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Midwest Engineering Services/Geotechnical Engineering
CITY OF OSHKOSH DEPARTMENT OF PUBLIC WORKS 215 CHURCH AVENUE, P.O. BOX 1130, OSHKOSH, WI 54903-1130 PHONE: (920)236-5065 FAX(920) 236-5068 LETTER OF TRANSMITTAL To: Mr. Ryan Portman Date: December 12, 2013 Midwest Engineering Services, Inc. Subject: Executed Agreement 1125 West Tuckaway Lane Geotechnical Engineering Services Suite B Menasha, WI 54952 Please find: ® Attached ❑ Under Separate Cover ❑ Copy of Letter ® Contracts ❑ Amendment ❑ Report ❑ Agenda ❑ Meeting Notes ❑ Photos ❑ Mylars ❑ Change Order ❑ Plans ❑ Specifications ❑ Estimates ❑ Diskette ❑ Zip Disk ❑ Other Quantity Description 1 Executed Agreement These are being transmitted as indicated below: ❑ For Approval ® For Your Use ❑ As Requested ❑ For Review&Comment Remarks: Enclosed is a copy of the executed agreement for geotechnical engineering services. A copy of a City of Oshkosh Purchase Order will follow shortly. Please reference this Purchase Order number on all of your invoices. If you have any questions, please contact us. City Attorney's Office — Original Joe Sargent - Copy City Clerk's Office—Original I pal cc: _ File—Original Signed: ,LLL� "NM" Tracy .. taylor I:1 Engineering\Soil Borings120141MES LOT-Executed Agreemnt_12-12-13.docx AGREEMENT THIS AGREEMENT, made on the 11T14 day of c.. • , 2013, by and between the CITY OF OSHKOSH, party of the first part, hereinafter referred to as CITY, and MIDWEST ENGINEERING SERVICES, INC., 1125 West Tuckaway Lane, Suite B, Menasha, WI 54952, party of the second part, hereinafter referred to as the CONSULTANT, WITNESSETH: That the CITY and the CONSULTANT, for the consideration hereinafter named, enter into the following AGREEMENT for GEOTECHNICAL ENGINEERING SERVICES. The CONSULTANT's Proposal and the City of Oshkosh's Request for Proposal are attached hereto and reflects the agreement of the parties except where they conflict with this AGREEMENT, in which case this AGREEMENT shall prevail. ARTICLE I. PROJECT MANAGER A. Assignment of Project Manager. The CONSULTANT shall assign the following individual to manage the project described in this AGREEMENT: Ryan J. Portman — Menasha Branch Manager B. Changes in Project Manager. The CITY shall have the right to approve or disapprove of any proposed change from the individual named above as Project Manager. The CITY shall be provided with a resume or other information for any proposed substitute and shall be given the opportunity to interview that person prior to any proposed change. ARTICLE II. CITY REPRESENTATIVE The CITY shall assign the following individual to manage the project described in this AGREEMENT: Joseph R. Sargent, P.E. — Civil Engineer Senior ARTICLE III. SCOPE OF WORK The CONSULTANT shall provide the services described in the CONSULTANT's Proposal. The CONSULTANT may provide additional products and/or services if such products/services are requested in writing by the Authorized Representative of the CITY. 1:1Engineering\Soil Borings120141MES Agreemnt_12-6-13.docx Page 1 of 4 All reports, drawings, specifications, computer files, field data, notes, and other documents and instruments prepared by the CONSULTANT as instruments of service shall remain the property of the CITY. ARTICLE IV. CITY RESPONSIBILITIES The CITY shall furnish, at the CONSULTANT's request, such information as is needed by the CONSULTANT to aid in the progress of the project, providing it is reasonably obtainable from City records. To prevent any unreasonable delay in the CONSULTANT's work, the CITY will examine all reports and other documents and will make any authorizations necessary to proceed with work within a reasonable time period. ARTICLE V. TIME OF COMPLETION The work to be performed under this AGREEMENT shall be commenced and the work completed within the time limits as agreed upon in the CITY's Request for Proposal. The CONSULTANT shall perform the services under this AGREEMENT with reasonable diligence and expediency consistent with sound professional practices. The CITY agrees that the CONSULTANT is not responsible for damages arising directly or indirectly from any delays for causes beyond the CONSULTANT's control. For the purposes of this AGREEMENT, such causes include, but are not limited to, strikes or other labor disputes, severe weather disruptions or other natural disasters, failure of performance by the CITY, or discovery of any hazardous substances or differing site conditions. If the delays resulting from any such causes increase the time required by the CONSULTANT to perform its services in an orderly and efficient manner, the CONSULTANT shall be entitled to an equitable adjustment in schedule. ARTICLE VI. COMPONENT PARTS OF THE AGREEMENT This AGREEMENT consists of the following component parts, all of which are as fully a part of this AGREEMENT as if herein set out verbatim, or if not attached, as if hereto attached: 1. This Instrument 2. City of Oshkosh's Request for Proposal 3. Consultant's Proposal In the event that any provision in any of the above component parts of this AGREEMENT conflicts with any provision in any other of the component parts, the provision in the component part first enumerated above shall govern over any other component part which follows it numerically except as may be otherwise specifically stated. I:1Engineering1Soil Borings12014 1MESAgreemnt_12-6-13.docx Page 2 of 4 ARTICLE VII. PAYMENT A. The Agreement Sum. The CITY shall pay to the CONSULTANT for the performance of the AGREEMENT the total sum as set forth below, adjusted by any changes hereafter mutually agreed upon in writing by the parties hereto: • Time and Materials Not to Exceed $25,131.30 (Twenty Five Thousand One Hundred Thirty One Dollars and Thirty Cents). B. Method of Payment. The CONSULTANT shall submit itemized monthly statements for services. The CITY shall pay the CONSULTANT within 30 calendar days after receipt of such statement. If any statement amount is disputed, the CITY may withhold payment of such amount and shall provide to CONSULTANT a statement as to the reason(s) for withholding payment. C. Additional Costs. Costs for additional services shall be negotiated and set forth in a written amendment to this AGREEMENT executed by both parties prior to proceeding with the work covered under the subject amendment. ARTICLE VIII. CONSULTANT TO HOLD CITY HARMLESS The CONSULTANT covenants and agrees to protect and hold the City of Oshkosh harmless against all actions, claims, and demands of any kind or character whatsoever which may in any way be caused by or result from the intentional or negligent acts of the CONSULTANT, his agents or assigns, his employees, or his subcontractors related however remotely to the performance of this AGREEMENT or be caused or result from any violation of any law or administrative regulation, and shall indemnify or refund to the CITY all sums including court costs, attorney fees, and punitive damages which the CITY may be obliged or adjudged to pay on any such claims or demands within thirty (30) days of the date of the CITY's written demand for indemnification or refund. ARTICLE IV. INSURANCE The CONSULTANT agrees to abide by the attached City of Oshkosh Insurance Requirements. ARTICLE X. TERMINATION A. For Cause. If the CONSULTANT shall fail to fulfill in timely and proper manner any of the obligations under this AGREEMENT, the CITY shall have the right to terminate this AGREEMENT by written notice to the CONSULTANT. In this event, the CONSULTANT shall be entitled to compensation for any satisfactory, usable work completed. B. For Convenience. The CITY may terminate this AGREEMENT at any time by giving written notice to the CONSULTANT no later than 10 calendar days before the I:1Engineenng\Soil Bonngs120141MES Agreemnt_12-6-13.docx Page 3 of 4 termination date. If the CITY terminates under this paragraph, then the CONSULTANT shall be entitled to compensation for any satisfactory work performed to the date of termination. This document and any specified attachments contain all terms and conditions of the AGREEMENT and any alteration thereto shall be invalid unless made in writing, signed by both parties and incorporated as an amendment to this AGREEMENT. In the Presence of: CONSULTANT By: _�t /lam. (Seal of Consultant (Specify Title) if a Corporation.) By: (Specify Title) CITY OF OSHKOSH By: (Witness) Mai=k A. Rohloff, City Mana er U L And: (Witness) Pamela R. Ubrig, City Clerk APPROVED: I hereby certify that the necessary provisions have been made to pay the liability which it; which will accrue under this AGREEMENT. •ity Attorney". City Comptroller I:1Engineering\Soil Bonngs120141MES Agreemnt_12-6-13.docx Page 4 of 4 Taylor, Tracy L From: Sargent, Joseph R Sent: Thursday, November 21, 2013 1:41 PM Subject: Request for Proposal for Subsurface Exploration and Geotechnical Engineering Evaluation for the 2014 Capital Improvement Projects Attachments: Scope of Work& Cost Breakdown.pdf; Maps.pdf; RFP Attachments.pdf Dear Perspective Bidder: The City of Oshkosh is hereby requesting proposals be submitted for Subsurface Exploration and Geotechnical Engineering services related to the City's 2014 Capital Improvement projects. The purpose of this exploration program is to identify the soil and groundwater conditions within the depths of the project excavations. The reports are to provide a summarization of pavement and base coarse thicknesses, soil type verification, bedrock depth if encountered, and groundwater levels. In addition,field screening of the soil samples are to be completed to identify potential environmentally impacted soil. The proposal shall include at a minimum: related project experience, planned project team and resumes, engineering fee schedule, and a breakdown of costs as requested in the attached Scope of Services. This contract will have four separate deliverables each with unique due dates that are also listed in the Scope of Services. The proposals will be reviewed for completeness and how well it is demonstrated that the needs of the City of Oshkosh can be met. The award of this work will not be based solely on cost of the proposal. Questions regarding this request for proposal shall be emailed to me at isargent@ci.oshkosh.wi.us (with the subject heading of"2014 Subsurface Exploration and Geotechnical Engineering Evaluation RFP Questions") by 12:00 noon on Wednesday, December 4, 2013. The questions and appropriate responses will be distributed to all parties receiving this Request for Proposals by 2:00 p.m. on Thursday, December 5, 2013. Please submit four (4) copies of the proposal to my attention no later than 2:00 p.m. on Friday, December 6, 2013. It is anticipated that award of this contract will be made by Friday, December 13, 2013. Please ensure you have the proper insurance paperwork, so the award is not delayed. Attached to this letter are copies of the Scope of Services, Sample Boring Log, Standard Engineering Services Agreement, Insurance Requirements, and the City of Oshkosh Contractor Safety Program.The information contained within these attachments shall become a part of the Contract with the Consultant selected to perform the Services. If you have any questions, please do not hesitate to contact us. Respectfully, Joe Joseph R. Sargent, P.E., LEEDS AP Civil Engineer Senior City of Oshkosh 215 Church Avenue Oshkosh, WI 54903-1130 Main Office: (920)236-5065 Cell: (920)410-3569 Fax: (920) 236-5068 Email: jsargent(c�ci.oshkosh.wi.us 1 SCOPE OF SERVICES FOR SUBSURFACE EXPLORATION AND GEOTECHNICAL ENGINEERING SERVICES 2014 CAPITAL IMPROVEMENT PROJECTS 1. The scope of this contract is to identify subsurface conditions within the depths of various project excavations. The final reports are to provide a summarization of existing pavement and base coarse thicknesses, soil classifications,bedrock depth if encountered, groundwater levels, and deep utility construction recommendations. In addition, field screening of the soil samples are to be completed to identify potential environmentally impacted soil. Reports shall be prepared in general accordance with normally accepted geotechnical engineering practices. A. A total of 35 soil borings are anticipated for the following Capital Improvement projects. i. Contract 14-04—Concrete Paving &Utilities a.Bowen Street(New York Avenue to Nevada Avenue) a. (1) 10-ft boring, (4) 25-ft borings, (10) 30-ft borings b. Pavement type is concrete. c. Borings north of Nevada are required to be on the east side of the road. ii. Contract 14-05 —Concrete Paving &Utilities a. Central Street(Church Avenue to W. Irving Avenue) a. (7) 20-ft borings b. Pavement type is hot mix. b.Ida Avenue (Frederick Street to Division Street) a. (2) 15-ft borings b. Pavement type is road mix c.W. Parkway Avenue (Frederick Street to N. Main Street) a. (4) 15-ft borings b. Pavement type is road mix from Frederick Street to Division Street. c. Pavement type is asphalt over concrete from Division Street to N. Main Street. iii. Contract 14-08 —Lake Butte Des Morts/Ryf/Edgewood Water Main Loop a. (4) 15-ft borings, (3) 20-ft borings b. Pavement type is Concrete on Lake Butte Des Morts Drive. c. Pavement type is Hot Mix on Ryf Road. d. Pavement type is Hot Mix on Edgewood Road. e. Borings will be in gravel shoulder or ditch where possible. 2. The City of Oshkosh will perform the following tasks: A. Provide consultant with diagrams/maps indicating general locations and drilling depths of individual borings prior to work commencing. B. Retain services of an Environmental Consultant to provide suspect locations for sampling and other pertinent information prior to drilling. C. Provide consultant with an engineering staff member to assist in boring layout. Page 1 of 4 D. Provide consultant final location diagrams with GPS coordinates. E. Provide ground elevations for each boring location for the consultant's use in boring log development. 3. The Consultant will perform the following tasks: A. All items necessary to perform the tasks detailed in the scope of services. B. Subsurface Exploration and Reporting i. Mark the borings in the field and coordinate with Digger's Hotline. Remarking of soil boring locations due to weather will be the responsibility of the consultant. ii. Set a meeting for boring layout per street with Consultant, all Digger's Hotline locators, and City of Oshkosh layout representative. The City Utility locator will NOT mark utilities down the entire street due to the length of time this will take,but rather will provide a radius around the specific boring locations. iii. Coordinate with the City of Oshkosh on drilling schedule and provide 7-day notice of the onsite boring layout meeting. iv. All streets are to remain open to traffic. The consultant will be responsible to furnish all necessary barricades, flares or flashers, flag persons, etc. to provide adequate traffic control and still maintain the accesses as described herein. The signs shall conform to Sections 637 and 643 of the State of Wisconsin Standard Specifications for Highway and Structure Construction. v. If a particular boring cannot be accessed during drilling operations,work with the City of Oshkosh on a revised location. vi. Standard geotechnical practices for subsurface sampling,borehole abandonment, and laboratory testing. vii. Standard geotechnical sampling with 1.5' split-spoon samples spaced 1' (vertically) apart starting at an even point below the pavement (i.e. 1'). Representative soil samples are to be obtained in the borings using split barrel techniques. Soil samples are then to be sealed immediately in the field and returned to the laboratory for further examination and testing. viii. If refusal is reached prior to the indicated drilling depth, contact the City of Oshkosh immediately and locate an additional boring in the same vicinity. If this boring also has refusal at a depth similar to the initial boring, a collaborative decision will be made whether or not rock coring is necessary. Boring lengths are selected based on the depths of the proposed sewers; therefore, accurate identification of material type down to the indicated depth is necessary. Due to the depths of the proposed sewers and material type in Oshkosh, the consultant is required to anticipate hard drilling throughout. ix. Soil parameters for pavement design are not being requested at this time. Any laboratory testing is at the discretion of the consultant in order to provide services as detailed in the RFP. At a minimum, moisture contents and unconfined compressive strengths should be noted on the soil boring diagrams. x. Pavement shall be restored in-kind. It is the consultant's responsibility to know current pavement type. xi. Groundwater elevations shall be estimated for every borehole. xii. Field Screening and Environmental a. PID/FID every soil sample as described below. b.Representative soil samples are to be obtained in the borings using split barrel techniques. Soil samples are then to be sealed immediately in the field and returned to the laboratory for further examination and testing. In the laboratory, prepare a Page 2 of 4 portion of the field samples for PID/FID screening (i.e. sealed bags) and place in an environment where they will be allowed to equilibrate to a temperature of approximately 70° Fahrenheit. Once this temperature is reached,use the PID probe until the readings become steady or consistently decline. If a there is a reading of 20 or more PID units, immediately place the main sample in the refrigerator or on ice and notify the City of Oshkosh so arrangements can be made for sample exchange with our Environmental Consultant. Main samples are to remain cool until PID readings are taken. c. Split samples may be taken by Environmental Consultant during drilling operations. We will inform the selected consultant of these locations; however,no additional work will be required. xiii. Reporting Requirements a.Project Overview b.Field Procedures c. Laboratory Procedures d.Exploration Results (broken up by street) e. Considerations and Recommendations a. Recommendations for deep sanitary sewer construction are requested (i.e. slope stability and dewatering). b. Other information as appropriate. f. General Qualifications g.Individual Soil Boring Logs (include PID readings) h.Soil Boring Location Diagram i. Summary Table (separate table for each street) a. Boring Identification b. Boring Depth (proposed& actual) c. Pavement Thickness d. Base Coarse Thickness e. Fill Thickness f. Depth of Bedrock or Refusal, if present g. PID Reading 4. Project Deliverables A. Schedule of Project Deliverables i. Contract 14-04 report due January 10, 2014. ii. Contract 14-05 report due January 31, 2014. iii. Contract 14-08 report due TBD. B. Drilling can be completed at the consultant's convenience as long as the reports are submitted no later than their respective due date. 5. Proposal Cost Breakdown A. Boring Layout i. Cost to include coordination with Diggers Hotline,Utility Locators, and the City of Oshkosh engineering staff. ii. Cost to include laying out and marking the borings in the field. B. Mobilization/Daily Travel/Traffic Control for drilling (lump) i. Additional payment for mobilization/daily travel/traffic control will not be considered if the total footage of drilling, including the contingency amount is not exceeded. Page 3 of 4 C. Soil Borings (per foot) i. Cost to include proper borehole abandonment and street patching. ii. Cost to include field screening (i.e. PID/FID as appropriate). iii. Unit cost will also be used for additional drilling, if needed. iv. A contingency amount is added to the proposal cost breakdown sheets attached. v. Anticipate hard drilling throughout the depths of the borings in this cost. A hard drilling surcharge once the contract has been awarded will not be approved. D. Project Engineering and Reporting (lump sum) i. Additional payment for project engineering and reporting will not be considered if the total footage of drilling, including the contingency amount, is not exceeded. E. Steam cleaning costs will be handled on a contingency basis. If drilling in areas of known contamination, steam cleaning is more than likely required. Actual costs are to be billed to the specific contract. Do not cross contaminate samples. F. Rock Coring will be handled on a contingency basis. Quantities are not guaranteed. Actual costs are to be billed to the specific contract. Be prepared to rock core on a daily basis. G. Blind drilling will be handled on a contingency basis. Quantities are not guaranteed. Actual costs are to be billed to the specific contract. One possible example where blind drilling might be used is if a boring hits refusal prior to the indicated depth. Then another boring would be located a few feet away and blind drilled to the initial refusal depth. H. Provide general rate sheets for items not covered in this RFP. 6. Additional Information A. All work shall be performed by qualified personnel under the supervision of a Registered Professional Engineer in the State of Wisconsin. Reports shall bear the certificate and seal of said Professional Engineer. The ASTM or other recognized standard test methods and soil classifications used in preparation of the reports shall be identified. B. The consultant shall take all necessary precautions to prevent damage to all adjacent property. The site is to be restored upon completion of drilling to its existing condition including backfilling of borings and patching of slabs and pavements. The City of Oshkosh is not responsible for the cost of repair or replacement of any drilling equipment utilized on this project due to difficult or adverse subsurface conditions. C. The entire soil profile is required from the surface to the indicated depth. D. Additional geotechnical recommendations may be required for the structural design of storm water junction chambers. Payment for these extra services will be negotiated at a later date, if necessary. E. The number of borings and depths are subject to change. Additional street borings and pond projects may be added to this contract, or borings/work may be deleted at any time. F. It is the contractor's responsibility to locate a dump site. The City of Oshkosh will not provide a location to dump spoil material. G. This contract will be per the City of Oshkosh Agreement form only; unless the consultant already has a negotiated services agreement on file with the City of Oshkosh. A sample agreement form is attached to this RFP. The consultant's standard or general services agreement language will NOT apply. Page 4 of 4 PROPOSAL COST BREAKDOWN FOR SUBSURFACE EXPLORATION AND GEOTECHNICAL ENGINEERING SERVICES 2014 CAPITAL IMPROVEMENT PROJECTS CONTRACT 14-04 CONCRETE PAVING& UTILITIES ITEM DESCRIPTION UNIT EST. BID UNIT PRICE PRICE BID TOTAL QTY. 1. Boring Layout Lump Sum 1 $ $ 2. Mobilization/Daily Travel/Traffic Control Lump Sum 1 $ $ 3. Soil Borings(estimated quantity includes an additional 40'for contingency purposes) Feet 450 $ $ 4. Project Engineering and Reporting Lump Sum 1 $ $ SUB-TOTAL CONTRACT 14-04 $ CONTRACT 14-05—CONCRETE PAVING& UTILITIES ITEM DESCRIPTION UNIT EST. BID UNIT PRICE PRICE BID TOTAL QTY. 1. Boring Layout Lump Sum 1 $ $ 2. Mobilization/Daily Travel/Traffic Control Lump Sum 1 $ $ 2. Soil Borings(estimated quantity includes an additional 20' for contingency purposes) Feet 250 $ $ 3. Project Engineering and Reporting Lump Sum 1 $ $ SUB-TOTAL CONTRACT 14-05 $ 1 CONTRACT 14-08—LAKE BUTTE DES MORTS/RYF/EDGEWOOD WATER MAIN LOOP ITEM DESCRIPTION UNIT EST. BID UNIT PRICE PRICE BID TOTAL QTY. 1. Boring Layout Lump Sum 1 $ $ 2. Mobilization/Daily Travel/Traffic Control Lump Sum 1 $ $ 2. Soil Borings(estimated quantity includes an additional 20' for contingency purposes) Feet 140 $ $ 3. Project Engineering and Reporting Lump Sum 1 $ $ SUB-TOTAL CONTRACT 14-08 $ STEAM CLEANING OF DRILLING EQUIPMENT (UNIT COST $ )X 5 TIMES= $ ROCK CORING (UNIT COST$ )X 75 FEET= $ BLIND DRILLING (UNIT COST$ )X 100 FEET=$ ATV RIG FOR BORING (UNIT COST$ )X 100 FEET=$ TOTAL PROPOSAL COST $ 2 AGREEMENT THIS AGREEMENT, made on the day of , 2013, by and between the CITY OF OSHKOSH, party of the first part, hereinafter referred to as CITY, and (CONSULTANT'S NAME and address) , party of the second part, hereinafter referred to as the CONSULTANT, WITNESSETH: That the CITY and the CONSULTANT, for the consideration hereinafter named, enter into the following Agreement for CONSULTANT'S SERVICES The CONSULTANT's Proposal and the City of Oshkosh's Request for Proposal are attached hereto and reflects the agreement of the parties except where they conflict with this Agreement, in which case this Agreement shall prevail. ARTICLE I. PROJECT MANAGER A. Assignment of Project Manager. The CONSULTANT shall assign the following individual to manage the project described in this Agreement: Name —Title B. Changes in Project Manager. The CITY shall have the right to approve or disapprove of any proposed change from the individual named above as Project Manager. The CITY shall be provided with a resume or other information for any proposed substitute and shall be given the opportunity to interview that person prior to any proposed change. ARTICLE II. CITY REPRESENTATIVE The CITY shall assign the following individual to manage the project described in this Agreement: Name —Title ARTICLE III. SCOPE OF WORK The CONSULTANT shall provide the services described in the CONSULTANT's Proposal. The CONSULTANT may provide additional products and/or services if such products/services are requested in writing by the Authorized Representative of the CITY. C:\Users\joes\AppData\Local\Temp\BCL Technologies\NitroPDF6\@BCL @B 8 0 A 55 1 E 6\@ BCL @ B 8 0 A5 1 E 6 . do c x Page 1 of 4 All reports, drawings, specifications, computer files, field data, notes, and other documents and instruments prepared by the CONSULTANT as instruments of service shall remain the property of the CITY. ARTICLE IV. CITY RESPONSIBILITIES The CITY shall furnish, at the CONSULTANT's request, such information as is needed by the CONSULTANT to aid in the progress of the project, providing it is reasonably obtainable from City records. To prevent any unreasonable delay in the CONSULTANT's work, the CITY will examine all reports and other documents and will make any authorizations necessary to proceed with work within a reasonable time period. ARTICLE V. TIME OF COMPLETION The work to be performed under this Agreement shall be commenced and the work completed within the time limits as agreed upon in the CITY's Request for Proposal. The CONSULTANT shall perform the services under this Agreement with reasonable diligence and expediency consistent with sound professional practices. The CITY agrees that the CONSULTANT is not responsible for damages arising directly or indirectly from any delays for causes beyond the CONSULTANT's control. For the purposes of this Agreement, such causes include, but are not limited to, strikes or other labor disputes, severe weather disruptions or other natural disasters, failure of performance by the CITY, or discovery of any hazardous substances or differing site conditions. If the delays resulting from any such causes increase the time required by the CONSULTANT to perform its services in an orderly and efficient manner, the CONSULTANT shall be entitled to an equitable adjustment in schedule. ARTICLE VI. COMPONENT PARTS OF THE AGREEMENT This Agreement consists of the following component parts, all of which are as fully a part of this Agreement as if herein set out verbatim, or if not attached, as if hereto attached: 1. This Instrument 2. City of Oshkosh Request for Proposal 3. Consultant's Proposal In the event that any provision in any of the above component parts of this Agreement conflicts with any provision in any other of the component parts, the provision in the component part first enumerated above shall govern over any other component part which follows it numerically except as may be otherwise specifically stated. C:\Users\joes\AppDatal Local\Temp\BCLTechnologies\NitroPDF6\@BCL @B8OA51E6\@BCL @B80A51E6 e docx Page 2 of 4 ARTICLE VII. PAYMENT A. The Agreement Sum. The CITY shall pay to the CONSULTANT for the performance of the Agreement the total sum as set forth below, adjusted by any changes hereafter mutually agreed upon in writing by the parties hereto: • Time and Materials Not to Exceed $ Dollars). • Attached fee schedules shall be firm for the duration of this Agreement. B. Method of Payment. The CONSULTANT shall submit itemized monthly statements for services. The CITY shall pay the CONSULTANT within 30 calendar days after receipt of such statement. If any statement amount is disputed, the CITY may withhold payment of such amount and shall provide to CONSULTANT a statement as to the reason(s) for withholding payment. C. Additional Costs. Costs for additional services shall be negotiated and set forth in a written amendment to this Agreement executed by both parties prior to proceeding with the work covered under the subject amendment. ARTICLE VIII. CONSULTANT TO HOLD CITY HARMLESS The CONSULTANT covenants and agrees to protect and hold the City of Oshkosh harmless against all actions, claims, and demands of any kind or character whatsoever which may in any way be caused by or result from the intentional or negligent acts of the CONSULTANT, his agents or assigns, his employees, or his subcontractors related however remotely to the performance of this Agreement or be caused or result from any violation of any law or administrative regulation, and shall indemnify or refund to the CITY all sums including court costs, attorney fees, and punitive damages which the CITY may be obliged or adjudged to pay on any such claims or demands within thirty (30) days of the date of the CITY's written demand for indemnification or refund. ARTICLE IV. INSURANCE The CONSULTANT agrees to abide by the attached City of Oshkosh Insurance Requirements. ARTICLE X. TERMINATION A. For Cause. If the CONSULTANT shall fail to fulfill in timely and proper manner any of the obligations under this Agreement, the CITY shall have the right to terminate this Agreement by written notice to the CONSULTANT. In this event, the CONSULTANT shall be entitled to compensation for any satisfactory, usable work completed. C:1 Users ljoeslAppDatalLocal\TempIBCL TechnologieslNitroPDF61 @BCL @B 8 0A5 1 E 6\@ B CL @ B 8 0 A51 E 6 .do cx Page 3 of 4 • B. For Convenience. The CITY may terminate this Agreement at any time by giving written notice to the CONSULTANT no later than 10 calendar days before the termination date. If the CITY terminates under this paragraph, then the CONSULTANT shall be entitled to compensation for any satisfactory work performed to the date of termination. This document and any specified attachments contain all terms and conditions of the Agreement and any alteration thereto shall be invalid unless made in writing, signed by both parties and incorporated as an amendment to this Agreement. In the Presence of: CONSULTANT By: (Seal of Consultant (Specify Title) if a Corporation.) By: (Specify Title) CITY OF OSHKOSH By: (Witness) Mark A. Rohloff, City Manager And: (Witness) Pamela R. Ubrig, City Clerk APPROVED: I hereby certify that the necessary provisions have been made to pay the liability which which will accrue under this Agreement. City Attorney City Comptroller C:\Users\joes\AppData\Local\Temp\BCL Technologies\NitroPDF61 @BCL @B80A51E6\@BCL @B80A51E6 . docx Page 4 of 4 1 ® DATE(MMIDDIYYYY) ,4�° CERTIFICATE OF LIABILITY INSURANCE 12/9/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Michelle Bandlow R & R Insurance Services, Inc. PHONE (262)953-7229 FAX (262)953-1337 N80 W14824 Appleton Ave E-MAIL michelle.bandlow @rrins.com ADDRESS: PO Box 160 INSURER(S)AFFORDING COVERAGE NAIC it Menomonee Falls WI 53052-0160 INSURER A:Liberty Mutual 23043 INSURED INSURERB:United Wisconsin Ins Co 29157 Midwest Engineering Services Inc INSURERCArchitects and Engineers Ins. 1125 Tuckaway Ln INSURER D: _INSURER E: Menasha WI 54 952 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1332241822 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER (MM/DDIYYYY) (MM/DDIYYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 500,000 X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ A CLAIMS-MADE X OCCUR X YVJZ91456564023 3/23/2013 3/23/2014 MED EXP(Any one person) $ 5,000 X LG3178(0505) PERSONAL BADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY 5i1 TNT _ LOC $ AUTOMOBILE LIABILITY COa a INEDt SINGLE LIMIT $ 1,000,000 — X ANY AUTO BODILY INJURY(Per person) $ A ALL OWNED SCHEDULED X ASJZ91456564013 AUTOS AUTOS 3/23/2013 3/23/2014 BODILY INJURY(Per accident) $ X x NON-OWNED (PeOraccident)DAMAGE $ HIRED AUTOS AUTOS $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED X RETENTIONS 10,000 TH7Z91456564033 3/23/2013 3/23/2014 $WC STATU-B WORKERS COMPENSATION X TORY LIMITS OTH- AND EMPLOYERS'LIABILITY Y I N ER ANY PROPRIETOR/PARTNER/EXECUTIVE N N f A E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? 0400132650 12/1/2013 12/1/2014 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 C Professional / Pollution AEICPG11 3/23/2011 3/23/2014 Per Claim 1,000,000 — $50,000 deductible Aggregate 3,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required) RE: Soil borings: 2014 City of Oshkosh Capitol Improvement Projects City of Oshkosh, and its officers, council members, agents, employees and authorized volunteers are additional insureds for general liability and automobile liability per a written contract or agreement. The umbrella policy's underlying insurance includes the general liability, automobile liability and employers liability in the schedule of underlying insurance. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Oshkosh 215 Church Ave P 0 Box 1130 AUTHORIZED REPRESENTATIVE Oshkosh, WI 54903-1130 J Vanderveldt/LJ332 x . "'�__ ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 omnns m The AR(1Rn nnmo onrt Innn are.mu-act/areal morkc of Aman tyil H1(0/111 Of OM THE WATER CITY OF OSHKOSH CONTRACTOR SAFETY PROGRAM , .......,-&- ., ‘.- .: ,,...,y, '414,qetet':I:: ( ° '-::--'' 9 -'' t, '-' "l' cgt1.1',1,....-,4 C 4tt.0 I ,offer :` - wy- x...m. aw,.,..w NI a X pit1j 1 ir,.,.., ,7 ,. - , ... 0 Original:September2006 Revised:March 2010 City of Oshkosh Contractor Safety Program TABLE OF CONTENTS Introduction 1 General 1 Project Safety Coordinator Responsibility 2 City of Oshkosh 2 Contractor 2 Fire Prevention and Protection 2 Hot Work 2 Smoking Policy 3 Chemical Safety 3 Material Safety Data Sheets 3 Chemical Management 3 Container Labeling 3 Environmental Compliance 4 Waste Disposal 4 Hazardous Waste 4 Chemical Spills 4 Personal Protective Equipment 5 Elevated/Overhead Work 5 Excavation/Trenching 5 Summary 6 City of Oshkosh Project Manager Contractor Notes and Check List 7 Contractor Qualifications 7 Information Exchange Check List 8 Contractor Project Manager Contractor Safety Program Acknowledgement Form 9 Contractor Safety Program Qualification Questionnaire 10 INTRODUCTION Work-related accidents damage property, cause serious injury and may even result in death. Most accidents are preventable with good planning, up-to-date training, good communication and most of all . . . commitment. It is the intent of the City of Oshkosh, that all work conducted, is done in a safe, healthful and environmentally responsible manner. Employers have the duty and responsibility to provide a safe work place for their employees as well as contractor and vendor employees. Contractors, likewise, have a responsibility to keep their workers safe, and to work in a manner that does not compromise the safety of City of Oshkosh employees, while protecting, preserving and enhancing the environment. Therefore, the City expects contractors to meet all safety and health performance requirements and to comply with all applicable laws, regulations, ordinances and codes. For purposes of this program, a "Contractor" may be defined as: a) Construction contractor — project oriented work such as new construction or remodeling b) Service Contractor — a contractor that installs, services or performs maintenance of equipment, tools, systems or processes c) Vendor— a provider of definable services for a facility d) Task Oriented Contractor— performs a specific work task e) Sub-contractor— assumes some of the obligations of a primary Contractor f) Temporary Labor Contractor — provides workers on a temporary, as needed basis with on-site supervision by an employee of the Contractor On-the-job safety is especially important for contract workers. You are called upon to perform highly specialized and potentially hazardous tasks. Working conditions and safety procedures may change each day. Good communication between the contract employer, the City project manager and the contract crew is essential so that proper hazard control measures are followed. The following rules and guidelines promote safety and are an effort to highlight major safety and environmental concerns. THEY ARE NOT INTENDED OR DESIGNED TO BE COMPREHENSIVE, TO SUPPLEMENT OR LIMIT APPLICABLE LEGAL REQUIREMENTS OR TO RELIEVE THE CONTRACTOR OF ANY SAFETY, HEALTH AND ENVIRONMENTAL RESPONSIBILITIES. The Contractor should always refer to the specific requirements of applicable laws, regulations, codes and/or specific standards to assure safety and compliance. GENERAL The following information is provided to the Contractor by the City of Oshkosh, understanding that these guidelines are not intended in any way to be all-inclusive or to relieve the Contractor of any part of the responsibility for the safe performance of the work outlined in the Introduction of this document. The objective of this policy is to prevent the failures that cause injuries, illnesses, fatalities, property damage, or environmental pollution. 1 No portion of this document is to be construed as establishing a master-servant relationship between the Contractor and the City of Oshkosh. In all cases, the Contractor shall be deemed to be an independent contractor and the sole employer. As a minimum, Contractor safety rules, work practices, and procedures must be compatible with existing City of Oshkosh policies and procedures. PROJECT SAFETY COORDINATOR RESPONSIBILITY City of Oshkosh The City of Oshkosh project coordinator shall be your primary contact. The Safety & Risk Management Coordinator for the City of Oshkosh is Paul Greeninger. He has the overall responsibility for safety and health issues. If you have a concern regarding our safety policies, you may contact him at (920) 236-5117 or (920) 233-7852. Contractor Each Contractor shall designate a responsible member of its management team as the Safety Coordinator for the project. The designee's duty shall be prevention of accidents and other job losses. This person shall have control of and be familiar with day-to-day activities of the Contractor. This person will be responsible for initiating, maintaining, and supervising all safety and loss prevention programs and procedures. FIRE PREVENTION AND PROTECTION The Contractor shall take all necessary precautions to prevent fire and injuries or property damage relative to welding, cutting or other spark or flame producing processes and procedures. It is the responsibility of the Contractor to follow City of Oshkosh Hot Work permitting policies and procedures. Contractors shall also establish procedures for storage, handling and use of flammable or combustible materials, which comply with City of Oshkosh policies and procedures, as well as all applicable laws, regulations and fire codes. The Contractor shall ensure that employees and all Third Parties under their direction are familiar with fire protection and alarm systems in their work area. The Contractor shall also be responsible for supplying and maintaining a sufficient number of appropriate types of fire extinguishers to support the work. HOT WORK At any time during the work, where spark or flame producing operations are conducted (such as welding, cutting, grinding or open flame), the Contractor shall establish a fire watch during and after (for at least 60 minutes) such operations to ensure that fires do not ignite. The Contractor shall insure that fire watch personnel are trained in fire fighting and are aware of procedures for sounding alarms and making notifications in the event of fire. "Hot Work Permits" are required when working within buildings or within 35 ft. of combustible materials, including flammable liquids, vapors or dusts. 2 SMOKING Smoking is prohibited in all City of Oshkosh buildings. The Contractor based on the hazards present shall control smoking at outdoor job sites. CHEMICAL SAFETY Chemicals are important tools in a wide variety of work activities, but many chemicals can cause serious health and environmental issues. The Contractor shall obtain all information necessary to be fully aware of all potential exposures to hazardous materials in the performance of the work. The Contractor shall provide, to their employees, all information and training on the nature and scope of potential hazards as required by all laws, regulations, ordinances and codes, regardless of the source of such hazards. The Contractor is also responsible for communicating to the City of Oshkosh any hazards created by the work being performed. The City of Oshkosh also has the right to restrict the type and amount of chemicals being brought on to the job site. Products containing Methylene Chloride (CAS #75-09-2) and paints containing Isocyanates such as (CAS #91-08-7 or #584-84-9) are two examples of restricted chemicals. Certain other chemical and physical agents (asbestos, PCB's, lead-based paints, radiation sources, etc.) are specifically regulated by Federal, State and/or local agencies. When the work involves a potential exposure to any such hazards, the Contractor shall maintain compliance with all applicable regulations. MATERIAL SAFETY DATA SHEETS Material Safety Data Sheets (MSDS) must be provided to your City of Oshkosh contact for ALL chemicals prior to being brought on site. This requirement includes all liquids, pastes, powders and gas products. CHEMICAL MANAGEMENT Chemicals brought onto City of Oshkosh property must be removed when work has been completed. Any changes must have approval of the project manager and the Safety Coordinator. All waste materials must be managed as identified in the Environmental Compliance and Waste Disposal sections of this booklet. LABELING All containers shall be labeled in accordance with the OSHA Hazard Communication Standard. Waste containers shall be labeled according to all applicable federal, state and/or local laws, regulations, ordinances, codes and/or standards. 3 ENVIRONMENTAL COMPLIANCE The City of Oshkosh is committed to the responsibility to protect, preserve and enhance the environment wherever it conducts business. The Contractor shall be fully and solely responsible for compliance with all environmental laws and regulations applicable to the transportation, packing, labeling, handling, use, storage, or disposal of materials, including liquid and solid wastes and hazardous substances, brought onto City of Oshkosh property or used in the performance of work, or generated as a result of the work. WASTE DISPOSAL Waste and the disposal of many chemicals and products may result in damage to the environment. Environmental laws and regulations closely monitor waste handling and disposal. The City of Oshkosh, therefore, closely manages what happens to waste products, recycled chemicals and abandoned materials. Many chemicals and products are not to be disposed of into sanitary waste containers or into drains. Nothing may be discarded onto facility grounds, parking lots, or waterways. Some of the waste products that are controlled may include, but not limited to: used or waste oil and grease; paints, paint thinners, solvents and cleaning fluids; strong acids or caustics; sorbents, rags and materials used to cleanup wastes; electronic components, fluorescent light bulbs and ballast's; pesticides, herbicides and related chemicals. Because of the complexity and extensive lists of waste streams, prior approval must be obtained for disposal, and the method of disposal. HAZARDOUS WASTE The Contractor must receive approval from the City of Oshkosh to transport or dispose of hazardous waste from the work site. The Contractor shall provide the City of Oshkosh with copies of all records relating to waste management activities associated with the work including copies of hazardous waste manifests, waste disposal locations and waste transportation and disposal agreements. CHEMICAL SPILLS If spills or unauthorized releases of any product occur, the Contractor shall notify the City of Oshkosh Project Manager or Safety & Risk Management Coordinator immediately of the nature of the incident. If the contact or Safety & Risk Management Coordinator is not available, contact the Oshkosh Fire Department at 236-5700. The Contractor shall provide all required information necessary for reporting of the incident and to notify the appropriate agency(s) in a timely manner. A copy of the written notification to the agency(s) shall be provided to the City of Oshkosh Safety & Risk Management Coordinator. 4 • PERSONAL PROTECTIVE EQUIPMENT All employees of the Contractor, and other persons entering City of Oshkosh property in connection with the work, shall wear appropriate personal protective equipment (PPE) such as, but not limited to, safety glasses, steel toe shoes, hard hats, and proper work clothing. Special personal protective devices and/or equipment must be used where needed based on the hazards of the work. This equipment shall include, but not limited to: • Hearing protection devices • Respiratory protection devices • Fall protection devices • Hand protection • Lifelines and body harnesses • Any other special equipment/devices necessary to provide appropriate protection ELEVATED/OVERHEAD WORK Whenever work is to be done above walking or working areas at a height greater than four feet, which may present a hazard to personnel or property below, all necessary safety precautions shall be taken by the Contractor. This action shall include, without limitations, roping off the area and posting warning signs to caution personnel below from falling materials. If necessary, a flagman shall be stationed below to warn persons in the area. All such barriers and signs shall be removed as soon as the work is completed. All personnel under Contractor supervision or control working at elevations greater than four feet shall be protected by guardrails, ANSI approved body harnesses and lanyards or lifelines, or other effective means that comply with applicable federal, state, and local regulations. The use of safety belts is prohibited as a fall protection device. The use of ladders, scaffolding or work platforms must comply with all federal, state, and local regulations. EXCAVATION/TRENCHING Contractors performing excavation/trenching must meet the qualifications set forth during the bid process. The Contractor shall comply with all OSHA/D-COMM regulations. The Contractor shall have a competent person or persons on the site to inspect the work and to supervise the conformance of Contractor's operations with the regulations. The Contractor shall take all necessary precautions for the safety of employees on the job site. 5 •SUMMARY Contractor safety takes teamwork. The City of Oshkosh is committed to providing a safe and healthful workplace while protecting and preserving the environment. We will work with you to help ensure that no injuries occur and that the environment is not harmed. Contractors are responsible for their employee's safety through training, ensuring that the information regarding hazards and safe work practices is communicated to them and making sure that they follow all safety and environmental rules. 6 City of Oshkosh Project Manager Contractor Notes and Checklist Contractors are not only responsible for their tools and equipment and the safety of their employees, but also to our property and the safety and health of our employees. In addition, damage to the environment or failure to properly manage waste disposal may cause long term and costly issues to the City of Oshkosh. These issues pertain in different degrees to all vendors and contractors, anyone who performs a service for the City. A "Contractor" may be defined as: A) Construction Contractor- project oriented work such as new construction or remodeling, B) Service Contractor - a contractor that installs, services or performs maintenance of equipment, tools, systems, or processes C) Vendor- a provider of definable services for a facility D) Task-Oriented Contractor- performs a specific work task E) Sub-contractor- assumes some of the obligations of a primary contractor F) Temporary Labor Contractor - provides workers on a temporary, as needed, basis with onsite supervision by an employee of the Contractor G) The City expects its contractors to meet its safety and health performance requirements and to comply with all applicable laws, regulations, ordinances and codes. When selecting contractors, safety performance must be included in the selection process. Unsafe acts of contract employees can put our workers' safety in jeopardy. In addition, there are always potential legal and liability issues, including citations from EPA, DNR, or D-Comm. Contractor Qualification The Contractor Qualification process (and the qualification questionnaire), may not be required for contractors servicing their own equipment or contractors who have been designated by the manufacturer as the manufacturer's representative or distributor, when the contractor employee is performing a low risk activity. This exception does not apply to Construction Contractors or Service Contractors performing high risk work activities including hot work, use of hazardous chemicals, working with hazardous voltages, control of hazardous energy (lockout/tagout), operation of powered equipment, work at hazardous elevations, excavation work, or confined space entry. Contractors exempted from the qualification process are still required to meet all other requirements of the Contractor Safety Program, including the attached Acknowledgement Form. 7 City of Oshkosh Contractor Safety Program Acknowledgement Form The City of Oshkosh (City) is required by law to carry Workers Compensation Insurance (WCI) on our permanent employees. As an independent contractor/vendor, your firm is required by law to carry WCI on your employees. As an independent contractor/vendor, you are not under the direct supervision of the City and are not covered by the WCI or Liability Insurance maintained by the City for their employees. Please attach a copy of your current Workers Compensation Certificate and a copy of your certificate of liability insurance. It is required that you notify the City immediately if any of the required insurance or bonding should be cancelled or notify the City within 30 days of a change in bond status or insurance carriers. Please complete and return to Paul Greeninger, City of Oshkosh, Safety & Risk Management Coordinator. Date: I)e c c Ye\ c r 9 , 2O 13 Contractor/Vendor Name: M ` ngineer ;/A3 lSe,- v cvsy Inc Address: 1125 TT c lc.00nfol L-Art �5'..'4 c J City, State,Zip: 1" e,r\o•`Zh0. ) I 54952_ Telephone Number: c17.O . 135. I a©O E-mail Address: rpo {-w%c r��a rYliccvf is+tfV4. COPrTh Contractor/Vendor Representative: ?•,,fc r-" t—n{'-4 -c o c Title: iY'pr■C.V-.\ MooY;O (50L- '- Individual Responsible for: J Safety Coordination: .,,>.n Pa ,,,r•c„rN Phone: qap,-135, t2z Environmental Issues: R c..v∎ Porn-ry osir∎ Phone: 9X. 135. I?,OO I understand that it is my obligation to notify my employees of their responsibilities for health and safety. further understand that if any unsafe work activities are found, the City has the right to immediately contact the Contractor's Safety Coordinator. If this unsafe practice is not corrected, the work may be stopped until corrective acti s been t and agreed upon. Signed; 1 0.:74,fr Date: /2V9/ X Certificate of Insurance Attached k Workers Compensation Insurance Certificate attached 9 City of~~. � ~~. ~~_..~.~~ ~. Contractor Safety Program Qualification Questionnaire Date: /0//.3 1 � ContractorNendor Name: ~ / r-i/79 ^: // 7e' Person completing form: /�u�m /��-�^�Z�x7 / �� ' / �� Title: <�/rom�h //cir1�/��� ~, In keeping with the City of Oshkosh commitment to provide a safe and healthful workplace while protecting and preserving the anvironment, we require the following safety questionnaire be completed and returned to Paul Greeninger, City of Oshkosh Safety & Risk Management Coordinator, 215 Church Ave., Oshkosh, WI 54903. Completion of this questionnaire does not in any way relieve the contractor of their obligations to comply with all applicable legal requirements (fedana|, state, and local). This questionnaire has been designed to help the City to better understand your safety program and in no way does it represent a complete list of the Contractor's applicable safety obligations. Your response to some of the following questions may require that you provide documents, however, PLESE DO NOT SEND CONF|OENT|AL, PROPRIETARY OR TRADE SECRET INFORMATION. 1 Provide a brief description of the primary service your company provides the City. � eJA� �f// t '~� /�, / /f�yu,y�� �/°�i� �/��w���� ~. &����L * zcuuc . .� �/ y- rc� r m�� �' ' . ' _' . ^ . / / "Y. � .'/' ' ~��� ��Y// y- � ��// z��y ^uu� C '/ / ~-- � ' -' - - 7', /---d -- // - /� l' � � ' � �' — � � �^ ~1 � 7��� p". �� ��, 2. Do you require the following safety training programs? A. Right to Know/Hazard Communication Yes X No � B. Fire Prevention ^` onondP,oteotinn Yes No � C. Hot Work Permits Yes '. No X O. Environmental Compliance Yes » , No � E. Excavation/Trenching Yes /` No X F. VVorkmgatE|eva� ,. Elevations Yes No G. Confined Space Entry Yes '1/ No 10 - H. � Control /\ n| ofHozerdovmEn�rOy (|uokout) Yes No Operation of Powered Equipmentivehicles Yes /�� No �� J. VVorkingwith hazardous voltages Yes No ^� � K. Personal Protective Equipment Yes No L. Process Safety Yes Nu ^~/ 3. If you answered NO to any of the above, please comment: Z-l'ewiJ 7~awd 7 -1 ~~/ e1/90 ./ 5 his _ y '' '/-6A'3 Sr "� ~"°. ~. � 4. Are the training records available upon request?? Yma No 5. Please provide your Total OSHA Incident Rate and Lost Workday Rate for each of the last three years by completing the table below. A. Year Ju�� All_ dm'u B, Number of employee hours worked (7/5-0 7M9- C Number of lost workday cases D D. . Number of cases due to injury or ' Illness defined as recordable // / E. Total number of recordable cases � (Add C and D above) // `/ F. Calculate your incident rate by using the following formula: Total cases on line E x 200.000 hours Employee hours on line B 7.48'_LE 6. Management Certif cation Signature: /Or-- 74`-6r�44—� Date: _.220/1___/ / �� � �� Print Name and Title: /TVa� /���!rna�/ - �/,m^'e'` ��pimf�c/` / 11