CENTRAL MICHIGAN UNIVERSITY

Transcription

1 CENTRAL MICHIGAN UNIVERSITY 2016 ASBESTOS CONSULTANT INITIAL PREQUALIFICATION APPLICATION Consultants wishing to provide asbestos related services to Central Michigan University (CMU) must first be prequalified by the Department of Environmental Health and Safety (EH&S). Consultants selected for prequalification will be approved for the 2016 calendar year and will need to reapply each year to maintain prequalification status. Successful prequalification does not specifically guarantee work with CMU. COMPLETED APPLICATIONS, INCLUDING ALL REQUIRED AND OPTIONAL ATTACHMENTS, MUST BE ED TO AND RECEIVED BY October 2, :00 P.M. EST. APPLICATIONS RECEIVED AFTER THIS DEADLINE WILL NOT BE ACCEPTED. SUBMITTED APPLICATIONS WILL RECEIVE AN AUTO-RESPONSE CONFIRMING RECEIPT. IF YOU DO NOT RECEIVE THIS AUTO-RESPONSE CONFIRMATION RECEIPT WITHIN ONE (1) HOUR IMMEDIATELY CONTACT EH&S AT

2 2016 ASBESTOS CONSULTANT INITIALPREQUALIFCATION APPLICATION Company Information Company Name: Company Physical Address: Company Mailing Address: Primary Contact Information (Street Address) (Street or P.O. Box) Year Business Started: (City, State, Zip) (City, State, Zip) Name: Title: Phone: Cell Phone: Address: Secondary Contact Information Name: Title: Phone: Cell Phone: Address: 1. Has the owner or primary/secondary contact had a role in another company or DBA that performed asbestos and/or lead activities in the last 5 years? If yes, please state the company or DBA s name and address: 2. Has the company ever filed for bankruptcy? If yes, please explain: 3. Does anyone in the company have a familial relationship with any CMU personnel? If yes, please list: 2

3 4. Has the company received citation, notice of violation, or other disciplinary action of any kind from any federal, state, or local agency in the last six years? Please provide detailed information on the date and location, nature of the violation, corrective actions taken, and a written description detailing the steps taken to prevent a reoccurrence of such violation. Attach a typed sheet in PDF with additional information, if necessary. 5. Has the company ever been terminated by a client or not completed a contract awarded for any reason? If yes, please provide detailed information. Attach a typed sheet in PDF with additional information, if necessary. 6. Has the company ever been a party to claims, litigation, or arbitration regarding asbestos or lead or other closely related service? If yes, please provide detailed information including case name and number, year, and court or jurisdiction. Attach a typed sheet in PDF with additional information, if necessary. 7. Is the company interested in providing related services (such as industrial hygiene services, indoor air quality investigations, etc.)? If yes, please list the related services the company offers. 3

4 Qualifications & References The following items must be attached to this completed application. The attachments must be in color and in Portable Document Format (PDF). 1. A copy of the company s current National Voluntary Laboratory Accreditation Program (NVLAP) Accreditation Certificate. If analytical work is subcontracted, provide the subcontracted laboratory s accreditation certificate. 2. A copy or detailed description of the company s current intra-laboratory quality assurance program for Phase Contrast Microscopy (PCM). If analytical work is subcontracted, provide the subcontracted laboratory s program. 3. A copy or detailed description of the company s current inter-laboratory quality assurance program. If analytical work is subcontracted, provide the subcontracted laboratory s program. 4. Documentation demonstrating the successful participation in a national testing scheme, such as the Proficiency Analytical Testing (PAT), or the Asbestos Registry by the American Industrial Hygiene Association (AIHA). If analytical work is subcontracted, provide the subcontracted laboratory s documentation. 5. A copy of all other company (not employee) licenses, certifications and accreditations for related services. 6. Safety Data Sheets (SDS) for each hazardous chemical product the company regularly uses on project sites during asbestos and/or lead related activities. 7. Provide a recent (within one year) example asbestos air monitoring report, asbestos building inspection report, and an asbestos abatement project specification document. Provide four references for projects on which the company has provided similar services (include facility name, address, contact person, and phone number):

5 Compliance and Standard Operating Procedures 1. Describe the company s anticipated standard operating procedure (SOP) while conducting project oversight and an accidental asbestos spill occurs, such as a bag of ACM waste tearing open. Attach a typed sheet in PDF with additional information, if necessary. 2. Describe the company s anticipated SOP for an accidental spill of acetone during PCM analysis on CMU property. Attach a typed sheet in PDF with additional information, if necessary. 3. Describe the company s anticipated SOP for an asbestos air monitoring project in which a perimeter sample with a volume of 400 liters contains 0.01 fibers per cubic centimeter (f/cc). Attach a typed sheet in PDF with additional information, if necessary. 4. Describe the company s anticipated SOP when conducting project oversight and the air monitoring professional observes improper worker decontamination procedures. Attach a typed sheet in PDF with additional information, if necessary. 5

6 Additional Information and Consultant Certification Please provide any additional information to help demonstrate the company s qualifications and commitment to service: THE UNDERSIGNED ASBESTOS CONSULTANT CERTIFIES THAT THE INFORMATION GIVEN HEREIN IS SUBSTANTIALLY CORRECT AND FURTHER AGREES: 1. That all work will be performed in accordance with all applicable federal, state and local regulations, and completed with quality workmanship, subject to final inspection and approval by Central Michigan University and/or its representatives. 2. That he/she has read, completely understands and agrees to conduct all asbestos related work in compliance with CMU s Asbestos Management Plan. 3. That if the work performed by the asbestos consultant is found to be unsatisfactory by Central Michigan University for any reason, the consultant s name may be removed from the preapproved consultant list, with such accompanying publicity as it deems necessary. 4. That all familial relationships with elected officials, board members, faculty or staff of Central Michigan University have been disclosed. 5. That all licenses, certifications and accreditations included within this application or as an attachment will be maintained throughout the prequalification year. 6. To provide proof of satisfactory insurance coverage upon successful prequalification and to maintained this insurance throughout the prequalification year with Central Michigan University. Details on insurance and bond requirements can be found here. Printed name Title Signature Date 6