Attachments.pdf

CONTRACTOR AFFIRMATIVE PROCUREMENT REPORT FORM FOR

ESTIMATION OF RECOVERED MATERIAL CONTENT LEVELS

FOR EPA DESIGNATED ITEMS

(PER EXECUTIVE ORDER 13101)

CONTRACTOR: ______________________________________________

CONTRACT/DO #: ___________________________________________

BLDG # (if applicable): ________________________________________

PROJECT MANAGER: ________________________________________

INSTRUCTIONS

1. Use this form to document estimation of recovered material content levels per FAR provision 52.223-9, “Certification and Estimate of Percentage of Recovered Material for EPA Designated Items.”

2. Complete the table below for those EPA Designated Items used in performance of work under this contract/ delivery order that met or exceeded the minimum materials content levels (see 2nd column in table below).

Provide the actual recovered material content (if different from 2nd column) and quantity for these items in the appropriate column, if available.

3. Mark each line with “N/A” for those item/s not used in the performance of this contract/delivery order.

4. Note any exemptions in 5th column for each item for which a Contractor Waiver Form was previously submitted.

5. Submit to the Contracting Officer at the completion of the contract.

RECYCLED OR RECOVERED

PRODUCT

TOTAL RECOVERED

MATERIALS

CONTENT (RMC)

ACTUAL

RMC (%)

QUANTITY

USED

EXEMPTION

(1,2,3)

Rock Wool Insulation 75% Fiberglass Insulation 20-25% Cellulose loose fill/Spray-on Insulation 75% Perlite Composition Board Insulation 23% Plastic Rigid Foam Insulation 9% Plastic Foam In Place Insulation 5% Plastic Foam, Glass Fiber Reinforced Insulation

6%

Phenolic Rigid Foam Insulation 5% Structural Fiber Board 80-100% Laminated Paper Board 100% Cement/Concrete (FLYASH) See www.epa.gov/cpg High Fly Ash Flowable Fills 95% Low Fly Ash Content Flowable Fill 6-14% Carpet (PET) 25-100% Bonded polyurethane Carpet Cushion 15-50% Jute Carpet Cushion 40% Synthetic fibers Carpet Cushion 100% Rubber Carpet Cushion 60-90% Rubber Plastic Patio Blocks 90-100% Rubber or Plastic Floor Tile 90-100% Steel Restroom Divider/Partition 15% Plastic Restroom Divider/Partition 20-100% Concrete Railroad Crossing 15-20% Rubber Railroad Crossing 85-95% Steel Railroad Crossing 25-30%

BOF/100%EAF2

Traffic cones made from PVC, LDPE, crumb Rubber

50-100%

Traffic Barricades (Type I and II only) made from HDPE, LDPE, PET, steel, fiberglass

100%

TOTAL RECOVERED

MATERIALS

CONTENT (RMC)

ACTUAL

RMC (%)

QUANTITY

USED

EXEMPTION

(1,2,3)

Channelizers, Plastic 25-95% Channelizers, rubber base 100% Delineators, plastic 25-90% Delineators, rubber base 100% Delineators, steel base 25-50% Flexible plastic delineators 25-85% Parking Stops, Plastic or Rubber 100% Parking Stops, Concrete containing coal fly ash

20-40%

Parking Stops, Concrete containing Ground- Granulated Blast Furnace Slag

25-70%

Playground Surfaces, including rubber or plastic

90-100%

Plastic Fencing for use to control snow, drifting Sand, or as a safety barrier

90-100%

Running Tracks. Including rubber or plastic

90-100%

Plastic Park benches and Picnic Tables

100%

Plastic composite Park benches and Picnic Tables

100%

Aluminum Park benches and Picnic Tables

25%

Concrete Park benches and Picnic Tables

15-40%

Steel Park benches and Picnic Tables 25-30%

BOF/100%EAF

Plastics Playground Equipment 100% Plastic Composites Playground Equipment

95-100%

Steel Playground Equipment 25-30% BOF/100%

EAF

Aluminum Playground Equipment 25% Garden hose, rubber or plastic 60-65% post consumer materials

Soaker hose, rubber or plastic 60-70% post consumer materials

Lawn/garden edging, plastic or rubber 30-100% Paper-based hydraulic mulch 100% Wood-based hydraulic mulch 100% Compost Purchase or use compost made from yard trimmings, leaves, grass clippings, and food waste

100%

HDPE lumber timbers and posts 75-100% Mixed plastics/Sawdust lumber timbers and posts

100%

HDPE/Fiberglass lumber timbers and posts

95%

Other mixed resins lumber timers and posts

95-100%

Latex Paint; white, off-white or pastel colors

20%

Latex Paint; gray, brown, earth-tones, other dark colors

50-99%

TOTAL RECOVERED

MATERIALS

CONTENT (RMC)

ACTUAL

RMC (%)

QUANTITY

USED

EXEMPTION

(1,2,3)

Consolidated Latex Paint (when color and performance doesn’t matter)

100%

Plastic Non-road Signs 80-100% Aluminum Signs 25% Plastic Sign Posts and Supports 80-100% Steel Sign Posts and Supports 25-30%

BOF/100%EAF

Awards and Plaques

Glass 75-100 Wood 100% Paper 40-100 Plastic and Plastic/ Wood Composite

50-100

The following exemptions may apply to the non-procurement of recycled/recovered content materials:

1. The product is not available from a sufficient number of sources to maintain a sufficient level of competition (i. e., available from two or more sources) or is not available a reasonable price.

2. The product is not available within a reasonable period of time.

3. The product does not meet the performance standards in applicable specifications to fails to meet reasonable performance standards of the agency.

CERTIFICATION

I hereby certify the Statement of Work/Specifications for the requisition/procurement of all materials listed on this form comply with EPA standards for recycled/recovered materials content.

CONTRACTOR DATE

Contractor Request for Waiver For Non-EPA Comprehensive Guideline Items1

Contract No. ______________________________

This form is to be completed by the contractor when items subject to ANAD’s Affirmative Procurement (AP) Policy are not purchased. This form is required for all contracts (including services using such items). NOTE: The Contractor must obtain signature of the Contracting Officer indicating concurrence of the waiver.

INSTRUCTIONS

1. List the EPA Guidelines item(s)1 not procured, check the appropriate justification(s), provide a written explanation and sign and date the form.

2. Obtain Contracting Officer for waiver concurrence.

3. Submit the original approved form to the Directorate of Contract and retain copy for Contractor files.

4. The Contracting Officer will provide a copy of the completed signed form to the Directorate of Risk Management Pollution Prevention Program Manager.

EPA Guideline item not purchased below (refer to EPA Guideline Items1 list):

Products containing recovered materials and meeting ANAD’s AP standards for the above EPA Guideline Items1 were not obtained because items:

_____ Do not meet all reasonable performance specifications.

_____ Are not available within a reasonable period of time.

_____ Use of minimum content standards would result in inadequate competition.

_____ Products containing recovered materials would require paying a price premium.

5. Written Justification For Not Purchasing EPA Guideline Items1 (continue on back if necessary):

Contractor Signature Date

6. CONCURRENCE ___________________________________DATE

Contracting Officer

7. DATE SUBMITTED TO THE POLLUTION PREVENTION MANAGER

1 – Also referred to as recovered material content items

EPA Guideline Items (Recovered Materials Content) List

Paper and Paper Products

• Printing and writing paper

• Newsprint

• Commercial sanitary tissue products

• Paperboard and packaging products

• Miscellaneous papers

Transportation Products

• Channelizers

• Delineators1

• Flexible delineators

• Parking stops

• Traffic barricades

• Traffic cones

Vehicular Products

• Engine coolants

• Re-refined lubricating oils

• Retread tires

Landscaping Products

• Garden and soaker hoses

• Hydraulic mulch

• Lawn and garden edging

• Yard trimmings compost

• Food waste compost

• Landscaping timbers and posts

(plastic lumber) Construction Products

• Building insulation products

• Laminated paperboard

• Structural fiberboard

• Floor tiles (heavy duty or commercial)

• Patio blocks

• Carpet

• Cement and concrete containing fly ash

• Cement and concrete containing ground granulated blast furnace slag

• Shower and restroom dividers/partitions

• Consolidated and reprocessed latex paint

• Carpet cushion

• Flowable fill

• Railroad grade crossings/surfaces

Non-Paper Office Products

• Binders (paper, plastic covered)

• Office recycling containers

• Office waste receptacles

• Plastic desktop accessories

• Plastic envelopes

• Plastic trash bags

• Printer ribbons

• Toner cartridges

• Binders (solid plastic)

• Plastic clipboards

• Plastic clip portfolios

• Plastic file folders

• Plastic presentation folders

Miscellaneous Products

• Pallets

• Sorbents

• Awards and plaques

• Industrial drums

• Mats

• Signage

• Strapping and stretch wrap

Park and Recreation Products

• Plastic fencing (used for erosion control or as a safety barrier at construction sites)

• Playground surfaces

• Running tracks

• Park and recreational furniture

• Playground equipment

List reflect EPA’s changes effective as of January 2001

Refer to EPA’s Comprehensive Procurement Guideline website for recovered materials content levels – www.epa.gov/cpg.

EVIDENCE OF AUTHORITY TO SIGN OFFERS

Reference the solicitation provision in Section I entitled “Signature Authority.” Evidence of the authority of individuals signing offers to submit firm offers on behalf of the Offeror is required except for the owner in the case of sole proprietorships. When Contractor is a corporation, complete this certificate.

CERTIFICATE OF CORPORATE OFFICIAL/AGENT’S AUTHORITY TO BIND CORPORATION

I, _________________________________, Secretary of ________________________________________

_________________________________, a corporation created and organized under the law of the State of

__________________________, do hereby certify that ___________________________ is an official/agent of said corporation and is empowered to represent, bind and execute contracts on behalf of said corporation, subject to the following limitations:__________________________________________________________.

(if none, so state)

Witness my hand and the corporate seal of said corporation this ______ day of ______________, 20____.

(CORPORATE SEAL) ________________________________________

Secretary

When Contractor is a Partnership, Unincorporated Firm or a Corporation for which completion of the first statement would be impracticable, complete this certificate:

CERTIFICATE OF AUTHORITY TO BIND PARTNERSHIP

We, the undersigned, comprising the total membership of _____________________________________________

_________________________________________________, a partnership/unincorporated firm doing business at_______________________________________________________________________, do hereby certify that ____________________________________ is a ____________________________ of said firm and is empowered to represent, bind, and execute contracts on behalf of said partnership/ unincorporated firm.

Witness our signatures, this _______ day of ________________, 20____.

Members of Partnership/Unincorporated Firm:

Past Performance Questionnaire This Questionnaire relates to solicitation requirements for

PAST PERFORMANCE QUESTIONNAIRE –

Your assistance is requested in support of a source selection for Anniston Army Depot.

Please complete this Questionnaire and e-mail or send by facsimile [FAX: 256-235-6353 Director of Contracting Anniston Army Depot 7 Frankford Ave.

Anniston, AL 36201-4199

ATTN:

Phone:

E-mail:

Desired Response Date:

When complete, the information on this form is SOURCE SELECTION SENSITIVE INFORMATION (41 U.S.C. 423) and shall be protected accordingly.

Proposed prime contractor

1. OFFEROR NAME OFFEROR ADDRESS

Contractor Name and Address and contract/project information being addressed in this questionnaire

2. CONTRACTOR NAME & ADDRESS: 2. CONTRACT NO.:

3. CONTRACT INITIATION DATE:

4. COMPLETION DATE:

5. CONTRACT VALUE (with options):

6. TYPE OF CONTRACT:

7. DESCRIPTION OF PROJECT REQUIREMENTS:

8. Point of Contact: Provide the following information for the company and individual completing this questionnaire:

Company/Agency Name and Address:

Name of person completing this questionnaire:

Title:

Role/responsibility for the effort being addressed in the survey:

Phone Number:

E-Mail:

Rating Scale:

EXCELLENT: Superior performance. Objectives/requirements essentially always achieved or exceeded, with inconsequential exceptions.

GOOD: Highly satisfactory performance. Objectives/requirements achieved with only rare exceptions, and the exceptions had minor consequences.

ADEQUATE: Generally satisfactory performance. Objectives/requirements generally achieved with occasional exceptions, and, in most cases, the exceptions had minor consequences.

MARGINAL: Occasionally unsatisfactory performance of significance.

Objectives/requirements were not fully achieved, with significant consequences in some cases.

POOR: Frequently unsatisfactory performance of significance. Objectives/requirements frequently not achieved, with significant consequences.

UNKNOWN: Unable to rate, not observed, or not a significant aspect of performance.

9. Questionnaire: Please indicate the rating that best reflects your experience with this contractor and provide a short narrative addressing the basis for the ratings assigned. Address compliance with requirements, actual performance, problems encountered and problem resolution. Use additional sheets if necessary. Excellent contract management, attention to Detail and Quality Assurance.

A. Customer Satisfaction – Assess the contractor’s business-like concern for its customers, including such factors as dependability, flexibility, early problem identification, communication, and responsiveness.

B. Schedule – Assess the contractor’s adherence to delivery commitments; responsiveness to requests for accelerations; and early identification and mitigation of schedule slippages.

C. Technical Requirements – Assess the contractor’s performance in conforming to contract specifications:

D. Technical Responsiveness – Assess the contractor’s ability to identify and resolve technical problems effectively and in a timely manner, including correction of faulty work and warranty claims:

Excellent Good Adequate Marginal Poor Unknown

E. Overall Assessment: Provide your overall assessment.