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HomeMy WebLinkAboutHerbert Walkup Pipeline Replacemenet - Grant Forms (1)_RedactedSECTION 00 75 00 GRANT FORMS PART 1 GENERAL 1.01 SUMMARY A. Section Includes: 1. To comply with the Contract requirements for Grant Funding, the Contractor must complete the following forms (attached) and submit them with the Bid: a. Form 4500-3: DBE Subcontractor Performance b. Form 4500-4: DBE Subcontractor Utilization 2. To comply with Contract requirements for Grant Funding, the Contractor must complete the following forms and submit them at the District's request in accordance with Section 00 20 00, Part 2.06.A: a. American Iron and Steel Certification b. Build America, Buy America Certification c. Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion d. Lobbying Forms, only one shall be completed, as applies: 1) Certification Regarding Lobbying, or 2) Disclosure of Lobbying Activities e. Form 1: DBE "Good Faith" Effort List of Subcontractors Solicited f. Form 5: Summary of Bids Received — DBE and non -DBE. 3. To comply with Contract requirements for Grant Funding, the Contractor must complete the following forms and submit them at the District's request following award of the arollect. a. Certification of Non -Segregated Facilities b. Drug -Free Workplace Certification c. Non -Discrimination Clause d. Form 4500-2: DBE Subcontractor Participation Form B. The certification requirements included herein are described fully in Section 00 74 00, Grant Conditions. NOVEMBER 2023 SECTION 00 75 00 2024 HERBERT WALKUP PIPELINE GRANT FORMS REPLACEMENT PROJECT 1 THIS PAGE LEFT INTENTIONALLY BLANK NOVEMBER 2023 SECTION 00 75 00 2024 HERBERT WALKUP PIPELINE GRANT FORMS REPLACEMENT PROJECT 2 AMERICAN IRON AND STEEL CERTIFICATION CONTRACTORIAPPLICANT: F.1W • C WSavl. Co. 1. Identification of American -made Iron and Steel: Consistent with the terms of the Purchaser's bid solicitation, the Bidder certifies that this bid reflects the Bidder's best, good faith effort to identify domestic sources of iron and steel for every component contained in the bid solicitation where such American -made components are available on the schedule and consistent with the deadlines prescribed in or required by the bid solicitation. 2. Verification of U.S. Production: The Bidder certifies that all components contained in the bid solicitation that are American -made have been so identified, and if this bid is accepted, the Bidder agrees that it will provide reasonable. sufficient, and timely verification to the Purchaser of the U.S. production of every component so identified. 3. Documentation Regarding Non -American -made Iron and Steel: The Bidder certifies that for any component or components that are not American -made and are so identified in this bid, the Bidder has included in or attached to the bid one or both of the following, as applicable: a. Identification of and citation to a categorical waiver published by the U.S. Environmental Protection Agency in the Federal Register that is applicable to such component or components, and an analysis that supports its applicability to the component or components. b. Verifiable documentation sufficient to the Purchaser, as required in the bid solicitation or otherwise, that the Bidder has sought to secure American made components but has determined that such components are not available on the schedule and consistent with the deadlines prescribed in the bid solicitation, with assurance adequate for the Bidder under the applicable conditions stated in the bid solicitation or otherwise. 4. Information and Detailed Justification Regarding Non- American -made Iron and Steel: The Bidder certifies that for any such component or components that are not so available, the Bidder has also provided in or attached to this bid information, including but not limited to the verifiable documentation and a full description of the bidder's effort to secure any such American -made component or components, that the Bidder believes are sufficient to provide and as far as possible constitute the detailed justification required for a waiver under section 1605 with respect to such component or components. The Bidder further agrees that, if this bid is accepted, it will assist the Purchaser in amending, supplementing, or further supporting such information as required by the Purchaser to request and, as applicable, implement the terms of a waiver with respect to any such component or components. CERTIFICATION I, the official named below, hereby swear that I am duly authorized legally to bind the contractor or loan recipient to the above described certification. I am fully aware that this certification, executed on the date and in the county below, is made under penalty of perjury under the laws of the State of California. OFFICIAL'S NAME: -Trol cano" DATE EXECUTED: 1L1 15 4 23 CONTRACTOR/APPLICANT SIGNATURE TITLE: V : V. NOVEMBER 2023 2024 HERBERT WALKUP PIPELINE REPLACEMENT PROJECT EXECUTED IN COUNTY OF: W"V-04- J SECTION 00 75 00 GRANT FORMS 3 THIS PAGE LEFT INTENTIONALLY BLANK NOVEMBER 2023 SECTION 00 75 00 2024 HERBERT WALKUP PIPELINE GRANT FORMS REPLACEMENT PROJECT 4 BUILD AMERICA, BUY AMERICA CERTIFICATION CONTRACTOR/APPLICANT: C WS'm C0- The Contractor acknowledges to and for the benefit of the District ("Owner') and the California Drinking Water State Revolving Fund (DWSRF) Program (the "Funding Authority") that it understands the goods and services under this Agreement are being funded with federal monies and have statutory requirements commonly known as "Build America, Buy America;" that requires all of the iron and steel, manufactured products, and construction materials used in the project to be produced in the United States ("Build America, Buy America Requirements") including iron and steel, manufactured products, and construction materials provided by the Contactor pursuant to this Agreement. 1. The Contractor hereby represents and warrants to and for the benefit of the Owner and Funding Authority: a) The Contractor has reviewed and understands the Build America, Buy America Requirements, b) All of the iron and steel, manufactured products, and construction materials used in the project will be and/or have been produced in the United States in a manner that complies with the Build America, Buy America Requirements, unless a waiver of the requirements is approved, and c) The Contractor will provide any further verified information, certification or assurance of compliance with this paragraph, or information necessary to support a waiver of the Build America, Buy America Requirements, as may be requested by the Owner or the Funding Authority. CERTIFICATION I, the official named below, hereby swear that I am duly authorized legally to bind the contractor or loan recipient to the above described certification. I am fully aware that this certification, executed on the date and in the county below, is made under penalty of perjury under the laws of the State of California. OFFICIAL'S NAME: Tyv4 Cavico x DATE EXECUTED: EXECUTED IN COUNTY OF: 0G.S1n,0,e, CONTRACTOR/APPLICANT SIGNATURE: TITLE: V • P NOVEMBER 2023 SECTION 00 75 00 2024 HERBERT WALKUP PIPELINE GRANT FORMS REPLACEMENT PROJECT 5 THIS PAGE LEFT INTENTIONALLY BLANK NOVEMBER 2023 SECTION 00 75 00 2024 HERBERT WALKUP PIPELINE GRANT FORMS REPLACEMENT PROJECT 6 CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION CONTRACTOR/APPLICANT: VA14 - CAK-30'vN CV (1) The contractor certifies, by submission of this proposal, that it and its principals: (a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded by any Federal agencies; (b) Have not within a three year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; (c) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State or local) with commission of any of the offenses enumerated in paragraph (1)(b) of this certification; and (d) Have not within a three year period preceding this application/proposal had one or more public transactions (Federal, State or local) terminated for cause or default. (2) Where the contractor is unable to certify to any of the statements in this certification, such contractor shall attach an explanation to this proposal*. *Exceptions will not necessarily result in denial of award, but will be considered in determining bidder responsibility. For any exception noted, indicate to whom it applies, initiating agency, dates of action, and the type of violation. CERTIFICATION I, the official named below, hereby swear that I am duly authorized legally to bind the contractor or loan recipient to the above described certification. I am fully aware that this certification, executed on the date and in the county below, is made under penalty of perjury under the laws of the State of California. OFFICIAL'S NAME: TV01 Carrov, DATE EXECUTED: 1Z1L5 1 2-3 EXECUTED IN COUNTY OF: W CL0r'0 a CONTRACTOR/APPLICANT SIGNATURE: � TITLE: v Q J NOVEMBER 2023 SECTION 00 75 00 2024 HERBERT WALKUP PIPELINE GRANT FORMS REPLACEMENT PROJECT 7 THIS PAGE LEFT INTENTIONALLY BLANK NOVEMBER 2023 SECTION 00 75 00 2024 HERBERT WALKUP PIPELINE GRANT FORMS REPLACEMENT PROJECT 8 CERTIFICATION OF NON -SEGREGATED FACILITIES CONTRACTORIAPPLICANT. V-AA • C,of5m CO - Environmental Protection Agency Region IX 75 Hawthorne Street San Francisco, California 94105 (Applicable to federally assisted construction contracts and related subcontracts exceeding $10,000 which are not exempt from the Equal Opportunity Clause.) The federally assisted construction contractor certifies that he does not maintain or provide for his employees any segregated facilities at any of his establishments, and that he does not permit his employees to perform their services at any location, under his control, where segregated facilities are maintained. The federally assisted construction contractor certifies further that he will not maintain or provide for his employees any segregated facilities at any of his establishments, and that he will not permit his employees to perform their services at any location, under his control, where segregated facilities are maintained. The federally assisted construction contractor agrees that a breach of this certification is a violation of the Equal Opportunity Clause in this contract. As used in this certification, the term "segregated facilities" means any waiting rooms, work areas, restrooms and wash rooms, restaurants and other eating areas, time clocks, locker rooms and other storage or dressing areas, transportation, and housing facilities provided for employees which are segregated by explicit directive or are in fact segregated on the basis of race, creed, color, or national origin, because of habit, local custom, or otherwise. The federally assisted construction contractor agrees that (except where he has obtained identical certifications from proposed subcontractors for specified time period) he will obtain identical certifications from proposed subcontractors prior to the award of subcontracts exceeding $10,000 which are not exempt form the provisions of the Equal Opportunity Clause, and that he will retain such certifications in his files. CERTIFICATION I, the official named below, hereby swear that I am duly authorized legally to bind the contractor or loan recipient to the above described certification. I am fully aware that this certification, executed on the date and in the county below, is made under penalty of perjury under the laws of the State of California. OFFICIAL'S NAME: 11r-oy CGWSOVI DATE EXECUTED: 17,1 15 1,2-3 EXECUTED IN COUNTY OF: 0.SVLO-6 CONTRACTOR/APPLICANT SIGNATURE: j J TITLE: 1) . Q Note:The penalty for making false statements in offers is prescribed in 18 U.S.C. 1001. NOVEMBER 2023 SECTION 00 75 00 2024 HERBERT WALKUP PIPELINE GRANT FORMS REPLACEMENT PROJECT 9 THIS PAGE LEFT INTENTIONALLY BLANK NOVEMBER 2023 SECTION 00 75 00 2024 HERBERT WALKUP PIPELINE GRANT FORMS REPLACEMENT PROJECT 10 DRUG -FREE WORKPLACE CERTIFICATION CONTRACTORIAPPLICANT: ir.il, CAX-50Vk CO - The contractor or applicant named above hereby certifies compliance with Government Code Section 8355 in matters relating to providing a drug -free workplace. The above named contractor or applicant will: 1. Publish a statement notifying employees that unlawful manufacture, distribution, dispensation, possession, or use of a controlled substance is prohibited and specifying actions to be taken against employees for violations, as required by Government Code Section 8355(a). 2. Establish a Drug -Free Awareness Program as required by Government Code Section 8355(b), to inform employees about all of the following: (a) The dangers of drug abuse in the workplace, (b) The person's or organization's policy of maintaining a drug -free workplace, (c)Any available counseling, rehabilitation and employee assistance programs, and (d) Penalties that may be imposed upon employees for drug abuse violations. 3. Provide as required by Government Code Section 8355(c), that every employee who works on the proposed contract or loan: (a) Will receive a copy of the company's drug -free policy statement, and (b) Will agree to abide by the terms of the company's statement as a condition of employment on the contract or loan. CERTIFICATION I, the official named below, hereby swear that I am duly authorized legally to bind the contractor or loan recipient to the above described certification. I am fully aware that this certification, executed on the date and in the county below, is made under penalty of perjury under the laws of the State of California. OFFICIAL'S NAME: -vv-" GL.-sm DATE EXECUTED; CONTRACTOR/APPLICANT SIGNATURE: TITLE: �i • p - NOVEMBER 2023 2024 HERBERT WALKUP PIPELINE REPLACEMENT PROJECT EXECUTED IN COUNTY OF: O c�& V'°e, SECTION 00 75 00 GRANT FORMS 11 THIS PAGE LEFT INTENTIONALLY BLANK NOVEMBER 2023 SECTION 00 75 00 2024 HERBERT WALKUP PIPELINE GRANT FORMS REPLACEMENT PROJECT 12 CONTRACTORIAPPLICANT NON-DISCRIMINATION CLAUSE F. vs Ca' seM Co During the performance of this contract, contractor and its subcontractors shall not unlawfully discriminate against any employee or applicant for employment because of sex, race, religion, color, national origin, ancestry, physical disability (including HIV and AIDS), mental disability, medical condition (cancer), marital status, age (over 40) or denial of family care leave. Contractors and subcontractors shall insure that the evaluation and treatment of their employees and applicants for employment are free of such discrimination and harassment. Contractors and subcontractors shall comply with the provisions of the Fair Employment and Housing Act (Government Code Section 12900 (a-f) et seq.) and the applicable regulations promulgated thereunder (California Administrative Code, Title 2, Section 7285.0 et seq.). The applicable regulations of the Fair Employment and Housing Commission implementing Government Code, Section 12900 (a-f), set forth in Chapter 5 of Division 4 of Title 2 or the California Administrative Code are incorporated into this contract by reference and made a part hereof as if set forth in full. Contractor and its subcontractor shall give written notice of their obligations under this clause to labor organizations with which they have a collective bargaining or other agreement. 2. The contractor shall include the nondiscrimination and compliance provisions of this clause in all subcontracts to perform work under the contract. CERTIFICATION I, the official named below, hereby swear that I am duly authorized legally to bind the contractor or loan recipient to the above described certification. I hereby certify that the Contractor will abide by the above requirements. I am fully aware that this certification, executed on the date and in the county below, is made under penalty of perjury under the laws of the State of California. OFFICIAL'S NAME: Tom`{ caXSav" DATE EXECUTED: k21 i5 123 CONTRACTOR/APPLICANT SIGNATURE: TITLE: V.?. NOVEMBER 2023 2024 HERBERT WALKUP PIPELINE REPLACEMENT PROJECT EXECUTED IN COUNTY OF: L/&S�Iot' SECTION 00 75 00 GRANT FORMS 13 THIS PAGE LEFT INTENTIONALLY BLANK NOVEMBER 2023 SECTION 00 75 00 2024 HERBERT WALKUP PIPELINE GRANT FORMS REPLACEMENT PROJECT 14 CERTIFICATION REGARDING LOBBYING CONTRACTORIAPPLICANT. F.d) • CO)Ovk CO The undersigned certifies to the best of his or her knowledge and belief that- (1) No federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in conjunction with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. (2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan or cooperative agreement, the undersigned shall complete and submit Standard Form LLL, Disclosure Form to Report Lobbying, in accordance with its instructions. CERTIFICATION I, the official named below, hereby swear that I am duly authorized legally to bind the contractor or loan recipient to the above described certification. I am fully aware that this certification, executed on the date and in the county below, is made under penalty of perjury under the laws of the State of California. OFFICIAL'S NAME: �� Ca"OVi DATE EXECUTED: !g-1 1,j 1 23 EXECUTED IN COUNTY OF: 0 0ls vw& CONTRACTORIAPPL[CANT SIGNATURE: TITLE: v-P NOVEMBER 2023 SECTION 00 75 00 2024 HERBERT WALKUP PIPELINE GRANT FORMS REPLACEMENT PROJECT 15 THIS PAGE LEFT INTENTIONALLY BLANK NOVEMBER 2023 SECTION 00 75 00 2024 HERBERT WALKUP PIPELINE GRANT FORMS REPLACEMENT PROJECT 16 DISCLOSURE OF LOBBYING ACTIVITIES Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See reverse for public burden disclosure.) 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: a. contract El a. bid/offer/application ❑ a. Initial filing b. grant b. Initial award b. material change c. cooperative agreement c. post -award For Material Change Only: d.loan year quarter e. loan guarantee date of last report f. loan insurance 4. Name and Address of Reporting Entity: Prime ❑ Subawardee Tier , ff known: Congressional District, ffknown: 6. Federal Department/Agency: 8. Federal Action Number, if known: 10. a. Name and Address of Lobbying Registrant (if Individual, last name, first name, Ml): Informallon requested through this form Is authorized by title 31 U.S.C. section 11.1352. This disclosure of lobbying activities Is a material representation of fact upon which reliance was placed by the [ter above when this transaction was made or entered Into. This disclosure Is required pursuant to 31 U.S.C. 1352. This Informatlon will be reported to the Congress semi-annually and will be available for public Inspection. Any person who falls to file the required disclosure shall be subject to a civil penalty of not less that $10,000 and not more than $100,0Oo for each such failure. Federal Use Only: NOVEMBER 2023 2024 HERBERT WALKUP PIPELINE REPLACEMENT PROJECT Approved by OMB 0348-0046 5. If Reporting Entity in No. 4 is a Subawardee, Enter Name and Address of Prime: Congressional District, If known: 7. Federal Program Name/Description: CFDA Number, if applicable: 9. Award Amount, ffknown: b. Individuals Performing Services (including address If different from No. 10a ) (last name, first name, Ml): Signature: Print Name: Title: Telephone No.: Date: Authorized for Local Reproductlon Standard Farm LLL (Rev. 7-97) SECTION 00 75 00 GRANT FORMS 17 INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the Initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C. section 1352. The filing of a form Is required for each payment or agreement to make payment to any lobbying entity for influencing or attempting to Influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress In connection with a covered Federal action. Complete all items that apply for both the Initial filing and material change report. Refer to the Implementing guidance published by the Office of Management and Budget for additional Information. 1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to Influence the outcome of a covered Federal action. 2. Identify the status of the covered Federal action. 3. Identify the appropriate classification of this report. If this is a followup report caused by a material change to the information previously reported, enter the year and quarter In which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal action. 4. Enter the full name, address, city, State and zip code of the reporting entity. Include Congressional District, If known. Check the appropriate classification of the reporting entity that designates if It is, or expects to be, a prime or subaward recipient. Identify the tier of the subawardee, e.g., the first subawardee of the prime Is the 1 st tier. Subawards Include but are not limited to subcontracts, subgrants and contract awards under grants. 5. If the organization filing the report in Item 4 checks "Subawardee," then enter the full name, address, city. State and zip code of the prime Federal recipient. Include Congressional District, if known. 6. Enter the name of the Federal agency making the award or loan commitment. Include at least one organizational level below agency name, If known. For example, Department of Transportation, united States Coast Guard. 7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments. 8. Enter the most appropriate Federal Identifying number available for the Federal action identified In Item 1 (e.g., Request for Proposal (RFP) number; Invitation for Bid (IFB) number; grant announcement number; the contract, grant, or loan award number; the appllcatlon/proposal control number assigned by the Federal agency). Include prefixes, e.g., "RFP-DE-90-001." 9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan commitment for the prime entity identified In item 4 or 5. 10. (a) Enter the full name, address, city, State and zip code of the lobbying registrant under the Lobbying Disclosure Act of 1995 engaged by the reporting entity Identified In item 4 to Influence the covered Federal action. (b) Enter the full names of the Individual(s) performing services, and Include full address If different from 10 (a). Enter Last Name, First Name, and Middle Initial (MI). 11. The certifying official shall sign and date the form, print his/her name, title, and telephone number. According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of Information unless it displays a valid OMB Control Number. The valid OMB control number for this Information collection is OMB No. 0348-0046. Public reporting burden for this collection of information is estimated to average 10 minutes per response, Including time for reviewing Instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of Information. Send comments regarding the burden estimate or any other aspect of this collection of Information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0046), Washington, DC 20503. NOVEMBER 2023 SECTION 00 75 00 2024 HERBERT WALKUP PIPELINE GRANT FORMS REPLACEMENT PROJECT 18 Water Boards Disadvantaged Business Enterprise (DBE) Program DBE Subcontractor Participation Form A Financial Assistance Agreement Recipient must require Its prime contractors to provide this form to Its DBE subcontractors. This form gives a DBE'subcontractor' the opportunity to describe work received and/or report any concerns regarding the funded project (e.g., in areas such as termination by prime contractor, late payments, etc.). The DBE subcontractor can, as an option, complete and submit this form to the DBE Coordinator at any time during the project period of performance. Subcontractor Name Project Name WBE Traffic Control Inc. 2024 Herbert Walkup Pipeline Replacement Project Bid / Proposal No. Assistance Agreemen ID No. (If known) Point of Contact Brice Hughes Tele ho N Email Address WMEN Prime Contractor Name Issuing/Funding Entity FW Carson Co I STPUD Contract Item Description of Work Received from the Prime Contractor Involving Amount Received Number Construction, Services, Equipment or Supplies by Prime Contractor Traffic Control hourly rA DBE is a Disadvantaged, Minority, or Woman Business Enterprise that has been certified by an entity from which EPA accepts certifications as described in 40 CFR 33.204-33.2015 or certified by EPA. EPA accepts certifications from entities that meet or exceed EPA certification standards as described in 40 CFR 33.202. 'Subcontractor is defined as a company, firm, joint venture, or individual who enters into an agreement with a contractor to provide services pursuant to an award of financial assistance. FORM 4500-2 (DBE Subcontractor participation Form) NOVEMBER 2023 2024 HERBERT WALKUP PIPELINE REPLACEMENT PROJECT SECTION 00 75 00 GRANT FORMS 19 Please use the space below to report any concerns regarding the above funded project: Subcontractor Suture (/V e �T r �1 i ceHO P,r Q vi S Print Name 1,C� ��vLe� �' S Thepublic reporting and record keeping burden for this collection of information is estimated to average three (3) hours per response. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Do not send the completed form to this address. .......... ..... _......................................................... Send completed Form 4500-2 to: Mr. Joe Ochab, DBE Coordinator US EPA, Region 9 75 Hawthorne Street San Francisco, CA 94105 .......................................................................................... FORM 4500-2 (DBE Subcontractor Participation Form) NOVEMBER 2023 SECTION 00 75 00 2024 HERBERT WALKUP PIPELINE GRANT FORMS REPLACEMENT PROJECT 20 Water &cards Disadvantaged Business Enterprise (DBE) Program DBE Subcontractor Performance Form This form is intended to capture the DBE' subcontractor's°description of work to be performed and the price of the work submitted to the prime contractor. A Financial Assistance Agreement Recipient must require its prime contractor to have its DBE subcontractors complete this form and Include all completed forms in the prime contractor's bid or proposal package. Subcontractor Name I Project Name HANSEN TRUCKING INC 2024 Herbert Walkup Pipeline Replacement Project Bid / Proposal No Assistance Agreement ID No. (if known) Point of Contact i024 Herbert Walkup Pipeline Project LANA HANSEN Prime Contractor Name F.W. Camon Co. Contract Item Number 9, N'f Jri I S7r i Y IssuinglFunding Entity South Tahoe Public Utility District Description of Work Submitted from the Prime Contractor Involving Construction, Services, Equipment or Supplies TRUCKING I i DBE Certified By kDOS,i SBA Other. CUCP. NDOT & WSENC National WEE Cede Price of Work Submitted to the Prime Contractor HOURLY Meetstexceeds EPA certification standards? YES NO 'A DBE Is a Disadvantaged, Minority, or Woman Business Enterprise that has been certified by an entity from which EPA accepts certifications as described in 40 CFR 33.201.2015 or certified by EPA. EPA accepts certifications from entities that meet or exceed EPA certification standards as described In 40 CFR 33.202. 'Subcontractor is defined as a company, firm, joint venture, or Individual who enters into an agreement with a contractor to provide services pursuant to an award of financial assistance. FORM 4500-3 (DBE Subcontractor fMrJormanm Form) NOVEMBER 2023 2024 HERBERT WALKUP PIPELINE REPLACEMENT PROJECT SECTION 00 75 00 GRANTFORMS 21 I certify under penalty of perjury that the forgoing statements are true and correct. Signing this form does not signify a commitment to utilize the subcontractors above. I am aware that in the event of a replacement of a subcontractor, I will adhere to the replacement requirements set forth in 40 CFR Part 33 Section 33.302 (c). Prime actor Signature Title Subcof rS 'nature Title PRESIDENT Print Name Date l2� 15 �23 Print Name LANA HANSEN Date 12/14/23 The public reporting and record keeping burden for this collection of information is estimated to average three (3) hours per response. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Do not send the completed form to this address. FORM 4500-3 (DBE Subcontractor Performance Form) NOVEMBER 2023 SECTION 00 75 00 2024 HERBERT WALKUP PIPELINE GRANT FORMS REPLACEMENT PROJECT 22 Water Boards Disadvantaged Business Enterprise (DBE) Program DBE Subcontractor Performance Form This form is Intended to capture the DBE'subcomractor'sadescription of work tote performed and the Price of the work submitted to the prime contractor. A Financial Assistance Agreement Recipient must require Its prime contractor to have its DBE eubcoMractore complete this form and molude all completed forma In the prime contractors bid a proposal package. Subcontractor Name rojed Name 2b2 a WAWer RhAne Bid Proposal i to Aeebtence AHraernam lD No. giipman) Polmof CAmad x3+1 N 4iP �peu oii et S mum nme ontractor Name F• W (�,pKsevt. GO. _ _ SowFh Tw�.oa. QublUc U}iltfy DtSh+=4 --.-7�_— Price of Work Contract tern , Description of Work Submitted from me Prime Contractor Involving submaedtotlle Number Construction. Services. Egrdpmentor Supplier Prime Contractor �as� -- DBECBRNedBy-- Meela(eraaeda EPA oetsgeagon sterderdel Other._W 13E YES NO Unk 'A DBE Is a Disadvantaged, Minority, or Woman Business Enterprise that has been certified by an entity from which EPA accepts certifications as described in 40 CFR 33.204-33.2015 or certified by EPA. EPA accepts certifications from entities that men or aaceed EPA certification standards as described In 40 DFR 33.202. 'Subcontractor Is defined as a company, firm, joint venture, or Individual who enters into an agreement with a contractor to provide services pursuant to an award of financial assistance. FORM 4500-3 (DBE Subcontractor Pecormanre Form) N0VEMBER 2023 2024 HERBERT WALKUP PIPELINE REPLACEMENT PROJECT SECTION DO 7500 GRANTFORMS 21 i certify under penalty of perjury that the forgoing statements are true and correct, Signing this form does not signify'a commitment to utilize the subcontractors above. I am aware that in the event of a replacement of a subcontractor, I will adhere to the replacement requirements set forth in 40 CFR Part 33 Section 33.302 (c). Prime Contractor Signature U•Q• Subcontractor 5' nature r itle �, Print Name "[rD`� CAJ�So'h - - Date �2 15 t 23 Print Name tLt toDate The public reporting and record keeping burden for this collection of information is estimated to average three (3) hours per response. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minim6rig respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Do not send the completed form to this address. FORM 4500-3 (DBE Subcontractor Performance Form) NOVEMBER 2023 SECTION 00 75 00 2024 HERBERT WALKUP PIPELINE GRANT FORMS REPLACEMENT PROJECT 22 7G5 Pnnh!Om Wly MT:L4:WAM Tolo:mtps:/luuw.ra�nm:re.u.gov O(rtce of Small Business & DVBE Services EM14 Anrl-,: cnlrKaNm.w:xassTe] LepleuAnmxalne: - WBETRA ICCONTROLINC e�mMm We0Po6a: WRM COM Doing Ou0nm N lD" Name 1: &Mnm Pflone NumEac DoiQgi%i Im MlDeAl Namex: _ euanenI Pax Number. TUT)ws TX61 Mcnenan 5]so RAlRonxsxLVD Bus1nQ35 Dvs: COrt N[Uan,Service NL�z C RMICMAEL CA95608 GMfl[l[im Typr Nypa rNm SH-PW Aopo XWXe M Stay lnfonoWl NEWYOUR CEATIFlGTION PROMM UPPATEDI { ?Natl I+nxtrt[f_Cn+ QuWorsi CaXMOSOE Main Number.9I6T5-43W0 NT ]M Strtet, I� W � W N 5a[rzm ermaG 95E05 To MMI%xxx[ Water Boards Disadvantaged Business Enterprise (DBE) Program DBE Subcontractor Utilization Form This form Is Intended to capture the prime contractor's actual and/or anticipated use of identified certified DBE' subcontractor's2 and the estimated dollar amount of each subcontract. A Financial Assistance Agreement Recipient must require Its prime contractors to complete this form and Include It In the bid or proposal package. Prime contractors should also maintain a copy of this form on Ole. Prime Contractor Name Project Name FIN Carson Co 2024 Herbert Walkup Pipeline Replacement Pmject Bid / Proposal No. Assistance Agreemen ID No (If known) Point of Contact Hunter Eidem Address Telephone No. Email Address IssulngIFundlng Entity South Tahoe Public Utility District I have Identified potential DBE certified subcontractors. ©E NO If yes, please complete the table below. If no, pleaseexplain Subcontractor Name/ Estimated Currently Company Name Company Address/Phone/Email Dollar DBE Amount Certified.' Hansen Trucking hourly YES #3o.eoo WBE Traffic Control Inc. hourly YES (/F 000 --Continue on back If needed-- rA DBE is a Disadvantaged, Minority, or Woman Business Enterprise that has been certified by an entity from which EPA accepts certifications as described in 40 CFR 33.204-33.2015 or certified by EPA. EPA accepts certifications from entitles that meet or exceed EPA certification standards as described in 40 CFR 33.202. 'Subcontractor is defined as a company, firm, joint venture, or individual who enters into an agreement with a contractor to provide services pursuant to an award of financial assistance. FORM 4500-4 (OBE Subcontractor Utilization Form) NOVEMBER 2023 2024 HERBERT WALKUP PIPELINE REPLACEMENT PROJECT SECTION 00 75 00 GRANTFORMS 23 I certify under penalty of perjury that the forgoing statements are true and correct. Signing this form does not signify a commitment to utilize the subcontractors above. I am aware that in the event of a replacement of a subcontractor, I will adhere to the replacement requirements set forth in 40 CFR Part 33 Section 33,302 (c). Prime Contractor Signature Print Name �_ Troy Carson Title Date Vice President 12/15/23 The public reporting and record keeping burden for this collection of information is estimated to average three (3) hours per response. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Do not send the completed form to this address. FORM 4500-4 (DBE Subcontractor Utilization Form) NOVEMBER 2023 SECTION 00 75 00 2024 HE;RBERT WALKUP PIPELINE GRANT FORMS REPLACEMENT PROJECT 24 FORM 1 Contractor Name South Tahoe Public Utility District DBE Good — Faith Effort Documentation Tr��ca vt� vJ DISADVANTAGED BUSINESS ENTERPRISE (DBE) , Cap^°\ "GOOD FAITH" EFFORT LIST OF SUBCONTRACTORS SOLICITED Contractor Address How Located Date of Contact Type of WorklTrade Contact Method NOVEMBER 2023 2024 HERBERT WALKUP PIPELINE REPLACEMENT PROJECT Provide complete list. Lse additional sheets, if necessary SECTION 00 75 00 GRANT FORMS 25 Response (Yes/No) ot Public utility Dmentation Tap°a Pu ort poc Soto � �, Faith Eff,�NPLLY 81-p`NK pgE GE DEFT tNSEN� -TNtS P P SE500 G'V1UN, � :69w Gam` EMBER 2 � NN ALKV GprPEr-1NE X40 EMBER pRpJE REp�GEMEN� Type of Work or Trade Pavi ng SwPpltev- -vvakfsc COVA"Yp\ 'Cv-uckl�9 I South Tahoe Public Utility District DBE Good — Faith Effort Documentation FORM 5 SUMMARY OF BIDS RECEIVED DBE & NON -DBE THIS SUMMARY IS PREPARED BY THE PRIME CONTRACTOR Company Name I Selected I Bid Amount Yes or No &VO4-es GolbreGwaL-5® ppvl�y � NO b1%'-45b.00 gNtstev�NeuadasuppIq Howdy WgtTrai{itConhrol `(FrS Rev-vly DAD Transport No "Oo Lv1y k\Wvv1Trm*Av'5 I `1 ES E}puN ly DBE NON -DBE (Check) (Check) (List type of jobs alphabetically, from low to high in each category and selected low bidder. Include subcontractors, suppliers, and brokers. Use additional sheets, if necessary. NOVEMBER 2023 SECTION 00 75 00 2024 HERBERT WALKUP PIPELINE GRANT FORMS REPLACEMENT PROJECT 27 South Tahoe Public Utlllty District DBE Good - Faith Effort Documentation THIS PAGE LEFT INTENTIONALLY BLANK NOVEMBER 2023 SECTION 00 75 00 2024 HERBERT WALKUP PIPELINE GRANT FORMS REPLACEMENT PROJECT 28