Solicitation Documents File 5_ARFQ_0313_DEP2700000018_Bridgeport (Tomes) Landslide.pdf

Office of Surface Mining Reclamation and Enforcement

Instructions for Completing the AML Contractor Form OMB #1029-0119

Purpose: The Office of Surface Mining Reclamation and Enforcement Applicant/Violator System (AVS) office is required to conduct eligibility checks for businesses performing abandoned mine land (AML) reclamation work to ensure those businesses are not associated with any coal mining violations in accordance with the Surface Mining Control and

Reclamation Act (SMCRA). This form is used to update the AVS database which maintains relationship information between individuals and their associated businesses. If you have any questions, please contact the AVS Office at 800-643-

9748.

Part A: General Information: Part A should be completed by the AML Contractor. You can find an electronic fillable form on our website (https://www.osmre.gov/programs/regulating-coal-mines/avs).

Part B: Obtain an Organizational Family Tree (OFT): Part B should be completed by the AML Contractor. An

Organizational Family Tree (OFT) indicates the relationships between individuals and their associated business.

You can obtain an OFT two ways:

1. Call the AVS Office at 800-643-9748 to request your company’s OFT.

2. Go to the AVS website (https://avss.osmre.gov). Click “Access AVS”, and then “Login as Guest”. Place your cursor on the “Entity” Module and click. Type your business name (or entity number) in search box and press enter. Select your company and then click on the “Relationship” tab to display your Entity OFT information. Print the Entity OFT from AVS. Review the OFT, if you need to make updates complete Part D.

Attach the OFT to your AML Contractor Form.

If you are a new company or this is your first AML bid: Your business is most likely not in the AVS. If your company does not appear in the AVS database, move on to Part C, check Box 3, and complete Part D of this form.

If your company has worked on previous AML projects or in the coal mining industry: Your business is most likely in the

AVS, but may need to be updated. Obtain and review your OFT and then complete Part C.

Part C: Certifying and updating information in the Applicant/Violator System (AVS). Part C should be completed by the AML Contractor. Please check the box that best describes your situation, sign and date.

Note: Signature date must be recent (within 30 days) to be considered.

Part D: OFT Information. Part D should be completed by the AML Contractor only if you want to make updates to what information is in the AVS, or if your company does not have any information in the AVS. Include all fields, including the relevant begin and/or end dates for individuals, including middle name or initial for individuals if possible.

Answers to Part D FAQs:

Which employees should be included in Part D?

Any current or separated employee of significance should be listed. Refer to the list provided at the top of Part D.

For those owning less than 10% reporting the ownership is optional. Include those employees who direct, manage, or control the project. If, for example, a Professional Engineer has the power to determine how the project is conducted you should include him/her on Part D.

What address and phone number should I use?

Use the address and phone number where the person receives business correspondence.

What are the begin and end dates for?

Begin dates indicate when a person started in that position in your company. If an individual still works at the company you can simply fill in the begin date and leave the end date blank or write “N/A”. End dates are used for indicating that someone no longer works in that capacity or is no longer employed at the company. If an employee has held more than one position or title, note the begin dates/end dates for each position.

https://www.osmre.gov/programs/regulating-coal-mines/avs https://avss.osmre.gov

OMB # 1029-0119

Expiration Date:

01/31/2028

ABANDONEDMINELANDS(AML)CONTRACTOR INFORMATIONFORM

You must complete this form for your AML contracting officer to request an eligibility evaluation from the Office of Surface Mining Reclamation and Enforcement (OSMRE) to determine if you are eligible to receive an AML contract. This requirement can be found under OSMRE’s regulations at 30 CFR 874.16. NOTE: This form must be signed and dated within 30 days of submission to be considered for a current bid.

Part A: General Information

Business Name:

Tax ID #:

Address:

City, State, & Zip:

Phone Number:

Email Address:

Part B: Obtain an Organizational Family Tree (OFT) from the Applicant Violator System (AVS)

If you plan to certify the existing AVS information or submit updates under Part C, you must include an OFT.

Instructions for downloading an OFT from the AVS can be found at: https://www.osmre.gov/sites/default/ files/2022-02/OMB%201029-0119%20instructions.pdf. If you require assistance you may contact the AVS Office by phone at: 800-643-9748, or by email at: avshelp@osmre.gov.

Part C: Certifying and updating information in the AVS

Select one of the options, follow the instructions for the selected option, sign, and date below.

I, , have express authority to certify that:

(Print Name)

1. Our business is listed in the AVS. The information is accurate, complete, and up to date. (If you select this option, you must attach an Entity OFT from the AVS to this form). Do not complete Part D.

2. Our business is in the AVS. The information needs to be updated. (If you select this option, you must attach an Entity OFT from the AVS to this form). Complete Part D to provide the missing or corrected information.

3. Our business is not listed in the AVS. The information needs to be added. Complete Part D to provide the information.

Date Signature Title

OMB # 1029-0119

Expiration Date:

01/31/2028 Part D: OFT Information

Contractor’s Business Name:

If the current Entity OFT information for your business is incomplete in the AVS, or if there is no information in the AVS for your business, you must provide all of the following information as it applies to your business.

Please include additional copies of this page if the space below is not sufficient to capture all information.

• Every officer (President,VicePresident, Secretary,Treasurer,etc.);

• AllDirectors, Partners, and Members;

• All persons performinga function similar to a Director;

• Every person or business that owns 10% or more of the voting stock in your business;

• Any other person(s)who has the ability to determinethe manner in which the AML reclamation project is being conducted.

• Please list an end date for any person who is no longer with your business.

Name:

Address:

City, State, Zip:

Begin Date:

End Date:

% Ownership:

Position/Title:

Phone Number:

Name:

Address:

City, State, Zip:

Begin Date:

End Date:

% Ownership:

Position/Title:

Phone Number:

Name:

Address:

City, State, Zip:

Begin Date:

End Date:

% Ownership:

Position/Title:

Phone Number:

Name:

Address:

City, State, Zip:

Begin Date:

End Date:

% Ownership:

Position/Title:

Phone Number:

PAPERWORK REDUCTION STATEMENT

The Paperwork Reduction Act of 1995 (44 U.S.C 3501) requires us to inform you that: Federal Agencies may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a current valid OMB control number. This information is necessary for all successful bidders prior to the distribution of AML funds, and is required to obtain a benefit.

Public reporting burden for this form is estimated to range from 15 minutes to one hour, with an average of 30 minutes per response, including time for reviewing instructions, gather and maintaining data, and completing and reviewing the form. You may direct comments regarding the burden estimate or any other aspect of this form to the Information Collection Clearance Officer, Office of Surface Mining Reclamation and Enforcement, 1849 C Street, NW, Room 4559, Washington, DC 20240.

DEP Construction Bid Submission Review Form Revised September 21, 2022

State of West Virginia

Department of Environmental Protection

Construction Bid Submission Review Form

This list has been provided for informational purposes only and is not to be construed as a complete list of request for quotation or bidding requirements for any individual construction project. This list does not and cannot include every item, mistake or oversight that could cause a contractor’s bid to be disqualified. Rather, this list is intended to draw attention to some of the most common problems that occur in the bidding process for construction projects. All potential bidders must read the request for quotation, all additional documents, and all instructions relating thereto (“Bid Documents”) in their entirety to identify the actual request for quotation and bidding requirements. Failure to read the Bid Documents in their entirety and comply with the stated requirements contained therein may result in bid disqualification.

Errors that shall be reason for immediate bid disqualification

4.

1. Failure to attend a mandatory pre-bid meeting

2. Failure to supply a valid bid bond

4. Failure to meet any mandatory requirement of the RFQ

5. Failure to submit bid prior to the bid closing date and time

7. Federal debarment

8. State of West Virginia debarment or suspension

9. Outstanding environmental enforcement actions

10. Unresolved DEP vendor complaints

Errors that May Be Reason for Bid Disqualification Before Contract Award

1. Debt to the State or Political Subdivision (must be resolved prior to award)

2. Workers’ Compensation or Unemployment Compensation delinquency (must be resolved prior to award)

3. Failure to obtain required bonds and/or insurance

Failure to supply West Virginia contractor's license number with bid or within one day of DEP request to do so.

Failure to provide sub contractor listing within one business day of bid opening or one business day of request to do so by DEP, if applicable.

5. Failure to supply a signed drug free workplace affidavit with bid or within one day of the DEP request to do so.

REV. 6/2013

BID BOND PREPARATION INSTRUCTIONS

AGENCY (A)

RFQ/RFP# (B)

Bid Bond

(A) WV State Agency (Stated on Page 1 “Spending Unit”)

KNOW ALL MEN BY THESE PRESENTS, That we, the undersigned,

(C) of (D) , (E) , as Principal, and (F) of (G) ,

(H) , a corporation organized and existing under the laws of the State of (I) with its principal office in the City of

(J) , as Surety, are held and firmly bound unto The State of West Virginia, as Obligee, in the penal sum of (K) ($ (L) ) for the payment of which, well and truly to be made, we jointly and severally bind ourselves, our heirs, administrators, executors, successors and assigns.

The Condition of the above obligation is such that whereas the Principal has submitted to the Purchasing Section of the Department of Administration a certain bid or proposal, attached hereto and made a part hereof to enter into a contract in writing for (M)

NOW THEREFORE

(a) If said bid shall be rejected, or

(b) If said bid shall be accepted and the Principal shall enter into a contract in accordance with the bid or proposal attached hereto and shall furnish any other bonds and insurance required by the bid or proposal, and shall in all other respects perform the agreement created by the acceptance of said bid then this obligation shall be null and void, otherwise this obligation shall remain in full force and effect. It is expressly understood and agreed that the liability of the Surety for any and all claims hereunder shall, in no event, exceed the penal amount of this obligation as herein stated

The Surety for value received, hereby stipulates and agrees that the obligations of said Surety and its bond shall be in no way impaired or affected by any extension of time within which the Obligee may accept such bid: and said Surety does hereby waive notice of any such extension.

WITNESS, the following signatures and seals of Principal and Surety, executed and sealed by a proper officer of Principal and Surety, or by Principal individually if Principal is an individual, the _(N)___ day of (O) , 20_(P)_.

Principal Seal (Q) (Name of Principal) (R)

By (S) (Must be President, Vice President, or Duly Authorized Agent)

(T) Title

Surety Seal (V)

(U) (Name of Surety)

(W)___________ Attorney-in-Fact

IMPORTANT – Surety executing bonds must be licensed in West Virginia to transact surety insurance, must affix its seal, and must attach a power of attorney with its seal affixed.

(B) Request for Quotation Number (upper right corner of page #1)

(C) Your Business Entity Name (or Individual Name if Sole Proprietor)

(D) City, Location of your Company

(E) State, Location of your Company

(F) Surety Corporate Name

(G) City, Location of Surety

(H) State, Location of Surety

(I) State of Surety Incorporation

(J) City of Surety’s Principal Office

(K) Minimum amount of acceptable bid bond is

5% of total bid. You may state “5% of bid” or a specific amount on this line in words.

(L) Amount of bond in numbers

(M) Brief Description of scope of work

(N) Day of the month

(O) Month

(P) Year

(Q) Name of Business Entity (or Individual Name if Sole Proprietor)

(R) Seal of Principal

(S) Signature of President, Vice President, or

Authorized Agent

(T) Title of Person Signing for Principal

(U) Seal of Surety

(V) Name of Surety

(W) Signature of Attorney in Fact of the Surety

NOTE 1:

Dated Power of Attorney with Surety Seal must accompany this bid bond.

Agency

REQ.P.O#

BID BOND

KNOW ALL MEN BY THESE PRESENTS, That we, the undersigned, of , , as Principal, and of , , a corporation organized and existing under the laws of the State of with its principal office in the City of , as Surety, are held and firmly bound unto the State of West Virginia, as Obligee, in the penal sum of ($ ) for the payment of which, well and truly to be made, we jointly and severally bind ourselves, our heirs, administrators, executors, successors and assigns.

The Condition of the above obligation is such that whereas the Principal has submitted to the Purchasing Section of the

Department of Administration a certain bid or proposal, attached hereto and made a part hereof, to enter into a contract in writing for

NOW THEREFORE,

(a) If said bid shall be rejected, or

(b) If said bid shall be accepted and the Principal shall enter into a contract in accordance with the bid or proposal attached hereto and shall furnish any other bonds and insurance required by the bid or proposal, and shall in all other respects perform the agreement created by the acceptance of said bid, then this obligation shall be null and void, otherwise this obligation shall remain in full force and effect. It is expressly understood and agreed that the liability of the Surety for any and all claims hereunder shall, in no event, exceed the penal amount of this obligation as herein stated.

The Surety, for the value received, hereby stipulates and agrees that the obligations of said Surety and its bond shall be in no way impaired or affected by any extension of the time within which the Obligee may accept such bid, and said Surety does hereby waive notice of any such extension.

WITNESS, the following signatures and seals of Principal and Surety, executed and sealed by a proper officer of Principal and

Surety, or by Principal individually if Principal is an individual, this day of , 20 .

Principal Seal (Name of Principal)

By

(Must be President, Vice President, or Duly Authorized Agent)

(Title)

Surety Seal (Name of Surety)

Attorney-in-Fact

IMPORTANT – Surety executing bonds must be licensed in West Virginia to transact surety insurance, must affix its seal, and must attach a power of attorney with its seal affixed.

WV-73

Approved / April 30, 2020

DRUG FREE WORKPLACE CONFORMANCE AFFIDAVIT

West Virginia Code §21-1D-5

I, , after being first duly sworn, depose and state as follows:

1. I am an employee of ; and, (Company Name)

2. I do hereby attest that (Company Name) maintains a written plan for a drug-free workplace policy and that such plan and policy are in compliance with West Virginia Code §21-1D.

The above statements are sworn to under the penalty of perjury.

Printed Name:

Signature:

Title:

Company Name:

Date:

STATE OF WEST VIRGINIA,

COUNTY OF ____________________________, TO-WIT:

Taken, subscribed and sworn to before me this day of , .

By Commission expires

(Seal)

(Notary Public)

Rev. July 7, 2017

WV-72

Approved / Revised 08/01/15

Purchasing Division

CERTIFIED DRUG-FREE WORKPLACE REPORT COVERSHEET

In accordance with West Virginia Code § 21-1D-7b, no less than once per year, or upon completion of the project, every contractor shall provide a certified report to the public authority which let the contract. That report must include each of the items identified below in the Required Report Content section.

Instructions: Vendor should complete this coversheet, attach it to the required report, and submit it to the appropriate location as follows: For contracts more than $25,000, the report should be mailed to the West Virginia Purchasing Division at 2019 Washington Street East, Charleston, WV 25305. For contracts of $25,000 or less, the vendor should mail the report to the public authority issuing the contract.

Contract Identification:

Contract Number:

Contract Purpose:

Agency Requesting Work: _____

Required Report Content: The attached report must include each of the items listed below. The vendor should check each box as an indication that the required information has been included in the attached report.

Information indicating the education and training service to the requirements of West Virginia Code §

21-1D-5 was provided;

Name of the laboratory certified by the United States Department of Health and Human Services or its successor that performs the drug tests;

Average number of employees in connection with the construction on the public improvement;

Drug test results for the following categories including the number of positive tests and the number of negative tests: (A) Pre-employment and new hires; (B) Reasonable suspicion; (C) Post-accident; and

(D) Random.

Vendor Contact Information:

Vendor Name: ____________________ Vendor Telephone: ___________________

Vendor Address: ___________________ Vendor Fax: ________________________

___________________ Vendor E-Mail: