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HomeMy WebLinkAbout2019-293 PO 20200228- Pump Pipe & Tank Services, LLC Purchase Order C�TY � Fiscal Year 2020 Page: 1 of: 1 B City of Ashland I ATTN: Accounts Payable Purchase Q AshlandaiOR 97520 Order# 20200228 T Phone: 541/552-2010 0 Email: payable@ashland.or.us V H C/O Facilities Maintenance Div E PUMP PIPE &TANK SERVICES, LLC l 90 North Mountain Ave N PO BOX 146 p Ashland, OR 97520 0 TALENT, OR 97540 Phone: 541/488-5358 R O Fax: 541/552-2304 r.-.1 R'�. ^Tt I�`l' i �E 'T"T"leaG 2 ,1,i. `es'`s.'lr �1�wriww - v.'- ,--,,.'.__-er-�• •Aa.h— a.�-c�t_ .'c,.Y .'_.E 541 535-6542 David Arnold ttIe R1=1 Aa 1?2,=t a t I 1 , _ 1 10/22/2019 468 468 FOB FOB ASHLAND OR CitAccountsable �1�,=- �,, = i; I� i rte. Replace Diesel Spill Bucket 1 Replacement of existing Diesel 5-gallon fill delivery bucket(spill . 1 $4,821.6900 $4,821.69 ' bucket) • Goods &Services Agreement Completion date: 06/30/2020 Project Account: ***************GL SUMMARY*************** 082400 602400 $4,821.69 • • • By: Date: 16 a __—. --_-- - - E: -- Authorized Signature .4 821.69 FORM 413 CITY OF . >. fl--- / ,—/ 0( °-1. A request for E Purchase OrderI ASHLAND REQUISITION` -te of request: 10/11/2019 () 7--'16) ,- -. - 'equired date for delivery: Vendor Name . Pump,Pipe and Tank Services LLC Address,City,State,Zip . PO Box 146,Talent,OR 97540 • Contact Name&Telephone Number Ryan McHenry 541-535-6542 Email address - SOURCING METHOD ❑ Exempt from Competitive Bidding ❑ Emergency ❑ Reason for exemption: 0 Invitation to Bid 0 Form#13,Written findings and Authorization O AMC 2.50 Date approved by Council: 0 Written quote or proposal attached ❑ Written quote or proposal attached (Attach copy of council communication) _(If council approval required,attach copy of CC) ® Small Procurement 0 Request for Proposal Cooperative Procurement Not exceeding$5,000 Date approved by Council: 0 State of Oregon ® Direct Award ' _(Attach copy of council communication) Contract# ❑ Verbal/Written quote(s)or proposal(s) 0 Request for Qualifications(Public Works) 0 State of Washington Date approved by Council: Contract# (Attach copy of council communication) 0 Other government agency contract Intermediate Procurement ❑ Sole Source Agency . GOODS&SERVICES 0 Applicable Form(#5,6,7 or 8) Contract# f Greater than$5,000 and less than$100,000 0 Written quote or proposal attached Intergovernmental Agreement O (3)Written quotes and solicitation attached 0 Form#4,Personal Services>$5K&<$75K Agency PERSONAL SERVICES 0 Special Procurement ,0 Annual cost to City does not exceed$25,000. Greater than$5,000 and less than$75,000 0 Form#9,Request for Approval Agreement approved by Legal and approved/signed by ❑ Direct appointment not to exceed$35,000 0 Written quote or proposal attached City Administrator.AMC 2.50.070(4) ❑ (3)Written proposals/written solicitation Date approved by Council: 0 Annual cost to City exceeds$25,000,Council ❑ Form#4,Personal Services>$5K&<$75K Valid until: (Date) approval required.(Attach copy of council communication) Description of SERVICES Total Cost Replacement of existing Diesel 5 gallon fill delivery bucket(spill bucket) $`4 82169 ` `` Item# Quantity Unit Description of MATERIALS Unit Price Total Cost Per attached quotelproposal _\TOTAL?COST' j Project Number _ _ Account Number 082400-602400 r .: a;4 ..:J *Expenditure must be charged to the appropriate account numbers for the financials to accurately reflect the actual expenditures. IT Director in collaboration with department to approve all hardware and software purchases: IT Director Date Support-Yes/No By signing this requisition form,I certify that the City' u c contracting requirements have been satisfied. Employee: Department Head: /:.. .�t/ i - D6r0 t7 (Equal to,or greater than$5,000) Department anagerlSupervisor: City Administrator: • • (Equal to or greater than$25,000) • Funds appropriated for current fiscal year: YES / NO Deputy Finance Director-(Equal to or greater than$5,000) Date Comments: GOODS & SERVICES AGREEMENT PROVIDER: Pump,Pipe and Tank Services,LLC CITY O F PROVIDER'S . Ryan McHenry ASH: LAND ;CONTACT: 20 East Main,Street - , Ashland,Oregon 97520 „ ADDRESS: PO Box 146 Telephone: 541/488-5587 Talent, OR,97540 Fax: 541/488-6006 • 6 : PHONE:, 541-535-6542 • This Goods and Services Agreement (hereinafter "Agreement") is entered into by and between the City of Ashland,an Oregon municipal corporation(hereinafter"City")and Pump,Pipe&Tank Services LLC,a domestic business corporation("hereinafter"Provider"), for spill bucket replacement. 1. PROVIDER'S OBLIGATIONS ' ' 1.1 Provide spill bucket replacement as set forth in the,"SUPPORTING DOCUMENTS" attached hereto and,by this reference,incorporated herein. Provider expressly acknowledges that time is of the essence of any completion date set forth in the SUPPORTING DOCUMENTS;and that no waiver--or extension - of such deadline may be authorized except in the same manner as herein provided for authority to exceed • the maximum compensation. The goods and services defined and described in the "SUPPORTING DOCUMENTS" shall hereinafter be coll'ectivelyreferred to as "Work:"• 1.2 Provider shall obtain and maintain during the"term of this'Agreement and until City's final acceptance of all Work received hereunder, a policy or policies of liability insurance including commercial general liability insurance with a combined single limit, or the equivalent, of not less than $2,000,000 (two million dollars)per occurrence for Bodily Injury and Property Damage.' ' 1.2.1 ' The insurance required in this Article shall include the following coverages: . • Comprehensive General or Commercial General' Liability, including personal injury, contractual liability, and products/completed operations coverage; and • Automobile Liability. 1.2.2 Each policy of such insurance'shall be on an "occurrence" and not "claims made" form, and shall: • Name as additional insured "the City of Ashland, Oregon, its officers, agents and employees" with respect to claims arising out of the provision of Work under this Agreement; • ,Apply toeach named and additional named insured,as though a separate policy had been issued to each,provided that the policy limits shall not be,increasedthereby; - • Apply as primary coverage for each additional named insured except to the extent that two or more such policies are intended to "layer" coverage and, taken together, they provide total coverage from the first dollar of liability; • Provider shall immediately notify the City of any change in insurance coverage • Provider shall supply an endorsement naming the City;its officers, employees and agents as additional insureds by the Effective Date of this Agreement; and • Be evidenced by&certificate or certificates of such insurance approved by the City. Page 1 of 5: Agreement between the City of Ashland and Pump,Pipe&Tank Services,LLC, 1.3 All subject employers working under this Agreement are either employers that will comply with ORS 656.017 or employers that are exempt under ORS 656.126. 1.4 Provider agrees that no person shall, on the grounds of race, color, religion, creed, sex, marital status, familial status or domestic partnership, national origin, age, mental or physical disability, sexual orientation, gender identity or source of income, 'suffer discrimination'in the performance of this Agreement when employed by Provider. Provider agrees to comply with all applicable requirements of federal and state civil rights and rehabilitation statutes, rules and regulations. Further, Provider agrees not to discriminate against a disadvantaged business enterprise,minority-owned business,woman-owned business, a business that a service-disabled veteran owns or an emerging small business enterprise certified under ORS 200:055,in awarding subcontracts as required by ORS 279A.110. 1.5 In all solicitations either by competitive bidding or negotiation made by Provider for work to be performed under a subcontract, including procurements of materials or leases of equipment, each potentialsubcontractor or supplier shall be notified by the Providers of the Provider's obligations under this Agreement and Title VI of the Civil Rights Act of 1964 and other federal nondiscrimination laws. 2. CITY'S OBLIGATIONS 2.1 " City shall pay Provider the sum of$4,821.69 as provided herein as full compensation for the Work as specified in the SUPPORTING DOCUMENTS. 2.2 In no event shall Provider's total of all compensation and:reimbursement under this Agreement exceed the sum of$4,821.69 without express,written approval from the City official whose signature appears below, or such official's successor.in office. Provider expressly acknowledges that no other person has authority to order or authorize additional Work which would cause this maximum sum to be exceeded and that any authorization from the responsible official must be in writing. Provider further acknowledges that any Work delivered or expenses incurred without authorization as provided herein is done at Provider's own risk and as a volunteer without expectation of compensation or reimbursement. 3. GENERAL PROVISIONS 3.1 This is a non-exclusive Agreement. City is not obligated to procure any specific amount of Work from Provider and is free to procure similar types of goods and services from other providers in its sole discretion. ' 3.2 Provider is an independent contractor and not an employee or agent of the City for any purpose. 3.3 Provider,is not entitled to, and expressly waives all claims to City benefits such as health and disability insurance;paid leave, and retirement.' 3.4 This Agreement embodies the full and complete understanding of the parties respecting the subject matter hereof. It supersedes all prior agreements;negotiations,and representations between the parties, whether written or oral. 3.5 This Agreement may be amended only by written instrument executed with the same formalities as this Agreement. ' 3.6 The following laws of the State of Oregon are hereby incorporated by reference into this Agreement: ORS 279B.220,279B.230 and 279B.235. Page 2 of 5: Agreement between the City of Ashland and Pump,Pipe&Tank Services,LLC 3.7 This Agreement shall be governed by the laws of the State of Oregon without regard to conflict of laws principles. Exclusive venue for litigation of any action'arising under this:Agreement shall be in the .• Circuit Court of the.State of Oregon for Jackson County unless exclusive jurisdiction is in federal court, in which case exclusive venue shall be in,the,federal district=court`for,the.district of Oregon. Each party expressly waives:any and all rights to,maintain.an action underthis,Agreement;inany other.venue, and expressly,consents that,!upon motion- of-the,.other_parry, any.case;May-.be -dismissed or its venue transferred, as appropriate, so as to effectuate this choice-of venue. 3.8 Provider shall defend,save,hold harmless and indemnify the City and its officers,employees,andagents from-and against.any and all claims; suits, actions, losses,,damages,:liabilities, costs, and expenses of , , . -:, ,any:nature resulting from; arising -out of,, or relating,to :the.activities -of Provider or r its. officers, employees, contractors, or agents under this,Agreement:• -' 3.9 Neither party to this Agreement shall hold the other responsible for damages or delay in performance caused by acts of God,strikes,lockouts,accidents,or other events beyond the control-of the other or the other's officers, employees or agents. • . •,..:.- .s; 1 3.10 If any provision of this Agreement is found by a court of competent jurisdiction to:be'unenforceable, such provision shall not affect the other provisions, but such unenforceable provision'shall be deemed modified to the extent necessary to render it enforceable, preserving to'the fullest extent permitted the intent of Provider and the City set forth in this Agreement. 4. SUPPORTING DOCUMENTS r The following documents are,by this reference,expressly incorporated in this Agreement,and are collectively referred to in this Agreement as the "SUPPORTING DOCUMENTS:" • The Provider's complete written Estimate dated October 7, 2019 5. REMEDIES 5.1 In the event Provider is in default of this Agreement, City may, at its option;.pursue'any i or all of the remedies available to it under this Agreement and at law or in equity, including,but'not limited to: 5.1.1 Termination of this Agreement; 5.1.2 Withholding all monies due for the Work that Provider has failed to deliver withinany'scheduled completion dates or any Work that have been delivered inadequately or defectively; 5.1.3 Initiation of an action or proceeding for damages, specific performance; or'declaratory or injunctive relief; . . , . ' .• _• ,., . , :,. . . -5.1.4:These remedies are cumulative to the extent the-remedies rare not.inconsistent,and City may pursue any remedy or remedies singly, collectively, successively or in any order whatsoever: . • 5.2 In no event shall City be liable to Provider for ariy`expenses related to termination of this Agreement or for anticipated profits. If previous amounts paid'to Provider exceed the amount due;Provider shall pay • immediately,any excess to City upon written demand.provided, ,, , . • • ,, 6. TERM AND TERMINATION-. _i : . ,, 6.1 Term • . . This,Agreement shall.be effective from thedate,of execution-on behalf,of the City as set forth below (the "Effective Date"), and shall continue in full'force and effect, until June.30, 2020, unless sooner terminated as.provided,in Subsection 6.2. . , ,• • Page 3 of 5: Agreement between the City of Ashland and Pump,Pipe,&.Tank.Services;,LLC ., . . . 6.2 Termination. " . : . . 612.1 The City and Provider may.terminate this Agreement by mutual agreement at any time. 6:2'.2 The City may;upon not less than thirty(30) days' prior written notice; terminate this Agreement for any reason:deemed appropriate:in its.sole discretion: • . 6.23=Eithenparty may terminate this Agreement,with cause;by not less!thanfourteen(14) days' prior written notice if the'cause is not cured within that`fourteen'(14) day period'after written notice. Such termination is in addition:to and not in lieu of any other remedy at'law or equity. 7:. NOTICE " . , . • ;o Whenever:notice is required or permitted.to'be given under this Agreement,,such notice.''shall be given in writing to the other party by personal delivery, by sending via a`reputabie'commercial overnight-courier, or by mailing using registered or certified United Statesmail; return receipt'requested postage:prepaid, to the address set forth below: If to'the City: , . . - , , ' City of Ashland—Facilities Maintenance Department Attn: David Arnold 90.North Mountain:Avenue. , . . , . • . ,• a. r• ) .Ashland, Oregon 97520 r , " . .• ' • , Phone .(541) 552-2292 •r With a copy to: City of Ashland—Legal Department • . 20 E. Main Street . . r Ashland, OR 97520 Phone: (541)488-5350 If to Provider: Pump,Pipe &Tank Services, LLC Attn:.Ryan•McHenry - •PO Box,146 : , • ; Talent, OR 97540 8. WAIVER OF BREACH .:t, . ,, F r One or more waivers or failures to object by either party to the other's breach of any provision,term,condition, • or covenant contained in this Agreement_.shall not be construed as aiwaiver of any subsequentbteach,whether or not of the same nature.- - . ' - t . 9. PROVIDER'S COMPLIANCE,WITH.TAX LAWS ; . 9.1 . Provider represents and warrants to the City,that:: . .. . .. , . . • , 9.1.1 Provider shall, throughout the term of this'Agreement, including'any extensions'hereof, comply with: (i) All tax laws of the State of Oregon, including but not'limited to ORS"305.620 and ORS chapters 316, 317, and 318; , (ii) Any tax.provisions'imposed by a politicalsubdivision'of the State of Oregon applicable to Provider; and' . . ;. . , (iii) Any rules,regulations, charter provisions, or ordinances that'implement or'enforce any of the foregoing tax laws or provisions. Page 4 of 5: Agreement between the City of Ashland and Pump,Pipe'&TankServices,,LLC ' • ' 9.1.2 Provider, for a period of no fewer than six (6) calendar years preceding the Effective Date of this Agreement, has faithfully complied with: (i) All tax laws of the State of Oregon, including but not limited to ORS 305.620 and ORS chapters 316, 317, and 318; (ii) Any tax provisions imposed by a political subdivision of the State of Oregon applicable to Provider; and (iii) Any rules,regulations, charter provisions, or ordinances that implement or enforce any of the foregoing tax laws or provisions. 9.2 Provider's failure to comply with the tax laws of the State of Oregon and all applicable tax laws of any political subdivision of the State of Oregon shall constitute a material breach of this Agreement. Further, any violation of Provider's warranty, as set forth in this Article 9, shall constitute a material breach of this Agreement. Any material breach of this Agreement shall entitle the City to terminate this Agreement and to seek damages and any other relief available under this Agreement,at law,or in equity. IN WITNESS WHEREOF the parties have caused this Agreement to be signed in their respective names by their duly authorized representatives as of the dates set forth below. CITY OF ASHLAND: Pump,P'. e : . Pump Pipe & Tank Services LLC Estimate e P.O. Box 146 CA lic#569114 aTm Date Estimate# Talent, OR 97540 CCB#63709/197390 "�R 10/7/2019 10072019 Phone (541) 535-6542 Fax(541) 535-5557 „st www.pumppipetank.com = 1 �- 'UR s YEARS /Address 30 1 EAR S City of Ashland 90 N.Mountain Avenue UFEXCELLENT SERVICE Ashland,OR 97520 t IV,E Wes Hoadley • wes.hoadley@ashland.or.us - Qty Description Cost Total Job Site:City Of Ashland ESTIMATED cost to replace existing Diesel 5 gallon fill delivery bucket. 1 1C-2100-DEVR 5 Gallon Spill Bucket 506.53 506.53 1 OPW 4"GREY FILL CAP 37.60 37.60 1 ,OPW 61SA FILL SWIVEL ADAPTER 237.56 237.56 1 Diesel Anchor Shank . 20.00 20.00 1 Diesel Cover ID Tag '20.00 20.00 1 Hydrostatic Testing of Bucket 125.00 125.00 1 Labor/ Install/concrete Cutting,Removal and disposal 3,875.00 3,875.00 • ACCEPTED BY(customer) DATE Phone Estimate Good For 15 days Total • $4,821.69 . . r Form W-9 Request for Taxpayer Give Form to the Identification Number and Certification requester.Mont (Rev.tmentorhe-De018) send to the IRS. phonal R venue Service �Onto emedr.gov/FormW9.for instructions and the latest ittto nation. Imemal Revenue SerNce 9 -. 1 Name(as shown on your Income tax return).Name Is required on this fins;do not leave this line blank • • • Pump Pipe&Tank Services,LLC 2 Business name/disregarded entity name.If different from above Pump Pipe&Tank Services,LLC m 3 Cheek appropriate box for federal taX classiflcatlon of the person whose name Is"entered en Una 1.Cheek only one ofttie 4 ExemptIons(cedes apply only to mfollowing seven boxes, certain entitles,not Individuals;see a insuuctions on page 9): S 0 Individual/sole proprietor or 0 a Corporation 0 s Corporation ❑Partnership ❑Trust/estate 'Exempt payee code fit enY) single-member ILO -II.ta - ,g F .Q limited liability company.Enter the tax classification(C--C corporation.9=8 corporation,P=P ership)v. S- `o Mote:'Checktha'appropriate box Lathe line above for.the tax classification of the single-member owner.Do not hheck" Exemption from FATbA reporthrp LLC if the LLC Is classified as a single-member LLC that Is disregarded from the owner'mime the owner of the LLC Is code(Many) 1 S another LLC that Is not disregarded from the owner for U.S.federal tax purposes Otherwise,a single-member LLC that ' 66§. Is disregarded from the owner should check the appropriate box for the tax etasslflcation of its owner. ,0 Other(see inswationa)I. - - _ .tapyfaato accounts mermahadau¢aathe ru! w6 Address(number,street,and apt.or suite no.)See Instructions. Requester's name end eddress_(optional 8 PO.Box 146. a city,state,end ZIP code - Talent,OR 97540 7 List account number(s)here(optional Part I Taxpayer Identification Number(TIN) .. Socialeewrttynumber Enter your TIN in the appropriate box.The TIN provided must match the name given on line 1 to avoid backup withholding.For individuals,this Is generally your social security number(SSN).rHowever,for a I I I -I I I I resident alien,sole proprietor,or disregarded entity,see the instructionstor Part I,later.For other entities.It Is your employer Identification number(SIN).If you do not have a number,see How to get a or 71N,later.• Employerldemi6eatlonnumber ;I Note:If the account is in more than one name,see the instructions for link 1.Also see Whet Name and Number To Give the Requester for guidelines on whose number to enter. 4 5 —ISI 216131°13121 . Part II CertificationS Under penalties of perjury,1 certify that 1.The number shown on this form is my correct taxpayer identification number(or 1 am walling for'a number to.be Issued to me);and 2.I em not subject to backup withholding because:(a)lam,exempt from backup withholding,or(b)I have not been nota ied by the Internal Revenue Service(IRS)_that 1 am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the iRS has notified me that I am no longer subject to backup withholding;and 3.1 am a U.S.citizen or other U.S.person(defined below);and 4.The FATCA code(s)entered on this form(If any)indicating that I em exempt from FATCA reporting Is correct. Certification instructions.You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return.For real estate transactions,item 2 does not apply.For mortgage interest paid, acquisition or abandonment of secured property,cancellation of debt,contributions to an Individual retirement arrangement IRA),and generally,payments other than interest and dividends, ou are not / npLfirredto sign thenaelfiA certification,but you must.provide your correct TIN.See the Instructionsfor Part II,later. Ze Her® U.9.person..._ 4 General Instructions i .99-DIV(dividends,"Including those from stocks or mutual .-I Section references are to the Internal Revenue Code unless otherwise: 1099-MISC.(varioustypes of income,pricks,awards,or gross noted. p• eeds) Future developments.For the latest information about developments •Form 1099-B(stock or mutual hind sales and certain other related to Form W-9 and'its Instructions,such as legislation enacted• transactions by brokers)- 'after they were published,go to www.lrs.gov/FormW9. - Form 1099-S(proceeds from real estate transactions) Purpose of Form - •Form 1099-K(merchant card and third party.network transactions) An individual or entity(Form W-9 requester).who Is required'to file an •Form 1098(home mortgage Interest),1098=E(student loan interest. information return with the IRS must obtain your correct taxpayer 1098 T(tuition) Identification number MN)which may be your social security number •Form 1099-C(canceled debt) ($SN),Individual:taxpayeridentification number(I fil ,'adgption .Form 1099-A(acquisition or abandonment of secured property) taxpayer Identification number(ATIN),or employer identification number Use Form W-9 only If you Bre a 0:S.person(triclud rug a resident • ' (MO,to report on an information return the amount paid to you,or other alien),to provide your correct TIN. amount reportable on an Information return.Examples of information - returns include,but are not limited to,the fotiowing. It you do not return Form W:9 to the requester with a,TIN,you might •Form 1099-INT(Interest earned or paid) be subject to backup withholding.See What Is backup withholding, later cat No.10231XForm W-9(Rev.10-2018) / , — PUMPP-1 OP ID:AD A ...1---"""1 O m ' DATE(MM/DO/YYYY) ` v�A� CERTIFICATE OF LIABILITY INSURANCE 07/26/2019 , THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED . REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). 817-640-5035 CONj}tCT Jim Beam,CIC PRODUCER PHONEI FAX 817.640.0131 Monroe&Monroe Insurance (A/C,No,Ext):817-640-5035 (NC,No): Agency,Ltd. .f�aa 2921 Galleria Dr., Suite 102 EAD REss: Arlington,TX 76011 )NSURER(S)AFFORDING COVERAGE NAIC# Jim Beam,CIC INSURER A:Mid-Continent Casualty Co. 23418 INSURED INSURER B:The Hanover Insurance Group 22292 Pump Pie&Tank Services LLC INSURER C RobertTaM Henrydba Pump Pipe& s Petroleum Pump Supply INSURER D: PO BOX 146 INSURER E: Talent,OR 97540 INSURER F: COVERAGES CERTIFICATE NUMBER: - REVISION NUNIDER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ADDL SUBR POLICY EFF POLICY EXP LIMITS INSR POLICY NUMBER /MM/DDIYYYYI IMMIDD/YYYYI LTR TYPE OF INSURANCE � ISP"WVD 1,000,000 A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE AD CLAIMS-MADE X OCCUR 04GL1014977 11/15/2018 11/15/2019 -OA;M„GETO RENTE„_. 100,000_ X Pollution Liab -0 MED EXP An one.ersan X Professional LlabPERSONAL&ADV INJURY 1,000,000 GENERAL AGGREGATE 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER 3,000,000 POLICY X 28-iLOC PRODUCTS-COMP/OP AGG S OTHER: ( COMBINED SINGLE LIMIT 1,000,000 B AUTOMOBILE LIABILITY ` X ANY AUTO AWDA75436203 10/15/2018 10/15/2019 BODILY INJURY Per.arson .S OWNED SCHEDULED BODILY INJURY Per accident S AUTOSRONLY AUUTNOSyyNEp BODPER •AMAGE X AUTOS ONLY X AUTOS ONLY Per atxl $ A UMBRELLA LIAB X OCCUR EACH OCCURRENCE 1,000,000 ' X EXCESS LLAB CLAIMS-MADE 04XS207529 11/1512018 11/15/2019 AGGREGATE 1,000,000 � _ • DED X RETENTION$ 10,000 $ WORKERS COMPENSATION I PERTUTE I I ER H ' AND EMPLOYERS'LIABILITY ANYPROPRIETORIPARTNER/DIECUTNE Y!N E.L EACH ACCIDENT S OFFICER/MEMBEREXCLUDED? ` I NIA A ) E.L.DISEASE-EA EMPLOYEE $ (Mandatory in NH) If yes,describe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below 4,900 A Equipment Floater 04CIM5129 11/1512018 11/15/2019 Owned Equ • DESCRIPTION OF OPERATIONS I LOCATIONS'VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It more space Is required) The General Liability and Commercial Auto policies include a blanket additional insured and waiver of subrogation endorsement which provides additional insured and waiver of subrogation status to the City of Ashland, Oregon,its officers,agents and employees only*when there is a written "insured contract"as defined by the SEE NOTES CERTIFICATE HOLDER CANCELLATION ` CITASHI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Ashland ACCORDANCE WITH THE POLICY PROVISIONS. Facility Maintenance Dept. , 90 North Mountain Ave. AUTHORIZED REPRESENTATIVE Ashland,OR 97520 e�/f�, � ACORD 25(2016103) ' ©1009((88 2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD BBS! 900621 A Ramon Rev=Management Campy August 01,2019 PUMP PIPE&TANK SERVICES LLC 5446 S PACIFIC HWY PHOENIX,OR 97535-6608 Re: Barrett Business Services, Inc.("BBSI") Letter of Self-Insurance for Workers'Compensation Coverage As the named addressee of this Letter, your company's required workers'compensation coverage is provided through BBSI's state approved Self-Insured Workers'Compensation Plan by way of your co-employment contract with BBSI. Additional information is as follows: State: Oregon Workers'Compensation limits: Employer Liability Limits: Self Insurance Certification#: 1068 Statutory $5,000,000.00 Each Accident $5,000,000.00 Disease Coverage Limit by Client ` $5,000,000.00 Disease;Each Employee Other Comments(place an"X"if applicable): El Named"Letter Holder": City of Ashland 20 E,Main St Ashland, OR 97520 n Other: Contract effective 5/1/2012,renewed through 4/30/2020.Subject to 30 days'notice of cancellation. Additionally,BBSI's self-insured program is further supported by an excess workers'compensation insurance policy with ACE American Insurance Co.. Copy of certificate is available upon request, For additional information,please contact your local BBSI office at: MEDFORD (541)772-5469 3512 Excel Drive Suite 107 Very truly yours, Medford,.OR 97504 Michael L.Elich President and Chief Executive Officer doc:Lost-2 • HOLDER CODE CITA$H1 PUMPP-1 PAGE NOTEPAD: INSUREDS NAME Pump Pipe Tank Services LLC OP ID:AD Dace 07/2612019 policy, between the named insured and the certificate holder which requires such. status. The General Liability policy_ contains a special endorsement with "primary and noncontributory" wording. . t • • •