Dbe Description Of Work And Field Monitoring Report (Exhibit A) Form Page 2
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1
2Minnesota Department of Transportation
Office of Civil Rights
Section (B):
TO BE COMPLETED ONLY BY THE DBE TRUCKER
1.
The number of hours contracted or quantities to be hauled on this project? __________________________________________
2.
How many fully operational units will be used on this Project? ________ (Tractor/trailers: _______ Dump trucks: ________
3.
How many fully operational units will be yours? _____________ (Dump trucks: __________ Tractors/trailers: __________)
4.
How many other units will be yours? __________________ (Tractors: __________________ Trailers: _________________)
5.
If ITO’s or trucking companies are to be used on this project answer the following:
Dollar Amount of
Number of Dump Trucks,
Name of ITO/Company
Contract/Agreement
Tractors/Trailers (specify)
1.
2.
3.
4.
Section (C): (All DBE Subcontractors, including Trucking firms, must complete Section C.)
I hereby certify that the information presented above is correct. I agree to inform the Office of Civil Rights in writing of any changes within 10 days
of the change(s).
DBE Company: _____________________________________________________________________________________________
DBE Principal: ___________________________________
_________________________
_____________________
Signature
Title
Date
Section (D):
TO BE COMPLETED BY Mn/DOT OFFICE OF CIVIL RIGHTS STAFF PERSON
Project Number: _____________________________________
District # _____________________________________
Mn/DOT OCR Staff Person: ___________________________
Phone No. _____________________________________
Project Engineer: ____________________________________
On-site Phone #: ________________________________
Office Phone #: ________________________________
Section (E):
TO BE COMPLETED BY PROJECT ENGINEER WHEN THE DBE’S
1
PORTION OF WORK IS
/
TO ½ COMPLETED
3
1.
Does it appear that the DBE firm is performing the work specified in (Exhibit “A”) description of work?
Yes __________
No __________
2.
Does it appear that the DBE contractor is managing their portion of the project and using their own company employees?
Yes __________
No __________
3.
Does it appear that the DBE contractor is providing the equipment for their items of work or other work specified?
Yes __________
No __________
4.
Does it appear that the quality of the DBE contractor’s performance, scheduling and project management are meeting industry standards?
Yes __________
No __________
5.
Comments:
NOTE: If you, as the Project Engineer, have checked “NO” to any of the above questions or have any other comments, it is important that you
contact the Mn/DOT Office of Civil Rights Staff Person assigned to this project.
Project Engineer: ______________________________________________
Date: __________________________________
Mn/DOT OCR
8/2010
DBE Page 2
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