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Home My WebLink AboutBid Forms .. ;.,. .. ] . .I i I I I I I I I I I I I I I I I 13.0 FEDERAL CONTRAct REQUIREMENTS 13.1 See Division D of this document for Federal Contract Requirements. 14.0 ITEMS TO BE SUBMITTED WITH BID 14.1 The bidder shall submit as a part of his bid, in duplicate, the following: A. Contractor's bid and bid schedule - completely executed and signed. (Executed) Indiana State Bid Form No. 96 (revised 1987). B. Non-Collusion Affidavit - completely executed, signed and notarized (Standard Form .::-_96, revised 1987). C. Bid Bond _ acceptable bidder's bond or certified check in the amount of not less than five (5) percent of the total bid price. D. Form 96A, or similar financial statement - completely executed and signed. E. EPA Form 6100-4. F. EPA From GEE-1, and OEE-2. G. Bidders List Form AJ401\ dum I AoOENJ/C/ /if 2 Dev1-ed 5-) -OJ ~2- S-f-oJ' S :\S"::>NEYlWPOOCS\08\08201SECK2. DOCX A-205 5: ISYD" EYlWPDOCS\08\0820\SECA2. DOCX A-206 I I;: .- I I I I I I I I I I I I I I I I I 15.0 BID FORMS CONTRACTOR'S BID FORL\1 JEFFERSONVILLE SEWER BOARD CITY OF JEFFERSONVILLE 500 QUARTERMASTER COURT JEFFERSONVILLE, IN 47130 RE: TENTH STREET INCEPTOR REHABILITAITON PROJECT JOB NO. 0820 SRF PROJECT NO. W'W'06121 002 ,. Gendemen::':- . We submit, herewith, our sealed proposal to furnish all necessary labor, material and equipment to construct the above captioned project, in accordance with the subject plans and specifications at the unit prices listed herein. "" .li ] I "" i I I I I I I I I I I I I I I I TENTH STREET INTERCEPTOR REHABILITATION PROJECT, JOB NO. 0820 ITEM NO. 1 APPROXIMATE QUANTITY 1593LF DESCRIPTION WITH lJNIT PRICE TOTAL UNIT PRICE IN AMOUNT FOR WRITTEN IN WORDS NUMBERS BID ITEM 36-inch Cuxed-in-Place Pipe Liner For........................................... $ \0'2... ,DD .... .... ... ............ ...DoJ.hu:s Per Linear Foot $ l~'2..14 5(,. DO 30-inch Cured-in-Place Pipe Liner For........................................... $ \ ~ 1:). IJO ... ...... ..... ... ...... ...DoJ.hu:s Per Linear Foot 24-inch Cuxed-in-Place Pipe Liner For........................................... $ (pe. DD .. ......... ..... ... .... ...DoJ.hu:s Per Linear Foot 4 1 LS Dewatering for eLP.p. Installation (if required) For........................................... $ /. 0 c) $ I () i> . .0....... ..... ... ........DoJ.hu:s Per Lump Sum 5 1 LS Traffic Control For........................................... S 1-, '.:;00. Db $ '1, t;; 00. 00 ....... ........... ...... .Dollars Per Lump Sum SUMMATION OF ITEMS 1 THRU 5 = TOTAL BID PRICE = $ 3\2. {; b7-: DC> f 2 126LF $ 1 t.} 356. be .:'f!!:,~- 3 2104LF $ fZ(..,2i.{.b. be BID OF: Insituform Technologies USA, Inc. CONTRACTOR S:\SYDNEYlWPDOCS\08\0820\SECA2-1. DOCX A-207 BID FOR: ...'f"-Insituf0.rm Technologies USA, Inc. I I I I I I I I I I I I I I I I I I I TENTH STREET INTERCEPTOR REHABILITATION PROJECT SRF PROJECT NO. WW06121002 JOB NO. 0820 CITY OF JEFFERSONVILLE CLARK COUNTY, INDIANA RESPECTFULLY SUBMITTED, NAME OF FIRM ../ ;; p~~/ ...c.-> PERSON H. Douglas Thomas, Vice President ATTEST May 7, 2009 Jana Lause, Contracting & Attesting Officer DATE S:\SYDNEYlWPDOCS\08\082O\SECA2-1.DOCX Accepted this day of ,2009 SEWER BOARD CITY OF JEFFERSONVILLE, INDIANA Mayor Thoroas R. Galligan, President William A. Saegesser, P.E., P.L.S., Member Dale L. Orero, Member A-2GB :IE ~ o u. l- ei) ::i en it: LLI C C ca N o o M N M \J) o 8: 8: o Z z <C g QJ rl rl .M :> ~ o OJ H QJ "" "" QJ t-:J "" o ;>, .w .M U 0"1 o '- t"- O '- U1 o ., UJ CD ~ W CD ::2: c: o c: "t:l c: Itl t: '" CI:l UJ 1l CJ..~_ rn .~. ~ CD E ::2: .E '5 c..!!l ..c.s:5 ~liis "t:lE5 -fie~ 1: ~.~ -:;.cao ~~~ <l)C:_ 0'.2 0 Q:g~~ ~-g-] (fJ1tl~ . "0 0 E ~ ~ 0..2 i5i~,5 Q)cn*E, 'o~co~ Q. c: ~ ~ ~~tlE - ~8 .~] - ~ ~~ard <c 55 () co D.."tluiCL W - c: . ~:5ItlCl:lrn ~ E5 -gO::3otl ::0 '" 0 ~ ~-g'tJ"E: e15~ 9 - Q.~..c 513rn::l ~.~ 8.; :1 e Q) c: lJ) a.~ ra o~~\U CI:l ~ - $: .~s1'-E Q.5g'~ ~o'" 25 .~ ro E CI:l-; .:.g a 0 ::)a;~a1 0"'0 a> c: o:Q.g-ro -o(!)c::1i :o~(/)o cri;..~.8 :5C1:l0- U)coo~ E ~:; E t;:: :J CD c:: -:;;E:;;.g '"",Eo; ~c:.g E :J(Qtno t3~~:s .Et-,CD cncatIJc ::I Co ::0 .~ ;,;Effi;:.g a~.Q~:2 iSrnu.rnQl s~ffi~~ E-=N~~ u.: a:: (fJ >- .c -0 ~ Qi o ~ III !( o o iii ~ o -M .w rO .w .M rl .M ..Q rO ..c: QJ ~ H QJ ~ QJ Ul H o .w p. QJ U H QJ :w ~ H .w QJ QJ H .w Ul ..c: .w ~ QJ E-< a: w z 3: o W -l l- f: I- U W a a: c.. I"- W ~ :a rn rn w a: o !i -l < :: uJ , c o oJ: c.. z o ct) a: w c.. I- ~ I- Z o u ct) 1Il ~ Q Q <C Cl z :J a ::E w ::E <c z If) >- I- I~ ! I 1 I \ I \ I \ I 1 I \ ~ ( ~ ~. )~ \0 I I .. ! I ".- I I t- o - I C I J ~ SIt OMB Control No: 2090-0030 Approved: 05/01/2008 Approval Expires: 01/31/2011 Environmental Protection Agency Disadvantaged Business Enterprise Program DBE Subcontractor Participation Form NAME OF SUBCONTRACTOR' PROJECT NAME ADDRESS -~-- " CONTRACT NO. - TELEPHONE NO. EMAIL ADDRESS PRIME CONTRACI'OR NAME , Please use the space below to report any concerns regarding the above EP A-funded project ~ reason for termination by prime contractor, late payment, etc.). AMOUNT CONTRACT ITEM OF WORK OR DESCRIPTION OF SERVICES RECEIVED FROM SUB CONTRACfOR ITEM NO. THEPRIMECONTRACfOR WAS PAID BY PRIME CONTRACTOR Subcontractor Signature Title/Date 'Subcontractor is defined as a company, firm, joint venture, or indivic.u?l who enters into an agreement with a contractor to provide services pursuant.to an EP A award of fina.'lcial assistance, EP A FORM 6100-2 (DBE Subcontractor Participation Form) D-I08 Culy Construction 610 N. 100 East Winchester, IN 47394 Randy Hart 765-546-0696 RHart@culyconstruction.com Scott Engineering 6695 E 34th Street Indianapolis, IN 46226-6121 Dennis Denney 317-501-6730 ddenney@hrtc.net Sewer Optical Services, Inc. (WBE) 1334 W. Main Street Lebanon, IN 46052 John Flanagan 765-485-0464 jfIanagan@seweroptical.com Atlas Daylighting (WBE) 4740 Swisher Road West Lafayette, IN 47906 David Kerper -14<;- ,I'Z.-~- 'i<t.Oi:-' ~<J;!.'L61>J.\"f. ~C6.~. ~...,""" Fluid Waste Services, Inc. 21787 Riverwood Avenue Noblesville, IN 46060 Rich Schroeder 317 -431-4543 fws1777@aol.com BIDDER'S LIST FORM ~.~.. ....... TechnoliJgles~lJ5(1nc.. Worldwide Pipeline Rehabilitation Tel: (317) 489-3863 Fax: (317)489-3872 2130 Stout Field West Drive Indianapolis, IN 46241 www.insituform.com Good Faith Efforts to Meet MBE/WBE Goals 1. DBE's were contacted via email and phone calls requesting quotes from M/WBE Contractors. 2. Plans and Specifications were made available for review at our office. In addition, plans and specifications were emailed to those contractors requesting the information electronically. Firms were placed as early in the bidding process as possible. ITUSA works regularly with DBE firms and they were contacted to increase interest in this project. 3. The specialized services and limited amount of sub work reduced the opportunity to split work up in order to increase opportunities for DBE firms. When possible, subs are requested to use DBE firms for any work they are unable to perform. 4. A consortium of DBE firm's was not practical for this project. 5. We utilized the M/WBE listing we have from previous projects, and those names collected utilizing the State of Indiana DBE listing as well as the City of Indianapolis listing. 6. We recommend that all subs investigate opportunities to increase DBE participation for all projects. 2009-05-06 1440 Scott Engineering, L 765-738-0097 >> P 3/4 ~ 2 OMB Control No: Approved: Approval Expires: Environmental Protection Agency Disadvantaged Business Enterprise Program DBE Subcontractor Performance Form NAME OF SUBCONTRACTOR1 Scott Engineering ,LL(. PROJECT NAME Jeffersonville. IN lOth Street Interceptor ADDRESS Po eo.,c 100 ,StflUtly.""]:..Pt.f7"Jg tf TELEPHONE NO. bs -7'3~"'OOq I'c BIDjPROPOSAL NO. c~of I E-MAIL ADDRESS k Jc:1~.JAv'< l.1(tC. dA~l PRIME CONTRACTOR NAME I tJ.)if.,4 (lJ/'w-. 'fec"'-db b(yllZ) (,\ sA I ,,.v c. 1 Sewer Cleaning and Televising PRICE OF WORK SUBMfITED TO PRIME CONTRACI'OR tJ ?--;,'a'c:'f3.75 CONTRACT ITEM NO. ITEM OF WORK OR DESCRIPTION OF SERVICES BID TO PRIME . . d as an MBE or WBE ~'" EPA's ODE Program~~ ~::~ Dare r ~~;Z;. Title L-No - $(''O( 04 Date Signature of Subcontractor DelA~'.s ,<, Oe~...e) Print Name o vi #.I{fl... Title 'Subcontractor is defined as a company, firm. joint venture, or individual who enters into an agreement with a contractor to provide services pursuant to an EPA award of finandal us18tanl.~. EPA FORM 6100.3 milE Subcnntractor Performance Fonn) 2009-05-06 14:40 Scott Engineering, L 765-738-0097 >> P 2/4 ~ St OMB Control No: 209()..()()30 Approved; 05/01/2008 Approval Expirl!s: 01/31/2011 Environmental Protection Agency Disadvantaged Business Enterprise Program ODE Sukontrilctor Participation Form NAME OF SUBCONTRAcrOR' PRO}Ecr NAME Scott Engineering I-l C. JefferBonville. IN 10th Street Interceptor ADDRESS CONTRACt NO. A:>&DlC{oO,..,,.,!-}1e~C~sr.5lh.,.l.tll ~~ 'i1li"i TELEPHONE NO. EMAIL ADDRESS 7~~ "'73g~oo~ fa d~ewt~~@hl"te....,e' ~MECONTRACTORNAME INSlTUFORM TECHNOLOGIES USA, INC. Please use the space below to report any concerns regarding the above EPA-funded project ~ reason for termination by prime contractor, late payment, etc.). AMOUNT CON'TRACf ITEM OF WORK OR. DESCRIPTION OF SERVlCBS RBcmVED FROM SUBCONTRAcroR ITEM NO. THE PRIME CONTRACTOR WAS PAID BY PRIME CONTRACTOR 1 Sewer Cleaning and Televising II 'JI'i'AJ~ {( j '^ .1 . '7 C)v/~"(l. .1/(0/09 v SubContractor Signature () Title/Date 'Sulx:cmtJ'llCt()r is defined as a oompDJ\y, firm, joint venture, or individual WM ft\tel8 into an agreement with.. c:ontrac:loJ' 1.0 ptovJ,Je lrervh,'\llI pW'IlWlllt II.IlIn EPA award uf ItnandalNlll&taI'ICe. CPA FORM &100-2 (DDB SUKontnwtor Participlltion Fonn) ^ ..."." & l~m;t:~olf\&} .~. A.pj1tWed:~10l72l103 AWrova1ltxpftes: O:i.l~lf2Oii Envit'PiXtnentaI Protection A :en.' '. . .' "...... g 0/ m$~,Jv.:nmged1J~ip:~$S lmfetp~ 1't()gfam 'DUIl gUDc(uifractC:)1'''arlicI all. nFonn . ....... ....'>..,.."...,;..... ..,. ...... ........ .J'.....Q". .' ....... NAMEOF$UBCQ~~<:rQ~! quly <;:Qn~tru9t~()~ Al)OlU!SS' 5" fpd\Q:~1;:rlAll p~ik pr{Y'~ ,- " ",-",,,_,,.~,,.c,,,'~_''''''''~'<'''''''' , rRbJEC't~~M~ Jef~ersonvii:lelm iOt:h stre-et tU'te~J?tor CdmltAcrl\l'(>: TEL,lWlJQ;NJfNP: . 165-584-8509 .' _0 ,;_"""~",._,.",_",."y<:,,,~L ,..:. ,. ,:-,,,"""_1'-<""""~n_, x>t!t~~~~9~~~:~{\~;"msiTUFORM EM!\U.APP~ijS$ . ..rtl.~tt:@cyJ:yt':;QJ1$.tttiC;etpq,."~}:~W . J:Nc;h Pl~~ i($@ tiJc;!' be!Qwto leJ'9ft ~ny't9~Miis f~g~ding the abc>ve EPA-funded project (e,e.. re'asort for terlrii...... "."nati.on Wi.'.;';;... .' ec6nuactoi Iatea.~t etC.)', .. ,.. .' .. . w:y ... ". .' . ... I .. P ytn I .... , co~cr ITE~OFWORK QR DESCRIrnoN'O'Ji stntVIcESRECmVEl> FROM IT~ !'l0, THE P~IME <::9m"RAg"()R AMOUNT SU'8CONTR:fCflJR WAS C 1 ~~~t <;J,~ning aJ:l<!!~3,E!y*s;1l9 'SUbl:O with~ .~t;~j2 ::o~=~r:l~~\i;,~tt,:!d'WJ:::}ai:~~:!lt() art agreem~~ ~~^ FQRM,: () f@-2 (DBE. $ubc:Oi1~ci!>r Pllrlicipati<m FOJlli) ... St , EUVlr(jl)1lletlhll Pr()t~qll Agency OM~ Ccifim?r~9: A Disadvantaged Business Enterprise Program DUE Sub~o-ntrador 'PerfQrlffm4:~ F'om ~.'... . NAM~ Oll SUBCO:N'l1tACTOR1 &:ily ~onsh'l.1cUon PROJ~CT NAME J:e;~~J;"j(~!:!'Y:!.JJ:~1 I~ 19J}~ ,~.!=:,i~~!:;, ~l)~~~CElptot .t\PDRES,S 5 InQ~sttial Pa1:':k Driye Winchester IN 47394 TELJrPffQNf! ~Q. 765-5~4-$?Q.9 J.>'RiME CONTttACTOR: NAME BID/PRQ!'O~AI,.I'YQ,. " Ol:5RES'S ,c~ty'c~nstrucHo~. C~?1n, , CONTRAcT ITEM NP, InM OF W(>RK OR DESCRIPtIoN OF s'ERVICES BID 1'0 PRIME PRIcn Q:FWOltK 1 SElW~:r CIEl~ning an4 ~~~Elyi~in9 urre y co . a as on MaE or WBE _ EPA'. ,DDE Prog<a~ Yes re 0 Prime Contractor Oate ~ PrintY~ rrl~ f/z. ~t; ffiilfN",M .'!f . ~NQ, - " 'i'!&1!)9 PCl~ ' lSH1x;()~J!ac.lQr ~ ~ef~~!! a,s !" c.ompany, firm, j~ij'lt y ", to previae SeMCl!SflU1'S'la~ to anEPA aw.a.rd on-ina " of~~t~l'Yllo l!!ltj;!1'l! #1t9 M, agt~nt w.i~!l~n~ol EPA FORM 61OQ~3 (ODE Silbconfractor Performam:e F?nn) ... St OMB Control No: Approved: Approval Expires: 2090-0030 05/01/2008 01/31/2011 Environmental Protection Agency Disadvantaged Business Enterprise Program DBE Subcontractor Performance Form The public reporting and recordkeeping burden for this collection of information is estimated to average fifteen (15) minutes. Burdf~r\ ;mea.I\Sthetc:>tal1:i.rne!.ef!o!1!or:Jin~cial resotll'ces expen~ed by persons to generate, maintain, retain, or-~ose or provide information to or for a Federal agency. This includes the time needed to review instructions;. develop, acquire, install, and utilize technology and systems for the purposes of collecting, validating, and verifying information, processing and maintaining information, and disclosing and providing information; adjust the existing ways to comply with any previously applicable instructions and requirements; train personnel to be able to respond to a collection of information; search data sources; complete and review the collection of information; and transmit or otherwise disclose the information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including the use of automated collection te.9miQues to the Director, Collection Strategies Division, U.s. Environmental Protection Agency (2822), 1200 Pennsylvania Ave., N\^1, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed EP A DBE Subcontractor Performance Form to this adchess. EPA FOR.\16100-3 (DBE Subcontractor Performance Forn,) 0-111 ~ SIt Environmental Protection Agency OMB Control No: Approved: Approval Expires: 2090-0030 05/01/2008 01/31/2011 Disadvantaged Business Enterprise Program DBE Subcontractor Utilization Form BIDjPROPOSAL NO. PROJECT NAt\fE JTL Job # 0820;SRF Proj. #WW06121002 Te!1th Street Intercepto::.- Sewer Rehabilitaticln NAME OF PRIMtliIDDER/PROPOSER E-MAfi, ADDRESS Insituform Technologies USA, Inc. N!A ADDRESS 17988 Edison Avenue, Chesterfield, MO 63005 TELEPHONE NO. 636-530-8000 FAX NO. 636-530-8701 The following subcontractorsl will be used on this project: COMPANY NAME, ADDRESS, PHONE TYPE OF WORK TO BE NUMBER, AND E-MAIL ADDRESS PERFORMED ESTIMATE D DOLLAR AJ.'vfOUNT CURRENTLY CERTIFIED AS AN MBE OR WBE? A-'1-L""'5 '"DA't't.\~~("'~ t.j'::}~~ ~W"5~lZ (2oAb \.u, L~ t:,l\ 't f('t-Trt "7::,,( c.(~qor" "'1&)- ,-/2'1- tf$ov &"".1& ~ 8 o-.{\p,.<; wca..v"f-,..s 'c<'n- ~~Y- ( \<.""" "J -t- '"t u iff ~, &'PP. vo W81{/tfOT ~(") I certify under penalty of perjury that the forgoing statements aJ'e true and correct. :n the event of a replacement of a subcontractor, I will adhere to the replacement requirements set forth in 40 CPR Part 33 Section 33.302(c). ~/ -/ Signatuh~ e Contractor 05/07/0S Date H, Douglas Thomas Print Name Vice =::.-esident -::-itle 'Subcontractor is c.e6ned as a company, firm. joint venture. or individual who enters into an ag=ee=ent with a contractor to provide services pursuant to an EPA award of financial assistance, EPA FORM 6100-4 (DEE Subcontractor Utilization Form) D-112 ~ SIl Environmental Protection Agency OMB Control No: Approved: Approval Expires: 2090-0030 05/01/2008 m/31/201l Disadvantaged Business Enterprise Program DBE Subcontractor Utilization Form The public reporting and recordkeeping burden for this collection ofinformation is estimated to average fifteen (15) minutes. Burden meaI\Sth~ total time, effort, or financial resources expended by persons to generate, maintain, retain, or disclose or provide information to or for a Federal agency. This includes the time needed to review instructionsplevelop, acquiIe, install, and utilize technology and systems for the purposes of collecting, validating, and venfylng information, processing and maintaining information, and disclosing and providing information; adjust the existing ways to comply with any previously applicable instructions and requirements; train personnel to be able to respond to a collection of information; search data sources; complete and review the collection of information; and transmit or otherwise disclose the information. An agency may not conduct or sponsor, and a person is not requiIed to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including the use of automated collection teChniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed EP A DBE Subcontractor Utilization Fo~ to this address. EPA FORM 6100-4 (DBE Subcontractor Utilization Form) D-l13 u.s. ENVIRONMENTAL PROTECTION AGENCY CERTIFICA nON OF NONSEGREGATED FACILITIES (Applicable to federally assisted 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, and that he does not permit his employees to perform their services at any location, under his control, where segregated facilities are maintained. The 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 perfonn their services at any location, under his control,_Where segregated facilities are maintained. The federally assisted construction contractor agrees that a breach of this certification is a violation of the Equal Opportunity clause in this . contract As used in this certification, the term "segregated facilities" means any waiting rooms, work areas, rest 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, creed, color, or nation origin, because of habit, local custom, or otherwise. The federally assisted construction contractor agrees that (except where he has obtained identical certifications from proposed subcontractors for specific time periods) he will obtain identical certifications from proposed subcontractors prior to the award of subcontracts exceeding $10,000 which are not exempt from the provisions ofthe Equal Opportunity clause, and that he will retain such certification in his files. ~/ Signa~ Date H. Douglas Thomas, Vice P~esident Name and Title of Signer (Please type) Insituform Technologies ~SA, Inc. Firm Name NOTE: The penalty for making false statements in offers is prescribed in 18 D.S.C. 1001. OEE-I (lln9) D-114 NOTICE TO LABOR UNIONS OR OTHER ORGANIZATIONS OF WORKERS NONDISCRIMINATION IN EMPLOYMENT TO: Laborers International Union of North America (Name of union or organization of workers) The undersigned currently holds contract(s) with Local 274, 120 & Operating Engineer's 103 (Name of Applicant) involving funds or credit of the U.S. Government or (a) subcontract(s) with a prime contractor bolding such contract(s). You are advised that under the provisions of the above contract(s) or subcontract(s) and in accord8DCe with Executive Order 11246, as amended, dated September 24, 1965, as amended, the underSigned is obliged not to discriminate against any employee or applicant for employment because ofrace, color, creed, or national origin. This obligation not to discriminate in employment includes, but is not limited to, the following: HIRING, PLACEMENT, UPGRADmG, TRANSFER, OR DEMOTION, RECRUITMENT, ADVERTISING, OR SOLICITATION FOR EMPLOYMENT, TRAINING DURmG EMPLOYMENT, RATES OF PAYOR OTHER FORMS OF COMPENSATION, SELECTION FOR TRAINING ThlCLUDThlG APPRENTICESHIP , LAYOFF OR TERMINATION. This notice is furnished you pursuant to the provisions of the above contract(s) or subcontract(s) and Executive Order 11246, as amended. Copies of this notice will be posed by the undersigned in conspicuous places available to employees or applicants for employment. Insituform Technologies USA, Inc. 17988 Edison Avenue Chesterfield, MO 63005 ./ / - ~~~tractor) H,Douglas Thomas, VP May 7, 2009 (Date) OEE-2 (11/79) D-115 !liB CON':'ROL NO.2030-0020 APPRovt!l: 1V30f(l2 API'RCi'J>.L EXPIRES: 12/31/05 u.s. ENVIRONMENTAL PROTECTION AGENCY MBEJWBE UTILIZATION UNDER FEDERAL GRANTS, COOPERATIVE AGREEMENTS, AND INTERAGENCY AGREEMENTS 1 A. FEDERAL FISCAL YEAR 1 B. REPORTING QUARTER (Check appropriate box) 200 - o 1st (Od-Dec) 02rd{.mMl} o 3rd (Apr-Jun) 0 4tl'l (Jul-Sep) o Annual 1 C. REVISION HIGHLIGHT ITEMS TO BE REVISED AND PROVIDE EXPLANATION IN BLOCK No.6 Yesr: Quarter: 2A FEDERAL FINANCIALASSISTANCE AGENCY 3A. REPORTING RECIPIENT (Name and Address) (SRF Office ,t,ddrest-mK: MBEM'BE Coofdlnator)' State Revolving Loan Fund Programs 100 N. SenateA.venue, Room 1275 Indianapolis, IN 46204 28. REPORllNG CONTACT 2C. PHONE: 38. REPORTING CONTACT (Recipient) 3C. PHONE: (SRF M8E1WBE Coordinator 317-234-1266 Doris Roberson 4A FINANCIAL ASSISTANCE AGREEMENT ID NUMBER 48. FEDERAL FINANCIAL ASSISTANCE PROGRAM (SRF Slate Recipients. Refer to Instructions for CClmpletlon of 4A. SA, and 5C) ,A. TOTAL ASSISTANCE AGREEMENT 5B. Check and skip to Block 5C. TOTAL PROCUREMENT AMOUNT THIS REPORTING AMOUNT No.7 if no procurements PERIOD (ONLY indude the amount net in any prior repor1i{lg and accomplishments period anc procurements made by SRF Loan Redpienls and Sub- EPA Share: $ Recipients ) wer]il made this reporting $ penod. (Exclude proOJrement amounts reported by Prime Contractors) Redpient Share: $ 0 - 50. ACruAL MBEmaE P~bCOREMENT ACCOMPLISHEDTHI$ 5E. ACTUAL MBEJWBE PROCUREMENT ACCOMPLISHED THIS REPORTING PERIQOI;lY R.ECIPIENT(sRF Slate Recipients, Report REPORTING PERIOD BY lOAN RECIPIENTS, SUB-RECIPIENTS, State PmcurementActivitIes Here) " AND PRIME CON1RACTORS $ MBE $WBE $MBE $WBE Construction Construction EqUipment Equipment Services Services Supplies Supplies TOTAL TOTAL 6. COMMENTS: 7. NAME OF AUTHORIZED REPRESENTATIVE TlTLE 8. SIGNATURE OF AUTHORIZED REPRESENTATIVE DATE i PART 1. (Reports are required even if no procurements are made during the reporting period.) EPA FORM 5700-52A - (5/96) available electronically at hfuJ:/Iwww.epa.oC\liosdbu/5700 52a.pdf NOTE: THIS REPORT IS DUE 30 DAYS AFTER THE END OF EACH FEDERAL FISCAL QUARTER OR ANNUAL: SUBMISSION DATES ARE: January 30, April 30, July 30, and October 30Y . ANNUAL REPORT D-116 Prescribed bv State Board of Accounts Form No. 96 (Revised 2005\ CONTRACTORS BID FOR PUBLIC WORKS - FORM 96 PART I (To be completed for all bids) (Please type or print) Date: May 7, 2009 1. Governmental Unit (Owner): Jeffersonville Sewer Board/City of Jeffersonville 2. County: Clark 3. Bidder (Firm): Insituform Technoloqies USA. Inc. Address: 17988 Edison Avenue City/State: Chesterfield, MO.63005 4. Telephone Number: (636) 530-8000 5. Agent of Bidder (if applicable): Pursuant to notices given, the undersigned offers to furnish labor and/or material necessary to Jeffersonville Sewer Board/City of Jeffersonville complete the public works project of . (Governmental Unit) in accordance with plans and specifications prepared by Jacobi, Toombs, and Lanz, Iile. , Clarksville IN April 2009 , and dated ' for the sum of,tHUi'I!. f:hl\l()IUJ> /\;,.;':;:1 Vi!: 7th u{;A-rib S'Y J./.vNDf.2..f<EJ> S&:"EN andt'l'/100 dollars ($;3I2.,tpO:r,tlD ). The undersigned further agrees to fumish a bond or certified check with this bid for an amount specified in the notice of the letting. If altemative bids apply, the undersigned submits a proposal for each in accordance with the notice. Any addendums attached will be specifically referenced at the applicable page. If additional units of material included in the contract are needed, the cost of units must be the same as that shown in the original contract if accepted by the Governmental Unit. If the bid is to be awarded on a unit basis, the itemization of the units shall be shown on a separate attachment. The Contractor and his subcontractors, if any, shall not discriminate against or intimidate any employee, or applicant for employment, to be employed in the performance of this contract, with respect to any matter directly or indirectly related to employment because of race, religion, color, sex, national origin or ancestry. Breach of this covenant may be regarded as a material breach of the contract. CERTIFICATION OF USE OF UNIJ"ED STATES STEEL PRODUCTS (If applicable) I, the undersigned bidder or agent as a contractor on a public works project, understand my statutory obligation to use steel products made in the United States. I.C. 5-16-8-2. I hereby certify that I and all subcontractors employed by me for this project will use U.S. steel products on this project if awarded. I understand that violations hereunder may result in forfeiture of contractual payments. 3-102 The above bid is accepted this ACCEPTANCE 1'2>1"'+ day of dvf'...\6 ,2l>t.f? , subject to the following conditions: NON6 Contracting Authority Members: M~ ort !\toN\A-~ K. ~'\1..U ~ ;Paes WH\,A1\\. A. S~t;1tlMWlSEtl ~ L. C)f2.G'M. t f\M11V\i~ PART II (For projects of $1 00,000 or more - IC 36-1-12-4) Governmental Unit: Jeffersonville Sewer Board/City of Jeffersonville Date: Insituform Technoloqies USA, Inc. May 7, 2009 Bidder (Firm): These statements to be submitted under oath by each bidder with and as a part of his bid. Attach additional pages for each section as needed. SECTION I EXPERIENCE QUESTIONNAIRE 1. What public works projects has your organization completed for the period of one (1) year prior to the date of the current bid? Contract When Amount Class of Work Completed Name & Address of Owner $202 256.00 Insituform@ OS/29/08 City of Jeffersonville. IN $585,264.00 Insituform@ 02/22/08 City of South Bend, IN $171,872.30 Insituform@ 08/13/08 Purdue Universitv, West Lafavette IN $344,502.00 Insituform@ 10/15/08 Coastal Gunite Const., Indianapolis IN Insituform@ Insituform@ 2. What public works projects are now in process of construction by your organization? When to Contract be Amount Class of Work Com DIeted Name & Address of Owner $293,505.00 Insituform@ 2009 Lebanon Utilities, IN $954,405.00 Insituform@ 2009 City of Fort Wayne, IN $256,272.25 Insituform@ 2009 Tow~ of Jamestown, IN $274,660.00 Insituform@ 2009 City of Frankfort, IN Insituform@ B-103 \ 3. Have you ever failed to complete any work awarded to you? NO If So, where and why? List referenced from private firms for which you have performed work. Reference Wade Osborne Clair Budhal 1. Explain your plan or layout for performing proposed work. (Examples could include a narrative of when you could begin work, completed the project, number of workers, etc. and any other information which you believe would enable the governmental unit to consider your bid.) 2. Please list the names and addresses of all subcontractors (i.e. persons or firms outside your own firm who have performed part of the work) that you have used on public works projects during the past five (5) years along with a brief description of the work done by each subcontractor. I See Attached 3. If you intend to sublet any portion of the work, state the name and address for each subcontractor, equipment to be used by the subcontractor, and whether you will require a bond. However, if you are unable to currently provide a listing, please understand a listing must be provided prior to contract approval. Until the completion of the proposed project, you are under a continuing obligation to immediately notify the governmental unit inthe event that you subsequently determine that you will use a subcontractor on the proposed project. Work Name and Address Equipment to Bond be Used Required See Attached 4. What equipment do you have available to qse for the proposed project? Any equipment to be used by subcontractors may also be required to be listed by the governmental unit. Support Truck Pick-up Truck(s) Reefer Truck TV Truck Pumps with hoses Compressor(s) Boiler Jet Truck and/or Vactor 5. Have you entered into contracts or receive~ offers for all materials which substantiate the prices used in preparing your proposal? Yes Otherwise, please explain the rationale used which would corroborate the prices listed. SECTION III CONTRACTOR'S FINANCIAL STATEMENT Attachment of bidder's financial statement is mandatory. Any bid submitted without said financial statement as required by statute shall thereby be rendered invalid. The financial statement provided hereunder to the governing body awarding the contract must be specific enough in detail so that said governing body can make a proper determination of the bidder's capability for completing the project if awarded. Insituform Technologies USA, Inc. financial statement is attached. B-I04 Attachment - SECTION II PLAN AND EQUIPMENT QUESTIONNAIRE 1. Explain your plan or layout for performing proposed work. (Examples could include a narrative of when you could begin work, completed the project, number of workers, etc. and any other information which you believe would enable the governmental unit to consider your bid.) Perform inspection services and develop SSES report. Set up traffic control and bypass pumping as required, clean and televise pipeline to prepare for installation. If any point repairs are required, notify the Owner or Engineer. Wet-out the Insitutube with resin, set up equipment at site, install the Insitutube and cure. Restore services and flow. Complete additional project work as identified in the scope. Clean-up site. 2. Please list the names and addresses of all subcontractors (Le. persons or firms outside your own firm who have performed part of the work) that you have used on public works projects during the past five (5) years along with a brief description of the work done by each subcontractor. Listed below are a number of the subcontractors that Insituform Technologies has worked with in the past five years. It should be noted that we are an international corporation and Insituform Technologies has worked with numerous Contractors on varying types of projects. If the list included below is not sufficient, please contact our corporate offices for a full listing. Video Job Site Control 1609 Southdale Avenue Ft. Wayne, IN 46816 Construction Video Shoot On Site Video Services 4101 Wyandotte Drive Ft. Wayne, IN 46815 Construction Video Sewer Optical Services, Inc. (WBE) 1334 W. Main Street Lebanon, IN 46052 Cleaning and CCTV Fluid Waste Services, Inc. 21787 Riverwood Avenue Noblesville, IN 46060 Cleaning and CCTV Atlas Daylighting 4740 Swisher Road West Lafayette, IN 47906 Cleaning and CCTV Accurate Bore Company 4937 Fieldstone Drive Whitestown, IN 46075 Cleaning, CCTV and Directional Boring F.M. Shelton (MBE) 972 Donnelly Avenue, Suite #2 Atlanta, GA 30310 Resin Supplier Blaylock Chemical P.O. Box 248 Stillwell, KS 64085 Resin Supplier Culy Construction 610 N. 100 East Winchester, IN 47394 MH Lining, Excavation, Cleaning and Televising Trotter Construction Co., Inc. (MBE) 4165 Millersville Road Indianapolis, IN 46201 Manhole Lining, rehabilitation and Excavation SpectraTech, LLC 16100 Allisonville Road Noblesville, IN 46060 Manhole Lining Municipal & Contractor Sealing Products 7740 Reinhold Drive Cincinatti, OH 45237 Chemical Grouting and Manhole Lining Mitchell & Stark Construction Co., Inc. P.O. Box 219 Medora, IN 47260 Excavation Scott Engineering 6695 E 34th Street Indianapolis, IN 46226-6121 Cleaning and Televising Atlas Excavating 4740 Swisher Road West Lafayette, IN 47906 Excavation Kreager Brothers Excavating Inc. P.O. Box 80187 Ft. Wayne, IN 46898 Excavation Corbitt & Sons (MBE) 8728 Robbins Road Indianapolis, IN 46268 Pipe Bursting, Directional Boring, Excavation Robinson Trenching & Boring 9915 Southeatern Ave. Indianapolis, IN 46239 Pipe Bursting, Directional Boring, Excavation Dave O'Mara Construction 1100 E 0 & M Avenue P.O. Box 1139 North Vernon, IN 47265 Excavation Godwin Pumps 16830 Chicago Avenue Lansing, Illinois 60438 Bypass Pumping 3. If you intend to sublet any portion of the work, state the name and address of each subcontractor, equipment to be used by the subcontractor, and whether you expect to require a bond. However, if you are unable to currently provide a listing, please understand a listing must be provided prior to contract approval. Atlas Daylighting 4740 Swisher Road West Lafayette, IN 47906 Cleaning and Televising No Bond Required SECTION IV CONTRACTOR'S NON - COLLUSION AFFIDAVIT The undersigned bidder or agent, being duly sworn on oath, says that he has not, nor has any other member, representative. or agent of the firm, company, corporation or partnership represented by him, entered into any combination, collusion or agreement with any person relative to the price to be bid by anyone at such letting nor to prevent any person from bidding nor to include anyone to refrain from bidding, and that this bid is made without reference to any other bid and without any agreement, understanding or combination with any other person in reference to such bidding. He further says that no person or persons, firms, or corporation has, have or will receive directly or indirectly, any rebate, fee, gift, commission or thing of value on account of such sale. SECTION V OATH AND AFFIRMATION I HEREBY AFFIRM UNDER THE PENALTIES OF PERJURY THAT THE FACTS AND INFORMATION CONTAINED IN THE FOREGOING BID FOR PUBLIC WORKS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. Dated at Chesterfield. Missouri this 7th day of May ,20 09 Insituform Technoloqies USA, Inc. (Nam~e ofOrganizatiOn)/ By _~ H. Dou as s vice President (Title of person signing) ACKNOWLEDGEMENT STATE OF MISSOURI COUNTY OF ST. LOUIS H Douglas Thomas. . Vice President . being duly sworn, deposes and says that he IS of the above Insituform Technoloqies USA, Inc. and that the answers to the questions in the foregoing questionnaires and all statements therein contained are true and correct. f . 7th Subscribed and sworn to be ore me this May 09 day of ,20 ~ ~Notary Public My Commission Expires: 12/5/09 ~ County of Residence: St. Louis JANA LAUSE NotarY Publlc.No~Seal State of MlsSOUlI ~~n&c.512009 My commission # ()5805G1S_ - 8-105 SECTION IV CONTRACTOR'S NON - COLLUSION AFFIDAVIT The undersigned bidder or agent, being duly sworn on oath, says that he has not, nor has any other member, representative, or agent of the firm, company, corporation or partnership represented by him, entered into any combination, collusion or agreement with any person relative to the price to be bid by anyone at such letting nor to prevent any person from bidding nor to include anyone to refrain from bidding, and that this bid is made without reference to any other bid and without any agreement, understanding or combination with any other person in reference to such bidding. He further says that no person or persons, firms, or corporation has, have or will receive directly or indirectly, any rebate, fee, gift, commission or thing of value on account of such sale. SECTION V OATH AND AFFIRMATION I HEREBY AFFIRM UNDER THE PENALTIES OF PERJURY THAT THE FACTS AND INFORMATION CONTAINED IN THE FOREGOING BID FOR PUBLIC WORKS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. ' Dated at Chesterfield, Missouri this 7th day of May ,20 09 Insituform TechnoloQies USA. Inc. By (N'~2// H. Dou~ Vice President (Title of person signing) ACKNOWLEDGEMENT STATE OF MISSOURI COUNTY OF ST. LOUIS . . Vice President being duly sworn, deposes and says that he IS of the above Insituform TechnoloQies USA. Inc. and that the answers to the questions in the foregoing questionnaires and all statements therein contained are true and correct. H. Douglas Thomas Subscribed and sworn to before me this 7th d f May 20 09 ayo. ~ ~ Notary Public My Commission Expires: 12/5/09 County of Residence: St. Louis <' JANA \.AUSE NotaI'Y Publlc- No~ Seal . State 0' M'asol,lll at. loou\S countY 5 2009 MyCo~=rss\OO~m-15' ~ B-I06 ()J .--i .--i "M :> - ~ - 0 L- en 0 en Ul +-' Q) H (,) L- ()J ~ "'0 4-1 +-' "'0 4-1 C $ ()J 0 t-:> c.5 ~ CJ) C 4-1 - I- 0 l.() <( l.() U >.. 0 Q) 0 W 0 CJ) ::J 0 .., -W N => C ('f) 0 -M Q) <.0 U "'0 en > 0:: ----- r- Q) Q) <( 0 Q. '"d 0 en H rl 0) ~ I ':; u.. 0 c 0:: :::s::: u. ({j ::Q Q) 0 0 0 0:: 0 0 0'\ 0::: 0 en "'0 U. p:) 0 '-" 0 c :0 Q) 0 0 <.0 o:l ..c W l+= 3: H ~ (,) L.. ()J 0) Q) co Q) U :3 I- CO +-' ()J 0 en :J r- Z E 0) Q) U} L- r--. ..c Dl >.. E .E ..-- () ::> ()J ({j .--i ~ L.. ::J Q. .--i 0 +-' 'M u.. "w :> c ~ c c 0 0 Q) Ul "'0 ~ ~ H Q) (,) CO ()J u:: <( ~ 4-1 4-1 ()J t-:> TO THE BIDDER- The following Form 96a is not requi1:ed by the State Board of Accounts. However, the bidder must either use this form or one similar to it prepared by their accountant. JACOBI, TOOMBS AND LANZ, INC. S;ISYDNEy\WPDOCSIQ810820\DIV8.DOCX B-l08 State board of Accounts Form #102 Approved 12/88 City of Indianapolis Marion County, Indiana Form #102 Standard Questionnaires and Financial Statement for Bidders For use in investigating the qualifications of bidders on public works contracts when the aggregate cost of such contract will be a hundred thousand dollars ($100,000) or more. This form may be used for any other contract when the ordering department requests it. These statements are to be submitted under oath by each bidder with and as a part of the bid. NOTE: THIS FORM BECOMES PART OF THE BID FILE, AND PURSUANT TO INDIANA'S PUBLIC RECORDS LAW (IND. CODE SS5-14-3-1-5-14-3-10), WILL BE AVAILABLE FOR PUBLIC INSPECTION AND COPYING DURING CENTRAL PURCHASING'S REGULAR BUSINESS HOURS WHEN THE TOTAL CONTRACT PRICE EXCEEDS $100,000. Submitted to: City of Indianapolis, Central Purchasing Company Name: Insituform Technologies USA, Inc. Address: 17988 Edison Avenue Chesterfield, MO 63005 Representative: H. Douglas Thomas, Vice President Telephone Number: 636-530-8000 Date Submitted: May 7, 2009 TO THE BIDDER: These forms, required by the City ofIndianapolis and Marion County, Indiana, have been prescribed by the State Board of Accounts. They properly filled out and attested, must accompany each bid of a hundred thousand dollars ($100,000), or more. If the ordering department requests it, they may be required for bids of lesser amounts as well. The forms are designed to cover all public work Contracts/all other applicable situations and the bidder is required to answer such questions as are pertinent to the work being bid/R.F.Q. The purpose of the questionnaire is to enable the awarding body to determine the qualifications of the bidder to carry out successfully the contract if the same is awarded to the bidder. The bidder will find it to his advantage to answer fully all questions coming within the range ofthe work being bid. Particular attention should be given to the "Financial Statement" and the details relative to the assets and liabilities set out. This form is made in extensive detail so that the bidder may explain his assets and liabilities in proper sequence and in a uniform manner. NOTE; FAILURE TO FILL OUT THESE FORMS COMPLETELY MAY BE GROUNDS FOR DECLARING THE ENTIRE BID NON-RESPONSIVE. -1- Submitted by Insituform Technologies USA, Inc. { ~ A Corporation o A Co-partnership o An Individual P. . IOffi 17988 Edison Avenue, Chesterfield, MO 63005 nnclpa Ice at To Jeffersonville Sewer Board/City of Jeffersonville EXPERIENCE QUESTIONNAIRE The signatory of this questionnaire guarantees the truth and accuracy of all statements and of all answers to interrogatories hereinafter made. How many years' experience in How many years has your organization been in business as a general contractor under your present business name? 26 14 1. 2. construction work has your organization had: 3. (a) As a general contractor What projects has your organization completed? 26 (b) as a sub-contractor 26 CONTRACT AMOUNT CLASS OF WORK WHEN COMPLETED NAME AND ADDRESS OF OWNER $294,076.00 Insituform 01/23/09 Lebanon Utilities, Lebanon IN $100,253.00 Insituform 10/31/08 Aqua Indiana, Valparaiso IN $338,965.00 Insituform 10/15/08 Coastal unite Construction, Cambridge IN $1,271,178.60 Insituform 08/15/08 Purdue University, West Lafayette IN 3A What projects has your organization now in process of construction? CONTRACT AMOUNT CLASS OF WORK WHEN TO BE COMPLETED NAME AND ADDRESS OF OWNER Town of Freemont Insituform Q2 2009 Town of Freemont, Freemont IN City of Portage Insituform Q2 2009 City of Portage, Portage IN A. Metz Sewers Insituform Q2 2009 A. Metz Sewers, Gary IN City of Lafayette Insituform Q3 2009 City of Lafayette, Lafayette IN 4. Have you ever failed to complete any work awarded to you? No If so, where and why? 5. Has any offer or partner of your organization ever been an officer or partner of some other organization that failed to complete a No construction contract? If so, state name of individual, other organization and reason therefor. 6. No Has any officer or partner of your organization ever failed to complete a construction contract handled in his own name? I f so, state name of individual, name of owner and therefor -2- 7. In what other lines of business are you financially interested? None 8. For what corporation or individuals have you performed work, and to whom do you refer? Abbott Laboratories Wade Osborne 847-935-5598 Connoco Phillips Clair Budhal 618-255-2961 Olin Corporation Kelly Rich 618-258-5475 9. For what cities have you performed work and to whom do you refer? See Attached See Attached 10. For what countries have you performed work and to whom do you refer? See Attached 11, For what State bureaus or departments have you performed work and to whom do you refer? 12. Have you ever performed any work for the U.S. Government? 1 f so, when and to whom do you refer? Yes See .Zl.ttached 13. What is the construction experience of the principal individual of your organization? YEARS OF INDIVIDUAL'S NAME PRESENT POSITION CONSTRUCTIO'\ MAGNITUDE AND IN WI-lA T CAPACITY OR OFFICE EXPERIENCE TYPE OF WORK J. Joseph Burgess President & CEO 21+ I-:anagement/Ops President/CEO H. Douglas Thomas Vice President 43 Const/Mngmnt/Ops PM, GM, VP David F. Morris Sr. VP, CAO & SEC 17 Leqal/Manaqement VP, Executive David Martin VP & CFO 18 Finance/Mnqmnt VP -3- ~ Insitufonn Thchnologies~ liS4; Inc. STANDARD QUESTIONNAIRES AND FINANCIAL STATEMENT FOR BIDDERS 9. For what cities have you performed work and to whom do you refer? Name Reference Phone Ci W of Evansville, IN Ardell Smith (812 421-2130 Ci ~ of Wheaton, IL Paul Redman (630 260-2000 Ci y of Fort Wayne, IN Mike Hicks (219 427-1160 Ci :y of Markle, IN Greg Sauter (219 758-3386 10. For what counties have you performed work and to whom do you refer? Name Reference Phone Lake County. IL Art Maim 847 680-1600 Johnson County, KS Jeffrev DOQQert 913 681-3200 DuPaQe County, IL Greg Wilcox 630 682-7000 11. For what state bureaus or departments have you performed work and to whom do you refer? Name Reference Phone Illinois Department of Transportation Victor Modeer 847 705-4131 Indiana Department of Transportation Tom Faulkner 317 462-7751 MichiQan Deoartment of Transoortation 269 849-1184 12. Have you ever performed any work for the U.S. Government? Yes If so, when and to whom do you refer? Name Reference U.S. ACE 509) 577-3356 U.S. Air Force Offut Air Base 797) 697-7376 U.S. Armv Newport Chemical Depot 765) 245-4403 U.S. Naw GL T Naval Base (847) 688-2311 PLAN AND EQUIPMENT QUESTIONNAIRE The signatory of this questionnaire guarantees the truth and accuracy of all statements and of all answers to interrogatories hereinafter made. 1. In what manner have you inspected this proposed work? Explain in detail. ""5~E ~~D 2. Explain your plan or layout for performing the proposed work (,;E-€ ~~ '"t> 3. The work, if awarded to you, will have the personal supervision of whom? ~, ~~p. .NjA- * 4. Do you intend to do the hauling on the proposed work with your own forces? If so, give amount and type of equipment used * 5. If you intend to sublet the hauling or perform it through an agent, state amount of sub-contract or agent's contract, and ifknown, the name and address of sub-contractor or agent, amount and type of his equipment and financial responsibility /V/;:a- * Items 4, 5, 6, and 7 may not be applicable in all building contracts; if not, omit. -4- * 6. Do you intend to do the grading on the proposed work with your own forces? If so, give type of equipment to be used ,J/A: * 7. If you intend to sublet the grading or perform it through an agent, state amount of subcontract or agent's contract, and if known, the name and address of sub-contractor or agent, amount and type of his equipment and financial responsibility. A/jt1- , 8. Do you intend to sublet any other portions of the work? 'If:..~ If so, state amount of sub-contract, and ifknown, the name and address of the sub-contractor, whether subcontract is a minority and/or women's business enterprise, amount, and type of his equipment and financial responsibility. 5'ft ~~t:> 9. From which sub-contractors or agents do you expect to require a bond? AloAlg 10. What equipment do you own that is available for the proposed work? QUANTITY ITEM DESCRIPTION, SIZE CONDITION YEARS OF PRESENT LOCATION CAPACITY, ETC. SERV[CE See Attached -5- Attachment - SECTION II PLAN AND EQUIPMENT QUESTIONNAIRE 1. In what manner have you inspected this proposed work? Explain in detail. Insituform personnel visited the site and conducted a detailed site review of the project area. In addition, plans and specifications were reviewed during the design process and input was provided to the engineer. 2. Please list the names and addresses of all subcontractors (Le. persons or firms outside your own firm who have performed part of the work) that you have used on public works projects during the past five (5) years along with a brief description of the work done by each subcontractor. Perform inspection services and develop SSES report. Set up traffic control and bypass pumping as required, clean and televise pipeline to prepare for installation. If any point repairs are required, notify the Owner or Engineer. Wet-out the Insitutube with resin, set up equipment at site, install the Insitutube and cure. Restore services and flow. Complete additional project work as identified in the scope. Clean-up site. 3. The work, if awarded to you, will have the personal supervision of whom? Alex Sharpe, Project Manager - 317-281-3767 8. If you intend to sublet any portion of the work, state the name and address of each subcontractor, equipment to be used by the subcontractor, and whether you expect to require a bond. However, if you are unable to currently provide a listing, please understand a listing must be provided prior to contract approval. Atlas Daylighting 4740 Swisher Road West Lafayette, IN 47906 Cleaning and Televising No Bond Required Jetter and Vactor Trucks ~ Insituform 7e.cl1Jwlogies"l.JS4, /11e. STANDARD QUESTIONNAIRES AND FINANCIAL STATEMENT FOR BIDDERS 10. What equipment do you own that is available for the proposed work? Description Present Quantity Cleaning Equipment Vactors 6 Jetters 11 Televisinn Equipment TV Vans 18 TV Cameras 44 Insltuform Trucks Support 12 Reefers i .. 17 Boilers 14 Water Tankers 2 Trailers 3 Insltuform Wet Out & Cutters Conveyors 4 I nsitucutters 36 Miscellaneous Compressors Generators 14 Static Mixers 3 Hilifts, Dozers, Backhoes 1 Laser 2 Pumps 60 Power Packs 10 Saws 24 Breakers 2 Pick Up Trucks 22 Tractors 6 II. What equipment do you intend to purchase for use on the proposed work, should the contract be awarded to VoU? QUANTITY ITEM DESCRIPTION, SIZE. CAPACITY, He. APPROXIMATE COST N/A /II / I'J 12. How and when will you pay for the equipment to be purchased? N/A 13. Do you propose to rent any equipment for this work? TBD if so, state type, quantity and reasons for renting. 14. Have you made contracts or received firm offers for all materials within prices used in preparing your proposal? Do not give names of dealers or manufacturers Yes 15. List all permits, licenses, or registrations, which you have and are required by law to maintain in order to bid on this work. Please include the type ofthe permit, license, or registration; the name of the issuing entity; the number ofthe licenses, permit, or registration; and the expiration date. kJt:. ~ t./~fh4:> L3 y 'Thte. //Vt),. 1:J.,V4 Sec,et ~'r ~ ~S t>l=RcE "';n ~IL (Ai 'HtJ..E ~~ ~ //Vt)/A-p4 Dated at Chesterfield, MO this 7th day of May ,20 09 Insituform Technologies USA, Inc. MISSOURI H. , Vice President By STATE OF (Title of Person Signing) ST. LOUIS COUNTY OF H. Douglas Thomas SS: Being duly sworn, deposes and says that he is of the above Vice President of the above Insituform Technologies USA, Inc. (Name of Organization) and that the answers to the questions in the foregoing questionnaires and all statements therein contained are true and correct. 7th April Subscribed and sworn to before me this day of * c;&- 12/05/09 ~ My Commission .vn;rpo . Notary Public ,20~. JANALAUSE NolalY Publlc- Notary'Seal StateofMissouii St Louis County My Commission expires Dee. 5, 2009 CommIssion # 05805615 -6- CONTRACTOR'S FINANCIAL STATEMENT 17988 Edison Avenue, Chesterfield, MO 63005 {_~ A Corporation o A Co-partnership o An Individual Submitted by Insituform Technologies USA, Inc. Principal Office at To Jeffersonville Sewer Board/City of Jeffersonville Condition at close of business December 31, (amounts in thousands) D 11 20~ C o IHS ts. ASSETS 1. Cash: (a) On Hand $ 0 , (b) In bank $ 0 , (c) Elsewhere $ 0 2. Notes receivable (a) Due within 90 days (b) Due after 90 days (c) Past Due 3. Accounts receivable from completed contracts, exclusive of claims not approved for payment 8 311 4. Sums earned on uncompleted contracts as shown by engineer's or architect's estimate 2, 26 (a) Amount receivable after deducting retainage (b) Retainage to date, due upon completion of contracts 2 525 5. Accounts receivable from sources other than construction contracts 6. Deposits for bids or other guarantees: (a) Recoverable within 90 days (b) Recoverable after 90 days 7. Interest accrued on loans, securities, etc. 8. Real Estate: (a) Used for business purposes 741 (b) Not used for business purposes 9. Stocks and bonds: (a) Listed - - present market value (b) Unlisted - - present value 10. Materials in stock included in Item 4 (a) For uncompleted contracts (present value) (b) Other materials (present value) 11. Equipment, book value ,6 4 12. Furniture and fixtures, book value 9 1 ,9 9 13. Other Assets Total assets 3 ,5 0 -7- LIABILITIES Do Ins Cts. 1. Notes payable (a) To banks regular (b) To banks for certified checks (c) To others for equipment obligations (d) To others exclusive of equipment obligations 2. Accounts payable (a) Not past due 12, 08 (b) Past due 3. Real estate encumbrances 4. Other liabilities 8 4 5. Reserves 1 6. Capital stock paid up: (a) Common (b) Common ( c) Preferred (d) Preferred 1 ,2 87 7. Surplus (net worth) Total liabilities 30, 10 II I. Liability on notes rece 2. Liability on accounts 3. Liability as bondsman 4. Liability as guarantor 5. Other contingent liabi CONTINGENT LIABILITIES ivable, discounted or sold receivable, pledged, assigned or sold on contracts or on accounts of others lities Total contingent liabilities -8- DETAILS RELATIVE TO ASSETS 1 (a) on hand $ Cash (b) deposited in banks named below (c) elsewhere - - (State where) NAME OF BANK LOCATION DEPOSIT IN NAME OF AMOUNT (a) due within 90 days $ 2* Notes Receivable (b) due after 90 days (c) past due DATE OF RECEIVABLE FROM: NAME AND ADDRESS FOR WHAT MATURITY HOW SECURED AMOUNT Have any of the above been discounted or sold? If so, state amount, to whom, and reason 3* I Accounts receivable from completed contracts exclusive of claims not approved for payment $ 8,319 AMOUNT OF AMOUNT NAME AND ADDRESS OF OWNER NATURE OF CONTRACT CONTRACT RECEIVABLE Too many to l~st 8,319 Have any of the above been assigned, sold, or pledged? No I f so, state amount, to whom and reason 4* Sums earned on uncompleted contracts, as shown by engineer's or architect's estimate: (a) Amount receivable after deducting retain age $ 2,263 (b) Retainage to date due upon completion of contract 2,525 DESIGNA TION OF CONTRACT AND NAME AMOUNT OF AMOUNT AMOUNT RET AINAGE AMOUNT EXCLUSIVE AND ADDRESS OF OWNER CONTRACT EARNED RECEIVED WHE1\ I AMOUNT OF RETAINAGE DUE Costs and estimated earnings ip excess of billings (Too many to lis:: 2,263 Retainaae (Too man" to list) 2,525 Have any of the above been sold, assigned, or pledged? ~ Ifso, state amount, to whom, and reason -List separately each item amounting to 10 percent or more of the total and comb:ne the remainder. -9- DETAILS RELATIVE TO ASSETS (continued) 5* I Accounts receivable not from construction contracts $ RECEIVABLE: NAME AND ADDRESS FOR WHAT WHEN DUE AMOUNT What amount, if any, is past due $ 6 I Dep()sits with bids or otherwise as guarantees $ DEPOSITED WITH: NAME AND ADDRESS FOR WHAT WHEN RECOVERABLE AMOUNT 7 Interest accrued on loans, securities, etc. $ ON WHAT ACCRUED TO BE PAID WHEN AMOUNT 8* Real estate (a) Used for business purposes $ 741 Book value (b) Not used for business purposes $ IMPROVEMENTS TOTAL BOOK DESCRIPTION OF PROPERTY NATURE OF IMPROVEMENTS BOOK VALUE VALUE I. Too many to list 741 2. 3. 4. 5. 6. 7. LOCATION HELD IN WHOSE NAME ASSESSED VALUE AMOUNT OF ENCUMBERANCES 1 2. 3. 4. 5. 6. 7. . List separately each item amounting to 10 percent or more of the total and combine the remainder. -10- DETAILS RELATIVE TO ASSETS (continued) 9 Stocks and bonds (a) Listed - - present market value $ b) Unlisted - - present value LAST INT PRESENT DESCRIPTION ISSUING COMPANY OR DIY PAID PAR MARKET QUAN- AMOUNT DATE % VALUE VALUE TITY I. 2. 3. 4. 5. 6. 7. AMOUNT WHO HAS POSSESSION IF ANY ARE PLEDGED OR IN ESCROW, STATE FOR WHOM AND REASON PLEDGED OR IN ESCROW I. 2 3. 4. 5. 6. 7. 10 Materials in stock and not included in Item 4, Assets: (a) For use on uncompleted contracts (present value) $ (b) Other materials (present value) QUANTITY PRESENT VALUE DESCRIPTION OF MATERIAL FOR UNCOM- OTHER PLETED MATERIALS CONTRACTS 11 Equipment at book value $ 3,694 QUAN- DESCRIPTION AND CAPACITY OF ITEMS AGE OF ITEMS PURCHASE I'RICE DEPRECIA TION TITY CHARGED OFF BOOK YALUE Too many to list 3,694 Are there any liens against the above? No If so, state total amount * If two or more items are lumped above. give the sum of their ages. -11- $ DET AILS RELATIVE TO ASSETS (continued) 12 Furniture and fixtures at book value $ 9 13 Other Assets $ 12,959 DESCRIPTioN AMOUNT r.L ",}'a..L' a.HU -ucner- ' U Goodwill 12,235 ". '^ "<=A I TOTAL ASSETS $ 30 510 I DETAILS RELATIVE TO LIABILITIES 1 Notes payable (a) To banks, regular $ (b) To banks for certified checks (c) To others for equipment obligations i d) To others exclusive of e lUinment obligations TO WHOM: NAME AND ADDRESS WHAT SECURITY WHEN DUE AMOUNT -c. 12,408 2 Accounts payable (a) Not past due $ (b) Past Due TO WHOM: NAME AND ADDRESS FOR WHAT DATE PAYABLE AMOUNT Too many to llst 12,408 , 3 Real estate encumbrances (see Item 8, Assets) $ 4 Other liabilities $ 818 DESCRIPTION AMOUNT l:lllllngs In excess OJ: COS1:S ana eS1:lma1:ea earnlngs \'1'00 many c:-o .LlS1:) tsits 5 Reserves $ INTEREST I INSURANCE BLDGS. & FIXT. I PLANT DEPR. I TAXES I BAD DEBTS I 1 S 1$ $ 1$ 1$ T$ 1$ 1$ $ 1 6 Capital stock paid up (a) Common (b) Preferred 7 Surplus 17,287 30,510 -12- If a corporation answer this: Amount for which incorporated Capital paid in cash When incorporated In what state Names and titles of all persons having authority to execute and receipt estimate vouchers and to conduct other business for the corporation, including its officers, the signatures of whom are legally binding. See Attached Do you have necessary "certificate of existence" (or certificate of authorization for a foreign corporation) to transact corporate business Yes in this state, under the terms of Public Law 149, Acts of 1986, and acts amendatory thereto? If a co-partnership answer this: N / A Date of organization State whether co-partnership is general, limited or association Give the names, addresses and proportional interests of all parties: Name Address Share $ $ $ $ $ $ $ The name of the partnership firm under which the above partners are operating is Give names and titles of all having authority to execute and receipt estimate vouchers and to conduct other business for the partnership, the signatures of whom are legally binding. -13- The undersigned hereby declares that the foregoing is a true statement of the financial condition of the individual, co-partnership, or corporation herein first named, as of the date herein first given; that this statement is for the express purpose of inducing the party to whom it is submitted to award the submitter a contract; and that any depository, vendor or other agency herein named is hereby authorized to supply such party with any information necessary to verify this statement. Insituform Technologies USA, Inc. 17988 Edison Avenue NOTE: A co-partnership must give firm name and signatures of all partners. A corporation must give full corporate name, signature of official and affix corporate seal. H. Affidavit for Individual STATE OF COUNTY OF } 5S: N/A being duly sworn, deposes and says that the foregoing financial statement, taken from his books, is a true and accurate statement of his financial condition as of the date thereof and that the answers to the foregoing interrogatories are true. Subscribed and sworn to before me this (Applicant must sign here) day of 20 Notary Public Affidavit for Co-Partnership COUNTY OF } SS: N/A STATE OF being duly sworn, deposes and says that he is a member ofthe firm of ; that he is familiar with the books of the said firm showing its financial condition; that the foregoing financial statement, taken from the books of said firm, is a true and accurate statement of the financial condition of the said firm as of the date thereof and that the answer to the foregoing interrogatories are true. Subscribed and sworn to before me this (Member of firm must sign here) day of 20 Notary Public Affidavit for Corporation MISSOURI STATE OF COUNTY OF ST. LOUIS } 5S: H. Douglas Thomas being duly sworn, deposes and says that he is Vice President of the Insituform Technologies USA, Inc. , corporation described in and which executed the foregoing statement; that he is familiar with the books of the said corporation showing its financial condition; that the foregoing financial statement, taken from the books ofthe said corporation, is a true and accurate statement of the financial condition of said corporation as of the date thereof and that the answers to the foregoing interrogatories are true. 7th May 20 09 H. President Subscribed and sworn to before me this Notary Public JANA LAUSE Notary Public- Notal}' Seal State of Missouri Sf. louis County My Commission Expires Dee. 5 200~ < Commission # 05805615' " -14- INSlTVFORM TECHNOLOGIES USA. INC. Assistaat SecretarY's Cerdftcate The undersigned, being the Assistant Secretary of Insituform Technologies OS~Inc.~ a Delaware corporation (the "Corporation"), hereby certifies that: 1. The following is a 1rUe and correct excerpt from the By-laws of the Corporation: Chief ExecIlliPe ()jJ'iar Appol1tInte1It& The Chief Executive Officer may from time to time appoint such officers of operating divisions. and such con1raetingan4 attesting officers~ of the Corporation as the Chief.ExClCUti-ve Officer may deem proper~ who shallhavesucb authority, subject to the control of the Board, as the CbiefExecutive Officer may from time to time prescribe. 2. The Chief Executive Officer of the Corporation bas, pursuant to the above authority, duly appointed H. Douglas Thomas as Vice Preside,nt. Lynn E. Osborn, Vice President. Joann Smith~ Assistant Secretary, Denise L. Carroll. Assistant SecretaJ)' and Debra J-.sper, Jana Lause and Diane Partridge as Contracting and Attesting Officers of the Corporation. Each of the foregoing have been fully authorized and empowered by the Chief Ex~utive Officer of the Corporation: "(i} to certify and to attest the signature of any officer of the Corporation, (ii) to enter into and to bind the Corporation to perform pipeline ~babilitation activities of the Corporation and all Jnatters ~I~ ~, including the maintenance of one or more ofti~ and facilities of the Corporation, (ui) to execute and to deUver ~lS ()D ~fQf~ Corporation and (iv) to take such other action as is or may be DeCeSS81Y and appropriate to carry out the projects, activities and work of the Corporation." IN WITNESS WHEREOF~ I have hereunto affIXed my name as Assistant Secretary, this 16th day of A~ 2008. INSITIJFORM TECHNOLOGIES US~ INC. BY:~ Er . . Kowly ') Assi$tant Secretary