HomeMy WebLinkAboutDBE Form 4500-4_RedactedWater, 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's' and the estimated dollar amount of each subcontract. A Financial Assistance Agreement
Recipient must require its prime contractors to complete this form and include kin the bid or proposal package.
Prime contractors should also maintain a copy of this form on file.
Flowline Contractors, Inc 2024 Herbert Walkup Pipeline Replacement Project
Bid I Proposal No. Assistance AgreementID No. (IF known) Point of Contact
None Provided None Provided Spencer Roberts
Address
Telephone No. Email Address
ISao n un Ing n
South Tahoe Public Utility District
I have identified potential DBE certified subcontractors. XS NO
N yes, please complete the table below. If no, please explain:
Solicited 30 DBE businesses as well as posted a Newspaper Advertisement and a posting on the Small
Business Administration online portal. Most businesses were not interested in the project or could not
provide a competitive quote.
Subcontractor Name/ Estimated Currently
Company Address I Phone I Email DBE
Company Name Ddlar_ Certified?
—Continue on back if needed —
'A DBE is a Disadvantaged, Minority, or Woman Business Enterprlse 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 4500-4 (DOE Subwntractor Utilization Form)
NOVEMBER2023
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
Ben Borba
Title
Date
CEO
12/15/2023
The public reporting and record keeping burden for this collection of i, l _ 1...c — 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
2024 HERBERT WALKUP PIPELINE
REPLACEMENT PROJECT
SECTION 00 75 00
GRANT FORMS
24