HomeMy WebLinkAbout2011-196 Contract - Brenntag Pacific Contract for Goods and Services
CITY OF CONTRACTOR: Brenntag Pacific, Inc.
ASHLAND CONTACT: Sam DeBellis
20 East Main Street
Ashland, Oregon 97520 ADDRESS: 5700 NW Front Ave, Portland, OR 97210
Telephone: 541/488-6002
Fax: 541/488-5311 TELEPHONE: 541-912-7104 (Cell)
DATE AGREEMENT PREPARED: 06/30/2011 FAX: 503-223-1055
BEGINNING DATE: July 1, 2011 COMPLETION DATE: June 30, 20 �Ll
COMPENSATION:
WTP— Sodium Hypochlorite (Hasa $1.35/Gal, Delivery charge $27.50 per order, No tote deposit)
WTP— Soda Ash (FMC $0.209/Lb, Delivery charge $27.50 per order)
WWTP—Sodium Hypochlorite (Hasa $1.35/Gal, Delivery charge $27.50 per order, No tote deposit)
WWTP—Citric Acid RZBC $1.149/Lb, Delivery charge $27.50 per order
GOODS AND SERVICES TO BE PROVIDED: WTP & WWTP Chemicals as specified and resulting from
Invitation to Bid 2011-101. Contract approved by City Council June 21, 2011.
ADDITIONAL TERMS:
NOW THEREFORE, pursuant to AMC 2.50.090 and after consideration of the mutual covenants contained herein the
CITY AND CONTRACTOR AGREE as follows:
1. All Costs by Contractor: Contractor shall, provide all goods as specified above and shall at its own risk and
expense, perform any work described above and, unless otherwise specified, furnish all labor, equipment and
materials required for the proper performance of such work.
2. Qualified Work: Contractor has represented, and by entering into this contract now represents, that any personnel
assigned to the work required under this contract are fully qualified to perform the work to which they will be assigned
in a skilled and worker-like manner and, if required to be registered, licensed or bonded by the State of Oregon, are
so registered, licensed and bonded. Contractor must also maintain a current City business license.
3. Completion Date: Contractor shall provide all goods in accordance with the standards and specifications, no later
than the date indicated above and start performing the work under this contract by the beginning date indicated
above and complete the work by the completion date indicated above.
4. Compensation: City shall pay Contractor for the specified goods and for any work performed, including costs and
expenses, the sum specified above. Payments shall be made within 30 days of the date of the invoice. Should the
contract be prematurely terminated, payments will be made for work completed and accepted to date of termination.
5. Ownership of Documents: All documents prepared by Contractor pursuant to this contract shall be the property of
City.
6. Statutory Requirements: ORS 279B.220, 279B.225, 279B.230, 279B.235, ORS Chapter 244 and ORS 670.600 are
made part of this contract.
7. Living Wage Requirements: If contractor is providing services under this contract and the amount of this contract
is $18,703 or more, Contractor is required to comply with chapter 3.12 of the Ashland Municipal Code by paying a
living wage, as defined in this chapter, to all employees performing work under this contract and to any subcontractor
who performs 50% or more of the work under this contract. Contractor is also required to post the notice attached
hereto as Exhibit B predominantly in areas where it will be seen by all employees.
8. Indemnification: Contractor agrees to defend, indemnify and save City, its officers, employees and agents harmless
from any and all losses, claims, actions, costs, expenses,judgments, subrogations, or other damages resulting from
injury to any person (including injury resulting in death), or damage (including loss or destruction) to property, of
whatsoever nature arising out of or incident to the performance of this contract by Contractor(including but not limited
to, Contractor's employees, agents, and others designated by Contractor to perform work or services attendant to this
contract). Contractor shall not be held responsible for any losses, expenses, claims, subrogations, actions, costs,
judgments, or other damages, directly, solely, and proximately caused by the negligence of City.
9. Termination:
a. Mutual Consent. This contract may be terminated at any time by mutual consent of both parties.
b. City's Convenience. This contract may be terminated at any time by City upon 30 days' notice in writing
and delivered by certified mail or in person.
C. For Cause. City may terminate or modify this contract, in whole or in part, effective upon delivery of
written notice to Contractor, or at such later date as may be established by City under any of the following
Contract for Goods and Services, Page 1 of 5
conditions:
i. If City funding from federal, state, county or other sources is not obtained and continued at levels
sufficient to allow for the purchase of the indicated quantity of services;
ii. If federal or state regulations or guidelines are modified, changed, or interpreted in such a way
that the services are no longer allowable or appropriate for purchase under this contract or are
no longer eligible for the funding proposed for payments authorized by this contract; or
iii. If any license or certificate required by law or regulation to be held by Contractor to provide the
services required by this contract is for any reason denied, revoked, suspended, or not renewed.
d. For Default or Breach.
i. Either City or Contractor may terminate this contract in the event of a breach of the contract by
the other. Prior to such termination the party seeking termination shall give to the other party
written notice of the breach and intent to terminate. If the party committing the breach has not
entirely cured the breach within 15 days of the date of the notice, or within such other period as
the party giving the notice may authorize or require, then the contract may be terminated at any
time thereafter by a written notice of termination by the party giving notice.
ii. Time is of the essence for Contractor's performance of each and every obligation and duty under
this contract. City by written notice to Contractor of default or breach, may at any time terminate
the whole or any part of this contract if Contractor fails to provide services called for by this
contract within the time specified herein or in any extension thereof.
iii. The rights and remedies of City provided in this subsection (d) are not exclusive and are in
addition to any other rights and remedies provided by law or under this contract.
e. Obligation/Liability of Parties. Termination or modification of this contract pursuant to subsections a, b, or
c above shall be without prejudice to any obligations or liabilities of either party already accrued prior to such
termination or modification. However, upon receiving a notice of termination (regardless whether such notice is
given pursuant to subsections a, b, c or d of this section, Contractor shall immediately cease all activities under
this contract, unless expressly directed otherwise by City in the notice of termination. Further, upon termination,
Contractor shall deliver to City all contract documents, information, works-in-progress and other property that are
or would be deliverables had the contract been completed. City shall pay Contractor for work performed prior to
the termination date if such work was performed in accordance with the Contract.
10. Independent Contractor Status: Contractor is an independent Contractor and not an employee of the City.
Contractor shall have the complete responsibility for the performance of this contract.
11. Non-discrimination Certification: The undersigned certifies that the undersigned Contractor has not discriminated
against minority, women or emerging small businesses enterprises in obtaining any required subcontracts.
Contractor further certifies that it shall not discriminate in the award of such subcontracts, if any. The Contractor
understands and acknowledges that it may be disqualified from bidding on this contract, including but not limited to
City discovery of a misrepresentation or sham regarding a subcontract or that the Bidder has violated any
requirement of ORS 279A.110 or the administrative rules implementing the Statute.
12. Asbestos Abatement License: If required under ORS 468A.710, Contractor or Subcontractor shall possess an
asbestos abatement license.
13. Assignment and Subcontracts: Contractor shall not assign this contract or subcontract any portion of the work
without the written consent of City. Any attempted assignment or subcontract without written consent of City shall be
void. Contractor shall be fully responsible for the acts or omissions of any assigns or subcontractors and of all
persons employed by them, and the approval by City of any assignment or subcontract shall not create any
contractual relation between the assignee or subcontractor and City.
14. Use of Recyclable Products: Contractor shall use recyclable products to the maximum extent economically feasible
in the performance of the contract work set forth in this document.
15. Default. The Contractor shall be in default of this agreement if Contractor: commits any material breach or default of
any covenant, warranty, certification, or obligation it owes under the Contract; if it loses its QRF status pursuant to
the QRF Rules or loses any license, certificate or certification that is required to perform the work or to qualify as a
QRF if Contractor has qualified as a QRF for this agreement; institutes an action for relief in bankruptcy or has
instituted against it an action for insolvency; makes a general assignment for the benefit of creditors; or ceases doing
business on a regular basis of the type identified in its obligations under the Contract; or attempts to assign rights in,
or delegate duties under, the Contract.
16. Insurance. Contractor shall at its own expense provide the following insurance:
a. Worker's Compensation insurance in compliance with ORS 656.017, which requires subject employers to
provide Oregon workers' compensation coverage for all their subject workers
b. General Li ' ce with a combined single limit, or the equivalent, of not less than Enter one:
$200,000, $500,006, 1,000,000 $2,000,000 or Not Applicable for each occurrence f r o Wiry and Property
Damage. It shall include con ractual liability coverage for the indemnity provided under this contract.
C. Automobile 'obit nce with a combined single limit, or the equivalent, of not less than Enter one:
$200,000, $500,000, $1,000,000,- Not Applicable for each accident for Bodily Injury and Prope Damage,
includin coverage for o ed fired or non-owned vehicles, as applicable.
Contract for Goods and Services, Page 2 of 5
d. Notice of cancellation or change. There shall be no cancellation, material change, reduction of limits or
intent not to renew the insurance coverage(s)without 30 days' written notice from the Contractor or its insurer(s)to
the City.
e. Additional Insured/Certificates of Insurance. Contractor shall name The City of Ashland, Oregon, and its
elected officials, officers and employees as Additional Insureds on any insurance policies required herein but only
with respect to Contractor's services to be provided under this Contract. As evidence of the insurance coverages
required by this Contract, the Contractor shall furnish acceptable insurance certificates prior to commencing work
under this contract. The contractor's insurance is primary and non-contributory. The certificate will specify all of the
parties who are Additional Insureds. Insuring companies or entities are subject to the City's acceptance. If
requested, complete copies of insurance policies, trust agreements, etc. shall be provided to the City. The
Contractor shall be financially responsible for all pertinent deductibles, self-insured retentions and/or self-
insurance.
17. Governing Law; Jurisdiction; Venue: This contract shall be governed and construed in accordance with the laws
of the State of Oregon without resort to any jurisdiction's conflict of laws, rules or doctrines. Any claim, action, suit or
proceeding (collectively, "the claim") between the City(and/or any other or department of the State of Oregon) and
the Contractor that arises from or relates to this contract shall be brought and conducted solely and exclusively within
the Circuit Court of Jackson County for the State of Oregon. If, however, the claim must be brought in a federal
forum, then it shall be brought and conducted solely and exclusively within the United States District Court for the
District of Oregon filed in Jackson County, Oregon. Contractor, by the signature herein of its authorized
representative, hereby consents to the in personam jurisdiction of said courts. In no event shall this section be
construed as a waiver by City of any form of defense or immunity, based on the Eleventh Amendment to the United
States Constitution, or otherwise, from any claim or from the jurisdiction.
18. THIS CONTRACT AND ATTACHED EXHIBITS CONSTITUTE THE ENTIRE AGREEMENT BETWEEN THE
PARTIES. NO WAIVER, CONSENT, MODIFICATION OR CHANGE OF TERMS OF THIS CONTRACT SHALL
BIND EITHER PARTY UNLESS IN WRITING AND SIGNED BY BOTH PARTIES. SUCH WAIVER, CONSENT,
MODIFICATION OR CHANGE, IF MADE, SHALL BE EFFECTIVE ONLY IN THE SPECIFIC INSTANCE AND FOR
THE SPECIFIC PURPOSE GIVEN. THERE ARE NO UNDERSTANDINGS, AGREEMENTS, OR
REPRESENTATIONS, ORAL OR WRITTEN, NOT SPECIFIED HEREIN REGARDING THIS CONTRACT.
CONTRACTOR, BY SIGNATURE OF ITS AUTHORIZED REPRESENTATIVE, HEREBY ACKNOWLEDGES THAT
HE/SHE HAS READ THIS CONTRACT, UNDERSTANDS IT, AND AGREES TO BE BOUND BY ITS TERMS AND
CONDITIONS.
19. Nonappropriations Clause. Funds Available and Authorized: City has sufficient funds currently available and
authorized for expenditure to finance the costs of this contract within the City's fiscal year budget. Contractor
understands and agrees that City's payment of amounts under this contract attributable to work performed after the
last day of the current fiscal year is contingent on City appropriations, or other expenditure authority sufficient to allow
City in the exercise of its reasonable administrative discretion, to continue to make payments under this contract. In
the event City has insufficient appropriations, limitations or other expenditure authority, City may terminate this
contract without penalty or liability to City, effective upon the delivery of written notice to Contractor, with no further
liability to Contractor.
20. Prior Approval Required Provision. Approval by the City of Ashland Council or the Public Contracting Officer is
required before any work may begin under this contract.
21. Certification. Contractor shall sign the certification attached hereto as Exhibit A and herein incorporated by
reference.
Contractor: City of Ashland
BY By e
Sig a e Department Head
IYXl ( r'e✓1ha
Print Name Print Name
Title Date
W-9 One copy of a W-9 is to be submitted with --Approved as to form:
the signed contract.
Date �J /
Purchase Order No. l �� '( �✓��>
low 86 cw �
Contract for Goods and Services, Page 3 of 5
EXHIBIT A
CERTIFICATIONS/REPRESENTATIONS: Contractor, under penalty of perjury, certifies that (a) the
number shown on the attached W-9 form is its correct taxpayer ID (or is waiting for the number to be
issued to it and (b) Contractor is not subject to backup withholding because (i) it is exempt from
backup withholding or (ii) it has not been notified by the Internal Revenue Service (IRS) that it is
subject to backup withholding as a result of a failure to report all interest or dividends, or (iii) the IRS
has notified it that it is no longer subject to backup withholding. Contractor further represents and
warrants to City that (a) it has the power and authority to enter into and perform the work, (b) the
Contract, when executed and delivered, shall be a valid and binding obligation of Contractor
enforceable in accordance with its terms, (c) the work under the Contract shall be performed in
accordance with the highest professional standards, and (d) Contractor is qualified, professionally
competent and duly licensed to perform the work. Contractor also certifies under penalty of perjury
that its business is not in violation of any Oregon tax laws, and it is a corporation authorized to act on
behalf of the entity designated above and authorized to do business in Oregon or is an independent
Contractor as defined in the contract documents, and has checked four or more of the following
criteria:
(1) 1 carry out the labor or services at a location separate from my residence or is in a
specific portion of my residence, set aside as the location of the business.
(2) Commercial advertising or business cards or a trade association membership are
purchased for the business.
(3) Telephone listing is used for the business separate from the personal residence listing.
(4) Labor or services are performed only pursuant to written contracts.
(5) Labor or services are performed for two or more different persons within a period of one
year.
(6) 1 assume financial responsibility for defective workmanship or for service not provided
as evidenced by the ownership of performance bonds, warranties, errors and omission .
insurance or liability insurance relating to the labor or services to be provided.
Contractor (Date)
Contract for Goods and Services, Page 4 of 5
CITY OF ASHLAND , • •
EXHIBIT B
City of Ashland
LIVING
WAGE
. .
®per hour effect�ue June 3020�1��1'
au iE:S.: W.3 1 y vrN ei�itY»un6`
�� :,(Increases annually,Te�ery�June" 3$0 by the
Consumer Price Index)
. . . . . - portion of business of their cafeteria plans(including
employer, if the employer has childcare) benefits to the
ten or more employees, and amount of wages received by
has received financial the employee.
assistance for the project or
➢ For all hours worked under a business from the City of ➢ Note: "Employee"does not
service contract between their Ashland in excess of$18,890. include temporary or part-time
employer and the City of employees hired for less than
Ashland if the contract ➢ If their employer is the City of 1040 hours in any twelve-
exceeds $18,890 or more. Ashland including the Parks month period. For more
h and Recreation Department. details on applicability of this
➢ For all h ours worked in a
month the employee spends policy, please see Ashland
➢ In calculating the living wage, Municipal Code Section
50% or more of the employers may add the value 3.12.020.
employee's time in that month of health care, retirement,
working on a project or 401 K and IRS eligible
additional For
Call the Ashland City Administrator's office at 541-488-6002 or write to the City Administrator, City Hall,
20 East Main Street, Ashland, OR 97520 or visit the city's website at www.ashland.or.us.
Notice to Employers: This notice must be posted predominantly in areas where it can be seen by all
employees.
CITY OF
ASHLAND
Contract for Goods and Services, Page 5 of 5
EXHIBIT A
City of Ashland
90 N. Mountain Avenue
Ashland, Oregon 97520
(541) 488-5354
FAX (541) 488-5320
BID FORM
I, the undersigned, an authorized representative of the bidder whose name is:
R O q e— �i c� �.� L �!
Address: S 7 0 d j(/W/ �r o,. / 1 (l-e—
City, State & Zip: /00 r /Gt/1 CY O/e 9-7-_2 /O
/
Phone No.-651L---0 0-7—OOFAX No. asS`-
have read and thoroughly understand the contract documents including the Invitation to Bid,
general conditions, special conditions, specifications, and all other conditions of the Invitation to
Bid issued by the City of Ashland for CHEMICALS FOR THE WATER &WASTE WATER
TREATMENT PLANTS.
Acting on behalf of my firm which is listed above, I do attest that the goods and services offered
by this firm meets the City's specifications in every respect except those described on the
attached list of exceptions, and that all exceptions are equal to, or better than, the goods and
services specified.
Barring circumstances beyond our control, we agree to deliver within (as specified) days
from receipt of an order.
This bid is set forth as follows: (Note: Pricing shall be provided as required in the specifications)
have attached to this bid a copy of all the bid documents issued by the City of Ashland for this bid.
By:
ig a ure_
Print Name
Title:
Date:
ITB—Chemicals for WTP&W WTP, Page 18 of 20.4/29/2011
EXHIBIT B
Certificate of Compliance
Residency Statement:
In compliance with ORS 279B.060(10),each bid must contain a statement as to whether the bidder
is a"Resident bidder". This is defined by ORS 279A.120:"Resident bidder"means a bidderthat has
paid unemployment taxes or income taxes in this state during the 12 calendar months immediately
preceding submission of the bid, has a business address in this state and has stated in the bid
whether the bidder is a "resident bidder°.
!� Yes, I certify that I am a "Resident bidder" as defined by ORS 279A.120.
No, I certify that I am not a"Resident bidder" as defined by ORS 279A.120.
1 am domiciled in the State of � O (Indicate State)
Compliance with Oregon Tax Laws:
In compliance with bAR 137-047-0255(2)(c)(C)(e), I hereby attest or affirm under penalty of perjury:
That I am authorized to act on behalf of the contractor in this matter, that I have authority and
knowledge regarding the payment of taxes, and that contractor is,to the best of my knowledge, not
in violation of any Oregon Tax Laws, as defined in ORS 305.380.
Compliance with Nondiscrimination Laws:
In compliance with ORS 279A.110(4), 1 hereby attest or affirm under penalty of perjury that I am
authorized to act on behalf of contractor in this matter, and to the best of my knowledge the
contractor has not discriminated against minority,women or emerging small business enterprises in
obtaining any required subcontracts, and that the Bidder is not in violation of any Discrimination
Laws.
By:
7-Signature
Print Name IF
Title: /S /G Z00A Ia., q ele_r
Date:
ITB—Chemicals for W TP&WV TP. Pase 19 of 20.429P_01 I
INVITATION TO BID 2011-101, WTP & WWTP CHEMICAL May 31, 2011
CHEMICAL BRENNTAG CASCADE NORTHSTAR SIERRA UNIVAR
COLUMBIA CHEMICAL CHEMICAL
Hasa Hasa
WTP- I $1.7175/Gal
Tote d
$1.35/Gal Tote de
CHEMICAL#1: Hasa deposit $700.00- Deposit
SODIUM on Tote(Paid
Delivery charge waived unless
HYPOCHLORITE once/Credit
12 5% $27.50 per damaged by the No Bid No Bid memos issued)
(6)Totes/12 times order City . n $95.00-Delivery
per year Deposit surcharge per charge is charged
Required invoice once, per each
delivery
WTP- $1.33/Lb $1.271/Lb
CHEMICAL 42: Delivery charge Minimum (4)
CYTEC $27.50 per drums per order
SUPERFLOC C- order $1.42/Lb Delivery charge
573 Cost per order: *$25.00 Energy $95.00 per order
FLOCCULANT- (4) 500Lb surcharge per No Bid No Bid Cost per order:
No Substitution Drums, $665.00 invoice (4) 500Lb Drums,
(4) Drums/Every 6 per drum, plus $635.50 per drum,
weeks on average $27.50 = plus $95.00=
(9 orders) $2,687.50 $2,637.00
WTP- $2.70/Lb
CHEMICAL#3: $3.11/Lb Delivery
CYTEC *$25.00 Energy $95.00 per order
SUPERFLOC N- surcharge per Minimum(6)%bags
300 LM W invoice (one pallet)per
FLOCCULANT- No Bid Cost per order: No Bid No Bid order
No Substitution (6) 55.12Lb Bags, Cost per order: (6)
(6) Bags/Every 12 $171.42 per bag, 55.12Lb Bags,
weeks on average plus$25.00= $148.81 per bag,
(4 orders) $1,053.52 plus$95.00=
$987.86
Univar/FMC
FMC Solvay FMC $0.1955/Lb
WTP $0.209/Lb $0.265/Lb $0.185/Lb Delivery charge
CHEMICAL#4: Delivery charge *$25.00 Energy Cost per order $350.00 per order
SODA ASH, $27.50 per surcharge per (Changed per Minimum 4
DENSE, FREE order invoice bidder to 864 pallets(216 bags)
No Bid
FLOWING
Cost per order: Cost per order: No per order
Or Equivalent (54Bgs/Pallet) (49Bgs/Pallet) Pallets) Cost per order:
(216)Bags/Every 50Lb Bags, (4) 50Lb Bags, (4) Cost per order (54Bgs/Pallet)
3-4 weeks on Pallets, Pallets, $7,992.00 50Lb Bags, (4)
average(15 orders) $2,257.20;plus. $2,597.00, plus Delivery Pallets,
$27.50= $25.00= Charge $2,111.40, plus
$2,284.70 $2,622.00 $2,100.00 $350.00=
$2,461.40
ITB 2011-101 WTP&W WTP CHEMICALS, PAGE 1 OF 2,05/31/2011
INVITATION TO BID 2011-101, WTP & WWTP CHEMICAL May 31, 2011
CHEMICAL BRENNTAG CASCADE NORTHSTAR SIERRA UNIVAR
COLUMBIA CHEMICAL CHEMICAL
Hasa
W WTP Hasa $1.7175/Gal
CHEMICAL#5: $135/Gal Hasa $700.00 - Deposit
SODIUM Delivery charge $1.59/Gal on Tote(Paid
HYPOCHLORITE order per *$25.00 Energy No Bid No Bid once/Credit
12.5% order surcharge per memos issued)
(3)Totes/3 Times No Tote invoice $95.00-Delivery
Deposit charge is charged
per year Required once, per each
delivery
Univar/RZBC
RZBC JBL JBL $1.135/Lb
$1.149/Lb $1.25/Lb Delivery charge
W WTP- Delivery charge *$25.00 Energy Delivery $95.00 per order
CHEMICAL#6: $27.50 per surcharge per Deli included Minimum 1 pallet
CITRIC ACID order invoice (43 bags)per
Cost per order: No Bid
Or Equivalent Cost per order: Cost per order: order 40(43) Bags/Two (2) 43 Bags/1 Pallet 40 Bags/1 Pallet $2 Bags/I Pallet Cost per order:
times per year $2,470.35,plus $2,500.00, plus $2,380.00(Delivery 43 Bags/I Pallet
$27.50= $25.00= $2,440.25, plus
$2,497.85 $2,525.00 included) $95.00=
$2,535.25
W WTP-
CHEMICAL#7:
ALUMINUM
SULFATE $0.121/Lb
Cascade Columbia No Bid *$25.00 Energy No Bid
No Substitution surcharge per
(4,000)Gal/Every invoice
2 weeks/May-
November
Declined to bid:
Sterling Water Technologies
Polydyne
Olin Corporation
I
ITB 2011-101 WTP& W WTP CHEMICALS, PAGE 2 OF 2, 05/31/2011
Substitute Form W-9
REQUEST FOR TAXPAYER
IDENTIFICATION NUMBER AND CERTIFICATION
Requester's name and address
NAME: Brenmag Pacific , Inc NAME:
STREET: 10747 Patterson Place STREET:
CITY/STATE: Santa Fe Springs, CA. 90670 CITY/STATE:
In compliance with Internal Revenue Service regulations, please provide us with your taxpayer identification
Number(TIN). Your name and your business name by completing the form shown below. We are required by
law to obtain this information when making a reportable payment to our vendors. Failure to provide us your
TIN may subject you to 31% federal income tax backup withholding and a$50.00 penalty. Even ifyour
business is exempt from receiving information returns, we must have this information.
Please return completed form by fax or mail. Thank you for your cooperation.
Please check appropriate box: ❑ Individual/Sole Proprietor ❑ Partnership
®Corporation ❑ Other
Legal Name: Brenntag Pacific, Inc.
Business Name: 10747 Patterson Place
Santa Fe Springs, CA. 90670
TAXPAYER IDENTIFICATION NUMBER
For individuals,enter social security number
For sole proprietors,enter owner's social security number
For partnerships,corporations and others,enter employer 20-0552611
Identification number
CERTIFICATION
Under penalties of perjury,I certify that:
1. The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me),
and
2. I am not subject to backup withholding because: (a)1 am exempt from backup withholding,or(b)I have not been notified by the
Internal Revenue Service that I 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 1 am no longer subject to backup withholding(does not apply to real estate transactions,mortgage
interest paid,the acquisition or abandonment of secured property,contributions to an individual retirement arrangement and
payments other than interest÷nds).
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 of under reporting interest or dividends on your tax return.
Signature Date ✓�/ �/ Z ��
CERTIFICATE OF LIABILITY INSURANCE D1200IDD YYYD
q,4CG7R[? 12m2o10
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 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).
PROOCCER NAME
LlXdl USA IrD. PHONE
TWOLOGANSQUARE A No:
PHILADELPHIA,PA 191012797 E-RAIL SS:
Am:PHLADEPHIACERTS@KVRSH.COMFAX-212948-0360 PRO R
42478PALL-GAW-11-12 INSUR S AFFORDWGCOWRAGE NAIC0
UMURED INSURER A:IasIraxe mnlpaly Of The Stab O PA 19429
BRENNTAG PACIFIC,INC. INSURER B:GesnImd;trAVrarKe omm 22322
10747 PATTERSON RACE XL Spaietly
SANTA FE SPRINGS,CA 90670 INSURER C
INSURER D:
INSURER E:
INSURER F,
COVERAGES CERTIFICATE NUMBER: CLE-OD2761141-11 REVISION NUMBER:3
THIS G 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.
1 TYPEOFINBURANCE POLICY NUNSER MWDD F awLICYE P UMITB
L
A GENERAL LIABILITY 0696955 01101/201) 0110112012 EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LMIBILTTY PR IS Im E 1000,000
CLAIMS-MADE M OCCUR MEDEXP(Aryone Person) E 10,000
PERSONAL B ADV INJURY S I.WO,000
GENERAL AGGREGATE s 2,OOD,DOO
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMFYOPAGG S 1.000,000
X ICY PRP LOC $
B AUTOMORLE LMIBIUTY RAD943713306(ADS) 01101/2011 OL012012 COMBINED SINGLE LIMIT s 1000,000
B X RAD943713106(MA) 01012011 01012012 (Ee. ,a)
ANY AUTO BODILY INJURY(Per pmsun) $
ALL OVIIRED AUTOS BODILY INJURY(Per a¢leem) $
SCHEDULED AUTOS PRCPERTY DAMAGE
HIREDAUTOS (Per accww) $
NON-O,NNED AUTOS S
s
UMBRELLA LIMB OCCUR EACH OCCURRENCE $
EXCESS LIM CLAIMS-MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ s
WORKERS COMPENSATION X 11C STATU- OTH-
AND EMPLOYERS'UABILITY Y UNITS ER
C ANY PROPRIEfOR/PAFRNERIE%ECUTNE YIN RWR943509006(WI) 011012011 011012012 E.L.EACH ACCIDENT $
1000.000
C OFpCERIMEMEL EXCLUDED? N❑ NIA RWD943509106(AGS) 01012011 01012012 1,000,000
(Mwwldo In NH) E.L.DISEASE-EA EMPLOY S
n yyeess eeaerbe Mwr 1.000.000
DESCRIPTION OFOPERATIONSCe E.LDISEASE-POLICYLIMIT $
DESCMPTION OF OPERAMOM I LOCATIONS I VEMCLES(ANStl,ACORD 101,M Ni m W Re aS 8tl ul,8 mom epsr»to regq I
RE SUPPLYING CHEMCALS TO THE WATER TREATMENT PLANT LOCATED AT:90 N.MOUNTAIN AVENUE ASHLAND,OR 97520
THE CITY OF ASHLAND,OREGON,AND ITS ELECTED OFFICIALS,OFFICERS AND EMPLOYEES ARE INCLUDED AS ADDITIONAL INSURED,EXCEPT FOR WORKERS COMPENSATION,WHERE
REQUIRED BY WRMEN CONTRACT.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
CITY OF ASHLAND,OR THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ATTN:KART OLSON ACCORDANCE WITH THE POLICY PROVISIONS.
90 NORTH MOUNTAIN AVENUE
ASHIM.OR 97520 AUTHORIZED REPRESENTATIVE
of Marsh USA Ine
Donna ClamP6t
®1888-2009 ACORD CORPORATION. All rights reserved.
ACORD 26(2009709) The ACORD name and logo are registered marks of ACORD
CITY RECORDER Page 1 / 1
�.
ASHLAND CITY OF
'
20 E MAIN ST. 7/6/2011 1 10241
ASHLAND, OR 97520
(541)488-5300
VENDOR: 011148 SHIP TO: Ashland Water Treatment Plant
BRENNTAG PACIFIC, INC (541) 488-5345
FILE#2674 ASHLAND, OR 97520
LOS ANGELES, CA 90074-2674
FOB Point: Req.No.:
Terms: Net 30 days Dept.:
Req.Del.Date: Contact: Greg Hunter
Special Inst: Confirming? Yes
Description - :. f 'Unit Price 1 -. . Ext.Price,
14.00 Ordr Invitation to Bid#2011-101 2,284.70 31,985.80
SODA ASH
14 Orders
216 Bags per order
FMC $0.209/Lb
Delivery charge $27.50 per order
12.00 Ordr SODIUM HYPOCHLORITE 2,700.50 32,406.00
12 Orders
6 Totes per order
Hasa $1.35/Gal
Delivery charge$27.50 per order
NO tote deposit
SUBTOTAL 64 391.80
BILL To:Account Payable TAX 0.00
20 EAST MAIN ST FREIGHT 0.00
541-552-2028 TOTAL 64,391.80
ASHLAND, OR 97520
'Accoun[Numtier.,. ;•Project Number"'' 'Amount -Account Number Project NUmtier_ ,'''Amount ,-' '
E 670.08.19.00.60150 64 391.80
Autho d Signature VENDOR COPY
FORM #3 CITY OF
ASHLAND
A ;Qqd.icfi(. for ? Plit'C)1c'1S: OrGCr
REQUISITION Date of request: 6 -2- 1 \
Required date for delivery: 7— I I
Vendor Name BRENN I AG
Address,City,State,Zip
Contact Name&Telephone Number 9317- 7,-49 - 6 3 07
Fax Number
SOLICITATION PROCESS
❑ Exempt from Competitive Bidding 100- 101 ❑ Emergency
❑ Written Findings(Form attached) Invitation to Bid (Copies on file) ❑ Written findings attached
❑ Quote or Proposal attached Date approved by Council: ❑ Quote or Proposal attached
❑ Small Procurement Cooperative Procurement
Less than$5.000 ❑ Request for Proposal (Copies on file) ❑ State of Oregon
Note:Total contract amount,including any Date approved by Council: Contract#
amendments may not exceed$6,000 ❑ State of Washington
Intermediate Procurement ❑ Sole Source Contract#
GOODS&SERVICES ❑ Written Findings(Form attached) ❑ Other government agency contrail
$5.000 to$100.000 ❑ Quote or Proposal attached Agency
❑ (3)Written quotes attached Contract#
PERSONAL SERVICES ❑ Special Procurement ❑ Intergovernmental Agreement
$5.000 to$75.000 ❑ Written Findings(Form attached) Agency
❑ Less than$35,000,by direct appointment ❑ Quote or Proposal attached Contract#
❑ 3 Written pro sals attached Date approved by Council: Date approved by Council:
Description of SERVICES Total Cost
RLAmKE T PvRC-HASE ORDE.R FOR 7- 1 - 11 To 6-30
WATF12 iKT•-ATMt`_N? C0EMICA1-S �
d
Item # Quantity Unit Description of MATERIALS Unit Price Total Cost
I Iq OROF-1Z5 216BA6—! 109KR SODA As 14 1Xa+.7° 119`d I
2 Z ORDERS TOTES Sa IUM Y c, 1.1Lo 1T— 9.10 o.so 240(a -°O
❑ Per attached QUOTE 4$'i
Project Number______-___ Account Number_ - • ______ Account Number 67O.o$.19 .00.601S0o
Account Number___-__-__-__• Account Number •__-__- _-
'Expenditure must be charged to the appropriate account numbers for the financials to reflect the actual expenditures accurately. Attach extra pages if needed.
By signing this requisition form,1 certify that the information provided above meets the City's public contracting requirements,and the documentation can be provided
upon request. /� S?
Employee Signature: (/ Department Head Signature: � Q
Additional signatures(if applicable):
Funds appropriated for current fiscal year: P/ NO lwy�" -71711/
Finance Director U Date
Comments:
G:FlnancaT*oedurelAPTomisTorm#3-Requisition updated on:602011