i United States wf OWIB Conivol No: 2090-0020
Py set rl Protection Approved: 8/13/2013
Approval Explres: 9/31/2015
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Disadvariiaged Business Zaterpris pra
DBE Subcontracior cm cation Form
This form is intended to capture the prime contractor's actual and/or anticinaced use of identified certified DBE
subcontractors? and the estimated dollar amount of each subcontract. An EPA Financial Assistance Agreement
Recipient must require its prime contractors to complete this form and include itin the bid or proposal package.
Prime contracters should also maintain a copy of this form on File.
Prime Contractor Name Project Name
TCs x\ Come nam Tat ile Corde On Lasse
Bid/ Proposal No. Assistance Agreement ID No. (if known) | Point of Contact
PIR, Pioudn OS Togs he. QUEs 3
Be BARS ‘ ( and ON Email Address
Issuing/Funding Entity:
Ihave identified potential DBE _
| certified subcontractors _ ae _ Ors oe —£ Gne een
if yes, eS, please complete ‘the table kelow. If no, please explain:
Subcontractor Name/ Company Address/ Phona/ Enall Esi.Dollar [| Currently
Company Name Amt DBE
Certified?
ieee a ; hy & Ld } AA uf
Rep G Fae OF AULDLIS 677° |
kKloonti / ,
VMWeLTOne 8000 ME Due Yo=x>
_ LkSa dA “
-~~——- Continue on back if needed -----~ store cena
*ADBE isa Disadvantaged, Miinarity, or Woman Businass Enterprisa that has beer cartified by an entity from which EPA accepts certifcations as
described in 40 CFR 33.204-33,205 o- certified by EPA. EPA accepts certifications from entliles that meet or exceed EPA certification standards as
described In 40 CFR 33.202,
? Subcontractor ts defined asa company, firro, jot venture, or individual who enters into an agreement with a contractor to provide
services pursuant to an EPA award of financial assistance
EPA FORM 6100-4 (DBE Subcontractor Utizaticn Form]
