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Contract 33666
CITY SECRETARY CONTRACT NO. CONTRACT Between CITY OF FORT WORTH and ENVIROCLEAN MANAGEMENT SERVICES INC. For The Collection and Disposal of USDA Garbage at . the City of Fort Worth Meacham International Airport Fort Worth, Texas Environmental Management Department Junq 2006 06-27-06 P02 :25 . 1 N ``'FTC FT. STATE OF TEXAS § COUNTIES OF TARRANT, § DENTON AND WEE § CONTRACT FOR THE COLLECTION AND DISPOSAL OF USDA REGULATED GARBAGE AT THE CITY OF FORT WORTH MEACHAM INTERNATIONAL AIRPORT THIS CONTRACT is made and entered into by and between the City of Fort Worth, a home-rule municipal corporation in Tarrant, Denton, and Wise Counties,Texas, acting herein by and through Libby Watson, its duly authorized Assistant City Manager,hereinafter called"City", and EnviroClean Ma-,�--agement Services, Inc., doing business in Texas, acting herein by and through LOflClj� X012 its duly authorized hereinafter called "Contractor." r_ 5t 0V ar THIS CONTRACT shall be for the collection and disposal ofiISI3A Regulated� atbage at the City of Fort Worth Meacham International Airport. 1. DEFINITIONS In this Contract,the following words and phrases shall be defined as follows; Applicable Law shall mean any statute, law, constitution, charter, ordinance, resolution, judgment, order, decree, rule, regulation, directive, interpretation, standard or similarly binding authority, which in any case, shall be enacted, adopted, promulgated, issued or enforced that relates to or affects the City, the Contractor, or the performance by a party of its obligations hereunder. City shall mean the City of Fort Worth,Texas. Commission shall mean the Texas Commission on Environmental Quality(TCEQ). Contract shall mean this document, Contractor's Proposal attached as Exhibit A and all other attachments to this document. If there is a conflict between the terms of the Contractor's Proposal and the terms of Contract,the Contract terms shall prevail. Contractor shall mean EnviroClean Management Services,Inc. CONTRACT FOR COLLECTIONAND DISPOSAL OF USDA REGULATED GARBAGE CRU6.07.002 1 DEM shall mean the Department of Environmental Management of the City of Fort Worth. Director shall mean the Director of DEM or his designated representative. Government Approvals shall mean all licenses, permits and approvals required from any Governmental Body for performance of the Contractor's obligations under this Contract. Person shall mean any individual, partnership, co-partnership, firm, company, corporation, association,joint stock company, trust, estate, governmental entity, or any other legal entity; or their legal representatives, agents,or assigns. This definition includes all governmental bodies. USDA Regulated Garbage shall mean all waste material derived in whole or in part from fruits, vegetables, meats, or other plant or animal (including poultry) material, and other refuse of any character whatsoever that has been associated with any such material aboard any means of conveyance and includes food scraps, table refuse, galley refuse, food wrappers or packaging materials, and other waste material from stores, food preparation areas, passengers, or crews, quarters,dinning rooms, or any other areas on vessels,aircraft,or other means of conveyances. Violation shall mean any determination by a governmental body that the Contractor is in violation of or not in compliance with any portion of its permit(s)or Applicable Law. 2. SCOPE OF CONTRACTOR'S SERVICES Upon request by the City, Contractor hereby covenants and agrees to diligently and faithfully perform the public service of the collecting and disposing of USDA Regulated Garbage at the City's Meacham International Airport. These services shall include the furnishing of all labor, tools, equipment, materials, and all other items necessary to provide storage and shipping containers, provide on-site pick-up, provide transportation, handle disposal, as applicable for USDA Regulated Garbage. All work and services to be performed under this Contract shall be carried out in the manner and at the unit prices specified herein. A. Contractor shall collect and containerize such USDA Regulated Garbage from a central pick up location at the Fort Worth Meacham International Airport; B. Contractor shall perform such services in accordance with the latest Federal regulations in 9 CFR Part 94.5 and 7 CFR Part 330; and C. Contractor shall perform such services required herein within five(5)business days from the time the City makes a request. CONTRACT FOR COLLECTIONAND DISPOSAL OF USDA REGULATED GARBAGE CRL06 07.06V2 2 J 2 Niro _ 3. SCOPE OF CITY SERVICES The City agrees to perform the following services: A. Designate a City representative to provide timely direction to the Contractor and render City decisions; and B. Timely review and respond, if necessary, to reports submitted by Contractor. 4. TERM The term of the Contract shall be for a period of one (1) year commencing on the date both parties have signed this Contract. This Contract may be renewed on an annual basis by written agreement signed by both parties. 5. PAYMENT A. For and in consideration of the above services performed in accordance with this Contract,City agrees to pay Contractor the agreed upon unit price of eighteen dollars and fifty cents($18.50)in a total amount not to exceed one thousand dollars($1,000). B. The agreed upon per unit price for the collection and disposal of USDA Regulated Garbage shall include any and all costs incurred by the Contractor including but not limited to packing, loading, labeling,transportation and disposal costs. C. Contractor shall submit to the City a weekly invoice, if a request for services has been made by the City. Payment shall be made to Contractor within ten (10) days of receipt and approval by the Director of the Contractor's invoice of the services provided. 6. LABOR FORCE The Contractor agrees that all persons employed in the performance of services under the Contract shall have sufficient skill, ability, and experience to properly perform the work assigned to them and operate any equipment and vehicles necessary to properly carry out the performance of the assigned duties. Contractor shall provide suitable operational and safety training for all of its employees who utilize or operate equipment, and vehicles for transportation of materials under the Contract. CONTRACT FOR COLLECTIONAND DISPOSAL OF USDA REGULATED GARBAGE CRL06.07.002 3 7. MWBE REQUIREMENTS The Director certifies that a requirement for MWBE participation is not necessary or has been waived for services provided for under this Contract. 8. REPORTING REQUIREMENTS Contractor shall maintain and submit to the City accurate reports, which detail certain activity related to the services pursuant to this Contract. These reports shall include data for all materials handled from Contractor's services to the City. 9. FORCE MAZEURE If, by reason of Force Majeure as hereinafter defined, any party shall be rendered wholly or partially unable to carry out its obligations under this Contract,then such party shall give written notice of the particulars of such Force Majeure to the other party within a reasonable time after the occurrence thereof. The obligations of the party giving such notice,to the extent affected by such Force Majeure, shall be suspended during the continuance of the inability claimed and for no longer period,and any such party-shall be in good faith exercise its best efforts to remove and overcome such inability. The term "Force Majeure" as utilized herein shall mean and refer to acts of God; strikes, lockouts or other industrial disturbances; acts of public enemies; orders of any kind of the government of the United States, the State of Texas, or any other civil or military authority; insurrections; riots; epidemics; landslides; earthquakes; lightning; fires; hurricanes; storms; floods; washouts; or other natural disasters; arrest; restraint of government and people; civil disturbances; explosions;breakage or accidents to machinery,pipelines or canals;or other causes not reasonably within the control of the party claiming such inability. 10. TERMINATION This Contract may be terminated with or without cause upon thirty(3 0)days written notice to the non-terminating party. CONTRACT FOR COLLECTION AND DISPOSAL OF USDA REGULATED GARBAGE CRL06.07.0612 4 11. INDEPENDENT CONTRACTOR It is expressly understood and agreed that Contractor shall perform all work and services described herein as an independent contractor and not as an officer, agent, servant or employee of the City, that Contractor shall have exclusive control of and the exclusive right to control the details of the services and work performed hereunder, and all persons performing the same; and shall be solely responsible for the acts and omissions of its officers, agents, employees, contractors and subcontractors; that the doctrine of respondeat superior shall not apply as between City and Contractor,its officers, agents, employees, contractors and subcontractors;and that nothing herein shall be construed as creating a partnership or joint enterprise between City and Contractor.No person performing any of the work and services described hereunder shall be considered an officer, agent,servant or employee of the City. 12. INDEMNIFICATION A. CONTRACTOR SHALL RELEASE, INDEMNIFY, REIMBURSE, DEFEND, AND HOLD HARMLESS, CITY, ITS OFFICERS, AGENTS, SERVANTS AND EMPLOYEES, FROM AND AGAINST ANY AND ALL CLAIMS OR SUITS FOR PROPERTY DAMAGE OR LOSS AND/OR PERSONAL INJURY, INCLUDING DEATH, TO ANY AND ALL PERSONS, ARISING OUT OF THE WORK AND SERVICES TO BE PERFORMED HEREUNDER BY CONTRACTOR, ITS OFFICERS, AGENTS, EMPLOYEES, CONTRACTORS, SUBCONTRACTORS, LICENSEES, OR INVITEES, INCLUDING DAMAGES, LOSS, INJURY OR DEATH, TO THE EXTENT CAUSED BY ANY ERROR, OMISSION, DEFECT, OR DEFICIENCY OF CONTRACTOR IN ACCORDANCE WITH THIS CONTRACT EXCEPT TO THE EXTENT ANY SUCH DAMAGES, LOSS, INJURY OR DEATH IS CAUSED BY ANY NEGLIGENT ERROR, OMISSION, DEFECT OR DEFICIENCY OF THE CITY. B. CONTRACTOR DOES HEREBY RELEASE, INDEMNIFY, REIMBURSE, DEFEND, AND HOLD HARMLESS THE CITY, ITS OFFICERS, AGENTS, SERVANTS, AND EMPLOYEES FROM AND AGAINST ANY AND ALL LIABILITY, CLAIMS, SUITS, DEMANDS, OR CAUSES OF ACTION WHICH MAY ARISE DUE TO ANY LOSS OR DAMAGE TO PERSONAL PROPERTY, OR PERSONAL INJURY, AND/OR DEATH OCCURRING AS A CONSEQUENCE OF THE PERFORMANCE OF THIS CONTRACT, WHEN SUCH INJURIES, DEATH, OR DAMAGES ARE CAUSED BY THE NEGLIGENCE OF CONTRACTOR, ITS OFFICERS, AGENTS, OR EMPLOYEES, OR SUBCONTRACTORS, OR THE JOINT NEGLIGENCE OF CONTRACTOR, ITS AGENTS, OR EMPLOYEES, OR SUBCONTRACTORS, CONTRACT FOR COLLECTIONAND DISPOSAL OF USDA REGULATED GARBAGE CRL06.07.06V2 5 AND ANY OTHER PERSON OR ENTITY, EXCLUDING ALL PARTIES INDEMNIFIED HEREUNDER, TO THE EXTENT CAUSED BY THE NEGLIGENT ACT OR OMISSION OF CONTRACTOR. C. The obligations of the Contractor under this section shall include,but not be limited to, the burden and expense of defending all claims, suits, and administrative proceedings (with counsel reasonably approved by the indemnified parties), even if such claims, suits or proceedings are groundless, false, or fraudulent, and in conducting all negotiations of any description, and paying and discharging, when and as the same become due, any and all judgments, penalties or other sums due against such indemnified persons. D. Upon learning of a claim, lawsuit, or other liability which Contractor is required hereunder to indemnify, the City shall provide Contractor with reasonably timely notice of same. E. The obligations of the Contractor under this section shall survive the expiration of this Contract and the discharge of all other obligations owed by the parties to each other hereunder. F. In all of its contracts with subcontractors for the performance of any work under this Contract,Contractor shall require the subcontractors to indemnify the City in a manner consistent with this section. G. In the event that a written claim for damages against Contractor or any of its subcontractors remains unsettled at the time all work on the assigned task has been completed to the satisfaction of the City Manager,as evidenced by a final inspection, final payment to Contractor shall not be recommended by the City Manager for a period of ninety (90) Days after the date of such final inspection, unless the Contractor submits written evidence satisfactory to the City Manager that the claim has been settled and a release has been obtained from the claimant involved, or offers reasonable security for payment of such claim. 1. If the claim concerned remains unsettled at the expiration of the said thirty (30) Day period, the Contractor may be deemed by the City Manager to be entitled to a semi-final payment for work completed, such semi-final payment to be in an amount equal to the total dollar amount then due less the dollar value of any written claims pending against the Contractor arising out of the performance of such work. 2. The City Manager shall not recommend final payment to Contractor if a claim for damages is outstanding for a period of six(6) months following the CONTRACT FOR COLLBCTIONAND DISPOSAL OF USDA REGULATED GARBAGE CRL06.07.06V2 6 date of the acceptance of the work performed unless the Contractor submits evidence in writing,satisfactory to the City Manager,that: a. The claim has been settled and a release has been obtained from the claimant involved; or b. Good faith efforts have been made to settle such outstanding claims, and such good faith efforts have failed. 3. If condition (a) above is met at any time within the six(6) month period, the City Manager shall recommend that the final payment to Contractor be made. If condition,(b) above is met at any time within the six-month period, the City Manager may recommend that final payment to Contractor be made. At the expiration of the six (6) month period, the City Manager may recommend that final payment be made if all other work has been performed and all other obligations of the Contractor have been met to the satisfaction of the City Manager. 13. INSURANCE Contractor shall not commence work under this Contract until it has obtained all the insurance required under the Contract, and such insurance has been approved by the City. Contractor shall keep the required insurance in force throughout the term of this Contract. A. WORKERS'COMPENSATION INSURANCE: Contractor shall maintain, during the term of this Contract, Workers' Compensation Insurance at statutory limits on all of its employees to be engaged in work under this Contract, and for all subcontractors. Employer's Liability (EL) Insurance shall also be maintained, at minimum limits as follows: $100,000 each accident, $100,000 disease each employee/$500,000 disease policy limit. B. GENERAL LIABILITY INSURANCE (CGL): Contractor shall procure and shall maintain during the term of this Contract a Commercial General Liability Insurance Policy at a minimum limits as one million dollars ($1,000,000.00) per occurrence with an aggregate of two million dollars($2,000,000.00). C. AUTOMOBILE INSURANCE: Contractor shall procure and maintain during the term of this Contract Comprehensive Automobile Liability Insurance covering all vehicles involved with Contractor's operations under this Contract. The minimum limits of liability coverage shall be in the amount of one million dollars($1,000,000) per occurrence combined single limit, during the effective dates of Contract and any CONTRACT FOR COLLECTIONAND DISPOSAL OF USDA REGULATED GARBAGE CR06.07.002 7 renewal period. The named insured and employees of Contractor shall be covered under this policy. The City of Fort Worth shall be named an additional insured on Endorsement TE 9901 or equivalent, as its interests may appear. The following shall pertain to all applicable policies of insurance(A. through C.)listed above: 1. Additional Insured Clause: "The City of Fort Worth, its officers, agents, employees, and representatives are added as additional insureds as respects operations and activities of, or on behalf of the named insured, performed under contract with the City of Fort Worth." An equivalent clause may be acceptable in the discretion of the City. 2. Subcontractors shall be covered under the Contractor's insurance policies or they shall provide their own insurance coverage; and, in the latter case, documentation of coverage shall be submitted to the Contractor prior to the commencement of work and the Contractor shall deliver such to the City. 3. Prior to commencing work under the Contract, the Contractor shall deliver to the City insurance cerdficate(s) documenting the insurance required and the terms and clauses required. 4. Each insurance policy required by this Contract shall contain the following clauses: "This insurance shall not be canceled, limited in scope or coverage, or non-renewed until after thirty (30) Days prior written notice has been given to the Director of Envlronmental Management, City of Fort Worth, 1000 Throckmorton, Fort Worth, Texas 76102."Note: Written notice can be by Contractor or insurance company. 5. The insurers for all policies must be approved to do business in the State of Texas and be currently rated in terms of financial strength and solvency to the satisfaction of the Risk Manager for the City. 6. The deductible or self-insured retention (SIR) affecting the coverage required shall be acceptable to the Risk Manager of the City; and, in lieu of traditional insurance, alternative coverage maintained through insurance pools or risk relations groups must be also approved. CONTRACT FOR COLLECTIONAND DISPOSAL OF USDA REGULATED GARBAGE CRL06.07.002 8 14. CUMULATIVE REMEDIES The rights and remedies granted in this Contract are cumulative, and the exercise of such rights shall be without prejudice to the enforcement of any other right or remedy authorized by law or this Contract.No waiver of any violation shall be deemed or construed by a court of law or an arbitrator to constitute a waiver of any other violation or other breach of any of the terms, provisions, and covenants contained herein. 15. REMEDIES FOR BREACH The parties agree that, except as otherwise provided in Section 11 with respect to termination, in the event that either party breaches this Contract, the other party may exercise any legal rights it has under this Contract under the security instruments and under Applicable Law to recover damages or to secure specific performance,and that such rights to recover damages and to secure specific performance shall ordinarily constitute adequate remedies for any such breach. 16. NO WAIVER OF RIGHTS No failure by the City or by the Contractor to insist upon the strict performance of any term, covenant, agreement, provision, condition or limitation of this Contract or to exercise any right or remedy hereunder, and no acceptance by the City of full or partial payment during the continuance of any such breach, shall constitute a waiver of any such breach or of such term, covenant, agreement, provision, condition or limitation. No term, covenant, agreement, provision, condition or limitation of this Contract to be kept, observed or performed by the City or by the Contractor, and no breach thereog may be waived, altered or modified except by a written instrument executed and acknowledged by and delivered to the City and the Contractor. No waiver of any breach shall affect or alter this Contract, but each and every term, covenant agreement, provision, condition and limitation of this Contract shall continue in full force and effect with respect to any other then existing or subsequent breach thereof. This Contract may be terminated (except by expiration of the term of this Contract) only by a written instrument of termination executed by the appropriate party and delivered to the non-terminating party. 17. RIGHT TO AUDIT Until the expiration of three(3)years after the final payment under this Contract,the City shall have access to and the right to examine any directly pertinent books, documents,papers and records of the Contractor involving transactions relating to this Contract. Contractor further agrees to include in all its subcontracts hereunder a provision to the effect that the subcontractor agrees that the City shall,until the expiration of three(3)years after final payment under the subcontract,have access to CONTRACT FOR COLLECTIONAND DISPOSAL OF USDA REGULATED GARBAGE CRLOQ07.0612 9 papers and records of such subcontractor involving transactions relating to the subcontract. The term"subcontract"as used herein includes purchase orders. 18. GOVERNMENTAL POWERS AND IMMUNITIES It is understood and agreed that, by execution of this Contract, the City does not waive or surrender any of its governmental powers or immunities. Contractor acknowledges that the City is a governmental body and as such has certain rights, powers and duties that may affect the Contractor's rights or obligations under the Contract.The Contractor agrees that no action by the City acting in its governmental capacity shall be construed as a breach by the City under this Contract, nor shall any such action excuse the Contractor from performance of its obligations under this Contract; provided, however, if such action constitutes a Force Majeure, the Contractor may assert any rights it may have under this Contract as is permitted herein. 19. COMPLIANCE WITH LAWS Contractor, its officers, agents, employees, contractors and subcontractors, shall abide by and comply with all Applicable Law, federal, state and local, including the City's charter and all ordinances, rules and regulations of the City and shall maintain all permits and approvals required for the services to be provided to City. It is agreed and understood that, if City calls the attention of Contractor to any such violations on the part of Contractor, its officers, agents, employees, contractors or subcontractors, then Contractor shall immediately desist from and correct such violation. 20. LICENSES.PERMITS AND FEES Contractor agrees to obtain and pay for and maintain all licenses, permits, certificates, inspections and all other fees required by law or otherwise necessary to perform the services prescribed hereunder. Contractor shall also pay, at its own expense, all fees necessary for the transportation of IWasle.• 21. NON ASSIGNMENT Contractor shall not assign, transfer, sublet, convey, or otherwise dispose of the Contract or the rights, title, or interest in or to the same or any part thereof without the previous consent of the City which consent will not be unreasonably withheld if the assignment is made to an Affiliate. In the event Contractor does, without such previous consent, assign, transfer,.sublet, convey or CONTRACT FOR COLLECTIONAND DISPOSAL OF USDA REGULATED GARBAGE CRL06.07.06V2 10 Yi r `vU. YY� uA, otherwise dispose of the Contract or of the right, title or interest therein or any part thereo4 City may, at its discretion,terminate the Contract in accordance with Section 11 hereof. 22. SUCCESSORS AND ASSIGNS All of the terms, covenants, and Contracts contained herein shall be binding upon and shall inure to the benefit of successors and assigns of the respective parties hereto. 23. NOTICES Any notices,bills, invoices or reports required by this Contract shall be sufficient if sent by the parties in the United States mail,postage paid,to the address noted below: If to the City: Brian Boerner, Director of Environmental Management Department 1000 Throckmorton Fort Worth,Texas 76102 If to the Contractor., bnWAOW7 Aw-vI� /077-0 tn&-# if 7?0 6IzV06 PGI19' 7X 757,51 A- n' MOM L OSSe 24. VENUE Should any action, whether real or asserted, at law or in equity, arise out of the terms and conditions of this Contract,venue for said action shall be in Tarrant County,Texas. 25. SAVINGS CLAUSE In case any one or more of the provisions contained`in this Contract shall, for any reason,be held to be invalid, illegal or unenforceable in any respect, such invalidity, illegality or unenforceability shall not affect any other provision of this Contract; this Contract shall be construed as if such invalid, illegal or unenforceable provision had never been contained herein. CONTRACT FOR COLLECTIONAND DISPOSAL OF USDA REGULATED GARBAGE CRL0b.07.002 11 26. NON-APPROPRIATION In the event that no funds or insufficient funds are collected, appropriated and budgeted or funds are otherwise unavailable for payment of amounts due hereunder by City to Contractor, City shall notify Contractor and this Contract shall terminate on the last day of the fiscal period for which appropriations were made without penalty or expense to City of any kind whatsoever, except as to the payment of amounts due and payable for which appropriations have been made for said fiscal period. City covenants that it will provide Contractor as much notice as possible of this contingency. X�VITINESS WHEREOF, The parties hereto have executed this Contract on this day of A.D.,2006,in Fort Worth,Tarrant County,Texas. CITY OF FORT WORTH ENVIROCLEAN MANAGEMENT SERVICES,INC. D BY: Loo Yl A Libby Watson' Assistant City 1Nfanager President/Vi President Date Signed: Date Signed:_ ATTEST: WITNESS: �� ZZ.• �� ��T OL A &-tl" r ij Marty Hendrix City Secretary APPROVED AS TO FORM CORPORATE SEAL: AND LEGALITY: Christa R.Lopez Assistant City Attorney �NO M&C REQUIRED CONTRACT FOR COLLECTIONAND DISPOSAL OF USDA REGULATED GARBAGE CRL06.07.06W 12 Ai S c• - CONTRACTOR COMPLIANCE WITH WORKERS' COMPENSATION LAW Pursuant to V.T.C.A. Labor Code §406.96 (2000), as amended, Contractor certifies that it provides workers' compensation insurance coverage for all of its employees employed on City of Fort Worth Department of Environmental Management Project No. DEM06- 08:USDA-RG ENVIROCLEAN MANAGEMENT SERVICES INC. By: Lan 0 le- Title e-Title 0 Ce Date STATE OF TEXAS § COUNTY OF TARRANT § Before mNy undersigned authority, on this day personally appeared A el 1 - known to me to be the person whose name is subscribed to the foregoing instrument, and�cknowle-'ged to me that he executed the same as the act and deed of �`-/K s T for the purposes and consideration therein expressed and in the capacity therein stated. Given Under My Hand and Seal of Office thisday of 2d4 Notary Public in and f6r the State of T r PU LUCY DILL ARD Texas p e� NOTARY PUBLIC STATE OF TEXAS My Commission Expires rFoc�`� APRIL 03,2010 Sent By: Enviroclean Management Systems; 972-5551212; Feb-22-06 11 :06AM; Page 2 PROPOSAL DOCUMENT C E KLIS All Proposal Documents, includi this Checklist, should be completed in full and submitted in a sealed envelope, in the req sted order,to be considered as a responsive submittal. Pr000sal Documents Initial K Included 1, PROPOSAL DO UMENT CHECKLIST 2_ ACKNOWLEDG REQUEST FOR PROPOSAL ADDENDA. I A 3. MINORITY and OMEN BUSINESS ENTERPRISES LI 4. PROPOSAL SU MARY 5. COST ESTIMAT C,C 6. PROVIDER'S C MPANY EXPERIENCE RECORD 7. VENDOR'S CO PLIANCE TO STATE LAW C,t 8. INSURANCE C TIFICATES 9, PROVIDER'S LI ENSES&CERTIFICATES (J- 10. PROVIDER'S.L AL&COMPLIANCE HISTORY l_L 11. OTHER DOCU NTS TO BE PROVIDED A. In ice B. Wa a Shipment/Handling/Disposal Report C. W to Manifest/Certificate of Disposal I understand that all of thes Items will be reviewed, and any items not Included may result in my Submittal b Ing considered non-responsive. p Name ��!'�n�1- P Title V'I Company 4 0 u fi k ,3 Sent By: Enviroclean Management Systems; 972-5551212; Feb-22-06 11 :07AM; Page 3 ACKNOWLEDGEMENT OF RE EIPT OF RE UEST FOR PROPOSAL ADDENDA Check if applicable The undersigned ack ledges the receipt of the following addendum(a) to the Request for Proposals, nd has attached all addenda following this page. (Add lines if necessary). Addendum Number 1 (Date received) Addendum Number 2 (Date received)Addendum Number 3 (Date received) Check if applicable The undersigned ackno ledges the receipt of no addenda to the Request for Proposals. PROVIDER: Z � V, �J �� 13Y: LAO{i1'1rl 1 Q Company Name (p t or type name of signatory) Address (Signature) City, State, Zip Title(print or type) W �L'r • 1 Sent By: Enviroclean Management Systems; 972-5551212; Feb-22-06 11 :07AM; Page 4 MINORITY and WOMEN B SI ESS ENTERPRISES MNVBE : The City's requirement for M/WBE participation has bee waived for these services. PROPOSAL_ SUMMARY TO THE CITY OF FORT WOR The undersigned hereby propo s to furnish storage and shipping containers, provide on- site pickup, provide transpor`ta n, handle disposal, as applicable for USDA Regulated Garbage as defined by 7 CFR its 330.100 and 330,400. Contractor equipment and pe nel are capable of performing each type of procedure listed above either with in house esources. All Proposal Documents have b en submitted in one sealed envelope. Addenda to the Request f Proposals have been received. Unit prices are provided within t e Proposal Documents in Section 2.5. Waste Shipments will be sch led and responded to five (5) calendar days after receipt of shipment notice. The additi al cost for responding within three (3) calendar days after receipt is and the dditional cost for responding within one (1) calendar day after receipt is _°!o, This Proposal Summary and t accompanying Proposal Documents are intended to be complete and will remain valid r sixty(60)days from the date of submittal. PROVIDER: \ ( p ,-t Lt C - -�'7gU BY: L n 1 (Company Name) (print or type name of signatory) � ? 1J (Address) (Signatu � 5 �s ( • �-Ap (City, State, Zip) Title(print or type) (Phone) (FAX) Sent By: Enviroclean Management Systems; 972-5551212; Feb-22-06 11 :07AM; Page 5 COST ESTIMATE: The tJbIeb identifies various types of materials, Contractor shall provide a cost for each type of rnaded on the Table. Cost shall be a `hum-ke ' cost and include packaging, loading, labelinortation, and disposal costs. No fees shall be added to Additionally,the Contraattach their Standard Price List at the end of this section along with any adiscount rate(percentage off standard)that applies to the City of FoTypical Waste streaCOST Per Container USDA Re ulated Ga e ""The City of Fort Worth is not responsible covering costs due to Contractors mishandling of waste causing breakage or other damage. Contractor must covet is for any damage due to mishandling of wastes during work performers under this contract_ - COST for the pickup,transp tion, and disposal of any waste Services atmd Supplies Service Price Field Technician—hourly rate AV Container(Boxes) ' �? At* f 01/ Container liners �r PROVIDER' COMPANY EX RIENCE RECORD Provider shall identify its co pany name, address, telephone number(s), and FAX number(s)for the focal office as e11 as the headquarters. Provider shall attach an up- date and concise copy of its current Statement of Qualifications. Provider shall identify key pe ns by name and title and describe the primary work assigned as well as the percen ge of time each person will devote to this contract. Provide listing of equipment caned and operated by the Provider including analysis capability for the equipment. In hort a ready reference of in-house capabilities for analysis. Document Provider's experle a managing and performing USDA Regulated Garbage disposal. Explain any web-based custo service system that may be available to view and track City projects. INCLUDE A COPY F THE QUALIFICATIONS FOLLOWING THIS PAGE SOU D WITHIN THE PROPOSAL PACKAGE r� � 'V iiyb Sent By: Enviroclean Management Systems; 972-5551212; Feb-22-06 11 :07AM; Page 6 VENDORS COMPLIANCE TO ATE LAW Artiefe 601g of Vernon Texas Civil Statues (1985) applies to the award of contracts to non-reside t contractors (out-o"tate contractors whose corporate offices or principal pla of business are outside of the State of Texas) who are required to proposal prof cis for construction, improvements, supplies or services in Texas at an amount Ie than the lowest Texas resident contractors would be required to under pro oral a non-resident contractor in order to obtain a comparable contract :in he state in which the non-resident's principal place of business is located. The ppropriate blanks in Section A below must be filled out by all out-of-state or nein- sident contractors in order for their submittal to meet specifications. The fail of out-of-state or non-resident contractors to do so will automatically disqualify t contractor. Resident contractors must check the box in Section B below. A. Non-resident Ga tractors in _ ive state), our principal place of busine , are required to be percent lower than resident contract rs by state law. A Dopy o the statute is attached. Non-resident tractors in (give state), our principal place of busines , are NOT required to underbid resident contractors. S. Our principal pi ce of business or corporate offices are in the State of Texas. [ ] ( heck this box if statement B is true) PROVIDER: �A0VO C,ckE_ lj BY. Lorn1e P (o let crz (Company Name) (print or type name f signatory) 17--7 so rY1kfL1T (Address) (Signature) D�AK t JX- -152 s1 � n VG r oft— l Cdo q_s ti (City, State, Zip) Title (print or type) A Sent By: Enviroclean Management Systems; 972-5551212; Feb-22-06 11 :07AM; Page 7 INSURANCE CERTIFICATES FOR PURPOSES OF THIS R UEST FOR PROPOSAL, PLEASE ATTACH A COPY OF YOUR CURRENT INSU CE CERTIFICATE(S) FOLLOWING THIS PAGE AND BOUND WITHIN THE PROPG PACKAGE. The successful Provider will be required by the contract to have insurance coverage as detailed below. Prior to corn encing work, the Provider shall deliver to Fort Worth certificates documenting this co rage. The City may elect to have the Provider submit its entire policy for Inspection. f 1. WORKERS' C PENSATION INSURANCE: Contractor shall maintain, during the term of this Contract, Workers' Compensation Insurance at statutory limits all of its employees to be engaged in work under this Contract, and fo II subcontractors. Employers Liability Insurance shall also be maintained, t minimum limits as follows: $100,000 disease each employee/$500, disease policy limit and $100,000 each accident. 2. GENERAL LI LITY INSURANCE (CGL); Contractor shall procure and shall maintain ring the term of this Contract a Commercial General Liability Insursn Policy at a minimum limits as One Million Dollars ($1,000,000) p occurrence with an aggregate of Two Million Dollars ($2,000,000). 3. AUTOMOBILE NSURANCE: Contractor shall procure and maintain during the to of this Contract Comprehensive Automobile Liability Insurance cove 'ng all Vehicles involved with Contractor's operations under this Cont ct. The minimum limits of liability coverage shall be in the amount of ne Million Dollars ($1,000,000) per accident combined single limit, or ve Hundred Thousand Dollars ($500,000) bodily injury - per person per occurrence and Two Hundred Fifty Thousand Dollars ($250,000) pro rty damage during the effective dates of Contract and any renewal od. The named insured and employees of Contractor shall be cover d under this policy. The City of Fort Worth shall be named an ditlonal insured on Endorsement TE 9901 or equivalent, a its Interests may appear. Liability for damage occurring wh loading, unloading and transporting materials collected unde the Contract shall be included under this policy. The following shall pertain all applicable policies of Insurance (1. through 3.) listed above: a) Additional Insured Clau e: "The City of Fort Worth, its officers, agents, employees, and representatives ar added as additional insureds as respects operations and activities of, or on beha of the named insured,,performed under Contract with the City of Fort Worth." Ex ption...the additional insured requirement does not apply to Workers' Compensatio policies b) Subcontractors shall b covered under the Contractor's insurance policies or they shall provide their own surance coverage; and, in the latter case, documentation of coverage shall be bmitted to the Contractor prior to the commencement of Sent By: Enviroclean Management Systems; 972-5551212; Feb-22-06 11 :08AM; Page 8/14 work and the Contractor hall deliver such to the City. c) Prior to commencing w under this Contract, the Contractor shall deliver to the City of Fort Worth ins u nce certificate(s) documenting the insurance required and terms and clauses quired. d) Each insurance policy required by this Contract shall contain the following clauses: "This insurain shall not be canceled, limited in scope or coverage, or non-renewed until after rty-five (45) Days prior written notice has been given to the Director of Envi nmental Management, City of Fort Worth, 1000 Throclkmorton, Fort W rth, Texas 76142" Note: Written notice can be by Contractor or insurance mpany. e) The insurers for all po cles must be licensed/approved to do business in the State of Texas, Exce t for workers' compensation, all insurers must have a minimum rating of A., I in the current A. M. Best Key Rating Guide or have reasonably equivalent ancial strength and solvency to the satisfaction of Risk Management. If the ting is below that required, written approval of Risk Management is require . f) The deductible or self-i ured retention (SIR) affecting the coverage required shall be acceptable to and: a proved in writing by the Risk Manager of the City of Fort Worth in regards to a et value and stockholders equity. In lieu of traditional insurance, alternative erage maintained through insurance pools or risk retention groups must b also approved by the City's Risk Manager. g) Waiver of rights of reco ry(subrogation)in favor of the City of Fort Worth. h) Such insurance policie shall be primary, without right of contribution and not subject to any offset by ny other insurance carried by the City or the Contractor. i) If insurance policies ar not written for specified coverage limits, an Umbrellas or Excess Liability insura for any differences is required. Excess Liability shall follow form of the prima coverage. j) "Unless otherwise stat , all required insurance shall be written on the"occurrence basis". If coverage is nderwritten on a claims-made basis, the retroactive date shall be coincident wit or prior to the date of the contractual agreement and the certificate of insuran shall state that the coverage is claims-made and the retroactive date. Thein ranee coverage shall be maintained for the duration of the contractual agreement nd for five (5) years following completion of the service provided under the con ctuai agreement or for the warranty period, whichever is longer. An annual certi to of insurance submitted to the City shall evidence such insurance coverage. k) The City, at its We discretion, reserves the right to review the insurance requirements and to, ke reasonable adjustments to insurance coverages and their limits when deem necessary and prudent by the City based upon changes in statutory law, court d cision or the claims history of the industry as well as of the contracting party to th City of Fort Worth. In the event the City requires the insurance limits to b increased or changes in policy categories or types of Sent By: Enviroclean Management Systems; 972-5551212; Feb-22-06 11 :08AM; Page 9/14 coverage, the City Shal provide written notice to the contracting party. The contracting party will ha ninety days (90) from the date of notice to comply with the additional requiremer ts. The City shall be entitled, up n request and without expense, to receive copies of policies and endorsements the to and may make any reasonable requests for deletion or revision or modifications f particular policy terms, conditions, limitations, or exclusions except where poll c provisions are established by law or regulations binding upon either of party or the and riter on any such policies. i Sent By: Enviroclean Management Systems; 972-5551212; Feb-22-06 11 :08AM; Page 10/14 PROVIDE R'S k.ICE4SFS& C, TIFICIATrES Provider shall procure all perm and licenses, pay all charges, costs, and fees, and give all notices necessary and Wnd0e to the due and lawful prosecution of the work. Provider must provide a copy the appropriate certifications, registrations, and licenses and related certificates with ftl ubmdtal. ATTACH COPIES OF CUR NT APPLICABLE LICENSES AND CERTIFICATES FOLLOWING THIS PAC AND BOUND WITHIN THE PROPOSAL PACKAGE ' � i;<,ihlc:cn ll�lnnett 1i-1)iic,(,7)airrnan 1 "� - !J�•��. )Z. ti. •��atpJ) jlaf(JU.^::,�.Gf71)771SSlOJ1P> i 1L~r�l �;� I''� � L:.i;��R. ,;uH<,td,Cornr,^is•'r„lar '� �`% Clenr ShAjAl,l:xerutitxr Dirnclor TEXAS COMJVISSION ON ENVIRONMENIAL QUALITY Prolecting 7'zxos by Reducing wed Prer:enling Pollution i ui j 18, 2005 ivli. Matthew H, i7eeger Er,r ro•^_;ean Mam igemeul.Services, lnc. i 12750 Merit Dr. PC-VTI Ste. 770 D31las. TX 7521-1250 ' I Subject. Medical Waste Transporter Registration - Brazos, Daflas, w Galveston, Harris. Nueces, Tarrant arld Tyler County � EaviroClear Management Services, lijc. TCEQ Registration Vo: MSW - 5T30>'' j Expiration Date: 07717=006 No ��iLT lvtr. Fleetr::*: We have received your com?Ieted R:E,31.57TRA=1N FORM Fop.TRANSPORTERS OF MPAZCAL Ass-m for the renewal ref the abovc- re:ereucec rtgisutuion A copy of th1S registration renewal confirmation letter and enclosed application mast ':,e retained at vola*desipa;:ed plaur of business and in each vehicle used to tranapon untreated special waste from health care related facihne!� (also lSiove—. as untreated medical waste). Youzassi}ted Texas Co>Yimission on Emvizoivaiental Quality (TCEC� regisrratior member appe;,:s cn tJle copy of the em.closed form and in the subject block of this letter- This numluer is to be used on the Pe., t.ak!6 Merical Wziae Matufcst” (ccrDy enc�osed), when contacting the TCEQ, and on trucks and trailers used for :he Ottminnn 2rri JLILJprma-don of• ••treated medico waste. Ar,c_-ptarc;.,of iuis reg stration renewal consrtutes an aclmowledgment that you will comply,with Title 30 Texas Administrarive Code Chapter 330,Su chapteT Y, and with the pertinent laws of the State of Texas. This registration renewal does not indicate th-at,rot:,:operation is M full compliance with TCEQ rules and resulations. The operatioi and management meWods of you:. business are sobjee: . to TCEQ inspection and review at all times. Failure to comply grith all state amd federal rules and reg',iUxiom regarnmg *he traucportat.p, entreated medica w e av result in enforcement action, revocation of Vou �t��oZerstratian r b t _. ==r" txY _ R�,�T �� .�ti� e`���`eas����rt y � =s•�3 i- ., r??:. c:_. .y r c� wok j t��' w9 o ani 1UJ i7t �xr � K •xn•c.ro:t:r f��- �7:y'yT l:It. �d'i6=` Gut ;�s�.it, rtitic1TR'stj*rmianTrn.a..;Tlatc `.r, t ►' s.� ctaLyfa>? ea1; �- ; ty : I-ar_h of the fo)lowhig changes requires a wriitefi notification to the TCEQ within 15 days: i i. the amoi nt of untreated specia' waste from health care related facilitiesortotal operation is e.7anded by 50% over that loriginally registered; 2. the office or place of businesslis moved, or the mailing address is changed; 3. the name of registrant or om7ii of the operation is changed; 4. the name of the partners, corporate directors, or corporate officers chane; or, 5. additional dr.-vers are emplcy7d- (The notification for additional drivers may be done at silt-month intervals.) 4 I If you have any questions,please contact the Mi a] Solid Waste(MSIAD Registration Teal i at(512)239-6001, select Option 2. t Siucezely, I i Doris Poole; pioor=Specialist *The enclosed manifest form meets Registration&Reporting Sectiou(MC 3 29) i USDOT and`I`��@ regulations. Registration, Review,.&Reportiag Division { b i Enclosures cc: Mr. Sam.Barrett, TCEQ Region 04 Office, Dal)as/Ft. Worth .. Mr. Michael.Brashear, TCEQ Region 05 rbf5ce. Tyler Mr. Don Wyrick,TCEQ Regiot109 Office, Waco I �, ,. Ms. Marsha Hili, TCEQ Region 12 Office, Houston INE, :..:: ..._. :vii. RussellLtw6, TCZQ: "` P.U.Box 13087 • Austir;,Texas 7877,1-30017 • 51209,1000 • 1nternetladdTCSS:WM-)Aceq.st e.t3hms -••�� �nq prin:e3 en r;rydee paper u:i��:a.,bas,i i:.i: :I , :'U•�:/U�U IR 9 �•�Gov o .. Client#: 1312 ENVIRMAN ZORD,M CERTIFICATE OF LIABILITY INSURANCE 08/16105DnYYY) IUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Southwest ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Box 218060 HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. ston,TX 77218-8060 -- 1-1496-3400 INSURERS AFFORDING COVERAGE NAIC# IED INSURER A: American International Specialty Lin 26883 Med Solutions, Inc.aka EnviroClean INSURER B: Illinois National Insurance Company 99999 Management Services,Inc. INSURER C: Commerce and Industry Insurance Comp 19410 12750 Merit Dr., Park Central VII#770 INSURER D: Argonaut Insurance Company 19801 Dallas,TX 75251 INSURER E: Texas Mutual Insurance Company 22945 ERAGES E POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING Y REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR 4Y PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH )UCIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. D POLICY EFFECTIVE POLICY EXPIRATION NSR TYPE OF INSURANCE POLICY NUMBER DATE EFFECTIVE YDATE fMM/DD/YYI LIMITS GENERALLIABILITY EG7564738 08/15/05 06/20/06 EACH OCCURRENCE $1000000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 5100,000 �j CLAIMS MADE 51OCCUR MED EXP(Any one person) $5,000 PERSONAL 8 ADV INJURY S1,000,000 GENERAL AGGREGATE s2,000,000 ,J X GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000 POLICY PRO X LOC AUTOMOBILE LIABILITY CA7564741 08/15/05 06/20/06 COMBINED SINGLE LIMIT X ANY AUTO CA7564740 08/15/05 06/20/06 (Ea accident) $1,000,000 ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S r"" ANY AUTO OTHER THAN EA ACC S AUTO ONLY: AGG S EXCESS/UMBRELLA LIABILITY EGU7564739 08/15/05 06/20/06 EACH OCCURRENCE $10,000,000 OCCUR Fx_]CLAIMS MADE AGGREGATE $10,000,000 r;l S DEDUCTIBLE S X RETENTION $10,000 $ WORKERS COMPENSATION AND 47683822815 06/20/05 06/20/06 XWC sTAru- JOTH r- - - 1 EMPLOYERS'LIABILITY I TOR FR ANY PROPRIETOR/PARTNER/EXECUTIVE 114710620040716 06/20/05 06/20/06 E.L.EACH ACCIDENT S1,000,000 OFFICEWMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEEI$1,000,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT 1$1,000,000 OTHER Pollution EG7564738 08/15/05 06/20/06 $1,000,000 Each Loss Legal Liability $25,000 Deductible :SCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS 'Niver of Subrogation(all policies)and Additional Insured(all policies cept WC)is provided in favor of the Certificate Holder as required by tritten contract but limited to the operations of the Named Insured. ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 11711 WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR MEN REPRESENTATIVES. AUTHORIZED REPRESENTATIVE @WORD 25(2001/08)1 of 2 #S197096/M197071 105 © CORPORATION 1988 Sent By: Enviroclean Management Systems; 972-5551212; Feb-22-06 11 :08AM; Page 11 /14 PROVIDER'S LEGAL AND CO LIANCE HIST.0 Provider's legal and complian history is a Critical component of this Request For Proposal. Read this section wit care and respond accordingly. Failure of the Provider to provide all the information requ ted and to certify the report, will result in the Provider's submittal being declared non-re onsive. Provider shall attach a written re ort of lWal action brought against: • Provider; • Provider's officers; • Provider's employees; N • Provider's proposed su tractors Relatim to the protection t environment. The report shall include all legal action brought within five (5) years of he closing date of this Request For Proposal. The report shall detail the substance, state and outcome of such legal action. This includes without limitation the names of the age Cy and/or persons bringing the action, all relevant dates, and all fines,judgments, and/or ettlements. "LEGAL ACTION" means: AN enforcement action by the United States Environmental Protection Agency, the Occup onal Safety and Health Administration, any other federal agency, the Texas Natural Res urce Conservation Commission (including its predecessor agencies the Texas Water iC mission and the Texas Air Control Board), the Texas Department of Health, and any ther state agency, commission or department, whether in Texas or elsewhere, as a result f violations, real or alleged, of any laws, licenses, permits, judicial orders, or administrative riders, relating to the Drotection of the environment. In this context, enforcement action s II include without limitation, written warnings, notices of violation, consent orders or ag ements, compliance orders, administrative hearings, and criminal prosecution. Legal a on also means any civil litigation brought by any person relatin to the protection of the vironment. "RELATING TO THE PROTE TION OF THE ENVIRONMENT' means: requirements pertaining to the manufact e, processing, distribution, use, handling, storage, transportation, reporting, rec ds keeping, permitting, licensing, treatment, disposal, emission, discharge, spill, refs e, or threatened release of: (a) Hazardous materials, hazardous substances, hazardous wastes, toxic substances, petroleum industrial waste, solid waste, pollutants or contaminants into or onto the: ' (1) Air, surface er, drinking water, groundwater, storm water, publicly owned treatme works, or land. Sent By: Enviroclean Management Systems; 972-5551212; Feb-22-06 11 :09AM; Page 12/14 THE REPORT SHALL BE SIGD AND CERTIFIED by an orthio the form Zed representative is to be f the Provider, using the form on a following page. The top pt completed if a report Is attach The bottom portion of the form is to be completed if Provider has no legal action to report An authorized representative of a Provider shall mean (1) if the Provider is a corporation: the president, secretary, or trey rer, or a vice president of the corporation in charge of a iprincipal business function, or y other person who performs similar policy or decision- making functions for the corpo on; (2) if the Provider is a partnership, a general partner; and (3)it the Provider is a sole p prietorship,the sole proprietor. INCLUDE A COPY OF HE REPORT FOLLOWING THE CERTIFICATION PAGE BOUh D WITHIN THE PROPOSAL PACKAGE Sent By: Enviroclean Management Systems; 972-5551212; � Feb-22-06 11 :09AM; Page 13/14 Certification of Pro dees Legal and Compliance History Complete E of the Following Certifications: I certify under penalty of law at the attached report of Providers Legal and Compliance History was prep' under my direction or supervision in accordance with a system designed to a re that qualified personnel properly gather and evaluate the information submitt d. Based on my inquiry of the person or persons who manage the system, or th a persons directly responsible for gathering the information, the information sub itted is, to the best of my knowledge and belief, true, accurate, and complete. am aware that there are significant penalties for submitting false information, in ding the possibility of fine and imprisonment for knowing violations. PROVIDER: LVII-6 BY: Company Name (print or type name of signatory) (signature) Title (print or type) Date 1 certify under penalty of law t t the legal and compliance history of Provider, Provider's officers, Provider's employees, and Provider's proposed subcontractors was researched under my direction or supervi n in accordance with a system designed to assure that qualified personnel properly ga er and evaluate the information submitted. Based on my inquiry of the person or pers ns who manage the system, or those persons directly responsible for gathering the.in rmation, I hereby certify that no legal action relating to the protection of the environment s brought against Provider, Provider's officers, Provider's employees, or Provider's prop d subcontractors within the preceding five years. To the best of my knowledge and :b ef, this statement is true, accurate, and complete. I am aware that there are signifiica t penalties for submitting false information, including the possibility of fine and imprison ent for knowing violations. PROVIDER: 13Y: _ Cgmpanv Name (print or type name of signatory) (signature) Title (print or type) Date Sent By: Enviroclean Management Systems; 972-5551212; Feb-22-06 11 :09AM; Page 14/14 OTHER Each Contractor shall submit aingle copy of a sample of the following documents for review: 1. Sample 1 nice 2. Sample V aste ShipmenttHandling/Disposal Report 3. Sample I Vaste Manifest/Certificate of Disposal INCLUDE PROY OF EACH DOCUMENT BOUND THIN THIS POS P CKA E FOLLOWING THIS PAGE -z ..110111 11 ��U��� �jn'f Management Services, Inc. Customer ID Past Due 006307 0.00% Invoice Date Invoice# 04/30/2005 0000052479 Billed To: Terms PO# Due Upon Receipt Accounting Office-Julie Markee 8900 Lakes at 610 Drive Houston, TX 77054 Date of Service Manifest #Cont. Description Weight Amount Dept#001 KS-CHAMPIONS(0055) --15555 Kuykendahl Ste 400 04/04/2005 0000105416 1 Corrugated Box 15.00 $ 10.00 04/11/2005 0000106962 3 Corrugated Box 44.00 $ 30.00 04/18/2005 0000108422 2 Corrugated Box 35.00 $ 20.00 04/25/2005 0000109946 2 Corrugated Box 33.00 $ 20.00 Dept Total: $ 80.00 Dept#001 KS-CLEAR LAKE(0014) --830 Gemini 04/05/2005 0000105453 3 Corrugated Box 46.00 $ 30.00 04/12/2005 0000106995 2 Corrugated Box 40.00 $ 20.00 04/19/2005 0000108456 1 Corrugated Box 12.00 $ 10.00 04/26/2005 0000109917 1 Corrugated Box 27.00 $ 10.00 Dept Total: $ 70.00 Dept#001 KS-CLEAR LAKE MED CTR(0058) --17448 Hwy 3 04/05/2005 0000105418 5 Corrugated Box 64.00 $ 50.00 04/12/2005 0000106964 6 Corrugated Box 85.00 $ 60.00 04/19/2005 0000108424 3 Corrugated Box 28.00 $ 30.00 04/26/2005 0000109918 4 Corrugated Box 46.00 $ 40.00 Dept Total: $ 180.00 Dept#001 KS-COPPERFIELD(0011) -8470 Hwy 6 North Easton Common 04/06/2005 0000105419 8 Corrugated Box 128.00 $ 80.00 04/20/2005 0000108425 6 Corrugated Box 70.00 $ 60.00 Dept Total: $ 140.00 Dept#001 KS-HOUSTON CENTER(0003) --1221 McKinney Ste 300 04/06/2005 0000105420 2 Corrugated Box 53.00 $ 20.00 04/13/2005 0000106965 2 Corrugated Box 54.00 $ 20.00 04/20/2005 0000108426 2 Corrugated Box 22.00 $ 20.00 04/27/2005 0000109919 2 Corrugated Box 32.00 $ 20.00 Dept Total: $ 80.00 Dept#001 KS-HUMBLE(0012) --8484 Will Clayton Parkway 04/07/2005 0000105421 4 Corrugated Box 70.00 $ 40.00 04/12/2005 0000106966 1 Corrugated Box 7.00 $ 10.00 04/19/2005 0000108427 4 Corrugated Box 49.00 $ 40.00 04/26/2005 0000109920 3 Corrugated Box 32.00 $ 30.00 Dept Total: $ 120.00 Dept#001 KS-KATY CLINIC(0015) --21660 Kingsland Blvd. 04/06/2005 0000105422 2 Corrugated Box 34.00 $ 20.00 04/13/2005 0000106967 3 Corrugated Box 39.00 $ 30.00 04/20/2005 0000108428 1 Corrugated Box 12.00 $ 10.00 04/27/2005 0000109921 2 Corrugated Box 36.00 $ 20.00 Page 1 of 4 lustomer ID: 006307 8900 Lakes at 610 Drive Invoice# 0000052479 Invoice Date: 04/30/2005 Date of Service Manifest #Cont. Description Weight Amount Dept Total: $ 80.00 Dept#001 KS-KINGWOOD CLINIC(0026) --2855 W Lake Houston Pkwy 04/07/2005 0000105423 6 Corrugated Box 95.00 $ 60.00 04/14/2005 0000106968 5 Corrugated Box 68.00 $ 50.00 04/21/2005 0000108429 6 Corrugated Box 76.00 $ 60.00 04/28/2005 0000109922 7 Corrugated Box 90.00 $ 70.00 Dept Total: $ 240.00 Dept#001 KS-PASADENA CLINIC(0008) --3508 East Pasadena Fwy 04/08/2005 0000105424 3 Corrugated Box 41.00 $ 30.00 04/13/2005 0000106969 2 Corrugated Box 27.00 $ 20.00 04/20/2005 0000108430 1 Corrugated Box 12.00 $ 10.00 -. 04/27/2005 0000109923 3 Corrugated Box 116.00 $ 30.00 Dept Total: $ 90.00 Dept#001 KS-QUAIL VALLEY CLINIC(0004) --2715 Cypress Point 04/07/2005 0000105425 2 Corrugated Box 34.00 $ 20.00 04/14/2005 0000106970 1 Corrugated Box 21.00 $ 10.00 04/21/2005 0000108431 1 Corrugated Box 19.00 $ 10.00 04/28/2005 0000109924 1 Corrugated Box 18.00 $ 10.00 Dept Total: $ 50.00 Dept#001 KS-MC ASC,AMBULATORY SURGERY --2727 W Holcombe 04/01/2005 0000103716 8 28 Gallon Reusable 112.00 $ 33.60 04/05/2005 0000105467 4 28 Gallon Reusable 41.00 $ 12.30 04/08/2005 0000105468 5 28 Gallon Reusable 93.00 $ 27.90 04/12/2005 0000107008 4 28 Gallon Reusable 58.00 $ 17.40 04/15/2005 0000107009 3 28 Gallon Reusable 51.00 $ 15.30 04/19/2005 0000108468 5 28 Gallon Reusable 95.00 $ 28.50 04/22/2005 0000108469 6 28 Gallon Reusable 142.00 $ 42.60 04/26/2005 0000109957 2 28 Gallon Reusable 45.00 $ 13.50 04/29/2005 0000109958 5 28 Gallon Reusable 79.00 $ 23.70 Dept Total: $ 214.80 Dept#001 KS-MAIN CAMPUS(Loading Dock) --2727 W Holcombe 04/01/2005 0000103713 7 Corrugated Box 143.00 $ 42.90 04/05/2005 0000105465 2 Corrugated Box 29.00 $ 8.70 04/08/2005 0000105466 8 Corrugated Box 149.00 $ 44.70 04/12/2005 0000107006 20 Corrugated Box 494.00 $ 148.20 04/15/2005 0000107007 6 Corrugated Box 108.00 $ 32.40 04/19/2005 0000108466 3 Corrugated Box 76.00 $ 22.80 04/22/2005 0000108467 9 Corrugated Box 123.00 $ 36.90 04/26/2005 0000109955 1 Corrugated Box 40.00 $ 12.00 04/29/2005 0000109956 8 Corrugated Box 120.00 $ 36.00 Dept Total: $ 384.60 Dept#001 KS-MAIN CAMPUS GI -2727 W Holcombe 04/01/2005 0000103719 1 28 Gallon Reusable 17.00 $ 5.10 04/05/2005 0000105469 1 28 Gallon Reusable 12.00 $ 3.60 04/08/2005 0000105470 1 28 Galion Reusable 20.00 $ 6.00 04/12/2005 0000107010 1 28 Gallon Reusable 14.00 $ 4.20 04/15/2005 0000107011 1 28 Gallon Reusable 17.00 $ 5.10 04/19/2005 0000108470 1 28 Gallon Reusable 12.00 $ 3.60 04/22/2005 0000108471 2 28 Gallon Reusable 24.00 _$__..7.20 04/26/2005 0000109959 1 28 Gallon Reusable 9.00 $ 2.70 04/29/2005 0000109960 2 28 Gallon Reusable 18.00' $ 5.40 Dept Total: $ 42.90 Dept#001 KS-SILVERLAKE(0016) --9430 Broadway#120 Page 2 of 4 lustorner ID: 006307 8900 Lakes at 610 Drive Invoice# 0000052479 Invoice Date: 04/30/2005 Date of Service Manifest #Cont. Description Weight Amount 04/04/2005 0000105471 1 Corrugated Box 12.00 $ 10.00 04/11/2005 0000107012 1 Corrugated Box 15.00 $ 10.00 04/18/2005 0000108472 2 Corrugated Box 44.00 $ 20.00 04/25/2005 0000109961 1 Corrugated Box 16.00 $ 10.00 Dept Total: $ 50.00 Dept#001 KS-SPRING CLINIC(0010) --4290 Cypress Hill 04/14/2005 0000106971 5 Corrugated Box 65.00 $ 50.00 04/27/2005 0000109925 5 Corrugated Box 80.00 $ 50.00 Dept Total: $ 100.00 Dept#001 KS-SUGARLAND(0028) --2121 Williams Trace Blvd 04/07/2005 0000105427 3 28 Gallon Reusable 57.00 $ 30.00 04/14/2005 0000106972 1 28 Gallon Reusable 18.00 $ 10.00 04/21/2005 0000108433 4 28 Gallon Reusable 57.00 $ 40.00 04/28/2005 0000109926 2 28 Gallon Reusable 42.00 $ 20.00 Dept Total: $ 100.00 Dept#001 KS-WEST CLINIC(0002) --1111 Augusta Drive 04/01/2005 0000103676 20 Corrugated Box 297.00 $ 200.00 04/08/2005 0000105428 8 Corrugated Box 139.00 $ 80.00 04/15/2005 0000106973 19 Corrugated Box 258.00 $ 190.00 04/22/2005 0000108434 8 Corrugated Box 196.00 $ 80.00 04/29/2005 0000109927 9 Corrugated Box 130.00 $ 90.00 Dept Total: $ 640.00 Dept#001 KS-WOMENS CTR CLINIC(0017) --7800 Fannin Ste 300 04/05/2005 0000105429 4 Corrugated Box 46.00 $ 40.00 04/12/2005 0000106974 3 Corrugated Box 51.00 $ 30.00 04/19/2005 0000108435 4 Corrugated Box 102.00 $ 40.00 04/26/2005 0000109928 3 Corrugated Box 46.00 $ 30.00 Dept Total: $ 140.00 Dept#001 KS-WOODLANDS CLINIC(0009) --17350 St Luke's Way#200 04/07/2005 0000105430 1 Corrugated Box 33.00 $ 10.00 04/13/2005 0000106975 2 Corrugated Box 28.00 $ 20.00 04/14/2005 0000108618 5 Corrugated Box 62.00 $ 50.00 04/28/2005 0000109929 4 Corrugated Box 58.00 $ 40.00 Dept Total: $ 120.00 Dept#001 KS-WOODLANDS OB/GYN(0043) --17198 St. Lukes Way#540 04/07/2005 0000105431 2 Corrugated Box 31.00 $ 20.00 04/14/2005 0000106976 2 Corrugated Box 22.00 $ 20.00 04/21/2005 0000108437 1 Corrugated Box 12.00 $ 10.00 04/28/2005 0000109930 2 Corrugated Box 29.00 $ 20.00 Dept Total: $ 70.00 Dept#001 KS-ST LUKES MED TOWERS(0001) --6624 Fannin St 19th Floor 04/04/2005 0000105432 1 Corrugated Box 19.00 $ 10.00 04/18/2005 0000108438 1 Corrugated Box 32.00 $ 10.00 Dept Total: $ 20.00 Treatment Total 354 5,868.00 $ 3,012.30 04/29/2005 143 Minimum Weight Charge 1,032.00 $ 309.60 04/29/2005 191 Reusable Washing Fee $ 47.75 Page 3 of 4 �ustomer ID: 006307 8900 Lakes at 610 Drive Invoice# 0000052479 Invoice Date: 04/30/2005 Date of Service Manifest #Cont. Description Weight Amount Total Invoice Amount: $ 3,405.65 Customer Statement Current Balance Over 30 Over 60 Over 90 Total Amount Due 3,405.65 0.00 0.00 0.00 3,405.65 Page 4 of 4 --Detach and mail bottom portion------------------------------------------------------------ Remit To: EnviroClean Mgt. Services, Inc. Invoice# Invoice Date P.O. Box 601942 0000052479 04/30/2005 Dallas, TX 75360 Customer# Terms 006307 Due Upon Receipt Telephone: (888) 797-0944 Invoice Payment Due Amount Enclosed Kelsey Seybold Mgmt. Services $ 3,405.65 8900 Lakes at 610 Drive Houston.TX 77054 REGULATED WAST MANIFES Name, Address, Telephone No. ST.LUKES EPISCOPAL HOSPITAL Monday 01-09-2006 6720 BERTNER I HOUSTON,TX 77225-0269 G (832)355-2049 1'111111111111111 11ill t i E Client ID 004638 &JAl - _ , N ITEMS SUPPLIED TO GENERATOR BY DRIVER AT PICKUP E Containers Liners Labels Trailer No. Other R A T US DOT Description (Including Proper Shipping Name,Hazard Class and ID Number) Regulated Medical Waste,6.2, UN3291 PG II O R GENERATOR'S CERTIFICATION: I certify that the information provided is true and correct and that the generated materials are properly classified, described, packaged,marked and labeled/placarded,and are in proper condition for transportation according to the applicable regulations of the Department of Transportation. NAME OF COMPANY REPRESENTATIVE(PRINT) REPRESENTATIVE SIGNATURE DATE PRIMARY TRANSPORTER: No. of Containers Collected: Certified Wt. of Containers Collected: VEgIIv5ij lea[�t M na� CTl�flk Sefvi In, TCEQ #50001 Service Area:Houston/Galveston �. f2750 Merit Ur., Suite atlas, TX F1gh1 (888) 797-0944 (972) 776-8777 T Person(s)collecting,transporting,or unloading waste. NAME(S) I INITIAL(S)----I- DATE COLLECTED R TRANSPORTER CERTIFICATION:I certify that the information provided above is true and correct and that only untreated medical or nonhazardous municipal wastes are contained in this load. A I am aware that falsification of this manifest may result in forfeiture of my transporter's registration and/or the privilege of utilizing State authorized facilities. N PRIMARY: NAME OF COMPANY REPRESENTATIVE(PRINT) REPRESENTATIVE SIGNATURE DATE S TRANSFER (IF APICABLE) P 0 TRANSFER STATION NAME: EMSI TCEQ# 40182 Transfer qty: R SECONDARY TRANSPORTER: No.Of Containers Collected: Certified Wt.Of Containers Collected: T Name,Address,Telephone No. E Same As Above TCEQ# Same As Above R Person(s)collecting,transporting,or unloading waste. NAME(S) - I INITIAL(S) I DATE COLLECTED TRANSPORTER CERTIFICATION:I certify that the information provided above is true and correct and that only untreated medical or nonhazardous municipal wastes are contained in this load. I am aware that falsification of this manifest may result in forfeiture of my transporter's registration and/or the privilege of utilizing State authorized facilities. SECONDARY: NAME OF COMPANY REPRESENTATIVE(PRINT) REPRESENTATIVE SIGNATURE DATE ❑EMSI ❑EMSI-LITMB ❑EMSI Tulsa ❑Chambers County ❑ Medical Waste Service ❑Texas Environmental ❑Other T 2821 Industrial Ln. 6th&Strand 2120 Southwest Blvd. Resource Recovery of America,LLC Services Garland,TX 75046 Galveston,TX 77550 Tulsa,OK 74107 7505 Highway 65 301 Soldier Colony Rd. 2607 Hwy.21 West R Anahuac,TX 77514 Canton,MS 39046 Dale,TX 78616 E TCEQ#MSW-2245 TCEQ#MSW-2232 OKD#987084068-TF TCEO#MSW-2239A Permit#50062/TRN-LA018 TCEQ#MSW-2260 s (972)840-3735 (409)621-4285 (918)587-9664 (409)267-8202 (601)859-0123 (888)383-9303 TCEQ# A Discrepancies/Special Handling Date Deposited/Unloaded Containers Deposited/Unloaded Total Wt. Deposited/Unloaded T M E TREATMENT FACILITY CERTIFICATION: I certify that I have been authorized by the Texas Commission on Environmental Quality to accept untreated medical N wastes and that I have received the above indicated wastes in accordance with the requirement outlined in that authorization. T DESIGNATED FACILITY REPRESENTATIVE REPRESENTATIVE SIGNATURE DATE • W001 Lim FT(ft ME*-r-rZFA-1y&11-1r1 Generator-White Corporate Office-Canary Treatment Facility-Pink Transporter-Green Generator-Blue �. REGULATED WASTE MANIFES Name, Address, Telephone No. } ST.LUKES EPISCOPAL HOSPITAL Monday 01-09-2006 6720 BERTNER I f I HOUSTON,TX 77225-0269 } G; (832)355-2049 r E Client IO W46V ITEMS SUPPLIED TO GENERATOR BY DRIVER AT PICKUP E Containers Liners Labels Trailer No. Other ,R ' T US DOT DesCription (Including Proper Shipping Name, Hazard Class and ID Number) Regulated Medical Waste,6.2, UN3291 PG II 01 R GENERATOR'S CERTIFICATION: I certify that the information provided is true and correct and that the generated materials are properly classified, described, packaged,marked and labeled/placarded,and are in proper condition for transportation according to the applicable regulations of the Department of Transportation. NAME OF COMPANY REPRESENTATIVE(PRINT) REPRESENTATIVE SIGNATURE DATE PRIMARY TRANSPORTER: No. of Containers Collected: Certified Wt. of Containers Collected: n1tvttr lea M r)aQ�m�r1t SP[1(i 11nc TCEQ #50001 Service Arlsa:Mouston/GaNeston 2750erit�Dr., Suite 0, atlas, TX (888) 797-0944 (972) 776-8777 T Person(s)collecting,transporting,or unloading waste. NAME(S) INITIAL(S) I DATE COLLECTED R TRANSPORTER CERTIFICATION:I certify that the information provided above is true and correct and that onlyntu reated medical or nonhazardous municipal wastes are contained in this load. A I am aware that falsification of this manifest may result in forfeiture of my transporter's registration and/or the privilege of utilizing State authorized facilities. N PRIMARY: NAME OF COMPANY REPRESENTATIVE(PRINT) REPRESENTATIVE SIGNATURE DATE (IF IIII_: ._ 0 TRANSFER STATION NAME: TCEQ# s Transfer qty: R SECONDARY TRANSPORTER: No. of Containers Collected: Certified Wt. of Containers Collected: T Name,Address,Telephone No. TCEQ# E R Persons collecting,transporting,or unloading waste. NAMES INITIALS I DATE COLLECTED TRANSPORTER CERTIFICATION:I certify that the information provided above is true and correct and that onlyntu reated medical or nonhazardous municipal wastes are contained in this load. I am aware that falsification of this manifest may result in forfeiture of my transporter's registration and/or the privilege of utilizing State authorized facilities. SECONDARY: LLLJJJ NAME OF COMPANY REPRESENTATIVE(PRINT) REPRESENTATIVE SIGNATURE y � q �t t ❑EMSI ❑EMSI-LITMB ❑EMSI Tulsa ❑Chambers County ❑ Medical Waste Serve ❑Texas Environmental ❑Other T 2821 Industrial Ln. 6th&Strand 2120 Southwest Blvd. Resource Recovery of America,LLC Services Garland,TX 75046 Galveston,TX 77550 Tulsa,OK 74107 7505 Highway 65 301 Soldier Colony Rd. 2607 Hwy,21 West R TCEQ#MSW-2245 TCEQ#MSW-2232 OKD#987084068-TF Anahuac,TX 17514 Canton,MS 39046 Dale,TX 78616 E TCEQ#MSW-2239A Permit#50062/TRN-LA018 TCEQ#MSW-2260 TCEO# (972)840-3735 (409)621-4285 (918)587-9664 (409)267-822 (601)859-0123 (888)383-9303 A Discrepancies/Special Handling Date Deposited/Unloaded Containers Deposited/Unloaded Total Wt. Deposited/Unloaded T E TREATMENT FACILITY CERTIFICATION: I certify that I have been authorized by the Texas Commission on Environmental Quality to accept untreated medical N wastes and that I have received the above indicated wastes in accordance'with the requirement outlined in that authorization. T DESIGNATED FACILITY REPRESENTATIVE REPRESENTATIVE SIGNATURE DATE Generator-White Corporate Office-Canary Treatment Facility-Pink •Transporter-Green Generator-Blue - Name, Address, Telephone No. REGULATED WASTE MANIFEST ♦iYii• •A. . �a4.x,•i �•' .•iii ,I64ii n -;14 It E N ITEMS SUPPLIED TO GENERATOR BY DRIVER AT PICKUP E R Containers Liners. Labels Trailer No. Other A T US DOT Description (Including Proper Shipping Name,Hazard Class and ID Number) Regulated Medical Waste,6.2,UN3291 PG II 0 R` GENERATOR'S CERTIFICATION: I certify that the information provided is true and correct and that the generated materials are properly classified, described, packaged,marked and labeled/placarded,and are in proper condition for transportation according to the applicable regulations of the Department of Transportation. NAME OF COMPANY REPRESENTATIVE(PRINT) REPRESENTATIVE SIGNATURE DATE PRIMARY TRANSPORTER: No. of Containers Collected: Certified Wt. of Containers Collected: TCEQ #50001 Service Area: 12756 Merit Or.,Suite 770, Dallas,TX 75251 (888) 797-0944 (972) 776-8777 T Person(s)collecting,transporting,or unloading waste. NAPJRf>; INITIAL(S) I DATE COLLECTED R TRANSPORTER CERTIFICATION:I certify that the information provided above is true and correct and that only untreated medical or nonhazardous municipal wastes are contained in this load. A I am aware that falsification of this manifest may result in forfeiture of my transporter's registration and/or the privilege of utilizing State authorized facilities. N PRIMARY: NAME OF COMPANY REPRESENTATIVE(PRINT) Rt_PRESENI'ATIVE SIGNATURE DATE S P IRAHM__ (IF �__ Ate) 0 TRANSFER STATION NAME: TCEQ# Transfer qty: R SECONDARY TRANSPORTER: No. of Containers Collected: ._ _ Certified Wt.of Containers Collected: T Name,Address,Telephone No. TCEQ# E R Person(s)collecting,transporting,or unloading waste. NAW 1S) ! INITIAL(S) I _ DATE COLLECTED TRANSPORTER CERTIFICATION:I certify that the information provided above is true and correct and that only untreated medical or nonhazardous municipal wastes are contained in this load. I am aware that falsification of this manifest may result in forfeiture of my transporter's registration and/or the privilege of utilizing State authorized facilities. SECONDARY: — NAME OF COMPANY REPRESENTATIVE(PRINT) REPHESENTATIVIEZIGNATURE MTE ❑EMSI ❑EMSI-UTMB ❑EMSI Tulsa ❑Chambers County ❑ Medical Waste Servil ❑Texas Eavirogaentat ❑Other T 2821 Industrial Ln. 6th&Strand 2120 Southwest Blvd. Resource Recovery of America,LLC Services Garland,TX 75046 Galveston,TX 77550 Tulsa,OK 74107 7505 Highway 65 301 Soldier Colony Rd. 2607 Hwy.21 West R TCEQ#MSW 2245 TCEQ#MSW 2232 OKD#987084088 TF Anahuac,TX 77514 Canton,MS 39046 Dale,TX 78616 E TCEQ#MSW-2239A Permit#50062/TRN-LA018 TCEQ#MSW-2260 TCEQ (972)840-3735 (409)621-4285 (918)587-9664 (409)267-8202 (601)859-0123 (888)383-9303 A Discrepancies/Special Handling Date Deposited/Unloaded Containers Deposited/Unloaded Total Wt. Deposited/Unloaded T M E TREATMENT FACILITY CERTIFICATION: I certify that I have been authorized by the Texas Commission on Environmental Quality to accept untreated medical N wastes and that I have received the above indicated wastes in accordance ihith the requirement outlined in that authorization. T DESIGNATED FACILITY REPRESENTATIVE REPRESENTATIVE SIGNATURE DATE Generator-White Corporate Office-Canary Treatment Facility-Pink Transporter-Green Generator-Blue REGULATED WASTE MANIFEST Name, Address, Telephone No. I ~ ialwi" 4A-0'--104kP G W.Miumillic ,E N ITEMS SUPPLIED TO GENERATOR BY DRIVER AT PICKUP E R Containers Liners, Labels Trailer No. Other A T US DOT Description (Including Proper Shipping Name, Hazard Class and ID Number) Regulated Medical Waste,6.2,UN3291 PG II 0 R GENERATOR'S CERTIFICATION: I certify that the information provided is true and correct and that the generated materials are properly classified, described, packaged,marked and labeled/placarded,and are in proper condition for transportation according to the applicable regulations of the Department of Transportation. NAME OF COMPANY REPRESENTATIVE(PRINT) REPRESENTATIVE SIGNATURE DATE PRIMARY TRANSPORTER: No. of Containers Collected: Certified Wt. of Containers Collected: TCEQ #50001 Service Area: �12750 Merit`�r'S'uite �%H, Dal'las, rt�`75751 (888) 797-0944 (972) 776-8777 T Person(s)collecting,transporting,or unloading waste. NAME(S) I INITIAL($) I DATE COLLECTED R TRANSPORTER CERTIFICATION:I certify that the information provided above is true and correct and that onlyntru eated medical or nonhazardous municipal wastes are contained in this load. A I am aware that falsification of this manifest may result in forfeiture of my transporter's registration and/or the privilege of utilizing State authorized facilities. N PRIMARY: NAME OF COMPANY REPRESENTATIVE(PRINT) REPRESENTATIVE SIGNATURE DATE S P TRANSFER__ ' .JCASW 0 TRANSFER STATION NAME: TCEQ# Transfer qty: R SECONDARY TRANSPORTER: No.of Containers Collected: ,_ Certified Wt.of Containers Collected: T Name,Address,Telephone No. TCEQ# E i R Person(s)collecting,transporting,or unloading waste. NAME(S) _I INITIAL(S) I, DATE COLLECTED_ TRANSPORTER CERTIFICATION:I certify that the information provided above is true and con d and that only untreated medical or nonhazardous municipal wastes are contained in this load. I am aware that falsification of this manifest may result in forfeiture of my transporter's registration and/or the privilege of utilizing State authorized facilities. SECONDARY: NAME OF COMPANY REPRESENTATIVE(PRINT) REPRESENTATIVE SIGNATURE d(tTe ❑EMSI ❑EMSI-UTMB ❑EMSI Tulsa ❑Chambers County ❑ Medical Waste Servil' ❑Texas Environmental ❑Other T 2821 Industrial Ln. 6th&Strand 2120 Southwest Blvd. Resource Recovery of America,LLC Services Garland,TX 75046 Galveston,TX 77550 Tulsa,OK 74107 7505 Highway 65 301 Soldier Colony Rd. 2607 Hwy.21 West R Anahuac,TX 77514 Canton,MS 39046 Dale,TX 78616 E TCEO#MSW-2245 TCEQ#MSW-2232 OKD#987084068-TF TCEQ#MSW-2239A Permit#50062/TRN-LA018 TCEQ#MSW-2260 (972)840-3735 (409)621-4285 (918)587-9664 (409)267-8ZO2 (601)859-0123 (888)383-9303 TCEQ# A Discrepancies/Special Handling Date Deposited/UnloadedContainers Deposited/Unloaded Total Wt. Deposited/Unloaded T E TREATMENT FACILITY CERTIFICATION: I certify that I have been authorized by the Texas Commission on Environmental Quality to accept untreated medical N wastes and that I have received the above indicated wastes in accordance`with the requirement outlined in that authorization. T DESIGNATED FACILITY REPRESENTATIVE REPRESENTATIVE SIGNATURE DATE Generator-White Corporate Office-Canary Treatment Facility-Pink Transporter-Green Generator-Blue REGULATED WASTE MANIFEST Name, Address, Telephone No. 'rir :.`• - +�!1 f� 4{ *T r�r4 R}�0 OIAM NMI N ITEMS SUPPLIED TO GENERATOR BY DRIVER AT PICKUP E` Containers Liners;, Labels Trailer No. Other A T US DOT Description (Including Proper Shipping Name,Hazard Class and ID Number) Regulated Medical Waste,6.2, UN3291 PG II GENERATOR'S CERTIFICATION: I certify that the information provided is true and correct and that the generated materials are properly classified, described, packaged,marked and labeled/placarded,and are in proper condition for transportation according to the applicable regulations of the Department of Transportation. �p NAME OF COMPANY REPRESENTATIVE(PRINT) REPRESENTATIVE SIGNATURE DATE PRIMARY TRANSPORTER: No. of Containers Collected: Certified Wt. of Containers Collected: TCEQ #50001 Service Area: 112760Merit dr:,Suite t7tl, Dallas,l'X 75251 (888) 797-0944 (972) 776-8777 T Person(s)collecting,transporting,or unloading waste. NAME(&) I INITIAL(S) I DATE COLLECTED R TRANSPORTER CERTIFICATION:I certify that the information provided above is true and correct and that only untreated medical or nonhazardous municipal wastes are contained in this load. A I am aware that falsification of this manifest may result in forfeiture of my transporter's registr2tion and/or the privilege of utilizing State authorized facilities. N PRIMARY: NAME OF COMPANY REPRESENTATIVE(PRINT) REPRESENTATIVE SIGNATURE DATE 0 TRANSFER STATION NAME: TCEQ# Transfer qty: R SECONDARY TRANSPORTER: No. of Containers Collected: Certified Wt.of Containers Collected: T Name,Address,Telephone No. TCEQ# E Person(s)collecting,transporting,or unloading waste. NAME(S) _ I INITIAL(S) I DATE COLLECTED TRANSPORTER CERTIFICATION:I certify that the information provided above is true and correct and that only untreated medical or nonhazardous municipal wastes are contained in this load. I am aware that falsification of this manifest may result in forfeiture of my transporter's registration and/or the privilege of utilizing State authorized facilities. err SECONDARY: NAME OF COMPANY REPRESENTATIVE(PRINT) REPRESENTATIVE SIGNATURE ( 9 � ❑EMSI ❑EMSI-UTMB ❑EMSI Tulsa ❑Chambers County ❑ Medical Waste Servict ❑Texas Environmental ❑Other T 2821 Industrial Ln. 6th 8 Strand 2120 Southwest Blvd. Resource Recovery of America,LLC Services Garland,TX 75046 Galveston,TX 77550 Tulsa,OK 74107 7505 Highway 65 301 Soldier Colony Rd. 2607 Hwy.21 West R Anahuac,TX 77514 Canton,MS 39046 Dale,TX 78616 E TCEQ#MSW-2245 TCEQ#MSW-2232 OKD#987084068-TF TCEQ#MSW-2239A Permit#50062rrRN-LA018 TCEQ#MSW-2260 TCEQ# (972)840-3735 (409)621-4285 (918)587-9664 (409)267-8202 (601)859-0123 (888)383-9303 A —Discrepancies/Special Handling Date Deposited/Unloaded Containers Deposited/Unloaded Total Wt. Deposited/Unloaded T i TREATMENT FACILITY CERTIFICATION: I certify that I have been authorized by the Texas Commission on Environmental Quality to accept untreated medical N wastes and that I have received the above indicated wastes in accordancem th the requirement outlined in that authorization. •. T DESIGNATED FACILITY REPRESENTATIVE REPRESENTATIVE SIGNATURE DATE • • �• Generator-White Corporate Office-Canary Treatment Facility-Pink Transporter-Green Generator-Blue