1. No category

 ALLEGANY COUNTY, MD
DEPARTMENT OF PUBLIC WORKS – ENGINEERING DIVISION
REQUEST FOR PROPOSAL FOR
PROFESSIONAL ENGINEERING SERVICES
GEORGES CREEK – SHAFT: STREAM RESTORATION
INTRODUCTION:
Proposals are being solicited from qualified and experienced consultants to perform a) a
watershed and stream reach assessment; b) an alternatives analysis for potential solutions; and c)
a design for the recommended and accepted alternative that will restore approximately 3,500
linear feet of Georges Creek in the unincorporated area of Shaft, south of Frostburg, Maryland.
See Exhibits A-E as listed on Page 9 of this Request for Proposal.
The recommended design will demonstrate the most cost-effective option to achieve the Project
Goals and Objectives while maximizing credit in the Chesapeake Bay Total Maximum Daily
Load (TMDL) model. Design deliverables will include Phase 1: Engineering Report; and Phase
2: Contract Plans and Specifications.
BACKGROUND INFORMATION:
A Stream Corridor Assessment Survey and Watershed Characterization Report were completed
for Georges Creek in 2001 as part of the Georges Creek Watershed Restoration Action Strategies
(WRAS) Plan, completed in June 2002 through a partnership of Georges Creek residents,
Allegany County, and Maryland Department of Natural Resources. The Stream Corridor
Assessment Survey assigns the proposed project area a “very severe” rating for “unusual
conditions”. The Report narrative mentions the very large lake (surface mine pit) and indicates
“the stream channel is dry and the mainstem of Georges Creek is several feet above the water
surface of the lake”. This site was the only site in the upper Georges Creek watershed assigned
this “very severe” rating. Notably, the 2001 Watershed Characterization Report identifies the
area of Winebrenner Run confluence as a “wetland restoration opportunity” due to existing
hydric soils.
Allegany County’s Watershed Implementation Plan (WIP) Committee for the Chesapeake Bay
TMDL, in an effort to achieve milestone goals for stream restoration, maintains a Stream
Restoration Priority List (List). The subject reach of Georges Creek is identified on the List due
to the existing poor condition of the stream, as noted in the WRAS and more current site visits.
Specifically, urban watershed development and disturbances associated with surface and deep
coal mining throughout the watershed over many decades has caused this gradual reach of
stream to aggrade over time. The channel alignment is variable from one high flow event to
Request for Proposals
Georges Creek – Shaft: Stream Restoration
Page 1 of 9
April 14, 2015
the next, causing erosion and sediment deposition. The 100-year FEMA mapped floodplain
encompasses an adjacent surface mine pit. Furthermore, the stream currently base flows into
the surface mine pit (see Exhibit C: Photos) where flow loss into deep mine workings and further
water quality degradation due to iron and acidity is highly suspected.
Notably, the Abandoned Mine Lands (AML) Division of Maryland Department of the
Environment (MDE) is undertaking a study titled “Upper Georges Creek Stream Sealing Project”
whereby stream flows will be monitored during the period of May to September 2015 to
determine points of stream loss into the underlying Hoffman Drainage Tunnel. This reach of
Georges Creek and the adjacent surface mine pit are highly suspected to be points of stream
loss. The Hoffman Drainage Tunnel was built in the early 1900s to drain groundwater from the
deep coal mines of a 10 square mile area surrounding Frostburg. The Hoffman Drainage
Tunnel still discharges to Braddock Run in the unincorporated area of Clarysville, east of
Frostburg, today. The results of this AML flow loss assessment are to be available by November
2015 and will be considered in proceeding towards the construction phase of this Georges CreekShaft: Stream Restoration.
The flat grade in this area and variable alignment of the Georges Creek channel also leads to
issues with the existing Georges Creek Interceptor Sewer. Infiltration of stream underflow into
the sanitary sewer is highly probable. Furthermore, sanitary manholes on the line are inundated
during high flow events, causing infrastructure damage and allowing stream flow to enter the
sanitary sewer system. Maintenance access to the sewer line is more difficult due to the variable
alignment of Georges Creek.
The current condition of the stream misses an excellent nutrient processing opportunity as the
stream carries stormwater runoff from the urban area of Frostburg through the Georges Creek
valley. The proposed project has great opportunity to improve water quality both in terms of
sediment and nutrient processing, as well as prevention of thermal and mine working impacts.
PROJECT GOALS AND OBJECTIVES:
Goal #1
Enhance Nutrient Processing
In support of the Chesapeake Bay TMDL for sediment, nitrogen and phosphorus, improve
opportunity for nutrient processing through this gradual stream reach to reduce sediment and
nutrient load to lower Georges Creek, the Potomac River, and ultimately the Chesapeake Bay.
Objective 1a: Re-define a stable, appropriately sized Georges Creek channel that will maintain
base flows and not aggrade or degrade over time.
Objective 1b: Provide floodplain connectivity to facilitate sediment deposition, provide
sediment storage and establish the water table to be in contact with the root zone
of a riparian buffer to promote denitrification.
Request for Proposals
Georges Creek – Shaft: Stream Restoration
Page 2 of 9
April 14, 2015
Objective 1c: Establish a riparian buffer to regulate surface water temperature, stabilize stream
banks, and provide nutrient uptake by riparian vegetation.
Goal #2
Address Sanitary Sewer Impacts
Address existing impacts to sanitary sewer due to poorly defined Georges Creek channel and
adjacent surface mine pit, specifically, the potential for inflow and infiltration.
Objective 2a: Re-define a stable Georges Creek channel that will be offset from the alignment
of the sanitary sewer to reduce infiltration into sanitary sewer during base flow
conditions and provide adequate maintenance access to sanitary sewer.
Objective 2b: Raise sanitary sewer manholes above 100-year floodplain elevation to reduce
inundation and inflow during flooding.
Objective 2c: Address whether lining or replacement/realignment of sanitary sewer is
warranted to further reduce inflow and infiltration.
SCOPE OF SERVICES:
1. Phase 1: Watershed and Stream Reach Assessment and Alternatives Analysis
The Consultant shall perform an appropriate assessment of the watershed and stream
reach to develop a thorough understanding of the contributing factors to the existing
stream condition. The Consultant shall develop two (2) or three (3) viable alternatives to
achieve Project Goals and Objectives and compare feasibility, long-term sustainability,
and cost of each. Based on consultation/site visit with MDE, each alternative must be
permittable by MDE Nontidal Wetlands and Waterways Division. The Consultant shall
recommend one (1) alternative for design.
Deliverable: Engineering Report
An Engineering Report is to be prepared and submitted, which must include results of
the Watershed and Stream Reach Assessment, a discussion of the proposed Design
Methods for each identified alternative, and an Alternatives Analysis comparing
feasibility, long-term sustainability and cost, as well as other relevant items considered.
As part of the Engineering Report, preliminary design drawings for each alternative shall
be submitted for review.
The Engineering Report shall meet the requirements referenced above and also include
(at a minimum):
 Executive Summary
 Scope
 Project Information
Request for Proposals
Georges Creek – Shaft: Stream Restoration
Page 3 of 9
April 14, 2015
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Need for Project
Watershed and Stream Reach Analysis
Alternatives Analysis (2 or 3 viable alternatives)
o Design Methods
o Feasibility (Construction and Permitting)
o Long-term sustainability
o Engineer’s Estimate of Probable Cost
Recommended Alternative
Summary and Conclusion
Appendices: Tables, Charts, Maps, Calculations, and Preliminary Design
Drawings (as applicable)
Prior to the completion and submission of the Final Engineering Report, the Consultant
shall submit three (3) copies of the Draft Engineering Report for review and comment by
Allegany County. Any comments and all agreed-upon revisions shall be incorporated
prior to the submission of the Final Engineering Report. Following Allegany County’s
approval of the Final Engineering Report, all electronic files (maps, estimates, reports,
design files, etc.) shall be provided to Allegany County. The Final Engineering Report
shall be due no later than September 7, 2015.
2. Phase 2: Design
Upon Allegany County acceptance of the Final Engineering Report and the
recommended alternative, the Consultant shall develop basic contract plans for
permitting and construction of the accepted alternative.
Deliverable: Contract Plans
Contract plans shall include the following information, at a minimum:


Plan/Profile/Cross Section Sheets (as appropriate)
Construction Details (Sewer, Environmental, etc.)
The purpose of required deliverable is to enable Allegany County to complete
development of full Contract Plans. All necessary “finish” design work (title block, notes,
legend, etc.) shall be developed by Allegany County and will not be the responsibility of
the Consultant.
The plans shall be developed in AutoCAD (*.dwg) format (2008 or later) and all
electronic drawing files and associated permissions shall be turned over to Allegany
County and/or its designees for future indefinite use.
Request for Proposals
Georges Creek – Shaft: Stream Restoration
Page 4 of 9
April 14, 2015
Deliverable: Contract Specifications
The Consultant shall provide contract technical specifications for construction of the
recommended design. Consultant will be responsible for completing all necessary
technical specifications for proposed design. This includes specifications for all proposed
work and associated measurement/payment explanations. Specifications shall be
developed to match other similar Allegany County projects. Examples will be provided
to Consultant.
Specifications shall be provided in Microsoft Word (*.docx) format (2007 or later) and all
electronic document files and associated permissions shall be turned over to Allegany
County and/or its designees for future indefinite use.
Deliverable: Documentation of Coordination with Permitting Agencies
The Consultant shall be responsible for developing a design that will meet permitting
requirements. At a minimum, permits will be required from MDE Nontidal Wetlands &
Waterways Division (Waterway Construction) and Allegany County (Sediment & Erosion
Control). Depending on the scope of the selected alternative, other permits may also be
required. The Consultant shall be responsible for coordinating with applicable
permitting agencies to ensure that the design meets all requirements of permitting
agencies. Allegany County will secure all necessary permits.
OTHER CONSIDERATIONS/EXPECTATIONS:
1. GIS Utilization
Data maintained within an ESRI ArcGIS geodatabase is available and can be provided in
this format or exported to any other GIS data formats as agreed upon between Allegany
County and the Consultant. The Consultant shall use GIS data maintained by Allegany
County in the design of the proposed project and in the preparation of the Engineering
Report.
As appropriate, all data and existing drawings maintained by Allegany County will be
made available to the Consultant. This data includes:

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Parcels
Addresses
Topography


Streets & Street
Names
Orthographic
Aerial Imagery

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Sanitary Sewers
Water Lines
Buildings, etc.
2. Computer Modeling/Design
The design must be completed using existing and proposed stream cross-sectional data.
Request for Proposals
Georges Creek – Shaft: Stream Restoration
Page 5 of 9
April 14, 2015
The model/design and associated files (electronic or otherwise) must be made available
to Allegany County at the conclusion of the project for future indefinite use by Allegany
County and/or its designees.
3. Coordination/Progress Meetings
The Consultant shall make an allowance in the proposal for progress meetings at the
Allegany County Office Complex with personnel from Allegany County and other
review agencies, as necessary, to review progress and coordinate procedures and data.
The meetings shall be held over the contract period and based on the various milestones
as identified in the Consultant’s proposal. As a minimum, the milestones must include a
kickoff meeting, Draft Engineering Report review meeting, and Final Engineering
Report review meeting.
4. MBE/WBE Participation
Allegany County encourages the participation of Minority and Women Business
Enterprises (MBE/WBE) in this project and is an Equal Opportunity Employer. The
Consultant is required to make a good-faith effort to solicit any small, minority, and
women’s businesses that are qualified to participate in the design process. The Consultant
shall be required to demonstrate and document the affirmative steps to provide
opportunities for MBE/WBE firms to share in this proposal. There is no fixed MBE/WBE
goal for this project.
SUBMITTAL REQUIREMENTS:
The Consultant shall provide submittals and meeting notes as needed throughout the contract
period summarizing work progress (including field data gathering). The Consultant shall
submit three (3) paper copies of each submittal. All submittals must be clearly copied and the
Consultant shall incorporate changes into each subsequent submittal based on comments from
Allegany County. The Final Engineering Report shall contain two (2) bound copies, one (1)
reproducible and unbound paper copy, and one (1) electronic copy (Adobe Acrobat PDF format
on CD-ROM preferred). Electronic submittal of AutoCAD files shall also be required (e-mail or
CD-ROM).
TENTATIVE PROJECT SCHEDULE:
Consultant to commence Phase 1: Study
Consultant to submit Draft Engineering Report
County to complete review of Draft Engineering Report
Consultant to submit Final Engineering Report
Commencement of Phase 2: Design
Consultant to submit Contract Plans/Specs
to County/Permitting Agencies
Request for Proposals
Georges Creek – Shaft: Stream Restoration
Page 6 of 9
June 1, 2015
August 10, 2015
August 24, 2015
September 7, 2015
September 14, 2015
October 26, 2015
April 14, 2015
County to complete review of Contract Plans/Specs
Consultant to submit Final Contract Plans/Specs
Final Report/Deliverables due
to MDE Science Services Administration
November 9, 2015
December 21, 2015
December 31, 2015
CONSULTANT QUALIFICATIONS:
The successful Consultant firm and assigned personnel will have strong backgrounds in
conducting such studies, which must include extensive experience in stream restoration analysis
and design that meets efficiency requirements of the Chesapeake Bay TMDL Model, treatment
of abandoned mine lands, field data gathering and cost estimating. The firm must have capacity
to assign adequate personnel to complete the study in an ongoing and timely manner. No time
extension will be granted under this project.
ALLEGANY COUNTY RESPONSIBILITIES:
Allegany County will provide the successful Consultant with general guidance and liaison
services to other agencies. Background material will also be provided.
Allegany County will be responsible for:
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Providing general assistance in the investigation of the project area.
Providing available GIS mapping, as appropriate.
Serving as primary contact with the impacted property owners in the project area.
Providing copies of as-built drawings for any existing systems (as available from
Allegany County and Maryland Department of the Environment - Abandoned Mine
Lands Division).
Providing bid tabulations for similar work awarded in Allegany County, as available.
Providing applicable “front-end” documents for use in assembly of Contract
Specifications.
Securing necessary permits
All of these services shall be provided to the Consultant at no cost.
COMPENSATION:
The Consultant will be paid monthly within thirty (30) days upon submission of an acceptable
and approved invoice.
PROPOSAL SUBMISSION:
Your proposal must include the following:
Request for Proposals
Georges Creek – Shaft: Stream Restoration
Page 7 of 9
April 14, 2015
1. Relevant firm qualifications and experience on similar types of projects with
documentation of successful projects.
2. List of any sub-consultants you propose to use and their qualifications and experience.
3. Demonstration of a working knowledge of the regulations and processes of Maryland
Department of the Environment (MDE) and Allegany County. Explain applicable
experience with each agency.
4. Demonstrated experience in watershed and stream reach assessment, analysis and
restoration design that qualifies for maximum credit in the Chesapeake Bay Model.
5. The identity, qualifications, and relevant experience of key personnel, sub-consultants,
etc., who will supervise the project and actually perform the work. This item will receive
particular consideration in evaluating proposals.
6. A project approach and detailed scope of services, including but not limited to, a
discussion of the level of assessment needed to diagnose the existing condition and the
level of analysis needed to compare alternatives and determine cost and feasibility.
Include computer software anticipated to be used.
7. A minimum of four references complete with names, addresses, and telephone numbers
of clients familiar with your firm’s work on similar projects.
8. A refined project schedule and information regarding your assessment of and ability to
meet the project schedule. Note: project completion date is December 31, 2015 (FIRM).
9. A Lump Sum cost proposal and man-hour summary broken down into the following
categories (as a minimum):
 Project Planning and Information Gathering
 Field Work
 Watershed and Stream Reach Assessment
 Alternatives Analysis
 Recommendations
 Draft Report
 Final Report
 Contract Plans/Specifications/Permitting Coordination
10. Hourly rates and associated charges for additional consulting services.
11. Sample reports for similar projects (to be returned to consultant).
12. Any additional information or unique qualifications you feel may be relevant to this
project or the criteria being used in the selection process.
13. Other information or suggestions you feel will enhance your firm’s position to be
selected for this project.
14. Documentation of good faith effort to solicit MBE/WBE participation. See Exhibit D for
required documentation.
15. Consulting firms who have not completed work for Allegany County within the past two
(2) calendar years must complete Attachment E: Consulting Firm Qualification
Statement.
Three (3) printed copies of each proposal shall be submitted. Proposal must be received no later
than 3:00 PM on Friday, May 15, 2015. No e-mail or fax copies will be acceptable.
Request for Proposals
Georges Creek – Shaft: Stream Restoration
Page 8 of 9
April 14, 2015
Allegany County may short list and interview selected consultants based on review of the
submitted proposals.
PRE-PROPOSAL MEETING:
A mandatory pre-proposal meeting will be held on Wednesday, May 6, 2015 at 10:00 AM, at the
Allegany County Office Complex, Room 100, 701 Kelly Road, Cumberland, MD 21502. An
optional site visit will be held after the meeting for anyone who may wish to attend.
CONSULTANT SELECTION CRITERIA:
Consultants shall be selected based upon the following:
a. Qualifications and experience of the Engineer and team with similar-type projects (40%)
b. Completeness and quality of proposal and project approach (40%)
c. Cost (20%)
ATTACHMENTS:
Exhibit A – Watershed Map
Exhibit B – Site Plan Map
Exhibit C – Photos
Exhibit D – Good Faith Effort Checklist/Documentation
Exhibit E – Consulting Firm Qualification Statement
QUESTIONS:
Questions may be directed to Daniel S. DeWitt, P.E., Allegany County Department of Public
Works via telephone (301-876-9560) or e-mail (ddewitt@alleganygov.org). Questions received up
to the question deadline (to be set at the pre-proposal meeting) will be answered via e-mail, as
appropriate, to all firms who sign attendance sheet at the May 6, 2015 pre-proposal meeting.
Request for Proposals
Georges Creek – Shaft: Stream Restoration
Page 9 of 9
April 14, 2015
0
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Exhibit A
Watershed Map
Georges Creek Stream
Restoration
Commercial (0.14 sq mi or 1.5%)
Impervious Areas (0.81 sq mi or 8.4%)
Forest, Ag, Preservation (5.76 sq mi or 59.6%)
Watershed (9.66 sq mi total)
Industrial, Institutional (1.3 sq mi or 13.5%)
Stream Channels
Residential (1.87 sq mi or 19.4%)
Frostburg
36
¬
«
MapmyIndia, © OpenStreetMap contributors, and the
Transportation Esri,
(0.59 HERE,
sq mi orDeLorme,
6.0%)
GIS user community
SW
DR
ISTA
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EY V
Surface Mine
Now Reclaimed
(Non-Forest, Undeveloped)
#
To Frostburg
Ru
VAL
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B
CA
IN
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RD
SW
Surface
Mine
Pit
¯
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TYSON CORNER SW
Georges Creek
Allegany Coal & Land Co.
M. 36 / P. 104
62 Ac
936
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400
800
Feet
Exhibit B
Site Plan Map
Tipple Site
Reclaimed by MDE
Abandoned Mine Lands Division
(Non-Forest, Undeveloped)
N
ef f
n
Ru
Georges Creek
Stream Restoration
Stream Channels
Project Study Area
Sanitary Sewer Manhole
Georges Creek Sewer Interceptor
FEMA 100 Year Floodplain
Parcels
To Midland
#
!
(
EXHIBIT C: PHOTOS
Photo 1: Georges Creek looking downstream at dry channel. Base flow turns right and discharges into adjacent surface mine pit. Photo 2: Base flow of Georges Creek mainstem is flowing into surface mine pit. Attachment C-11
OMB Control No: ________
Approved:
________
Approval Expires: ________
Environmental
Protection Agency
Disadvantaged Business Enterprise Program
DBE Subcontractor Participation Form
NAME OF SUBCONTRACTOR1
PROJECT NAME
ADDRESS
CONTRACT NO.
TELEPHONE NO.
E-MAIL ADDRESS
PRIME CONTRACTOR NAME
Please use the space below to report any concerns regarding the above EPA-funded project (e.g., reason for
termination by prime contractor, late payment, etc.).
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRACT
ITEM NO.
ITEM OF WORK OR DESCRIPTION OF SERVICES RECEIVED FROM
THE PRIME CONTRACTOR
_________________________________
Subcontractor Signature
AMOUNT
SUBCONTRACTOR
WAS PAID BY PRIME
CONTRACTOR
______________________________________
Title/Date
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 EPA award of financial assistance.
1
EPA FORM 6100-2 (DBE Subcontractor Participation Form)
OMB Control No: ________
Approved:
________
Approval Expires: ________
Environmental
Protection Agency
Disadvantaged Business Enterprise Program
DBE Subcontractor Participation Form
The public reporting and recordkeeping burden for this collection of information is estimated to average fifteen (15)
minutes. Burden means the total time, effort, or financial resources expended by persons to generate, maintain,
retain, or disclose or provide information to or for a Federal agency. This includes the time needed to review
instructions; develop, acquire, install, and utilize technology and systems for the purposes of collecting, validating,
and verifying information, processing and maintaining information, and disclosing and providing information;
adjust the existing ways to comply with any previously applicable instructions and requirements; train personnel
to be able to respond to a collection of information; search data sources; complete and review the collection of
information; and transmit or otherwise disclose the information. An agency may not conduct or sponsor, and a
person is not required to respond to, a collection of information unless it displays a currently valid OMB control
number.
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 the use of automated collection techniques to
the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822), 1200 Pennsylvania Ave.,
NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the
completed EPA DBE Subcontractor Participation Form to this address.
EPA FORM 6100-2 (DBE Subcontractor Participation Form)
Attachment C-12
OMB Control No: _________
Approved:
_________
Approval Expires: _________
Environmental
Protection Agency
Disadvantaged Business Enterprise Program
DBE Subcontractor Performance Form
NAME OF SUBCONTRACTOR1
PROJECT NAME
ADDRESS
BID/PROPOSAL NO.
TELEPHONE NO.
E-MAIL ADDRESS
PRIME CONTRACTOR NAME
CONTRACT
ITEM NO.
ITEM OF WORK OR DESCRIPTION OF SERVICES
BID TO PRIME
PRICE OF WORK
SUBMITTED TO
PRIME CONTRACTOR
Currently certified as an MBE or WBE under EPA’s DBE Program? ______ Yes ______ No
Signature of Prime Contractor
Date
Print Name
Title
___________________________________________
Signature of Subcontractor
__________________________________________
Date
___________________________________________
Print Name
__________________________________________
Title
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 EPA award of financial assistance.
1
EPA FORM 6100-3 (DBE Subcontractor Performance Form)
OMB Control No: _________
Approved:
_________
Approval Expires: _________
Environmental
Protection Agency
Disadvantaged Business Enterprise Program
DBE Subcontractor Performance Form
The public reporting and recordkeeping burden for this collection of information is estimated to average fifteen
(15) minutes. Burden means the total time, effort, or financial resources expended by persons to generate,
maintain, retain, or disclose or provide information to or for a Federal agency. This includes the time needed to
review instructions; develop, acquire, install, and utilize technology and systems for the purposes of collecting,
validating, and verifying information, processing and maintaining information, and disclosing and providing
information; adjust the existing ways to comply with any previously applicable instructions and requirements; train
personnel to be able to respond to a collection of information; search data sources; complete and review the
collection of information; and transmit or otherwise disclose the information. An agency may not conduct or
sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid
OMB control number.
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 the use of automated collection techniques to
the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822), 1200 Pennsylvania Ave.,
NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the
completed EPA DBE Subcontractor Performance Form to this address.
EPA FORM 6100-3 (DBE Subcontractor Performance Form)
Attachment C-13
OMB Control No: _________
Approved:
_________
Approval Expires: _________
Environmental
Protection Agency
Disadvantaged Business Enterprise Program
DBE Subcontractor Utilization Form
BID/PROPOSAL NO.
PROJECT NAME
NAME OF PRIME BIDDER/PROPOSER
E-MAIL ADDRESS
ADDRESS
TELEPHONE NO.
FAX NO.
The following subcontractors1 will be used on this project:
COMPANY NAME, ADDRESS, PHONE
NUMBER, AND E-MAIL ADDRESS
TYPE OF WORK TO BE
PERFORMED
ESTIMATE
D DOLLAR
AMOUNT
CURRENTLY
CERTIFIED
AS AN MBE
OR WBE?
I certify under penalty of perjury that the forgoing statements are true and correct. 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).
Signature Of Prime Contractor
Date
Print Name
Title
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 EPA award of financial assistance.
1
EPA FORM 6100-4 (DBE Subcontractor Utilization Form)
Environmental
Protection Agency
OMB Control No: _________
Approved:
_________
Approval Expires: _________
Disadvantaged Business Enterprise Program
DBE Subcontractor Utilization Form
The public reporting and recordkeeping burden for this collection of information is estimated to average fifteen (15)
minutes. Burden means the total time, effort, or financial resources expended by persons to generate, maintain,
retain, or disclose or provide information to or for a Federal agency. This includes the time needed to review
instructions; develop, acquire, install, and utilize technology and systems for the purposes of collecting, validating,
and verifying information, processing and maintaining information, and disclosing and providing information;
adjust the existing ways to comply with any previously applicable instructions and requirements; train personnel
to be able to respond to a collection of information; search data sources; complete and review the collection of
information; and transmit or otherwise disclose the information. An agency may not conduct or sponsor, and a
person is not required to respond to, a collection of information unless it displays a currently valid OMB control
number.
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 the use of automated collection techniques to
the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822), 1200 Pennsylvania Ave.,
NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the
completed EPA DBE Subcontractor Utilization Form to this address.
EPA FORM 6100-4 (DBE Subcontractor Utilization Form)
&2168/7,1*),50
QUALIFICATION STATEMENT
The Undersigned certifies under oath that the information provided herein is true and
sufficiently complete so as not to be misleading. If a FRQVXOWLQJILUP has completed work for
the owner within a 2-year period of the bid opening, the c
RQVXOWLQJILUP is EXEMPT from
completing the Qualification Statement.
SUBMITTED TO:
DATE:
SUBMITTED BY:
Corporation
NAME:
Partnership
ADDRESS:
Individual
PRINCIPAL OFFICE:
Joint
Other
NAME OF PROJECT:
Venture
MBE/WBE Certification # (if applicable):
1.
ORGANIZATION
1.1
1.2
How many years has your organization been in business?
How many years has your organization been in business
under its recent business name?
1.2.1Under what other or former names has your
organization operated?
1.3
If your organization is a corporation, answer the
following:
1.3.1Date of Incorporation:
1.3.2State of Incorporation:
1.3.3President's Name:
1.3.4Vice-president's Name(s):
1.3.5Secretary's Name:
1.3.6Treasurer's Name:
1.4
If your organization is a partnership, answer the
following:
1.4.1Date of Organization:
1.4.2Type of Partnership (if applicable):
1.4.3Name (s) of General Partner(s):
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1.5
If your organization is individually owned, answer the
following:
1.5.1Date of Organization:
1.5.2Name of Owner:
1.6
2.
If the form of your organization is other than those
listed above, describe it and name the principles.
LICENSING
2.1
List jurisdictions and trade categories in which your
organization is legally qualified to do business, and
indicate registration or license numbers, if applicable
2.1.1
2.1.2
2.1.3
2.1.4
2.1.5
2.2
List
jurisdictions in which your organization's
partnership or trade name is filed.
2.2.1
2.2.2
2.2.3
2.2.4
2.2.5
3.
EXPERIENCE
3.1
List the categories of work that your organization
normally performs with its own force.
3.1.1
3.1.2
3.1.3
3.1.4
3.2
3.1.5
List the work your firm has completed in the past five
years on similar projects that would qualify you for the
work proposed under this contract.
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3.2.1
3.2.2
3.2.3
3.2.4
3.2.5
3.3
List the software/design programs you have available
and/or intend to utilize on the project. (Be specific)
)
3.3.1
3.3.2
3.3.3
3.3.4
3.3.5
3.4
Describe the tasks to be employed for the project.
3.4.1
3.4.2
4.
REFERENCES
4.1
List of Owners for whom you have completed similar
projects, including name and phone number for contact
persons.
4.1.1
4.1.2
4.1.3
5.
SUBCONSULTANTS
5.1
Provide list of subconsultants you intend to use on this
project, the type of work they will be assigned, & their status
as a MBE/WBE (certification #, if applicable).
5.1.1
5.1.2
5.1.3
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5.1.4
5.1.5
6.
WARRANTY
6.1
7.
Provide the terms of the warranty you intend to provide.
SIGNATURE
7.1
Dated at
this
day of
Subscribed and sworn before me this
20__
day of
Name of Organization:
By:
State of:
County of:
Notary Public:
My Commission Expires:
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,