Atch4-GPP-CertForm.pdf

GREEN PURCHASING PROGRAM CERTIFICATION DETERMINATION

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 $2,500. The completed form becomes part of the contracting office contract file.

PROCUREMENT TITLE: SXHT 11-1055 Repair Lift Station Pumps at Building 650, Building 1497 & Lift Station 943

PROCUREMENT REQUEST NO. F3K3DD9189A001

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

Cenospheres

Silica fume

Floor tiles (rubber & plastic)

Laminated paperboard

Modular threshold ramps

Nonpressure pipe

Patio blocks

Railroad grade crossings/

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, safety barriers)

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

Cement & concrete containing:

Coal fly ash

Ground granulated blast furnace slag

Flowable fill

Latex paint surfaces

Roofing materials Shower & restroom dividers/partitions http://www.epa.gov/cpg/products

PROCUREMENT TITLE: SXHT 11-1055 Repair Lift Station Pumps at Building 650, Building 1497 & Lift Station 943

PROCUREMENT REQUEST NO. F3K3DD9189A001

PART 1: RECOVERED MATERIALS DETERMINATION (CONT’D)

FAR 11.002(d) 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 does not meet appropriate performance standards (in accordance with National

Institute of Standards and Technology (NIST) guidelines

2. The product is not available within a reasonable time frame

3. The product is not available competitively (from two or more sources)

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

Designated Item Justification #

1.

2.

3.

4.

5.

Design/Specifying Agent Signature Date

Requiring Organization’s Technical Representative Signature Date

X

PROCUREMENT TITLE: SXHT 11-1055 Repair Lift Station Pumps at Building 650, Building 1497 & Lift Station 943

PROCUREMENT REQUEST NO: F3K3DD9189A001

PART 2: GREEN PROCUREMENT CERTIFICATION

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.

The exemption being claimed for this purchase is:

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

Institute of Standards and Technology (NIST) guidelines.)

2. The product is not available within a reasonable time frame

3. The product is not available competitively (from two or more sources)

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

Designated Item Justification #

1.

2.

3.

4.

5.

Contractor/Supplying Agent Signature Date

Requiring Organization’s Technical Representative Signature Date

GREEN PURCHASING PROGRAM

EPA CPG DESIGNATED ITEM PURCHASE EXEMPTION

PROCUREMENT TITLE: SXHT 11-1055 Repair Lift Station Pumps at Building 650, Building 1497 & Lift Station 943

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:

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

2. The product is not available within a reasonable time frame

3. The product is not available competitively (from two or more sources)

4. 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):

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.

F3K3DD9189A001