HomeMy WebLinkAboutGrant Forms_Redacted Enviranmardal Protection any sr t OMB Control NO:2090HI d
p ro al Ott° ; J 701'
Disadvantaged BUSineSS Enterprise t Program
Subcontractor r It li atio Form
This,fort is intended to capture the prinie.contractor's actual and/or anticipated use of identified certified DBEI
subcontractors"and the estimated dollar aniowit of each subcontract. An EPA 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 file.
s ' Prime Contractor Name 1 Project Name
4 Co
fit Pr pos l ast rr ree rterrt is .(if known) Point s Contact 3
Address
F i'ele s one N
o. P �
sstrat /iaz di
7 `
1 have identified potential IYES No
Rl
g certified subcontractors
KE is
r ;�eNO
lf, es,please complete the tab)e below. of no, please explain.
a
Subcontractor Name/ Company address/Phone/Ernail Est. Dollar Currently
Company Name Arat DBE
rti
c
j
_l
Y a
Continue on back if needed
'ABBE is a Disadvantaged,Knority,or Woman Business Enterprise that has been certified by are a^tity from which EPA accepts certifications as
described 1n 40 CFR 33.204-31205 or cer sfi d iry EPA.EPA accepts certifications from Pntit vs thit meet or exceed EPA cerflficatfan star lards as
21 Subcontractor is defifl d as a company,resin,joint venture,or individual who enters:into an agx eernertt wi1b a contra ctor to pr vilLL
,services Pursuant to an EPA awnrd of financial asmstance,.
BPA FORM - (LIBE Subcontractor Utilkation F
EF
Au"'ted
€rs at r tr ti ea
Agency
ONM Control No:2090-0030
.�i�a�rove :8/13/201
Approval Expires:8/31/2015
Disadvantaged Business Enterprise(DBE) Program
BE Subcontractor Utilization;Form
I certify under penalty of perju r that the forgoing statements are true and correct. Signing this form floes not
signify a commitment utilize the subcontractors above. I am aware of that in the event at a replacement ent of
..., subcontractor,I will adhere to the replacement requirements set forth in 40 CFR Pert 33 Section 33.3 (c),
Prinie €rtratr t t€tre Print Name
mow,. AP
# R ,
t ,
Title Date l
The public reporting and recordkeeping burden for this collection of information is estimated to average three ( )fours
per response. Send comments on the Agency's geed for this information,the accuracy of the provided burden
estimates, and any suggested methods for minimizing respondent burden, including through the use of automated
1 collection techniques to the Director,Collection Strategies Division, U.S. Environmental protection Agency( 22T) @
Pennsylvania Ave., NW, Washington, D.C. 20460. include the OMB control number in any correspondence, Do not send
the completed form to this address.
EPA<FORM 6100-4(DBE Subcontractor Utilization Form)
k
ifsa3ied SWIPS ) 1R Cis11tr0l o:2090-oil
an0roamenial Protection
Agency Approver;8113J2013 F"
a
Disadvantaged Business EnterpriSe B Program ;
D13E SubcontractorPer c tar
l
This form is tit ended to capture the DBEI subcontr ctorV description of work to be performed and the price of
dace work submitted to the prime contractor. An EPA Financial A:� istn�re .�l�re eat ecipiout must r'c usr e its i
prime contractor to have its DBE subcontractors complete this form and include all completed fornis in the prime
contractors bid or proposal package.
j Subcontractor-Name � Project Name
Bid/Proposal No. � s5istarice eement ID No. it-known Point of Contact m �
3 i i
-address
T�*i o p
F
a
Contract Item Number ascription f WorkSubmitted to the Prime Contractor Z=Wtted
off r
involving Cow cti e.N, uip t r Sapp esto the
Prime
l
a �
DBE Certified B DOS` SBA Meets/exceeds EPA certification standards?
n Other; YES o cry
I A DOE is a Disadvantaged,mmoray,or Y-/oman ausiness Enterpr ise€hat has been certified by an entity from which EPA accPpUcertifications as
descr'led in 40 CFR 33.204- 3 2 a orce€tified by EPA,EPA accepts certificarmsftoin entities that meet or exceed EPA certfficatlow standards as
descdbed is 40 CFR 33,202. l
`Subcontmctor as dca#enpc6 a rrr.r ry e..firm,joint;ea"n'lure or inl;a on go,:,:-e+tr entw9th a cvntr actor-ta pro r3�t�s�s`t(ces
pursuant to an EPA award of financial a stance,
t
Wgonry
nited States OMB Control No,Z090-0030
I EVA E f nrrie i�fl'rtr ciic�n Approved:8f13f2013
_approval Expiate 8/31'
Disadvantaged Business Enterprise(DIRE)Program
DRE Subcoittractor Performance Form
I certi r under penalty of perjury that the forgoing statements are true and correct. Signin this form sloes not
signify a commitment to utilize the subcontractors above, I am aware of that in the evert of a replacement of a
subcontractor,S will adhere to the replacement requirements set forth in 40 CFR Part 33 Section 33.302 (c).
3 PriTne Contractor Slanatare Print Name I
- `�; r 1'-► � I V' tom--. j
I1tle Date
x bru €racar Si Pint Name Signature i
3
amric y
Title Hate , 311
z
r
i
i
t,
y
The public reporting and reco'rdkeeping burden for this collection of information is estimated to average three(3)hours
per response,Send comments can the Agency's need for this information,tfie accuracy of the provided burden
estirnaies, and any suggested methods for minimizing respondent burden,inclining through the use of automated
collection techniques to the Director Collection:strategies Division,i1.5_Environmental Protection Agency(2 22T), 1200
Pennsylvania Ave.,NW,Washington, D.C.20460.Include the OiV R control number in any correspondence. Do not send
the completed form to this address.
PA FORM 6100-3 DBE Subcontractor Performance Fern)
AMERICAN ]RON AND STEEL CERTIFICATION
CONTRACTORIAPPLI A T
1. Identification of American-made iron and Steel:Consistent with the terms o=the Purchaser's bid solicitation, the
Bidder certifies that this bid reflects the bidder's best,good faith effort to idenfi domestic sources of iron and steel
for every component contained in the bid solicitation where such American-made components is are available can the
schedule and consistent with the deadlines prescribed in or required by the bid solicitation
Verification of U.S. Production:The Bidder certifies that all components contained in the bid solicitation that are
Arnerican-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?ron and Steel."The Bidder ceitifies that for any component or
coinpo eats that are net A nericara=rmade 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 repaired in the bid solicitation or otherwise,that the
Bidder has sought to secure American made components but has determined that such components are riot
2Vailabla 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-Arnerican-!made Iron area Steel.The Bidder certifies that for
any such component or components that are not so available,the Bidder has also provided i;,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 laid is accepted,it will assist the Purchaser in
amending, supplementing,or further supporting such information as required by the Purchaser to request and,a
applicable,implement the terms of a waiver with respect to any such component or components.
CERTIFICATION
is the official named below, hereby swear that i am duly authorized legally to Mild the contractor
or loan recipient to the above described certification, 1 am fully aware that this certification,
executed on the date and in the county below, i ;made;under penalty of perjury parader the lags
of the State of California.
O ICIAL' TAME: r L
DATE EXECUTED; - EXE IJTED fN CQUNW CI":
CON TRACTOR/APPLICANT SIGNATURE.,
TITLE
12/21118 SECTION oil 75 00
WATER METER IN TALLATiON PROJECT—PHASE 5 GRANT FORM
3
THIS PACE LEFT I# TI" NT16NALLY WANK
120118 SECTION 00 75 00
WATER METER IN TALLATION PROJECT-PHASE 5 GRANTFORMS
4
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND
VOLUNTARY EXCLUSION
CONTRACTOR/APPLI CANT,
(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, Mate 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 ing false statements, or receiving stolen property;
(c) Are not presently indicted for of 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.
( ) Where the contractor is Linable 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
1, the official named below, hereby swear that l 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 Mate of California.
OFFICIAL NAME: r �� CA
DATEEXECUTED: EXECUTED IN COUNTY O
CONTRACTOR APPLICANT SIGNATURE: '
TITLE:
12121118 ECTION 00 75 00
WATER METER INSTALLATION PROJECT--PHASE> GRANTFORMS
5
THIS PAGE LEFT INTENTIONALLY BLANK
E
12/21/18 SECTION 00 75 0
WATER METER INSTALLATION PROJECT-PHASE 5 GRANTFORM3
6
CERTSCATION REGARDING LOBBYING
The undersigned certifies to the best of his or her knowledge and belief that;
1 o 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, are officer or employee of Congress, or an employee of
Member of Congress in conjunction with the awarding of any Federal contract, the snaking 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 are officer or employee of any agency, a
Member of Congress, are officer or employee of Congress, or an employee of a Member of
Congress in connection with this federal contract, grant, lean or cooperative agreement, the
undersigned shall complete and submit Standard Form LLL; Disclosure Form to eport
Lobbying in accordance with its instructions,
CERTIFICATION
1, the official named below, hereby swear that 1 am dubs authorized legally to bird the contractor
or loan recipient to the above described certification. l;am fully aware that this certification,
executed on the date and in the county below, is made under penalty of perjury under the lasts
of the Mete of California.
OFFICIAL'S NAtvlE: -1
DATE EXECUTED: EXECUTED IN COUNTY OF:
CONTRA TORfAPPI-I CANT SIGNATURE:
TITLE:
THIS PAGE LEFT INTENTIONALLY BLANK,
i
7
DISCLOSURE OF LOBBYING ACTI {TIE Approved by OMB
Complete this form to disclose lobbying activities pursuant to 31 U.S. 1362 0 46
See reverse for public burden d s losur�.
1.Type of Federal Action: 2.Status of Federal Action: 3. RePort e:
a. contract a. bid/offer/application a. initial filing
b. grant b, initial award la. material change
c. cooperative agreement< c. post-award For Material Change Onlyr:
d. lean year qu rter
e. loam guarantee data of last report
fa loan insurance
4. Name and Address of Reporting Entity: 5. if Reporting Intl lrt ct_4 i�a ba r Enter Name
Prim [�Subs rrlee and dress of Prime:
Tier ifknown
Congressional District, ifknown: Congressional Die ict ifkrrown.-
.Federal Department/Agency.- 7. Federal Progral flame/Description:
F /Nber', applicable:
it.Fedeml Action Number, of known: 9.A Amount, if known:
10.a. Name and AddressLobbying Registrant .Individuals Pe orTning ervicesin irr ' cf r if
(ff individual,last name, fast rrarrre tit : dffferent from No. 10a
(last name, first name, l J}:
tnf4Prracshan raguaasdad ftmVh tl'is farrra is au#vwded by - 31 U.S.C.:. �s '
1352 This dlsd aavro of cbbyina acfru&es is a.:rMnatenal nWori of fact ` t�r��tlarif :
am 1rrhi riff am placed by the tier,above when t' transAtfio B was rr�rte a
Dr entered lrflot This d' is reg6rad pursmin 91'UX.C. 13 , this Print!Marne:
W loe rMll he arvaltabta rear putrlrr wnspe parm�i who fare to the y
ro wed dodos le shall be subj to a€jY9 or not les$than $10,0000d : rifle: B
not more than$100,000 for each such faRum,
Telephone N Data:
n Atrtholi7ed for Local ReprMuction
..:; Standard Form LLt Rev.7-97i
r
r"
INSTRUCTIONS FOR COMPLETION OF SF-LLL,DISCLOSURE OF LOBBYING ACTIVITIES
This disclosure farm shall be completed by the reporting entity,whether subawardee or prime Federal recipient,at the initiation or receipt of a covered Federal
notion,or if material change to a previous filing,pursuant to We 31 U-3.C.section 1352.The Ming of a form is required for each paymentor agreement to make
payment to any lobbying entity for influencing or attempting to influence an officer or employeeof any agency,a Member of Congress,an officer or employee of
Congress,or an employeeof a Member of Congress in connection with a covered Complete all items that apply for booth 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 andtor 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 accurred Enter the date of the last previous lysubmitted 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 1st 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"Subs ardee,"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 organizationallevel below agency name,if known.For
example.Department of Transportation,United States Coast Guard:
7. Enter the Federal program name or description for tine 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:
It Enter the most appropriate Federal identifying number availablefor 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 application/proposal control number
assigned by the Federal agency).Include prefixes,e.g.,'"RFP-DE-90-0011."
9. For a covered Federal action where there has been artaward or loan cornmitmentby the Federal agency,enter the Federalamount 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 fall names of the individual(s)'performing services,and include full address if different from 10(a).Enter Last Name,First blame,and
Middle Initial(MI).
11,The certifying official shalt 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 Managementand Budget,Paperwork Reduction Project(0348-0046),Washington,
LAC 20503.