S-10000-00010976 Att C -Applicant Questionnaire and Service Selection.docx

S-10000-00010976– Hygiene Service Attachment C (Agency Internal #5877)

ATTACHMENT C

APPLICANT QUESTIONNAIRE AND SERVICES SELECTION

Submit this completed form with your Application Packet

Title

Phone

Email

Physical Address of Business Location

City, State, Zip

Note: If Applicant has more than one restaurant, food truck, etc. location they want to be considered for Price Agreement award, Applicant must list their additional business type and location information on a separate piece of paper and attach it to this Attachment C.

Applicant can supply, deliver, and set up portable restroom facilities, such as “porta potty” units, chemical toilets, or restroom trailers.

· ADA Options |_| YES |_| NO Are options available that meet Americans with Disability Act (ADA) standards?

· Maintenance |_| YES |_| NO Does the Applicant provide maintenance of their facilities, such as stocking supplies (e.g., toilet paper, hand sanitizer, etc.) and cleaning?

· Waste Removal (Select all that apply) |_| YES |_| NO Does Applicant have the means to service their facilities and remove waste?

Trash Removal |_| YES |_| NO Bio/Sewage Waste Removal |_| YES |_| NO Grey Water/Wastewater Removal |_| YES |_| NO

· Facility Requires Power? |_| YES |_| NO If yes, does Applicant have the means to provide power for the facility to make it operational? |_| YES |_| NO |_| N/A

· Facility Requires Water? |_| YES |_| NO If yes, does Applicant have the means to provide clean water for the facility to make it operational? |_| YES |_| NO |_| N/A Use the space below to provide any clarification or additional details about the facilities, such as site requirements or other considerations:

b. Shower Facilities |_| YES |_| NO Applicant can supply, deliver, and set up portable shower facilities, such as shower tents or shower trailers.

· ADA Options |_| YES |_| NO ADA accessible options are available for this type of facility or service.

· Maintenance |_| YES |_| NO Does the Applicant provide maintenance and cleaning of the shower facilities?

· Grey Water/Wastewater Removal |_| YES |_| NO Does Applicant have the means to pump and remove grey water/wastewater generated from their shower facilities?

· Facility Requires Power? |_| YES |_| NO |_| OPTIONAL (e.g., for hot water) If yes, does Applicant have the means to provide power for the facility to make it operational? |_| YES |_| NO

· Applicant Provides Water |_| YES |_| NO

· Hot Water Needs (Describe below)

Does Applicant have the means to provide clean water for the shower facilities?

Use the space below to provide any clarification or additional details about the facilities, such as site requirements or other considerations:

c. Laundry Facilities & Services |_| YES |_| NO Applicant can supply, delivery, and set up laundry facilities, such as laundry trailers, or provide laundry services for pickup, washing, drying and return of clients’ laundry?

· How do you provide your services? (Select all that apply) |_| Self-Service (Clients do laundry themselves ) |_| Staffed Services Onsite (Applicant’s staff do laundry through onsite facilities) |_| Staffed Services Offsite (Applicant’s staff pick up and return cleaned laundry)

· ADA Options |_| YES |_| NO |_| N/A ADA accessible options are available for this type of facility or service.

· Maintenance |_| YES |_| NO |_| N/A Does the Applicant provide maintenance and cleaning of the facility?

· Supplies |_| YES |_| NO Does the Applicant provide detergent and other supplies for laundry?

· Grey Water/Wastewater Removal |_| YES |_| NO |_| N/A Does Applicant have the means to pump and remove grey water/wastewater generated from their shower facilities?

· Facility Requires Power? |_| YES |_| NO |_| N/A If yes, does Applicant have the means to provide power for the facility to make it operational? |_| YES |_| NO

· Applicant Provides Water |_| YES |_| NO |_| N/A Does Applicant have the means to provide clean water for the shower facilities?

Use the space below to provide any clarification or additional details about the facilities, such as site requirements or other considerations:

d. Comfort Kits |_| YES |_| NO Applicant can supply and deliver personal hygiene kits including toothbrush, toothpaste, soap, etc.

e. Standalone Trash Removal Services |_| YES |_| NO Applicant provides trash pickup, independent from any other services specified above.

f. Standalone Bio/Sewage Waste Removal |_| YES |_| NO Applicant provides pumping and removal of biological and sewage waste, independent from any of the services specified above.

g. Standalone Grey Water/Wastewater Removal |_| YES |_| NO Applicant provides pumping and removal of grey water/wastewater, independent from any of the services specified above.

Applicant, if you specified any type of waste or wastewater removal above, please describe your practices for disposal. Otherwise, state “N/A.”

Note: If Applicant wants to provide Services in all Oregon Counties, write “All.”

a. If Applicant selected an individual Oregon County or Counties to provide services in, will Applicant only provide Services within a certain radius from their place of business? |_| YES |_| NO |_| N/A If yes, what is the radius in miles that Applicant will provide Services:_______________

6. Licenses/Certification:

Does the Applicant and if their staff (if applicable) have licenses or certifications as required by their industry and/or Oregon law? For example, wastewater transportation licensure.

|_| YES |_| NO |_| N/A

If yes, list relevant licenses and certifications:

Is Applicant willing to negotiate with Agency the Service rate or rates provided below?

|_| YES |_| NO

Example:

Description (service or facility type)

Description (service or facility type)

Are there any discounts or differentials based on quantity ordered, length of time, or other factors? If yes, explain below:

8. Signature.

Applicant Signature: _____________________________ Date: ___________________________

Printed Name: _________________________________ Title: ___________________________