RMD_Fm_(5.29.19).pdf

Revision Date: 04 May 2007

UNCLASSIFIED

UNCLASSIFIED

RECOVERED MATERIALS DETERMINATION FORM

(Part 1) Design/Procurement

INSTRUCTIONS

This form is to be completed by the requiring activity when EPA-designated items are applicable to the requirement. For questions on whether the product counts as “EPA-designated” or what the required recycled content is, refer to product descriptions on EPA’s website at www.epa.gov/cpg/products. This form is not required for construction item purchases less than $2,000, or for other purchases less than $3,000. The completed form becomes part of the contracting office contract file.

PROCUREMENT TITLE: DBEH 18-1547, Repair Envelope, F 1645, CCAFS

PROCUREMENT REQUEST NO.

PART 1: RECOVERED MATERIALS DETERMINATION

Part 1 shall be completed by the specifying authority when requesting a procurement action.

EPA-DESIGNATED ITEMS

(Place a check mark next to each product that applies to this procurement)

Construction Products:

Building insulation Polyester carpet Carpet Cushion

Cement & concrete containing:

Coal fly ash Ground granulated blast furnace slag Cenospheres Silica fume Floor tiles (rubber & plastic) Flowable fill Latex paint Laminated paperboard Modular threshold ramps Nonpressure pipe Patio blocks Railroad grade crossings/surfaces Roofing materials Shower & restroom dividers/ partitions Structural fiberboard

Landscaping Products:

Compost from yard trimmings or food waste Garden and soaker hoses Hydraulic mulch Lawn and garden edging Plastic lumber landscaping timbers and posts

Park & Recreation Products:

Park and recreational furniture Playground equipment Playground surfaces Running tracks Plastic fencing (snow or erosion control, safetybarriers) Non-paper Office Products:

Binders (paper, solid plastic or plastic covered)

Plastic clipboards Plastic file folders Plastic clip portfolios Plastic presentation folders Office furniture Office recycling containers Office waste receptacles Plastic desktop accessories Plastic envelopes Plastic trash bags Printer ribbons Toner cartridges

Paper & Paper Products:

Commercial/industrial sanitary tissue products Miscellaneous papers Newsprint Paperboard and packaging

Printing and writing papers Tray liners

Vehicular Products:

Engine coolants Rebuilt vehicular parts Re-refined lubricating oils Retread tires

Transportation Products

Channelizers Delineators Flexible delineators Parking stops Traffic barricades Traffic cones

Miscellaneous Products:

Awards and plaques Bike racks Blasting grit Industrial drums Mats Pallets Signage Sorbents

Strapping

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RECOVERED MATERIALS DETERMINATION FORM

(PART 1) Design/Procurement (Cont’d)

PROCUREMENT TITLE: DBEH 18-1547, Repair Envelope, F 1645, CCAFS

PROCUREMENT REQUEST NO.

FAR 11.2(c) requires the establishment of statements of work and specification requirements for the procurement of products containing recovered materials and environmentally preferable and energy-efficient products and services.

If no EPA designated items were checked on page 1, than check box A:

A. I hereby certify that no EPA designated guideline items are included in this procurement action

If any EPA designated items are checked on page 1, than mark box B or C:

B. I hereby certify that the EPA recycled content requirements have been specified for all of the designated guideline items in this procurement action

OR

C. I hereby certify that the EPA recycled content requirements have been specified for all but the following designated guideline items for which compliance with EPA standards is not attainable.

If Box C is checked, list each designated item and the corresponding justification number from the list below for each exemption being claimed. Attach the supporting documentation for each waiver.

The exemption being claimed for this purchase is:

1. The product is not available competitively (from two or more sources) within a reasonable time frame;

2. The product is only available at an unreasonable price (based on a life-cycle cost analysis);

3. The product does not meet appropriate performance standards (in accordance with National

Institute of Standards and Technology (NIST) guidelines.)

Designated Item Justification #

1.

2.

3.

4.

R. Constantinide, RAEIS Architect 11.08.2018

Design/Specifying Agent Signature Date

Requiring Organization’s Technical Representative Signature Date

WALLACE.BRIAN.K.1222107055 Digitally signed by WALLACE.BRIAN.K.1222107055 Date: 2019.02.12 16:05:49 -05'00'

UNCLASSIFIED

RECOVERED MATERIALS DETERMINATION FORM

(PART 2) Construction

PROCUREMENT TITLE: DBEH 18-1547, Repair Envelope, F 1645, CCAFS

PROCUREMENT REQUEST NO.

Part 2 of this certification is to be completed upon receipt of the purchase goods and services. If EPA designated items were specified in this procurement action, the contractor/supplying agent shall complete Part 2 of this certification upon delivery of the products or services. Attach supporting documentation identifying percentage of recovered material content used in each designated item. NOTE: A designated item is specified if no exemptions were prepared and identified in Part 1.C of this form during the development of this procurement action.

Check the appropriate box:

A. EPA recycled content requirements have been met for all designated items specified in this procurement action.

OR

B. EPA recycled content requirements have been met for all but the following EPA designated guideline item(s) for which compliance with EPA standards was not attainable.

If Box B is checked, list each designated item and the corresponding justification number from the list below for each exemption being claimed. Attach the supporting documentation for each waiver item listed.

The exemption being claimed for this purchase is:

1. The product is not available competitively (from two or more sources) within a reasonable time frame;

2. The product is only available at an unreasonable price (based on a life-cycle cost analysis);

3. The product does not meet appropriate performance standards (in accordance with National

Institute of Standards and Technology (NIST) guidelines.)

Designated Item Justification #

1.

2.

3.

Contractor/Supplying Agent Signature Date

Requiring Organization’s Technical Representative Signature Date

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RECOVERED MATERIALS DETERMINATION FORM

Waiver Form

PROCUREMENT TITLE: DBEH 18-1547, Repair Envelope, F 1645, CCAFS

PROCUREMENT REQUEST NO.

The technical authority shall prepare a separate justification for each designated item purchased that does not meet EPA standards as part of this procurement action:

The following item does not comply with EPA standards for recycled/recovered materials:

The exemption being claimed for this purchase is:

The product is not available competitively (from two or more sources) within a reasonable time frame;

The product does not meet appropriate performance standards (in accordance with National Institute of Standards and Technology (NIST) guidelines);

The product is only available at an unreasonable price (based on a price analysis that considers life-cycle cost). The recycled-content product costs $ per and the non-recycled-content product costs $ per . .

This written justification is made in accordance with 42USC 6962(c)(1):

R. Constantinide, RAEIS Architect 11.08.2018

Design/specifying Agent’s Signature Date

Requiring Organization’s Technical Representative Signature Date

Contracting Officer’s Signature Date

Rationale for exemption: (Please provide the rationale upon which this justification was based. Include vendor names, points of contact, life-cycle cost analysis and any other documentation that supports this decision.

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Green Procurement Waiver Statement – Instructions

1. PURPOSE OF STATEMENT. This “Green Procurement Waiver Statement” provides documentation that GPP has been considered for projects that do not require the use of U.S. EPA-designated CPG items, USDA-designated biobased items, Energy Star® listed items, or FEMP Low Standby Power items. A similar memo or email statement can be used in lieu of this statement.

2. OPR. Civil Engineering and all other organizations procuring items through other avenues than the Government-wide Purchase Card (GPC).

3. OCR. Contracting, Civil Engineering/Operations, Civil Engineering/Construction, Civil Engineering/SABER, and Civil Engineering/Materiel Acquisition.

4. APPLICABILITY. This “Green Procurement Waiver Statement” applies to procurement actions (other than GPC purchases) that do not require items that must comply with CPG, biobased, Energy Star®, or FEMP requirements.

5. INTENT FOR USE.

a. GPC cardholders should not complete this form and use the “GPC Green Procurement Purchasing Log” instead.

b. The Environmental Flight will incorporate this “Green Procurement Waiver Statement” into the PAFB Environmental Requirements Specification boilerplate documentation. These specifications will be included in all service and construction contracts, as well as all in-house work orders greater than $3,000.

c. For in-house job and work orders (regardless of project cost), contractors and CE Operations shop personnel will be responsible for completing this “Green Procurement Waiver Statement” for all procurement actions if none of the items on the mandatory purchasing lists are required. The OCR organizations listed above will be responsible for checking and verifying the completed GPP Waiver Statement.

d. If the procurement action includes any CPG, biobased, Energy Star®, or FEMP Low Standby Power items, use the Recovered Materials Determination Form (RMDF) instead.

6. FILING PROCEDURE. If applicable, a completed “Green Procurement Waiver Statement” will be included in the purchasing or contracting file. Contracting is responsible for ensuring that either a “Green Procurement Waiver Statement” or RMDF is included in contracting files.

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DIRECTIONS FOR USE OF THE RECOVERED

MATERIALS DETERMINATION FORM

Complete top of the Recovered Materials Determination Form (RMDF) Form and check mark all EPA-designated items applicable to this acquisition.

Complete page 2 of the RMDF Form

Check mark Box A on Part 1 of the RMDF

Form. Provide signatures/dates.

Were any EPA-designated items checked on page 1of the RMDF Form?

Yes

No

Yes

No Were all possible

EPA-designated items specified in the procurement action?

Check mark Box C on Part 1 of the RMDF

Form and complete the justification section.

Provide signatures/dates.

Check mark Box B on Part 1 of the RMDF Form.

Provide signatures/ dates.

Complete Part 2 of the RMDF Form

Were all EPA-designated items specified in the procurement action purchased?

No

Yes

Check mark Box A on Part 2 of the RMDF

Form. Provide signatures/dates.

Check mark Box B on Part 2 of the RMDF Form and complete the justification section. Provide signatures/dates.

Complete page 2 of Part 2 for each EPA-designated item for which an exemption has been claimed on Part 1 or 2 of the RMDF Form.

Place all forms in the Contracting Office contract/project file.

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GPC Green Procurement Purchasing Log – Page 1 Purchaser/Requester completes this form prior to making any purchases and retains a copy in their purchasing records. Copy and attach additional sheets, as needed. Consult the Patrick GPP OPLAN for additional guidance. Submit quarterly a copy of the completed log to Wayne Neville, 45 CES/CEVC. Complete the first line and submit a blank form if no GPP purchases were completed.

Purchase Requester Name, Office Symbol, Phone:

Date Project Name Item Purchased

EPP

Considered?

(Y/N)

Item Purchased

GPP-

Compliant?

(Y/N)

If not a GPP-compliant purchase, circle the appropriate exemption or reason for non-compliance C J/U/G Purchase NA P S T

C J/U/G Purchase NA P S T

C J/U/G Purchase NA P S T

C J/U/G Purchase NA P S T

C J/U/G Purchase NA P S T

C J/U/G Purchase NA P S T

C J/U/G Purchase NA P S T

C J/U/G Purchase NA P S T

C J/U/G Purchase NA P S T

C J/U/G Purchase NA P S T

C J/U/G Purchase NA P S T

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GPC Green Procurement Purchasing Log – Page 2

Date Project Name Item Purchased

EPP

Considered?

(Y/N)

Item Purchased

GPP-

Compliant?

(Y/N)

If not a GPP-compliant purchase, circle the appropriate exemption or reason for non-compliance C J/U/G Purchase NA P S T

C J/U/G Purchase NA P S T

C J/U/G Purchase NA P S T

C J/U/G Purchase NA P S T

C J/U/G Purchase NA P S T

C J/U/G Purchase NA P S T

C J/U/G Purchase NA P S T

C J/U/G Purchase NA P S T

C J/U/G Purchase NA P S T

LEGEND

C = Item was not competitively available GPP = Green Procurement Program (see GPP Requirements Reference Sheet) EPP = Environmentally Preferable Purchasing J/U/G Purchase = Item was purchased under one of the mandatory purchase programs (JWOD, UNICOR), or GSA.

NA = Item is not on the U.S. EPA-designated list

P = Item was too expensive (price) S = Item did not meet technical specifications T = Item was not available in a timely manner Y/N = Yes or No

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GPC Green Procurement Purchasing Log – Instructions

1. PURPOSE OF STATEMENT. This “GPC Green Procurement Purchasing Log” (GPC Log) is intended to be used to document credit card holders’ purchases of items that are designated for green procurement under one of the mandatory Federal programs. The GPC Log identifies whether or not the product that was purchased, met GPP requirements and documents the reason for choosing a non-compliant product.

2. OPR. All GPC cardholders.

3. OCR. None.

4. APPLICABILITY. This GPC Log applies to all purchases made by GPC cardholders.

5. INTENT FOR USE. The GPC holder can maintain a running GPC Log to document each GPC purchase.

6. FILING PROCEDURE. The GPC Log must be included in the GPC holder purchasing file for auditing purposes.

7. REPORTING PROCEDURE. A copy of the completed GPC Log must be submitted to Wayne Neville, 45CES/CEVC on the last day of each quarter or four times annually. Complete the first line and submit a blank form if no GPP purchases were completed.