Common use of CERTIFICATION OF NON-SEGREGATED FACILITIES Clause in Contracts

CERTIFICATION OF NON-SEGREGATED FACILITIES. The Bidder certifies that he does not maintain or provide for his employees any segregated facilities at any of his establishments and that he does not permit his employees to perform their services at any location, under his control, where segregated facilities are maintained. The Bidder certifies further that he will not maintain or provide for his employees any segregated facilities at any of his establishments, and that he will not permit his employees to perform their services at any location under his control where segregated facilities are maintained. The Bidder agrees that a breach of this certification will be a violation of the Equal Opportunity clause in any contract resulting from acceptance of this bid. As used in this certification, the term "segregated facilities" means any waiting rooms, work areas, restrooms and washrooms, restaurants and other eating areas, timeclocks, locker rooms and other storage or dressing areas, parking lots, drinking fountains, recreation or entertainment areas, transportation, and housing facilities provided for employees which are segregated by explicit directive or are in fact segregated on the basis of race, color, religion or national origin, because of habit, local custom or otherwise. The Bidder agrees that (except where he has obtained identical certification from proposed subcontractors for specific time periods) he will obtain identical certification from proposed subcontractors prior to the award of subcontracts exceeding $10,000 which are not exempt from the provisions of the Equal Opportunity clause, and that he will retain such certifications in his files. Note: The penalty for making false statement in offers is prescribed in 18 U.S.C. 1001. DATE: , BY: (NAME OF XXXXXX) (TITLE) OFFICIAL ADDRESS: CONTRACTOR'S STATEMENT FOR PUBLIC DISCLOSURE *

CERTIFICATION OF NON-SEGREGATED FACILITIES. The Bidder certifies that he does not maintain or provide for his employees any segregated facilities at any of his establishments and that he does not permit his employees to perform their services at any location, under his control, where segregated facilities are maintained. The Bidder certifies further that he will not maintain or provide for his employees any segregated facilities at any of his establishments, and that he will not permit his employees to perform their services at any location under his control where segregated facilities are maintained. The Bidder agrees that a breach of this certification will be a violation of the Equal Opportunity clause in any contract resulting from acceptance of this bid. As used in this certification, the term "segregated facilities" means any waiting rooms, work areas, restrooms and washrooms, restaurants and other eating areas, timeclocks, locker rooms and other storage or dressing areas, parking lots, drinking fountains, recreation or entertainment areas, transportation, and housing facilities provided for employees which are segregated by explicit directive or are in fact segregated on the basis of race, color, religion or national origin, because of habit, local custom or otherwise. The Bidder agrees that (except where he has obtained identical certification from proposed subcontractors for specific time periods) he will obtain identical certification from proposed subcontractors prior to the award of subcontracts exceeding $10,000 which are not exempt from the provisions of the Equal Opportunity clause, and that he will retain such certifications in his files. Note: The penalty for making false statement in offers is prescribed in 18 U.S.C. 1001. DATE: , BY: (NAME OF XXXXXXBIDDER) (TITLE) OFFICIAL ADDRESS: CONTRACTOR'S STATEMENT FOR PUBLIC DISCLOSURE *

CERTIFICATION OF NON-SEGREGATED FACILITIES. (Applicable to construction contracts and related subcontracts exceeding $10,000 which are not exempt from the Equal Opportunity Clause). The Bidder construction contractor certifies that he he/she does not maintain or provide for his his/her employees any segregated facilities at any of his establishments his/her establishments, and that he he/she does not permit his his/her employees to perform their services at any location, under his his/her control, where segregated facilities are maintained. The Bidder construction contractor certifies further that he he/she will not maintain or provide for his his/her employees any segregated facilities at any of his his/her establishments, and that he he/she will not permit his his/her employees to perform their services at any location location, under his control his/her control, where segregated facilities are maintained. The Bidder construction contractor agrees that a breach of this certification will be is a violation of the Equal Opportunity clause Clause in any contract resulting from acceptance of this bidcontract. As used in this certification, the term "segregated facilities" means any waiting roomsroom, work areas, restrooms rest rooms and washroomswash rooms, restaurants and other eating areas, timeclockstime clock, locker rooms and other storage or dressing areas, parking lots, drinking fountains, recreation recreating or entertainment areas, transportation, and housing facilities provided for employees which are segregated by explicit directive or are in fact segregated on the basis of race, creed, color, religion or national origin, because of habit, local custom custom, or otherwise. The Bidder construction contractor agrees that (except where he he/she has obtained identical certification certifications from proposed subcontractors for specific time periods) he he/she will obtain identical certification certifications from proposed subcontractors SUBCONTRACTORS prior to the award of subcontracts exceeding $10,000 which are not exempt from the provisions of the Equal Opportunity clause, Clause and that he he/she will retain such certifications in his his/her files. NoteSIGNED: The penalty for making false statement in offers is prescribed in 18 U.S.C. 1001TITLE: SUBSCRIBED AND SWORN to before me this day of , 2016. DATE: , BYNOTARY PUBLIC My Commission Expires: (NAME OF XXXXXX) (TITLE) OFFICIAL ADDRESS: CONTRACTOR'S STATEMENT FOR PUBLIC DISCLOSURE *This page intentionally left blank)

CERTIFICATION OF NON-SEGREGATED FACILITIES. This form must be signed by the prime contractor and submitted by the time of contract award from the Loan Recipient. A copy must be included in the contract copy to DEQ. The Bidder prime contractor must obtain a signed copy of this form from each subcontractor, and retain them in the prime contractor’s contract file. Applicable to federally-funded construction contracts and related subcontracts exceeding $10,000 which are not exempt from the Equal Opportunity clause. The federally-assisted construction contractor certifies that he does not maintain or provide for his employees any segregated facilities at any of his establishments establishments, and that he does not permit his employees to perform their services at any location, under his control, where segregated facilities are maintained. The Bidder federally-assisted construction contractor certifies further that he will not maintain or provide for his employees any segregated facilities at any of his establishments, and that he will not permit his employees to perform their services at any location location, under his control control, where segregated facilities are maintained. The Bidder federally-assisted construction contractor agrees that a breach of this certification will be is a violation of the Equal Opportunity clause Clause in any contract resulting from acceptance of this bidcontract. As used in this certification, the term "segregated facilities" means any waiting rooms, work areas, restrooms rest rooms and washroomswash rooms, restaurants and other eating areas, timeclockstime clocks, locker rooms and other storage or dressing areas, parking lots, drinking fountains, recreation or entertainment areas, transportation, and housing facilities provided for employees which are segregated by explicit directive or are are, in fact fact, segregated on the basis of race, creed, color, religion or national origin, because of habit, local custom custom, or otherwise. The Bidder federally-assisted construction contractor agrees that (except where he has obtained identical certification certifications from proposed subcontractors contractors for specific time periods) he will obtain identical certification certifications from proposed subcontractors prior to the award of subcontracts exceeding $10,000 which are not exempt from the provisions of the Equal Opportunity clauseClause, and that he will retain a copy of such certifications in his filescertification. Signature Date Name and Title of signer (please type) Note: The penalty for making false statement statements in offers is prescribed in 18 U.S.C. 1001. DATECertification for Non-Segregated Facilities Updated: 10/01/2013 Page 1 of 1 Oregon Clean Water State Revolving Fund Non-Discrimination in Employment Notice to Labor Unions or Other Organizations of Workers The CWSRF loan recipient must provide this notice to the contractor and subcontractor(s) advising the labor union or workers' representative of the contractor's commitments under Executive Order No. 11246. The contractor will send a signed notice to each labor union or representative of workers with which he has a collective bargaining agreement or other contract or understanding, BYand shall post copies of the notice in conspicuous places available to employees and applicants for employment. TO: (NAME Name of Union or Organization of Workers) The undersigned currently holds contract(s) with (Name of CWSRF Loan Recipient) Using funds or credit of the U.S. government, or one or more subcontracts with a prime contractor holding such contracts. * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * You are advised that under the provisions of the above contract(s) or subcontract(s) and in accordance with Section 202 of Executive Order 11246 dated Sept. 24, 1965, as amended, the undersigned is obliged not to discriminate against any employee or applicant for employment because of race, color, religion, sex or national origin. This obligation not to discriminate in employment includes, but is not limited to, the following: - EMPLOYMENT, UPGRADING, TRANSFER OR DEMOTION - RECRUITMENT OR RECRUITMENT ADVERTISING - RATES OF XXXXXXPAY OR OTHER FORMS OF COMPENSATION - SELECTION FOR TRAINING INCLUDING APPRENTICESHIP, LAYOFF OR TERMINATION * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * This notice is furnished to you pursuant to the provisions of the above contract(s) or subcontract(s) and Executive Order #11246. Contractor or Subcontractor(s) Date NON-DISCRIMINATION IN EMPLOYMENT UPDATED: 10/01/2013 PAGE 1 OF 1 Oregon Clean Water State Revolving Fund Debarment and Suspension Form Executive Order No. 12549 The CWSRF loan recipient must complete and sign this form, and submit it to the DEQ project officer before the CWSRF loan project contract is awarded, along with a System for Award Management report for each contractor and subcontractor proposed to perform work within the scope of the CWSRF loan. The loan recipient and all subsequent prime and subcontractors must fully comply with Subpart C of 2 Code of Federal Regulations Part 180 and 2 CFR Part 1532, entitled “Responsibilities of Participants Regarding Transactions (TITLEDoing Business with Other Persons).” Award approval by DEQ is contingent on none of the contractors and subcontractors being excluded on the System for Award Management document at xxx.xxx.gov. The following contractors and subcontractors are proposed to perform work within the scope of the CWSRF loan agreement. Loan recipient: Loan number: Project: Contractor name and mailing address Phone number and email address DUNS and CAGE number codes for contracts equal to or greater than $25,000 Contract $ Amount (Use additional pages if necessary) OFFICIAL ADDRESSSignature of Authorized Loan Recipient Representative Date Name and Title of Authorized Representative (type or print clearly) Debarment and Suspension Form Updated: CONTRACTOR'S STATEMENT FOR PUBLIC DISCLOSURE *10/01/2013 Page 1 of 1 OMB Control No: 2090-0030 Approved: 8/ 13/ 2013 Approval Expires: 8/ 31/ 2015 Disadvantaged Business Enterprise (DBE) Program DBE Subcontractor Performance Form This form is intended to capture the DBE1 2 description of work to be performed and the price of the work submitted to the prime contractor. An EPA Financial Assistance Agreement Recipient must require its prime contractor to have its DBE subcontractors complete this form and include all completed forms in the prime contractors bid or proposal package. Subcontractor Name Project Name Bid/ Proposal No. Assistance Agreement ID No. (if known) Point of Contact Address Telephone No. Email Address Prime Contractor Name Issuing/Funding Entity: Contract Item Number Description of Work Submitted to the Prime Contractor Involving Construction, Services , Equipment or Supplies Price of Work Submitted to the Prime Contractor DBE Certi ied By: DOT SBA Other: Meets/ exceeds EPA certiication standards? YES NO Unknown 1 A DBE is a Disadvantaged, Minority, or Woman Business Enterprise that has been cerfied by an enty from which EPA accepts cerficaons as described in 40 CFR 33.204-33.205 or cer fied by EPA. EPA accepts cerfica ons from enes that meet or exceed EPA cerficaon standards as described in 40 CFR 33.202. 2 Subcontractor is defined as a company, firm, joint venture, or individual who enters into an agreement with a contractor to provide services pursuant to an EPA award of financial assistance. OMB Control No: 2090-0030 Approved: 8/ 13/ 2013 Approval Expires: 8/ 31/ 2015 Disadvantaged Business Enterprise (DBE) Program DBE Subcontractor Performance Form I certify under penalty of perjury that the forgoing statements are true and correct. Signing this form does not signify a commitment to utilize the subcontractors above. I am aware of that in the event of a replacement of a subcontractor, I will adhere to the replacement requirements set forth in 40 CFR Part 33 Section 33.302 (c). Prime Contractor Signature Print Name Title Date Subcontractor Signature Print Name Title Date The public reporng and recordkeeping burden for this collecon of informaon is esmated to average three (3) hours per response. Send comments on the Agency's need for this informa on, the accuracy of the provided burden es mates, and any suggested methods for minimizing respondent burden, including through the use of automated collec on techniques to the Director, Collecon Strategies Division, U.S. Environmental Protecon Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address. Oregon Clean Water State Revolving Fund Bidders List