S-10000-00014721 Att C -Applicant Questionnaire and Service Selection.pdf

S-10000-00014721– Hygiene Service Attachment C (Agency Internal #6163)

ATTACHMENT C

APPLICANT QUESTIONNAIRE AND SERVICES SELECTION

Submit this completed form with your Application Packet

1. Applicant’s Point of Contact for Price Agreement Negotiations:

Name

Title

Phone

Email

2. Applicant’s Business Name:

Name of Business

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.

3. Applicant Service Selection:

Please select which Hygiene Services you want to provide. Applicants may select one or more option.

Note: The following questions are intended to provide us with as much information as possible about the array of services and capabilities from each Applicant. Selecting “no” to any of the following does not disqualify you from moving forward in the solicitation process.

a. Restroom Facilities: YES NO

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.

h. Other Services YES NO

4. Environmental Practices:

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

5. Service Area:

a. Applicant, please list the Oregon County or Counties you wish to provide Services in:

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:

7. Applicant Service Rates.

Applicants, please provide your current Service rate or rates below for the Services you are applying to provide.

Whenever possible, Agency prefers rates to all inclusive of costs to provide services. For example, a flat rate per week that includes staff time and travel costs to deliver the facility, provide relevant maintenance/servicing, and pickup of the facility when services are no longer needed.

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

YES NO

Example:

Description

(service or facility type)

Unit Price

Unit Type (hour, day, week, month, gallon, lb., etc.)

Notes Stock Available

Standard Porta Potty $100 Week 45” x 45”, 50 gallon tank 100

ADA Porta Potty $150 Week 60” x 80”, 35 gallon tank, includes ramp

Restroom Trailer, 6 Stalls $500 Week 8’ x 17’ 2 trailers

Sewage/Waste Removal $100 Per pickup Pickup once per week or every 75 uses

N/A

Handwashing Station $25 Week Requires external water delivery

Comfort Kit $100 Case of 100

Description

(service or facility type)

Unit Price

Unit Type (hour, day, week, month, gallon, lb., etc.)

Notes Stock Available

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: ___________________________