T2549 Appendix B - Sample Forms 2024 4.17.24.docx
DOCX document 72 KB Posted
- Attached to
- T2549 Subsurface Remedial Action Services NJDEP
- Solicitation number
- 24DPP00928
- Issued by
- New Jersey
About this file
This document contains sample forms for a subsurface remedial action services contract (Contract No. 24-PROSX-XXXXX) between the New Jersey Department of Environmental Protection (NJDEP) and Subsurface Company, Inc. The forms include a Daily Scheduled Labor Report, a Daily Scheduled Equipment, Materials and Services Report, a Daily Non-Scheduled Equipment, Materials and Services Report, a Purchase Approval Memorandum, a Summary of Telephone Quotations, a Release of All Claims against the State of New Jersey, and an Affidavit Concerning Subcontractor Payments. The contract is for a project located at the Sample Site with the PI# 123456.
The sample forms provide templates for the contractor to document labor, equipment, materials, and services provided on a daily basis. The Purchase Approval Memorandum and Summary of Telephone Quotations forms are used for purchases under the contract's General Allowance provisions. The Release of All Claims and Affidavit Concerning Subcontractor Payments forms are required certifications from the contractor.
View the file
Other files
Show all 12
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Bid Solicitation # 24DPP00928 T2549 Subsurface Remedial Action Services, NJDEP
APPENDIX B
SAMPLE FORMS
A. sample forms The following sample forms are included in this appendix:
1. Daily Scheduled Labor Report (Form DEP-024A);
2. Daily Scheduled Equipment, Materials and Services Report (Form DEP-024B);
3. Daily Non-Scheduled Equipment, Materials and Services Report (Form DEP-024C);
4. Purchase Approval Memorandum;
5. Summary of Telephone Quotations (Form PB-119);
6. Release of All Claims against the State of New Jersey; and
7. Affidavit Concerning Subcontractor Payments.
2-7
DEP-024A 2024
NEW JERSEY DEPARTMENT OF ENVIRONMENTAL PROTECTION
| DAILY SCHEDULED LABOR REPORT FOR: |
| 4/1/2024 |
| CONTRACT NO.: |
| 24-PROSX-XXXXX |
| Page 1 of |
| 1 |
| CONTRACTOR: |
| Subsurface Company, Inc. |
| PROJECT: |
| Sample Site |
| JOB #: |
| P0333990 |
| PI#: |
| 123456 |
| EMPLOYEE NAME AND PERSONNEL CLASSIFICATION |
| LEVEL OF PROTECTION |
| PRICE LINE |
| STRAIGHT TIME RATE |
| ST HOURS |
| STRAIGHT TIME TOTAL |
| OT RATE |
| OT HOURS |
| OT TOTAL |
| DAILY TOTAL |
John Doe Site Supervisor
| D |
| 11 |
| $60.00 |
| 8 |
| $480.00 |
$480.00
Michael Smith Heavy Equipment Operator
| D |
| 14 |
| $80.00 |
| 8 |
| $640.00 |
$640.00
Thomas Jones Laborer
| D |
| 15 |
| $70.00 |
| 8 |
| $560.00 |
$560.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
TOTALS
| 24 |
| $1,680.00 |
$1,680.00
I certify that this is an accurate statement of the services provided for the date(s) indicated above.
Signature of Contractor Representative
DEP-024B 2024
NEW JERSEY DEPARTMENT OF ENVIRONMENTAL PROTECTION
| DAILY SCHEDULED EQUIPMENT, MATERIALS AND SERVICES REPORT FOR: |
| 4/1/2024 |
| CONTRACT NO.: |
| 24-PROSX-XXXXX |
| Page 1 of |
| 1 |
| CONTRACTOR: |
| Subsurface Company, Inc. |
| PROJECT: |
| Sample Site |
| JOB #: |
| P0333990 |
| PI#: |
| 123456 |
| EQUIPMENT, MATERIALS OR SERVICES |
| PRICE LINE |
| QUANTITY OR UNITS |
| NO. OF DAYS* |
| DAILY OPERATING RATE |
| WEEKLY OPERATING RATE |
| RATE TOTAL(S) |
| MOBILIZATION DEMOBILIZATION |
| TOTAL |
| Loader Backhoe |
| 33 |
| 1 |
| 1 |
| $250.00 |
| $250.00 |
| $100.00 |
| $350.00 |
| Gasoline Powered Plate Tamper |
| 45 |
| 1 |
| 1 |
| $25.00 |
| $25.00 |
| $0.00 |
| $25.00 |
TOTAL
$275.00
$375.00
| * |
| or portion thereof |
I certify that this is an accurate statement of the equipment and services provided for the date(s) indicated above.
Signature of Contractor Representative
DEP-024C 2024
NEW JERSEY DEPARTMENT OF ENVIRONMENTAL PROTECTION
| DAILY NON-SCHEDULED EQUIPMENT, MATERIALS AND SERVICES REPORT FOR: |
| 4/1/2024 |
| CONTRACT NO.: |
| 24-PROSX-XXXXX |
| Page 1 of |
| 1 |
| CONTRACTOR: |
| Subsurface Company, Inc. |
| PROJECT: |
| Sample Site |
| JOB #: |
| P0333990 |
| PI#: |
| 123456 |
| DESCRIPTION OF ITEM / CAPACITY / SERVICES |
| QUANTITY UNITS |
| CONTRACTOR COST |
| PRICE LINE 123 % MARKUP |
| SUPPLIER OR SUBCONTRACTOR |
| TOTAL |
| Sand (delivered) |
| 10 |
| tons |
| $300.00 |
| 5% |
| Stone Depot |
| $315.00 |
$315.00
I certify that this is an accurate statement of the equipment, materials, and services provided for the date(s) indicated above.
Signature of Contractor Representative
BILLED AS:
| ENGAGEMENT MOD. |
| OR |
| ALLOWANCE |
PO#
X
PURCHASE APPROVAL MEMORANDUM
SUBSURFACE REMEDIAL ACTION SERVICES TERM CONTRACT
| Prepared by: |
| Joe Smith |
| Site Name & PI No.: |
| Sample Site; PI #123456 |
| Purchase Date: |
| 4/1/2024 |
ITEMS OR SERVICES REQUIRED:
| Quantity |
| Item/Service |
| Price |
| Extension |
| 1 |
| Portable Electric Heater |
| $50.00 |
| $50.00 |
Shipping
$10.00
Tax
$0.00
Subtotal
$60.00
Price Line 123 % Markup (5% used for this example)
$3.00
Total
$63.00
| Reason: |
| A heater is required to prevent freezing of water in the treatment system shed. |
| Vendor Name: |
| Heater Depot |
| Vendor Address: |
| 100 Main St. |
Anytown, NJ 08000
| Vendor Phone No. |
| 609-984-0000 |
The following documents are attached:
| X |
| No price competition is required. Cost is $1,000 or less. |
Telephone quotations are attached. Cost is more than $1,000 but less than $17,500.
Solicited written quotations are attached. Cost is more than $17,500 and less than $100,000.
Sole source letter is attached.
I certify that this is an accurate statement of equipment, materials, and/or services provided under Bid Solicitation Section 4.11.7 (General Allowance Purchases) on the purchase date above. Cost documentation is attached.
Signature of Contractor Representative
STATE OF NEW JERSEY
SUMMARY OF TELEPHONE QUOTATIONS
INSTRUCTIONS:
VENDOR INFORMATION
| Where telephone quotations are authorized by the Purchase Bureau in lieu of sealed bids and pursuant to the current Direct Purchase Authorization circular, State agencies shall use this form to obtain and record quotations from at least three (3) vendors prior to issuing a purchase order. After quotations have been recorded, this form must be signed and attached to the agency copy of the purchase order for the permanent file. |
| VENDOR NAME |
| VENDOR NAME |
| VENDOR NAME |
| VENDOR NAME |
| ADDRESS |
| ADDRESS |
| ADDRESS |
| ADDRESS |
| COMMODITY CODE |
| FISCAL YEAR |
| SAV1 CODE |
S/M/V
| FED. IDENTIFICATION NO. |
| FED. IDENTIFICATION NO. |
| FED. IDENTIFICATION NO. |
| FED. IDENTIFICATION NO. |
| ACCOUNT NUMBER |
| DATE OF QUOTATION |
| TELEPHONE NO. |
| TELEPHONE NO. |
| TELEPHONE NO. |
| TELEPHONE NO. |
| DESCRIPTION OF ITEM(S) |
| QUANTITY |
| ORDERING UNIT |
| UNIT COST |
| TOTAL PRICE |
| UNIT COST |
| TOTAL PRICE |
| UNIT COST |
| TOTAL PRICE |
| UNIT COST |
| TOTAL PRICE |
| REMARKS: |
| VENDOR'S TOTAL PRICE |
BILLING TERMS
DELIVERY DATE
COMMENTS
I certify that competition has been solicited and quotations obtained in accordance with current Purchase Bureau regulations governing Direct Purchase Authorization.
(signature of person obtaining quotations)
TITLE
DATE
Form CC-119 Rev. 1/24
CERTIFICATION
REGARDING [INSERT COMPANY NAME]
RELEASE OF ALL CLAIMS AGAINST THE STATE OF NEW JERSEY
I, [INSERT CONTRACTOR REPRESENTATIVE NAME], the [INSERT CONTRACTOR REPRESENTATIVE TITLE] of [INSERT COMPANY NAME], hereby aver as follows:
1. I have the authority to make this Certification on behalf of [INSERT COMPANY NAME].
2. [INSERT COMPANY NAME] hereby covenants that it will not make or maintain any claims, suits or demands against the State of New Jersey, or its Departments or employees, regarding Contract [INSERT CONTRACT NUMBER] and site-specific engagements for [INSERT SITE NAME], State of New Jersey Purchase Order Number [INSERT PURCHASE ORDER NUMBER].
BY:
Signature of Contractor Representative
Title
State of County of Sworn to and subscribed before me this day of , 20 .
Signature of Notary Public My Commission Expires
AFFIDAVIT
FROM [INSERT COMPANY NAME]
CONCERNING
SUBCONTRACTOR PAYMENTS
I, [INSERT CONTRACTOR REPRESENTATIVE NAME], the [INSERT CONTRACTOR REPRESENTATIVE TITLE] of [INSERT COMPANY NAME], hereby aver as follows:
1. I have the authority to make this affidavit on behalf of [INSERT COMPANY NAME].
2. [INSERT COMPANY NAME] has satisfied its monetary obligations to each and every subcontractor regarding Contract [INSERT CONTRACT NUMBER] and site-specific engagements for [INSERT SITE NAME], State of New Jersey Purchase Order Number [INSERT PURCHASE ORDER NUMBER].
BY:
Signature of Contractor Representative
Title
State of County of Sworn to and subscribed before me this day of , 20 .
Signature of Notary Public My Commission Expires
File details come from the government source that posted it. Updated .