RFQ_MASKB051126.pdf

STATE OF CALIFORNIA — DEPARTMENT OF STATE HOSPITALS Gavin Newsom, Governor

DEPARTMENT OF STATE HOSPITALS

Solicitation Number:

DSH 2010 - Revised 08/22/23

Except as outlined in PCC 12156 (b), it is unlawful to prohibit a printer or duplication cartridge that is sold to the State from being remanufactured or recycled.

General Provisions DGS.ca.gov - General Provisions

DEPT. OF STATE HOSPITALS - NAPA

General Services - Contracts and Procurement 2100 Napa Vallejo Hwy

Napa, CA 94558

DSH-Napa BuyerMay 11, 2026

Bidder Declaration Form Requirements

DGS.ca.gov - Bidder Declaration Use and Evaluation Procedure

Bidder Instructions DGS.ca.gov - Bidder Instructions

2100 Napa Vallejo Highway

Napa, CA 94558

(707) 253-5155 krystle.balintec@dsh.ca.gov

MASKB051126

The Department of State Hospitals (DSH) would like to request a quote from your company, which will be awarded to the lowest cost vendor. If your company/firm is interested in bidding, please note that the following provisions and instructions are in force for this solicitation. Bidders are advised to read each document.

Classification Non-Information Technology (Non-IT)

Recycled Products Requirement

Recycled products shall be offered and/or used to the maximum extent economically feasible.

Solicitation Method Competitive (<$200k) to submit a protest to the awarding department/buyer concerning the proposed contract award

DVBE Waiver Notification

The DVBE Program requirement is either not applicable or is waived for this solicitation and resulting contract.

Tie Breaking Ties between bidders will be resolved in accordance with GC 14838 and CCR, Title 2, 1896.6.

If a tie remains, a witnessed coin toss will determine the winner.

DVBE Incentive An incentive will be given to bidders who provide DVBE participation either as DVBEs or through subcontracting. The following percentages will apply:

DVBE Participation Incentive

GENAI Disclosure & Factsheet

The State of California seeks to realize the potential benefits of GenAI, through the development and deployment of GenAI tools, while balancing the risks of these new technologies.

Bidder/Offeror/Contractor must notify the State in writing if their solution or service includes, or makes available, any GenAI technology, including GenAI from third parties or subcontractors. The State has developed a GenAI Reporting and Factsheet (STD 1000) to be completed by the Bidder/Offeror/Contractor. Failure to submit the GenAI Reporting and Factsheet (STD 1000) will result in disqualification of the Bidder/Offeror/Contractor. Failure to report GenAI to the State may void any resulting contract. The State reserves its right to seek any and all relief it may be entitled to as a result of such non-disclosure. Upon receipt of a Bidder/Offeror/Contractor GenAI Reporting and Factsheet (STD 1000), 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.

5/29/2026 to file a full and complete written statement specifying in detail the ground of the protest and the facts in support thereof

5% 4% to 4.99% inclusive 4% 3% to 3.99% inclusive 3%

5% or Over

Small-Business Pref.: DGS.ca.gov - Small Business Preference

5/12/2026 to submit a written request to have notice of proposed award publicly posted

Post-Award Protests In accordance with PCC 10306, the following are the key action dates related to Post-Award Protests. All dates are Close of Business (COB).

5/19/2026

DEPT. OF STATE HOSPITALS - NAPA

Cert. #:

1.

2.

3.

4.

X

That the information provided is accurate to the best of my knowledge;

That the products I have identified in Attachment B meet the specifications as they are written in this solicitation and its attachments; AND

That I have understood and shall comply with the terms, conditions, and requirements as outlined in this solicitation and its attachments, including but not limited to, the General Provisions and Bidder's Instructions as referenced herein.

Printed Name and Title of Signatory:

Signature: Date Executed:

That I am duly authorized to legally bind the prospective Contractor to the specifications, clauses, and requirements of this solicitation and its attachments;

BIDDER'S REPRESENTATIVE

Designated Contact Person: Phone Number: E-Mail:

BIDDER'S CERTIFICATIONS

I, the official named below, CERTIFY UNDER PENALTY OF PERJURY, and under the laws of the State of California, the following:

Approximate Lead Time: Product Warranty Period: Date Quote Expires: DVBE Participation %:

Firm's Address: City, State, and Zip:

Bidder's FEIN Number: Claiming SB/MB or Non-SB Pref.? Certified DVBE? Cert. #:

MASKB051126 05/27/26 05/28/26 Low Cost Determination Delivery Location:

Main Warehouse, 2100 Napa Vallejo Hwy, CA 94558 Specific Instructions/Requirements (if any):

BIDDER'S INFORMATION

Firm's Legal Name: Seller's Permit / Cert. of Registration #:

REQUEST FOR QUOTATION

ATTACHMENT A - BIDDER'S INFORMATION AND CERTIFICATIONS

SOLICITATION SPECIFICS:

Solicitation Number: Solicitation Due Date: Solicitation Eval Date: Evaluation Method:

YES NO YES NO

DEPT. OF STATE HOSPITALS - NAPA

# DESCRIPTION OF GOODS / SERVICES MODEL # QTY UOM UNIT PRICE EXTENSION

Optical Coherence Tomography Device (diagnostic system) Mandatory Minimum Requirements:

a. Retinal Microvasculature Imaging

b. Macula & Optic Nerve Imaging

c. Minimum 100,000 Scan Rate

d. Minimum A-Scan Depth 2.0 mm minimum (in tissue)

e. Must have at least one: HL7, DICOM or DICOM TLS compatible

For Bid to be considered Responsive and Responsible, documentation must be submitted with bid to validate compliance of the following:

Local Image Review and Viewing Capability The system shall provide the capability for local viewing and review of acquired OCT and topography images and data. The system shall include an integrated display or dedicated viewing terminal physically associated with the acquisition unit, capable of displaying captured images and data in real time or near-real time. The integrated viewer shall provide, at minimum, the following control capabilities:

• Navigation and browsing of stored patient examinations

• Display of OCT B-scans, en face images, topographic maps, and associated quantitative reports as applicable to the system's modalities

• Basic image adjustment controls (e.g., brightness, contrast, scan position)

REQUEST FOR QUOTATION

ATTACHMENT B - GOODS AND SERVICES PRICING PAGE

Return E-mail Address:

Response Disclaimer:

Soliciting Office:

Solicitation #: MASKB051126

Vendor Name:

Medical Ancillary Services DSH-NProcurement1@dsh.ca.gov

The model number(s) listed in this RFQ is/are for reference for specifications only.

DSH will not be limiting bids to specific brand/model.

Solicitations sent to any other email will not be considered. To be considered, all pages and required documentation requested in this solicitation that are received prior to the bid solicitation deadline specified in the solicitation will be considered "the complete solicitation". Supplier shall carefully review all documents referenced and made a part of this solicitation to ensure that all information required to properly respond to the solicitation has been received or made available and all requirements are priced in the solicitation. Failure to examine any document, drawing, specification, or instruction will be at the supplier's sole risk.

PLEASE RECORD BID INFORMATION ON SECOND PAGE

Continuation from Page 1:

• Patient data management functions (search, select, and retrieve examinations

• Export of images and reports in standard formats (e.g., PDF, JPEG, DICOM)

• The local viewing solution shall be fully operational without requiring continuous connection to an external network or cloud service

• Access controls shall be supported, including at minimum user login authentication

• The viewing interface shall support display of all data generated by the system's acquisition modalities

f. Must comply with HIPAA standards.

g. Product Doumentation and User Manual

h. Manufacture Date: 2025 or Newer

_________ 1 EA $___________ $__________

2 Installation 1 EA $ $

Minimum one (1) year manufacturer's warranty including software support

1 EA $ $

5-year Comprehensive Extended Manufacturer's Warranty

1 EA $ $

5 On-Site Training (up to 16 people) 1 EA $ $

SHIPPING OPTIONS Initial

1 No shipping Fee is associated with this quote

2 ADD Shipping* (Non Taxable)

3 ADD Shipping* and Handling (Taxable)

SUBTOTAL:

OTHER, NON-SHIPPING ** CHARGES:

TOTAL:

**: Do NOT include tax in your pricing. Tax will be added later.

AmountDate

DEPT. OF STATE HOSPITALS - NAPA

Form Name Form Form Description

Darfur Contracting Act Certification

Darfur Public Contract Code section 10475, et. seq. prohibits state agencies from doing business with vendors which have certain business dealings with the Sudan. This form documents that the bidder has no such relationships and is therefore eligible to bid.

Payee Data Record STD204 This form provides the awarding department the bidder's legal name and address, corporate status, and tax identification number.

Bidders Declaration Form GSPD-05-106 This form is used to capture subcontractor information and is used to determine whether a bidder is performing a commercially useful function, as required by statute.

DVBE Declarations Form STD843 This form documents the ownership and broker-status of a disabled veteran business enterprise.

Recycled Content Certification Form

CalRecycle074 Effective 1/1/23 PCC 12201.c.2. During bid evaluation, DSH reserves the right to award to the vendor who meets recycled products content in lieu of lowest bid. Not in excess of 10% greater total cost than nonrecycled products.

Contractor Certification Form CCC Only required if the vendor will be performing services within the PO or if your request is for a Short Form Contract.

Insurance Requirements Exhibit G

See Attached (If Applicable)

The attached exhibit is hereby incorporated into this solicitation. By signing this solicitation, the bidder represents that they have read and agree to the contents of the exhibit.

Voluntary Statistical Data Sheet VSDS Utilized to track reporting data.

The Department of State Hospitals shall make available to each bidder the forms checked below by double clicking the form name under the "Form" header. However, failure on the part of the DSH to provide each form does not excuse the bidder from their responsibility to submit the required forms with their bids. Bidders are hereby advised that they may locate copies of each of the forms below at the Department of General Services' website, at www.pd.dgs.ca.gov. Bidders may also contact the Buyer for this solicitation and request a copy of some or all of these forms prior to the due date for the solicitation, and if the forms were not provided with the solicitation itself.

Required Forms Disclaimer:

If a box is checked below, the corresponding form must be submitted with a bidder's bid before the solicitation due date.

Other forms not check may be required after the close of the solicitation and prior to award. Failure on the part of the bidder to submit those forms may be grounds for disqualification.

REQUEST FOR QUOTATION

ATTACHMENT C - REQUIRED FORMS

Provision of Required Forms Disclaimer:

Solicitation #: MASKB051126

Vendor Name:

State of California Department of General Services, Procurement Division

GSPD 05 105 (EST 8/05) Instructions

Subcontractor Address & Email Address

Work performed or goods provided for this contract

Corresponding % of bid price

Good Standing?

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, 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.

c. If you are a California certified DVBE: (1) Are you a broker or agent? Yes No

(2) If the contract includes equipment rental, does your company own at least 51% of the equipment provided in this contract (quantity and value)? Yes No N/A

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

Subcontractor Name,Contact Person, Phone Number & Fax Number

CA Certification (MB, SB, DVBE or None)

51% Rental?

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 (EST 8/05)

Solicitation Number__________________

All prime bidders (the firm submitting the bid) must complete the Bidder Declaration. 2. (continued) Column Labels

BIDDER DECLARATION Instructions

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:

• Microbusiness (MB)

• Small Business (SB)

• Small Business Nonprofit Veteran Service Agency (SB/NVSA)

• Disabled Veteran Business Enterprise (DVBE)

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, DVBE or None) —If the subcontractor possesses a current State of California certification(s), verify on the OSDC website (www.pd.dgs.ca.gov/smbus) that it is still valid and list all current certifications here. Otherwise, enter “None”. [Note: A SB/NVSA should not be

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.

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 subcontracting 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.

Bidders certified as MB, SB, SB/NVSA, and/or DVBE must provide a commercially useful function as defined in Military and Veterans Code Section 999(e)(2)(A) for DVBEs and Government Code Section 14837(d)(4)(A) for small/microbusinesses. For questions regarding commercially useful function determinations made in conjunction with certification approval, contact the Department of General Services, Procurement Division, Office of Small Business and DVBE Certification (OSDC), OSDC Certification and Compliance Unit via email at: osdchelp@dgs.ca.gov

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:

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.

If subcontractors will be used, complete the table listing all subcontractors. If necessary, attach additional pages and complete the“Page of ” accordingly. Read the certification at the bottom of the page and complete the “Page of ” accordingly.

• Possesses valid license(s) for any license(s) or permits required by the solicitation or by law

• If a corporation, the company is qualified to do business in California and designated by the State of California Secretary of State to be in good standing

• Possesses valid State of California certification(s) if claiming MB, SB, and/or DVBE status

• Is not listed on the OSDC website as ineligible to transact business with the State

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 subcontractor 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.

51% Rental? —This pertains to the applicability of rental equipment. Based on the following parameters, enter either “N/A” (not applicable),“Yes” or “No” for each subcontractor listed.

Enter“N/A”if the:

• Subcontractor is NOT a DVBE (regardless of whether or not rental equipment is provided by the subcontractor) or

• Subcontractor is NOT providing rental equipment (regardless of whether or not subcontractor is a DVBE) (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.”

Enter “Yes” if the subcontractor is a California certified DVBE providing rental equipment and the subcontractor owns at least 51% of the rental equipment (quantity and value) it will be providing for the contract.

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.

Enter “No” if the subcontractor is a California certified DVBE providing rental equipment but the subcontractor does NOT own at least 51% of the rental equipment (quantity and value) it will be providing.

Page___of___

CITY

Napa

STATE

CA

Section 2 – Entity Type

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

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

SOLE PROPRIETOR / INDIVIDUAL

SINGLE MEMBER LLC Disregarded Entity owned by an individual

PARTNERSHIP

ESTATE OR TRUST

CORPORATION (see instructions on page 2) MEDICAL (e.g. , dentistry, chiropractic, etc .)

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 6 – Paying State Agency

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)

Please return completed form to:

STATE AGENCY/DEPARTMENT OFFICE

DSH - Napa

UNIT/SECTION

General Services

MAILING ADDRESS

2100 Napa Vallejo Hwy

FAX

(707) 254-2425

TELEPHONE (include area code)

(707) 253-5610

ZIP CODE

94558

E-MAIL ADDRESS

nshprocurement@dsh.ca.gov

Reset FormPrint Form

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.

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.

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… Individual Sole Proprietorship 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

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.

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

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

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 For hearing impaired with TDD, call: 1-800-822-6268

E-mail address: wscs.gen@ftb.ca.gov 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 signee 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.

2SABRC

Product Category Code

M eets S

A B R C

The State Agency Buy Recycled Campaign (SABRC) is a state mandated program that requires the reporting of all purchases made within 16 specified product categories. All state agencies are required to verify the recycled-content of all products purchased within each of these categories.

All businesses shall certify the minimum percentage in writing to the contracting officer or his or her representative, if not the exact percentage, of postconsumer recycled-content (PCRC) material in the products, materials, goods, or supplies offered or sold to the State regardless of whether the product meets the minimum content requirements specified in law (see reverse side). The certification shall be furnished under penalty of perjury. The certification shall be provided regardless of content, even if the product contains no recycled material. A State agency may waive the certification requirement if the percentage of postconsumer material in the products, materials, goods, or supplies can be verified in a written advertisement, including, but not limited to, a product label, a catalog, or a manufacturer or vendor Internet website.

l

Public Contract Code sections 12205(a)(1), (2), (3) and (b)(1), (2), and (3)

Contractor/Company Name

Address Phone

STATE OF CALIFORNIA

Department of Resources Recycling and Recovery (CalRecycle) CalRecycle 74 (Revised 01/23)

Postconsumer Recycled-Content Certification

To be completed by the State agency

State Agency:

Department of State Hospitals

Purchasing Agent: PO #:

Phone: E-mail:

Item # 1Percent Postconsumer Recycled- Content

Material

Pursuant to Public Contract Code 12205(b)(1), I certify under penalty of perjury under the laws of the State of California that the above information is true and correct.

Print Name Signature Title Date

FOOTNOTES:

1. “Postconsumer recycled-content material” is defined as products that were bought, used, and recycled by consumers. For example, a newspaper

Product or Services Description that has been purchased, recycled, and used to make another product would be considered postconsumer material.

Optical Coherence Tomography Device

Purchase Order #

RFQ #

RFP #

IFB #

Cal Card Order #

2. “Product category” refers to one of the categories listed below, into which the reportable purchase is best placed.

3. If the product does not belong in any of the product categories, enter “N/A.” Common “N/A” products include wood products, aggregate, concrete, and electronics such as computers, TV, software on a disk or CD, and telephones.

4. For reused or refurbished products, there is no minimum content requirement. (PCC 12209(l))

Code* Product Categories Product Subcategories Product Examples in each SABRC Category (PCC 12207 )

Examples include, but are not limited to, these individual products/materials.

Minimum Post-Consumer Content Requirement per Statute (PCC 12209 )

1A Paper Products Toilet Paper Toilet paper. 45 percent by fiber weight post-consumer fiber.

California Department of Resources Recycling and Recovery (CalRecycle)

State Agency Buy Recycled Campaign (SABRC) - SABRC@CalRecycle.ca.gov

1B Paper Products Paper Towels Paper towels. 40 percent by fiber weight post-consumer fiber.

1C Paper Products Facial Tissues Facial tissue. 10 percent by fiber weight post-consumer fiber.

1D Paper Products Toilet Seat Covers Toilet seat covers. 20 percent by fiber weight post-consumer fiber.

1E Paper Products General Purpose Paper Wipes General purpose paper wipes. 40 percent by fiber weight post-consumer fiber.

1F Paper Products Food Serviceware Napkins, plates, bowls, food trays, takeout boxes, and placemats. 40 percent by fiber weight post-consumer fiber.

1G Paper Products Miscellaneous Paper Products Cartons, wrapping, packaging, file folders, hanging folders, building insulation and panels, corrugated boxes.

30 percent by fiber weight post-consumer fiber.

2 Printing and Writing Papers

Printing and Writing Papers Copy, xerographic, watermark, cotton fiber, offset, forms, computer printout paper, white wove envelopes, manila envelopes, book paper, note pads, writing tablets, newsprint, and other uncoated writing papers, posters, index cards, calendars, brochures, reports, magazines, and publications.

30 percent by fiber weight post-consumer fiber.

3A Soil Amendments and Toppings

Compost Soil amendments, soil conditioner for potting or plant mix, organic materials used for water conservation; organic materials such as biosolids or other comparable substitutes such as livestock, horse, or other animal manure, food residues or fish processing byproducts; mechanical breakdown of materials.

80 percent recovered material that would otherwise be normally disposed of in a landfill.

3B Soil Amendments and Toppings

Mulch Ground covers, weed suppressants. 80 percent recovered material that would otherwise be normally disposed of in a landfill.

4A Glass Products Glass Products Windows, test tubes, beakers, laboratory or hospital supplies, reflective beads, tiles, construction blocks, desktop accessories, flat glass sheets, loose- grain abrasives, deburring media, liquid filter media, and containers.

25 percent post-consumer, by weight.

4B Glass Products Fiberglass Fiberglass (insulation), 30 percent post-consumer, by weight.

5 Lubricating Oils Intended for use in a crankcase, transmission, engine, power steering, gearbox, differential chainsaw, transformer dielectric, fluid, cutting, hydraulic, industrial, or automobile, bus, truck, vessel, plane, train, heavy equipment, or machinery powered by an internal combustion engine.

70 percent re-refined base oil.

6 Plastic Products Printer or duplication cartridges, diskette, carpet, office products, plastic lumber, buckets, wastebaskets, containers, benches, tables, fencing, clothing, mats, packaging, signs, posts, binders, sheet, buckets, building products, garden hose, and trays.

20 percent postconsumer, by weight, is remanufactured or has a take back program.

7A Paint: Low-VOC: < 50 grams/liter Water-based paint, graffiti abatement, interior and exterior, and maintenance.

50 percent post-consumer paint.

7B Paint: Other VOC: > 50 grams/liter Water-based paint, graffiti abatement, interior and exterior, and maintenance.

50 percent post-consumer paint.

8 Antifreeze Recycled antifreeze, and antifreeze containing a bittering agent or made from polypropylene or other similar non-toxic substance.

70 percent post-consumer material.

9 Tires (Retreaded tires)

Truck and bus tires, and those used on fleet vehicles (and passenger cars where available).

Retreaded: Must use an existing casing that has undergone retreading or recapping process in accordance with Public Resource Code (commencing with section 42400).

10 Tire- Derived Products Flooring, mats, wheelchair ramps, playground surfacing, sports surfacing, parking bumpers, bullet traps, hoses, bumpers, truck bedliners, pads, walkways, tree ties, wheel chocks, rollers, traffic-related products, mudflaps, accessibility ramps, paths and sidewalks, animal care products, including, but not limited to, horse arena surfacing, stall mats, cow mats, and equestrian barn and breezeway flooring, artificial turf, landscaping and rubber mulch, outdoor surfacing, pavers and tiles, and posts.

50 percent recycled used tires.

11A Metal Products Metal Products Staplers, paper clips, steel furniture, desks, pedestals, scissors, jacks, rebar, pipe, plumbing fixtures, chairs, ladders, file cabinets, shelving, containers, lockers, sheet metal, girders, building and construction products, bridges, braces, nails, and screws.

10 percent post-consumer material, by weight.

11B Metal Products Vehicles Vehicles. 10 percent post-consumer material, by weight.

12 Building Finishes Open Office Panel Systems Open office panel systems. Middle range of state contracts.

13 Carpet Carpet Determined by DGS and Posted in SCM.

14A Erosion Control Products

Compost Filter Socks Compost filter sock. 100 percent post-consumer material.

14B

*It is each agency’s prerogative to assign internal codes/object codes for post-consumer recycled content products based on their internal paper or computer tracking systems.

For additional information, please visit www.CalRecycle.ca.gov/BuyRecycled/StateAgency/

15B Textiles General Textile Wipes General purpose wipes. 100 percent post-consumer material.

16A Pavement Surfacing Rubberized Pavement Surfaces Rubberized asphalt concrete and chip seal. 15 percent post-consumer material.

Erosion Control Products

Compost Blanket Compost blanket, layer of compost protecting bare soil surfaces. 100 percent post-consumer material.

16B Pavement Surfacing Recycled Asphalt Pavement Recycled Asphalt Pavement 25 percent post-consumer material.

14C Erosion Control Products

Hydraulic Mulch Hydraulic mulch or erosion control process that uses fiber slurry and tackifier.

100 percent post-consumer material.

15A Textiles Textiles 0 percent post-consumer material.