Bid Package 08 North Well Field - Garney Construction

Colorado River Municipal Water District
Ward County Water Supply Expansion Project – North Well Field
Category 20_____ 20_____ 20_____ 20_____ 20_____
D. Number of fatalities
(OSHA Form 300A Column G)
E. Total Number of Cases with Days
Away From Work / Restricted Duty
(OSHA Form 300A – Total From Column H & I)
F. OSHA Incidence Rate
(Line C Above x 200,000)
Line B Above
G. OSHA DART Rate
(Line E Above x 200,000)
Line B Above
H. Number of Restricted Days
(OSHA Form 300A – Column K)
I. Number of Lost Work Days
(OSHA Form 300A – Column L)
2.3 Regulatory Citations
Has your company received any state or government citations in the last 5 years? Yes No
If Yes, Please mark the box of the Agency from Which the Citations Were Received Below:
OSHA MSHA DOT EPA State / Local Other: ____________________________________
Please attach the citation information and an explanation of any citation (s) for all the boxes checked above.
3.0 Company Safety and Health Program
1. Does your company maintain a written Safety and Health Program? Yes No
If Yes, Please attach a copy of your Safety and Health Program
2. Does your company maintain a written Hazard Communication Program? Yes No
3. Does your company have a Safety and Health Leader? Yes No
If Yes, Please provide the contact information below
Name: ___________________________________
Telephone:________________________________________
Title:______________________________________ Email:_________________________________________________________
Bid Proposal Form – Bid Package #8
Colorado River Municipal Water District
Ward County Water Supply Expansion Project – North Well Field BP - 18
5/24/2012