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OSHA's Form 300A irev. 01/2004) Year 2019 <>
Summary of Work-Related Injuries and Illnesses US. Department of Labor

Occupational Satety and Health Administration

Form approved OMB no. 1218-0176
All establishments covered by Part 1904 must complete this Summary page, even if no injuries or

illnesses occurred during the year. Remember to review the Log to verify that the entries are complete

Using the Log, count the individual entries you made for each category. Then write the totals below, Establishment information
making sure you've added the entries from every page of the fog. If you had no cases write "0."
Emp. former employees, and their repr it have the right to review the OSHA Form 300 in Your establishment name Schroeder Construction Management, Inc.
its entirety. They also have limited access to the OSHA Form 301 or ifs equivalent. See 29 CFR
1904.35, in OSHA's Recordkeeping rule, for further details on the access provisions for these forms. Street 2 Townsend West #3
City Nashua State New Hampshire Zip 03063

Industry description (e.g., Manufacture of motor truck trailers)

Total number of Total number of — Total number of cases Total number of
deaths cases with days with job transfer or other recordable
away from work restriction cases Industrial Classification (SIC), if known (e.g., SIC 3715)
0 0 0 wt 7 5 1
{G) (H) (I) (J) OR North American Industrial Classification (NAICS), if known (e.g., 336212)
2 3 6 2 2 0

Employment information

Total number of Total number of days of
days away from Job transfer or restriction Annual average number of employees 11
te
wor Total hours worked by all employees last
0 e] year 22,287
®) oO ] LA
me aoe : é : ae Sign here A i ML
Total number of... Knowingly ifying this may result ina fine.
(M)
(1) Injury 0 (4) Poisoning 0 F
(2) Skin Disorder 0 (5) Hearing Loss 0 | . . .
. ——_a eo | certify that | have examined this document and that to the best af my knawledge the entries are true, accurate, and
(3) Respiratory complete.
Condition 0 (8) All Other Illnesses 0
John E. Schroeder President
Company executive Title
603-882-1822 162020
Post this Summary page from February 1 to April 30 of the year following the year covered by the form Phone Date

Public reporting burden for this collection of information is estimated to average 58 minutes per response, including time to review the instruction, search and

gather the data needed, and complete and review the collection of information. Persons are not required to respond to the calfection of information unless it

displays a currently valid OMB control number. If you have any comments about these astimates or any aspects of this data collection, contact’ US Department

of Labor. OSHA Office of Slatistics. Room N-3644, 200 Constitution Ave. NW. Washinaton. OC 20210. Do not send the completed forms to this affice.

a SSSI A SAL Ee SSS EASE SS AACAROFIS SU SESS ESAS SRE

See ee RE

OSHA's Form 300A «rev. 01/2004)
Summary of Work-Related Injuries and Illnesses

All establishments covered by Part 1904 must complete this Summary page, even if no injuries or
illnesses occurred during the year. Remember to review the Log to verify that the entries are complete

Using the Log, count the individual entries you made for each category. Then write the totals below,
making sure you've added the entries from every page of the fog. if you had no cases write "0."

Employees former employees, and their representatives have the right to review the OSHA Form 300 in
its entirety. They also have limited access to the OSHA Form 301 or its equivalent. See 29 CFR
1904.35, in OSHA's Recordkeeping rule, for further details on the access provisions for these forms.

Number of Cases

Total number of
deaths

Total number of
cases with days

Total number of
other recordable

Total number of cases
with job transfer or

away from work __ restriction cases
0 0 0
G) (H) a) W)
Number of Days
Total number of Total number of days of
days away from job transfer or restriction
wiark
0 0
(K) (D
Injury and Illness Types
Total number of...
(™)
(1) Injury 0 (4) Poisoning 0
(2) Skin Disorder 0 (5) Hearing Loss 0
(3) Respiratory
Condition 0 (6) All Other Illnesses 8]

Post this Summary page from February 1 to April 30 of the year following the year covered by the form

Public reporting burden for this collection of information is estimated to average 58 minutes per response, including time to review the instruction, search and
gather the data needed, and complete and review the collection of information. Persons are not required to respond to the collection of information unless it
displays a currently valid OMB control number. If you have any comments about these estimates or any aspects of this data collection, contact: US Department
of | ahor OSHA Office of Statistics Room N-3844 900 Constitution Ava NW Washinaton NC 20210 No not sand the enmoleted forms to this office

U.S. Department of Labor

Occupational Safety and Health Administration

Form approved OMB no. 1218-0176

Establishment information

Your establishment name Schroeder Construction Management, Inc.

Street 2 Townsend West #3

City Nashua State New Hampshire

Zip 03063

Industry description (e.g., Manufacture of motor truck trailers)
Construction management

Standard Industrial Classification (SIC), if known (e.g., SIC 3715)

1 7 5 1
OR North American Industrial Classification (NAICS), if known (e.g., 336212)
2 3 6 2 2 ie]

Employment information

Annual average number of employees 10

Total hours worked by all employees last
year 22,098

Sign here

Knowingly falsifying this document may result in a fine.

| certify that | have examined this document and that to the best of my knowledge the entries are true, accurate, and

camplete.

John E. Schroeder
Company executive

603-882-1822

Phone

President

Title

1168/2021
Date

07/30/2021

@ DATE (MM/DD/YYYY,
ACORD CERTIFICATE OF LIABILITY INSURANCE

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).

PRODUCER BONTACT Andrea Nicklin
FIAI/Cross Insurance IAG ND, Ext, (603) 669-3218 (Are, No); (603) 645-4334
1100 Elm Street EMA ss: Manch.certs@crossagency.com
INSURER(S) AFFORDING COVERAGE NAIC #
Manchester NH 03101 INSURERA: S€lective Insurance Co. of SC 19259
INSURED INSURERB: S€lective Insurance Co of Southeast 39926
Schroeder Construction Management Inc. INSURER C:
2 Townsend West, Unit 3 INSURER D:
INSURER E:
Nashua NH 03063 INSURER F:
COVERAGES CERTIFICATE NUMBER: = 21-22 All w/MA & NH WC REVISION NUMBER:

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.

INSR ADDLISUBR POLICY EFF_| POLICY EXP
LTR TYPE OF INSURANCE INSD | WWD POLICY NUMBER (MM/DDIYYYY) | (MM/DDIYYYY) LIMITS
x< COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED
| CLAIMS-MADE OCCUR PREMISES (Ea occurrence) $ 500,000
MED EXP (Any one person) $ 15,000
A Y $2437296 08/01/2021 | 08/01/2022 | seeconaLaapvinuury | 1,000,000
GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE g_ 2,000,000
POLICY oRo. Loc propucts-compiopace | 5 2:000,000
OTHER: Cyber Liability Coverage | $ 100,000
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
(Ea accident)
><] any auto BODILY INJURY (Per person) | $
OWNED SCHEDULED ;
A AUTOS ONLY SuToS $2437296 08/01/2021 | 08/01/2022 | BODILY INJURY (Per accident) | $
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY (Per accident)
$
><} UMBRELLA LIAB ><! occur EACH OCCURRENCE g 4,000,000
A EXCESS LIAB CLAIMS-MADE $2437296 08/01/2021 | 08/01/2022 | ,ccrecate s 4,000,000
DED | | RETENTION $ $
WORKERS COMPENSATION x] PER OTH-
AND EMPLOYERS' LIABILITY YIN STATUTE ER 7900000
BO CROMCNIBER OXCLUDLDD UTIVE NIA WC9083197 (3a.) MA & NH 08/01/2021 | 08/01/2022 [EL EACHACCIDENT go
(Mandatory in NH) E.L. DISEASE -EA EMPLOYEE | ¢ 1,000,000
If yes, describe under 1.000.000
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT | $ UY“?

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
RE: Proof of Insurance for bidding purposes.

CERTIFICATE HOLDER CANCELLATION

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Nashua, NH ACCORDANCE WITH THE POLICY PROVISIONS.

229 Main Street

AUTHORIZED REPRESENTATIVE

|

© 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD

Cross

IN S&S U RAN CE

November 1, 2021

City of Nashua — Purchasing Department Administrative Services, Division
229 Main St.
Nashua, N.H. 03060

Re: Schroeder Construction Management, Inc.
2 Townsend West, Unit 3, Nashua, NH 03063
PREQUALIFICATION

Project; Proposal IFB 0779-110321
Waste Line Replacement at the transit Administration Building
Located at; 11 Riverside Street, Nashua, N.H. 03062

To Whom It May Concern:

We have had the pleasure of providing Performance and Payment bonds to Schroeder Construction
Management, Inc. since 2007. Their surety company is Harco National Insurance Company, P.O. Box
10800, Raleigh, NC 27605. Harco National Insurance Company is listed on the Treasury Department

Circular 570,

Their current surety program is $7,500,000 single with an aggregate program of $15,000,000.
Schroeder Construction Management, Inc. is in good standing with Harco National Insurance
Company. Should they be awarded projects for the Commonwealth of Massachusetts, we are ina
position to issue the necessary bonds. These limits are not to be considered an absolute maximum or
minimum program and the Surety reserves the right to review individual projects.

Furthermore, any arrangements for bid, performance or payment bonds is a matter between the
contractor and-Surety and neither we nor the Surety assume any liability to third parties if, for any
reason, the Surety does not execute said bond or bonds.

If you need anything further, please don’t hesitate to contact us.

Very truly yours,

A, ices uf f Meveieete] fee

Susan J Motinsey Place, Attorney-in-fact
Harco National Insurance Company

1100 Elm Street
Manchester, NH 03101
Tel: (603) 669-3218

Fax: (603) 645-4331 “FIAI, Inc tha Cross Insurarice - Manchester is legally organized as a Maine business corprration
WWwW.crossinsurance.com and is separately and focoly manayed and aperatad a3.a wholly owned subsidiary of Cross Finanelal Com, Bangor ME;

. Cross

'ns& U RAN CE

October 29, 2021

Schroeder Construction Management, Inc.
2 Townsend West, Unit 3

Nashua, NH 03063

FID#743150716

Re: Experience Modification Factor

As of
8/1/2021 .80
8/1/2020 79
8/1/2019 79
Sincerely,

Anche o Nickle

Andrea Nicklin, ACSR, AAI-M, AIS, CRIS
Commercial Lines Director of Training
anicklin@crossagency.com

"ATA. document A305'- 2020 Exhibit D

Contractor’s Past Project Experience

1 2 3 4
PROJECT NAME Norwell Home Lantheus Medical Barrier Wall Project MST Airplane Hangar-
Bathroom Renovations Metal Building Addition
PROJECT 12 Concord St, Nashua, | 331 Treble Cove Rd., 177 Main St., Littleton, | 100 Gerald Connors
LOCATION NH Billerica, MA NH Circle, Manchester NH
PROJECT TYPE Design Build Toilet Room Renovation] SSA Office Renovation | Design Build
Renovations
OWNER The Front Door Agency | Lantheus Medical General Service Manchester Schoold
Imaging Inc Administration District
ARCHITECT Matuszewski Architects | Robert Wironen Colby Engineering Matuszewski Architects
CONTRACTOR’S Duane Provencher Jack Schroeder Jack Schroeder Jack Schroeder
PROJECT
EXECUTIVE

KEY PERSONNEL

Mark True -General

Michael Gagnon -

Mark True - General

Joe Pation & Jake

Completion Date
12/20/2020

% Self-Performed Work
55

Completion Date
7/16/2018

% Self-Performed Work
45

Completion Date
4/18/2016

% Self-Performed Work
32

(include titles) Superintendent Superintendent Superintenedent Phillips- Superintendents
Randy Franco- Project
Manager
PROJECT DETAILS | Contract Amount Contract Amount Contract Amount Contract Amount
181,901. 358,916 1,035,590 234,110

Completion Date
6/30/2021

% Self-Performed Work
30

PROJECT L_] Design-bid-build CL] Design-bid-build CJ Design-bid-build CJ Design-bid-build
DELIVERY _] Design-build () Design-build CL) Design-build [>] Design-build
METHOD E] CM constructor EX] CM constructor —X] CM constructor LJ CM constructor
[] CM advisor L] CM advisor CJ CM advisor OO CM advisor
(_] Other: (] Other: () Other: LJ Other:
SUSTAINABILITY
CERTIFICATIONS

AIA Document A305” = 2020 Exhibit D. Capyright © 2020 by The American Institute of Architects. All rights reserved. The “American Institute of Architects,’
“AIA,” the AIA Lago, and “AIA Contract Documents* are registered (rademarks and may not be used without permission. This document was produced by AIA
software at 12:03:46 ET on 11/03/2021 under Order No.4399661920 which expires on 03/30/2022, is not for resale, is licensed for one-time use only, and may
only be used in accordance with the AIA Contract Documents® Terms of Service. To report copyright violations, e-mail copyright@ala.org.

User Notes: (SB8ADA40)

Federal Clauses —- Sewer Line Replacements & Associated Administrative Building
Repairs

1. No Federal Government Obligation to Third Parties,

The City and the Contractor acknowledge and agree that, notwithstanding any concurrence by the Federal
Government in or approval of the solicitation or award of the underlying contract, absent the express written
consent by the Federal Government, the Federal Government is not a party to this contract and shall not be
subject to any obligations or liabilities to the City, the Contractor, or any other party (whether or not a party
to that contract) pertaining to any matter resulting from the underlying contract.

The Contractor agrees to include the above clause in each subcontract financed in whole or in part with
Federal assistance provided by FTA. It is further agreed that the clause shall not be modified, except to
identify the subcontractor who will be subject to its provisions. Incorporate FTA Terms

2. Termination and Suspension.
Please see Termination and Suspension Language in Article 15 of the
Agreement

3. Program Fraud and False or Fraudulent Statements or Related Acts.

The Contractor acknowledges that the provisions of the Program Fraud Civil Remedies Act of 1986, as
amended, 31 U.S.C.§ 3801 et seq. and U.S. DOT regulations, "Program Fraud Civil Remedies," 49 C.F.R.
Part 31, apply to its actions pertaining to this Project. Upon execution of the underlying contract, the
Contractor certifies or affirms the truthfulness and accuracy of any statement it has made, it makes, it may
make, or causes to be made, pertaining to the underlying contract or the FTA assisted project for which this
contract work is being performed. In addition to other penalties that may be applicable, the Contractor further
acknowledges that if it makes, or causes to be made, a false, fictitious, or fraudulent claim, statement,
submission, or certification, the Federal Government reserves the right to impose the penalties of the
Program Fraud Civil Remedies Act of 1986 on the Contractor to the extent the Federal Government deems
appropriate.

The Contractor also acknowledges that if it makes, or causes to be made, a false, fictitious, or fraudulent
claim, statement, submission, or certification to the Federal Government under a contract connected with a
project that is financed in whole or in part with Federal assistance originally awarded by FTA under the
authority of 49 U.S.C.§ 5307, the Government reserves the right to impose the penalties of 18 U.S.C.§ 1001
and 49 U.S.C.§ 5307(n)(1) on the Contractor, to the extent the Federal Government deems appropriate.

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The Contractor agrees to include the above two clauses in each subcontract financed in whole or in part with
Federal assistance provided by FTA. It is further agreed that the clauses shall not be modified, except to
identify the subcontractor who will be subject to the provisions.

4, Records.

Retention. The Contractor will retain, and will require its subcontractors of all tiers to retain, complete and
readily accessible records related in whole or in part to the contract, including, but not limited to, data,
documents, reports, statistics, sub-agreements, leases, subcontracts, arrangements, other third party
agreements of any type, and supporting materials related to those records.

Retention Period. The Contractor agrees to comply with the record retention requirements in accordance with
2 C.F.R. § 200.333. The Contractor shall maintain all books, records, accounts and reports required under
this contract for a period of at not less than three (3) years after the date of termination or expiration of this
contract, except in the event of a dispute, or litigation or settlement of claims arising from the performance of
this contract, in which case records shall be maintained until the disposition of all such dispute, litigation,
appeals, claims or exceptions related thereto,

Where the City is not a State but a local government and is the FTA Recipient or a subgrantee of the FTA
Recipient in accordance with 49 C. F. R. 18.36(i), the Contractor agrees to provide the City, the FTA
Administrator, the Comptroller General of the United States or any of their authorized representatives
sufficient access to any books, documents, papers and records of the Contractor which relate to this contract
for the purposes of inspection, making audits, examinations, excerpts and transcriptions as reasonably may
be required. Contractor also agrees, pursuant to 49 C, F. R. 633.17 to provide the FTA Administrator or his
or her authorized representatives including any PMO Contractor access to Contractor's records and
construction sites pertaining to a major capital project, defined at 49 U.S.C, 5302(a)1, which is receiving
federal financial assistance through the programs described at 49 U.S.C. 5307, 5309 or 5311,

The Contractor agrees to permit any of the foregoing parties to reproduce by any means whatsoever or to
copy excerpts and transcriptions as reasonably needed.

Access to the Sites of Performance. The Contractor agrees to permit the City, the FTA Administrator, the
Comptroller General of the United States or any of their authorized representatives and contractors access
to the sites of performance under this contract as reasonably may be required.

5. Civil Rights.

a. Title VI of the Civil Rights Act of 1964
The Contractor agrees to comply with all requirements of Title VI of the Civil Rights Act of 1964, 42 U.S.C. §
2000d section 303 of the Age Discrimination Act of 1975, 42 U.S.C. §6102, section 202 of the Americans

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with Disabilities Act of 1990, § 12132, and Federal transit law at 49 U.S.C. § 5332, all as amended as well
as USDOT regulations, "Nondiscrimination in Federally-Assisted Programs of the Department of
Transportation", 49 CFR Part 21. In addition, the Contractor agrees to comply with applicable Federal
implementing regulations and other implementing requirements FTA may issue.

b, Equal Employment Opportunity

The Contractor will not discriminate against any employee or applicant for employment because of race,
color, creed, sex, disability, age, or national origin. The Contractor agrees to take affirmative action to ensure
that applicants are employed, and that employees are treated during employment, without regard to their
race, color, creed, sex, disability, age, or national origin. Such action shall include, but not be limited to, the
following: employment, upgrading, demotion or transfer, recruitment or recruitment advertising, layoff or
termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship.
The Contractor shall insert the foregoing provision (modified only to show the particular contractual
relationship) in all its third party contracts, except contracts for standard commercial supplies or raw materials
and construction contracts, and shall require all such third party contractors to insert a similar provision in all
subcontracts, except contracts for standard commercial supplies or raw materials.

c. Access Requirements for Individuals with Disabilities

The Contractor shall comply with 49 USC 5301(d), stating Federal policy that the elderly and persons with
disabilities have the same rights as other persons fo use mass transportation services and facilities and that
special efforts shall be made in planning and designing those services and facilities to implement that policy.
The Contractor shall also comply with all applicable requirements of Sec, 504 of the Rehabilitation Act (1973),
as amended, 29 USC 794, which prohibits discrimination on the basis of handicaps, and the Americans with
Disabilities Act of 1990 (ADA), as amended, 42 USC 12101 et seq., which requires that accessible facilities
and services be made available to persons with disabilities, including any regulations and subsequent
amendments.

d. Inclusion

The Contractor agrees to include the requirements of subsections (a) —(c) in each subcontract financed in
whole or in part with Federal assistance provided by FTA, modified only if necessary to identify the affected
parties,

e, Disadvantaged Business Enterprise (DBE)

This Contract is subject to the requirements of Title 49, Code of Federal Regulations, Part 26, Participation
by Disadvantaged Business Enterprises in Department of Transportation Financial Assistance Programs.
The national goal for participation of Disadvantaged Business Enterprises (OBE) is 10%. Nashua Transit's
overall goal for DBE participation is .7%. A separate contract goal has not been established for this
procurement.

The Contractor shall not discriminate on the basis of race, color, national origin, or sex in the performance of
this contract, The Contractor shall carry out applicable requirements of 49 CFR Part 26 in the award and

3|Page

administration of this DOT-assisted contract, Failure by the Contractor to carry out these requirements is a
material breach of this contract, which may result in the termination of this contract or such other remedy, as
the City deems appropriate, Each subcontract the Contractor signs with a subcontractor must include the
assurance in this paragraph (see 49 CFR 26.13(b)).

The Contractor will be required to report its DBE participation obtained through race-neutral means
throughout the period of performance,

The Contractor is required to pay its subcontractors performing work related to this contract for satisfactory
performance of that work no later than 30 days after the Contractor's receipt of payment for that work from
the City,

The Contractor must promptly notify the City whenever a DBE subcontractor performing work related to this
contract is terminated or fails to complete its work, and must make good faith efforts to engage another DBE
subcontractor to perform at least the same amount of work. The Contractor may not terminate any DBE
subcontractor and perform that work through its own forces or those of an affiliate without prior written consent
of the City.

Failure of the Contractor to comply with this section or to include itin any subcontract of any tier will constitute
a breach of contract and, after notification to the DOT, may result in termination of the Contract by the City
or such remedy as the City deems appropriate.

6. Incorporation of Federal Transit Administration (FTA) Terms,

The preceding provisions include, in part, certain Standard Terms & Conditions required by USDOT, whether
or not expressly stated in the preceding contract provisions. All USDOT required contractual provisions, as
stated in FTA Circular 4220.1F, are hereby incorporated by reference, Anything to the contrary herein
notwithstanding, all FTA mandated terms shall be deemed to control in the event of a conflict with other
provisions contained in this contract. The Contractor shall not perform any act, fail to perform any act, or
refuse to comply with any request that would cause the City to be in violation of FTA terms and conditions.

7. Environmental Resource Conservation and Energy Conservation.

(a) Energy Conservation,
Contractor shall comply with mandatory standards and policies relating to energy efficiency that are

contained in the New Hampshire energy conservation plan issued in compliance with the Energy Policy
and Conservation Act, 42 U.S.C. § 6321 et seq.

(b) Clean Air.

1. Contractor shall comply with all applicable standards, orders or regulations pursuant to Section 306
of the Clean Air Act, as amended, 42 U.S.C. § 7606, and other requirements of the Clean Air Act,
as amended, 42 U.S.C. §§ 7401 —7671q. Contractor shall report each violation to the City and
understands and agrees that the City will, in turn, report each violation as required to FTA and the
appropriate EPA Regional Office,

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