Government Code Section 8355(c)).

a. A state agency may cancel a contract if it finds that the contractor has falsely certified a drug-free workplace or failed to fulfill the requirements defined in Government Code Section 8355(a) thru (c). Every month the Department of General Services is required to publish a list of individuals and organizations whose contracts have been canceled; this list will appear in the State Contracts Register. State agencies are forbidden to contract with, or award to, individuals or organizations appearing on this list.

1-10. The California Taxpayer and Shareholder Protection Act of 2003, Public Contract Code section 10286, et seq., which prohibits state agencies from contracting with expatriate companies, unless they satisfy minimum requirements related to shareholder rights, or obtain a waiver, effective April 1, 2004. An expatriate company is a United States company that has moved, in name and on paper only, to a tax haven country (typically Bermuda or the Bahamas) and has no substantial business activities in the country of reincorporation.

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1-11. Antitrust Claims (GC §§ 4552, 4553 & 4554) are hereby incorporated by reference and made part of this solicitation as if attached hereto. This provision can be viewed on the DGS/OLS website http://www.dgs.ca.gov/pd/Home.aspx

1-12. TACPA Preference, if applicable (GC § 4530, et seq. and 2 CCR § 189.30) is hereby incorporated by reference and made part of this solicitation as if attached hereto. Contact DGS/Dispute Resolution/Preference Program Section for information on TACPA at (916) 375-4604 or (916) 375-4600.

1-13. Loss Leader Provisions (PCC § 10344) are hereby incorporated by reference and made part of this solicitation as if attached hereto.

1-14. Iran Contracting Act Certification (PCC § 2202) are hereby incorporated by reference and made part of this solicitation as if attached hereto.

1-15. Executive Order N-6-22 – Russia Sanctions – On March 4, 2022, Governor Gavin Newsom issued Executive Order N-6-22 (the EO) regarding Economic Sanctions against Russia and Russian entities and individuals. “Economic Sanctions” refers to sanctions imposed by the U.S. government in response to Russia’s actions in Ukraine, as well as any sanctions imposed under state law. By submitting a bid or proposal, Contractor represents that it is not a target of Economic Sanctions. Should the State determine Contractor is a target of Economic Sanctions or is conducting prohibited transactions with sanctioned individuals or entities, that shall be grounds for rejection of the Contractor’s bid/proposal any time prior to contract execution, or, if determined after contract execution, shall be grounds for termination by the State.

1-16. In the event of a precise tie, the CA Military Department will utilize a coin toss, observed by witnesses documented in the procurement file. In the event of a precise tie between two SB supplies in which one is also a DVBE, the award shall go to the SB that is also a DVBE. It is unlawful for any person engaged in business within this state to sell or use any article or product as a “loss leader” as defined in §17030 of the Business and Professions Code.

Completed certification applications and required support documents must be submitted to the office of Small Business and DVBE Certification (OSDC) no later than 5:00 p.m. on the bid due date, and the OSDC must be able to approve the application as submitted. Questions regarding certification should be directed to the OSDC at (916) 375-4940. The DVBE Participation Program Requirements have been waived for this solicitation.

1-17. Mandatory GenAI Notification Clause - The State of California seeks to realize the potential benefits of GenAI, through the development and deployment of GenAI, while balancing the risks of these technologies.

Bidder/Offeror must notify the State in writing if it: (1) intends to provide GenAI as a deliverable to the State; or (2), intends to utilize GenAI, including GenAI from third parties, to complete all or a portion of any deliverable that materially impacts: (i) functionality of a State system, (ii) risk to the State, or (iii) Contract performance. For avoidance of doubt, the term "materially impacts" shall have the meaning set forth in State Administrative Manual (SAM) 4986.2.

Failure to report GenAI to the State may result in disqualification. The State reserves its right to seek any and all relief it may be entitled to as a result of such non-disclosure.

Upon notification by a Bidder/Offeror of GenAI as required, the state reserves the right to incorporate GenAI Special Provisions into the final contract or reject bids/offers that present an unacceptable level of risk to the state.

Government Code 11549.64 defines “Generative Artificial Intelligence (GenAI)” as an artificial intelligence system that can generate derived synthetic content, including text, images, video, and audio that emulates the structure and characteristics of the system’s training data.

http://www.dgs.ca.gov/pd/Home.aspx

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SECTION 2

INSURANCE POLICIES/REQUIREMENTS

1. General Provisions Applying to All Insurance Policies

a. Coverage term – Coverage needs to be in force for the complete term of the contract. If insurance expires during the term of the contract, a new certificate must be received by the State at least ten (10) days prior to the expiration of this insurance. Any new insurance must still comply with the original terms of the contract.

b. Policy Cancellation of Termination and Notice of Non-Renewal – Contractor shall provide to the State within five (5) business days following receipt by contractor a copy of any cancellation or non-renewal of insurance required by this contract. In the event the contractor fails to keep in effect at all times the specified insurance coverage, the State may, in addition to any other remedies it may have, terminate this contract upon the occurrence of such event, subject to the provisions of this contract.

c. Deductible – Contractor is responsible for any deductible or self-insured contained within their insurance program.

d. Primary Clause – Any required insurance contained in the Contract shall be primary, and not excess or contributory to any other insurance carried by the State.

e. Insurance Carrier Required Rating – All insurance companies must carry a rating acceptable to the Office of Risk and Insurance Management. If the contractor is self-insured for a portion or all of its insurance, review of financial information including a letter of credit may be required.

f. Endorsements – Any required endorsement must be physically attached to all requested certificates of insurance and not substituted by referring to such coverage on the certificate of insurance.

g. Inadequate Insurance – Inadequate of lack of insurance does not negate the contractor’s obligations under the Contract.

2. Insurance Requirements

a. Commercial General Liability – Contractor shall maintain general liability on an occurrence form with limits not less than $1,000,000 per occurrence and $2,000,000 aggregate for bodily injury and property damage liability. The policy must include coverage for liabilities arising out of premises operations, independent contractors, products/completed operations, personal & advertising injury and liability assumed under an insured contract. This insurance shall apply separately to each insured against whom claim is made or suit is brought subject to the Contractor’s limit of liability. The policy must include:

Military Department, State of California, its officers, agents and employees are included as additional insured, but only with respect to work performed under this contract.

This endorsement must be supplied under form acceptable to the Office of Risk and Insurance Management.

In the case of Contractor’s utilization of subcontractors to complete the contracted scope of work, contractors shall include all subcontractors as insureds under Contractor’s insurance or supply evidence of insurance to the State equal to policies, coverage and limits required of Contractor.

b. Automobile Liability – If applicable, the certificate of insurance shall state an amount of Automobile Liability of no less than $1,000,000 per occurrence for bodily injury and property damage liability combined.

The same additional insured designation and endorsement required for general liability is to be provided for this coverage.

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c. Workers’ Compensation and Employers’ Liability – Contractor shall maintain statutory workers’ compensation and employers’ liability for all its employees who will be engaged in the performance of the contract. Employers’ liability limits of $1,000,000 are required.

When is performed on State owned or controlled property the workers’ compensation policy shall contain a waiver of subrogation in favor of the State. The waiver of subrogation endorsement shall be provided.

3. Terms of Policy (breakdown in accordance with the above requirements):

a. Minimum limit of coverage of the policy shall be:

(1) Vehicle Liability (BI & PD): $1,000,000 per occurrence

(2) Public Liability: $1,000,000 per occurrence/$2,000,000 Aggregate

(3) Workers Compensation: Statutory

b. State shall not be responsible for premiums or assessments on the policy.

c. The Military Department, The State of California, its officers, agents, and employees are included as additional insured, but only with respect to work performed under this contract.

NOTE: THE ENDORSEMENT SHEET MUST INCLUDE THE LANGUAGE AS WRITTEN IN

PARAGRAPH c. ABOVE.

Certificate of Insurance is to be mailed to the following address:

Military Department NGCA-JSD-SC (Future Contract Number) 10601 Bear Hollow Dr, Box 12 Rancho Cordova, CA 95670

The above certifications must be provided to the Military Department upon request of the Military Department’s Contracting Officer and mailed to the address above.

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PROPOSAL FORM

Roll Off Dumpster Service San Francisco, CA

TO: THE MILITARY DEPARTMENT

STATE OF CALIFORNIA

The undersigned hereby proposes and agrees to furnish all labor, materials and equipment necessary for the to perform Roll Off Dumpster Service from on or around October 19, 2026 through November 20, 2026 at the National Guard Armory located at 100 Armory Dr., San Francisco, California in accordance with the attached specifications for the total amount not to exceed:

($ ) dollars.

The foregoing figure includes the cost of bonds, insurance, sales tax, and every other item of expense incident to the contract. Contractor shall provide the following cost breakdown:

Type of Service Service Charge Total

40-yard roll-off dumpster rental & waste disposal per Statement of Work

$ x 2 = $

Total Cost = $

The Prime Contractor shall perform all work under the contract with its own organization. The Prime Contractor shall provide at all times sufficient competent labor, materials, and equipment to properly carry on the work and to ensure completion within the time agreed. The use of subcontractors is not permitted for this contract.

The prospective contractor's signature affixed here below and dated shall constitute a certification under the penalty of perjury, under the laws of the State of California, that all information provided by the contractor/vendor, is true and correct as written.

Failure to sign this proposal form may be cause for the rejection of your firm’s quote. Vendor’s original signature is required.

STATUS OF FIRM:

NAME OF COMPANY/FIRM: DATE:

FEDERAL ID NUMBER:

COMPANY COMPLETE PHYSICAL AND E-

MAIL ADDRESS:

SB/DVBE NUMBER:

LICENSE NUMBER:

DATE LICENSE EXPIRES: CLASS OF LICENSE:

PRINTED SIGNATURE BLOCK:

SIGNATURE OF COMPANY

REPRESENTATIVE:

TELEPHONE NUMBER:

STATUS OF FIRM must be given, whether an individual, partnership, or corporation. If partnership, list full names of partners, if firm is a corporation, identify the state in which incorporated and provide State of California Corporate Identification Number as issued by the Office of the Secretary of State for California. Firms bidding, as corporations must be registered with and in good standing with the Secretary of State’s Office at the time of the bid opening.

Proposals must be signed by the vendor or representative of the vendor who has authority to sign contracts binding upon the vendor. Corporate Identification Numbers shall be verified.

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STATEMENT OF COMPLIANCE APPLICABLE TO CONTRACTS OF $5,000 OR MORE: The prospective contractor's signature affixed hereto and dated shall constitute a certification under the penalty of perjury under the laws of the State of California that the vendor has, unless exempted, complied with the nondiscrimination program requirements of Government Code Section 12990 and Title 2, California Code of Regulations, Section 8103.

CONTRACTOR/OFFEROR SIGNATURE DATE

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CHECKLIST OF FORMS

Roll Off Dumpster Service San Francisco, CA

CHECKLIST OF FORMS TO BE RETURNED WITH PROPOSAL

SUBMIT ONE COPY OF THE ORIGINAL PROPOSAL FORM

FORM DESCRIPTION RETURNED WITH

PROPOSAL?

(Yes/No)

PROPOSAL

FORM

PROPOSAL, STATEMENT OF COMPLIANCE (COMPLETED AND

SIGNED)

STD 204 PAYEE DATA RECORD (AWARDEE MUST PROVIDE

SUBCONTRACTORS STD 204s AS WELL)

GSPD-05-105 BIDDER DECLARATION

STD 843 DISABLED VETERAN BUSINESS ENTERPRISE DECLARATIONS

(REQUIRED FOR CERTIFIED DVBEs ONLY)

DARFUR CONTRACTING ACT CERTIFICATION

CONTRACTOR CERTIFICATION CLAUSES

NOTE: ALL OF THE ABOVE DOCUMENTS REQUIRED AND MUST BE SUBMITTED WITH THE

PROPOSAL AND SIGNED. FAILURE TO DO SO MAY DEEM YOUR PROPOSAL TO BE NON-RESPONSIVE AND MAY BE CAUSE FOR BID REJECTION. SUBMIT ONE COPY OF THE ORIGINAL PROPOSAL FORM.

NOTE: ALL OF THE BELOW DOCUMENTS ARE OPTIONAL AND ARE NOT REQUIRED TO BE

SUBMITTED WITH THE PROPOSAL.

FORM DESCRIPTION RETURNED WITH

PROPOSAL?

(Yes/No)

GSPD 802 VOLUNTARY STATISTICAL DATA SHEET

STATE OF CALIFORNIA – DEPARTMENT OF FINANCE

PAYEE DATA RECORD

(Required when receiving payment from the State of California in lieu of IRS W-9 or W-7) STD 204 (Rev. 03/2021)

Section 1 – Payee Information NAME (This is required. Do not leave this line blank. Must match the payee’s federal tax return)

BUSINESS NAME, DBA NAME or DISREGARDED SINGLE MEMBER LLC NAME (If different from above)

MAILING ADDRESS (number, street, apt. or suite no.) (See instructions on Page 2)

CITY, STATE, ZIP CODE E-MAIL ADDRESS

Section 2 – Entity Type Check one (1) box only that matches the entity type of the Payee listed in Section 1 above. (See instructions on page 2)

CORPORATION (see instructions on page 2)SOLE PROPRIETOR / INDIVIDUAL MEDICAL (e.g., dentistry, chiropractic, etc.)SINGLE MEMBER LLC Disregarded Entity owned by an individual

PARTNERSHIP

ESTATE OR TRUST

LEGAL (e.g., attorney services)

EXEMPT (e.g., nonprofit)

ALL OTHERS

Section 3 – Tax Identification Number Enter your Tax Identification Number (TIN) in the appropriate box. The TIN must match the name given in Section 1 of this form. Do not provide more than one (1) TIN.

The TIN is a 9-digit number. Note: Payment will not be processed without a TIN.

For Individuals, enter SSN.

If you are a Resident Alien, and you do not have and are not eligible to get an SSN, enter your ITIN.

Grantor Trusts (such as a Revocable Living Trust while the grantors are alive) may not have a separate FEIN. Those trusts must enter the individual grantor’s SSN.

For Sole Proprietor or Single Member LLC (disregarded entity), in which the sole member is an individual, enter SSN (ITIN if applicable) or FEIN (FTB prefers SSN).

For Single Member LLC (disregarded entity), in which the sole member is a business entity, enter the owner entity’s FEIN. Do not use the disregarded entity’s FEIN.

For all other entities including LLC that is taxed as a corporation or partnership, estates/trusts (with FEINs), enter the entity’s FEIN.

Social Security Number (SSN) or Individual Tax Identification Number (ITIN)

OR

Federal Employer Identification Number

(FEIN)

Section 4 – Payee Residency Status (See instructions)

CALIFORNIA RESIDENT – Qualified to do business in California or maintains a permanent place of business in California.

CALIFORNIA NONRESIDENT – Payments to nonresidents for services may be subject to state income tax withholding.

No services performed in California

Copy of Franchise Tax Board waiver of state withholding is attached.

Section 5 – Certification I hereby certify under penalty of perjury that the information provided on this document is true and correct.

Should my residency status change, I will promptly notify the state agency below.

NAME OF AUTHORIZED PAYEE REPRESENTATIVE TITLE E-MAIL ADDRESS

SIGNATURE DATE TELEPHONE (include area code)

Section 6 – Paying State Agency Please return completed form to:

STATE AGENCY/DEPARTMENT OFFICE UNIT/SECTION

MAILING ADDRESS FAX TELEPHONE (include area code)

CITY STATE ZIP CODE E-MAIL ADDRESS

Print Form Reset Form

STATE OF CALIFORNIA – DEPARTMENT OF FINANCE

PAYEE DATA RECORD

(Required when receiving payment from the State of California in lieu of IRS W-9 or W-7) STD 204 (Rev. 03/2021)

GENERAL INSTRUCTIONS

Type or print the information on the Payee Data Record, STD 204 form. Sign, date, and return to the state agency/department office address shown in Section 6.

Prompt return of this fully completed form will prevent delays when processing payments.

Information provided in this form will be used by California state agencies/departments to prepare Information Returns (Form1099).

NOTE: Completion of this form is optional for Government entities, i.e. federal, state, local, and special districts.

A completed Payee Data Record, STD 204 form, is required for all payees (non-governmental entities or individuals) entering into a transaction that may lead to a payment from the state. Each state agency requires a completed, signed, and dated STD 204 on file; therefore, it is possible for you to receive this form from multiple state agencies with which you do business.

Payees who do not wish to complete the STD 204 may elect not to do business with the state. If the payee does not complete the STD 204 and the required payee data is not otherwise provided, payment may be reduced for federal and state backup withholding. Amounts reported on Information Returns (Form 1099) are in accordance with the Internal Revenue Code (IRC) and the California Revenue and Taxation Code (R&TC).

Section 1 – Payee Information Name – Enter the name that appears on the payee's federal tax return. The name provided shall be the tax liable party and is subject to IRS TIN matching (when applicable).

Sole Proprietor/Individual/Revocable Trusts – enter the name shown on your federal tax return.

Single Member Limited Liability Companies (LLCs) that is disregarded as an entity separate from its owner for federal tax purposes - enter the name of the individual or business entity that is tax liable for the business in section 1. Enter the DBA, LLC name, trade, or fictitious name under Business Name.

Note: for the State of California tax purposes, a Single Member LLC is not disregarded from its owner, even if they may be disregarded at the Federal level.

Partnerships, Estates/Trusts, or Corporations – enter the entity name as shown on the entity’s federal tax return. The name provided in Section 1 must match to the TIN provided in section 3. Enter any DBA, trade, or fictitious business names under Business Name.

Business Name – Enter the business name, DBA name, trade or fictitious name, or disregarded LLC name.

Mailing Address – The mailing address is the address where the payee will receive information returns. Use form STD 205, Payee Data Record Supplement to provide a remittance address if different from the mailing address for information returns, or make subsequent changes to the remittance address.

Section 2 – Entity Type If the Payee in Section 1 is a(n)… THEN Select the Box for…

Grantor (Revocable Living) Trust disregarded for federal tax purposes Sole Proprietor/Individual Limited Liability Company (LLC) owned by an individual and is disregarded for federal tax purposes Single Member LLC-owned by an individual Partnerships Limited Liability Partnerships (LLP) and, LLC treated as a Partnership Partnerships Estate Trust (other than disregarded Grantor Trust) Estate or Trust Corporation that is medical in nature (e.g., medical and healthcare services, physician care, nursery care, dentistry, etc. LLC that is to be taxed like a Corporation and is medical in nature

Corporation-Medical

Corporation that is legal in nature (e.g., services of attorneys, arbitrators, notary publics involving legal or law related matters, etc.) LLC that is to be taxed like a Corporation and is legal in nature

Corporation-Legal

Corporation that qualifies for an Exempt status, including 501(c) 3 and domestic non-profit corporations. Corporation-Exempt Corporation that does not meet the qualifications of any of the other corporation types listed above LLC that is to be taxed as a Corporation and does not meet any of the other corporation types listed above

Corporation-All Other

Section 3 – Tax Identification Number The State of California requires that all parties entering into business transactions that may lead to payment(s) from the state provide their Taxpayer Identification Number (TIN). The TIN is required by R&TC sections 18646 and 18661 to facilitate tax compliance enforcement activities and preparation of Form 1099 and other information returns as required by the IRC section 6109(a) and R&TC section 18662 and its regulations.

Section 4 – Payee Residency Status Are you a California resident or nonresident?

A corporation will be defined as a "resident" if it has a permanent place of business in California or is qualified through the Secretary of State to do business in California.

A partnership is considered a resident partnership if it has a permanent place of business in California.

An estate is a resident if the decedent was a California resident at time of death.

A trust is a resident if at least one trustee is a California resident.

o For individuals and sole proprietors, the term "resident" includes every individual who is in California for other than a temporary or transitory purpose and any individual domiciled in California who is absent for a temporary or transitory purpose. Generally, an individual who comes to California for a purpose that will extend over a long or indefinite period will be considered a resident. However, an individual who comes to perform a particular contract of short duration will be considered a nonresident.

For information on Nonresident Withholding, contact the Franchise Tax Board at the numbers listed below:

Withholding Services and Compliance Section: 1-888-792-4900 E-mail address: wscs.gen@ftb.ca.gov For hearing impaired with TDD, call: 1-800-822-6268 Website: www.ftb.ca.gov

Section 5 – Certification Provide the name, title, email address, signature, and telephone number of individual completing this form and date completed. In the event that a SSN or ITIN is provided, the individual identified as the tax liable party must certify the form. Note: the signee may differ from the tax liable party in this situation if the signe e can provide a power of attorney documented for the individual.

Section 6 – Paying State Agency This section must be completed by the state agency/department requesting the STD 204.

Privacy Statement Section 7(b) of the Privacy Act of 1974 (Public Law 93-579) requires that any federal, state, or local governmental agency, which requests an individual to disclose their social security account number, shall inform that individual whether that disclosure is mandatory or voluntary, by which statutory or other authority such number is solicited, and what uses will be made of it. It is mandatory to furnish the information requested. Federal law requires that payment for which the requested information is not provided is subject to federal backup withholding and state law imposes noncompliance penalties of up to $20,000. You have the right to access records containing your personal information, such as your SSN. To exercise that right, please contact the business services unit or the accounts payable unit of the state agency(ies) with which you transact that business.

All questions should be referred to the requesting state agency listed on the bottom front of this form.

STATE OF CALIFORNIA – DEPARTMENT OF GENERAL SERVICES PROCUREMENT DIVISION

DISABLED VETERAN BUSINESS ENTERPRISE DECLARATIONS

(Rev. /20 )

Instructions: The disabled veteran (DV) owner(s) and DV manager(s) of the Disabled Veteran Business Enterprise (DVBE) must complete this declaration when a DVBE contractor or subcontractor will provide materials, supplies, services or equipment [Military and Veterans Code Section 999.2]. Violations are misdemeanors and punishable by imprisonment or fine and violators are liable for civil penalties. All signatures are made under penalty of perjury.

SECTION 1

Name of certified DVBE: DVBE Ref. Number:

Description (materials/supplies/services/equipment proposed):

Solicitation/Contract Number: SCPRS Ref. Number:__________________________

(FOR STATE USE ONLY)

SECTION 2

APPLIES TO ALL DVBEs. Check only one box in Section 2 and provide original signatures.

I (we) declare that the DVBE is not a broker or agent, as defined in Military and Veterans Code Section 999.2 (b), of materials, supplies, services or equipment listed above. Also, complete Section 3 below if renting equipment.

Pursuant to Military and Veterans Code Section 999.2 (f), I (we) declare that the DVBE is a broker or agent for the principal(s) listed below or on an attached sheet(s). (Pursuant to Military and Veterans Code 999.2 (e), State funds expended for equipment rented from equipment brokers pursuant to contracts awarded under this section shall not be credited toward the 3-percent DVBE participation goal.)

All DV owners and managers of the DVBE (attach additional pages with sufficient signature blocks for each person to sign):

(Printed Name of DV Owner/Manager) (Signature of DV Owner/ Manager) (Date Signed)

(Printed Name of DV Owner/Manager) (Signature of DV Owner/Manager) (Date Signed)

Firm/Principal for whom the DVBE is acting as a broker or age nt:

(If more than one firm, list on extra sheets.) (Print or Type Name)

Firm/Principal Phone: Address:

SECTION 3

APPLIES TO ALL DVBEs THAT RENT EQUIPMENT AND DECLARE THE DVBE IS NOT A BROKER.

Pursuant to Military and Veterans Code Section 999.2 (c), (d) and (g), I am (we are) the DV(s) with at least 51% ownership of the DVBE, or a DV manager(s) of the DVBE. The DVBE maintains certification requirements in accordance with Military and Veterans Code Section 999 et. seq.

The undersigned owner(s) own(s) at least 51% of the quantity and value of each piece of equipment that will be rented for use in the contract identified above. I (we), the DV owners of the equipment, have submitted to the administering agency my (our) personal federal tax return(s) at time of certification and annually thereafter as defined in Military and Veterans Code 999.2, subsections (c) and (g). Failure by the disabled veteran equipment owner(s) to submit their personal federal tax return(s) to the administering agency as defined in Military and Veterans Code 999.2, subsections

(c) and (g), will result in the DVBE being deemed an equipment broker.

Disabled Veteran Owner(s) of the DVBE (attach additional pages with signature blocks for each person to sign):

(Printed Name) (Signature) (Date Signed)

(Address of Owner) (Telephone) (Tax Identification Number of Owner)

Disabled Veteran Manager(s) of the DVBE (attach additional pages with sufficient signature blocks for each person to sign):

(Printed Name of DV Manager) (Signature of DV Manager) (Date Signed)

Page of

BIDDER DECLARATION

1. Prime bidder information (Review attached Bidder Declaration Instructions prior to completion of this form):

a. Identify current California certification(s) (MB, SB, NVSA, DVBE): ____________ or None ____ (If “None”, go to Item #2)

b. Will subcontractors be used for this contract? Yes ___ No ___ (If yes, indicate the distinct element of work your firm will perform in this contract e.g., list the proposed products produced by your firm, state if your firm owns the transportation vehicles that will deliver the products to the State, identify which solicited services your firm will perform, etc.). Use additional sheets, as necessary.

2. If no subcontractors will be used, skip to certification below. Otherwise, list all subcontractors for this contract. (Attach additional pages if necessary):

Solicitation Number_____________________

Certification: By signing the bid response, I certify under penalty of perjury that the information provided is true and correct.

State of California—Department of General Services, Procurement Division

GSPD–05–105 (REV 08/09)

Page_____ of _____

BIDDER DECLARATION Instructions All prime bidders (the firm submitting the bid) must complete the Bidder Declaration.

1.a. Identify all current certifications issued by the State of California. If the prime bidder has no California certification(s), check the line labeled “None” and proceed to Item #2. If the prime bidder possesses one or more of the following certifications, enter the applicable certification(s) on the line:

1.b. Mark either “Yes” or “No” to identify whether subcontractors will be used for the contract. If the response is “No”, proceed to Item #1.c. If “Yes”, enter on the line the distinct element of work contained in the contract to be performed or the goods to be provided by the prime bidder. Do not include goods or services to be provided by subcontractors.

Bidders certified as MB, SB, NVSA, and/or DVBE must provide a commercially useful function as defined in Military and Veterans Code Section 999 for DVBEs and Government Code Section 14837(d)(4)(A) for small/ microbusinesses.

Bids must propose that certified bidders provide a commercially useful function for the resulting contract or the bid will be deemed non-responsive and rejected by the State. For questions regarding the solicitation, contact the procurement official identified in the solicitation.

Note: A subcontractor is any person, firm, corporation, or organization contracting to perform part of the prime’s contract.

1.c. This item is only to be completed by businesses certified by California as a DVBE.

(1) Declare whether the prime bidder is a broker or agent by marking either “Yes” or “No”. The Military and Veterans Code Section 999.2 (b) defines “broker” or “agent” as a certified DVBE contractor or subcon-tractor that does not have title, possession, control, and risk of loss of materials, supplies, services, or equipment provided to an awarding department, unless one or more of the disabled veteran owners has at least 51-percent ownership of the quantity and value of the materials, supplies, services, and of each piece of equipment provided under the contract.

(2) If bidding rental equipment, mark either “Yes” or “No” to identify if the prime bidder owns at least 51% of the equipment provided (quantity and value). If not bidding rental equipment, mark “N/A” for “not applicable.”

2. If no subcontractors are proposed, do not complete the table. Read the certification at the bottom of the form and complete “Page ___ of ___” on the form.

If subcontractors will be used, complete the table listing all subcontractors. If necessary, attach additional pages and complete the “Page ___ of ___” accordingly.

2. (continued) Column Labels

Subcontractor Name, Contact Person, Phone Number & Fax Number—List each element for all subcontractors.

Subcontractor Address & Email Address—Enter the address and if available, an Email address.

CA Certification (MB, SB, NVSA, DVBE or None)—If the subcontractor possesses a current State of California certification(s), verify on this website (www.eprocure.pd.dgs.ca.gov).

Work performed or goods provided for this contract—Identify the distinct element of work contained in the contract to be performed or the goods to be provided by each subcontractor. Certified subcontractors must provide a commercially useful function for the contract. (See paragraph 1.b above for code citations regarding the definition of commercially useful function.) If a certified subcontractor is further subcontract-ing a greater portion of the work or goods provided for the resulting contract than would be expected by normal industry practices, attach a separate sheet of paper explaining the situation.

Corresponding % of bid price—Enter the corresponding percentage of the total bid price for the goods and/or services to be provided by each subcontractor. Do not enter a dollar amount.

Good Standing?—Provide a response for each subcontractor listed. Enter either “Yes” or “No” to indicate that the prime bidder has verified that the subcontractor(s) is in good standing for all of the following:

51% Rental?—This pertains to the applicability of rental equipment.