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13-090 Crime Scene Steri-Clean, BMR Unit Clean Up in Prepartion for Resale / OFFICE OF THE CITY CLERK CITY HALL 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 s TELEPHONE: (408) 777-3223• FAX: (408) 777-3366 CUPERTINO WEBSITE:www.cupertino.org June 27, 2013 Crime Scene Steri-Clean 9785 Crescent Center Drive, Suite 302 Rancho Cucamonga, CA 91730 Re: Agreement Enclosed is a fully executed copy of your agreement with the City of Cupertino. If you have any questions or need additional information, please contact the Building Department at (408) 777-3228. Sincerely, -- -1) Brittany Care i'c Senior Office Assistant City Clerk's Office cc: Building Department Enclosure 9.9 CITY OF AGREEMENT CITY OF CUPERTINO 7�� r Est,or� 10300 Torre Avenue 1 Q Cupertino,CA 95014 CUPERTINO 408-777-3200 NO. THIS AGREEMENT, made and entered into this 4th day of Tune is by and between the CITY OF CUPERTINO (Hereinafter "CITY") and Crime Scene Steri-Clean, 9785 Crescent Center Drive, Suite 302, Rancho Cucamonga, CA 91730, Ph: 909-481-2285 Hereinafter "CONTRACTOR"), in consideration of their mutual covenants, the parties agree as follows: CONTRACTOR shall provide or furnish the following specified services and/or materials: BMR Unit Clean-up in preparation for resale. See detailed scope of work described in Exhibit A. EXHIBITS: The following attached exhibits hereby are made part of this Agreement: Exhibit A. TERM: The services and/or materials furnished under this Agreement shall commence on June 13th, 2013 and shall be completed no later than Tune 14th, 2013. COMPENSATION: For the full performance of this Agreement, CITY shall pay CONTRACTOR: $2,750.00 California Labor Code, Section 1771 requires the payment of prevailing wages to all workers employed on a Public Works contract in excess of$1,000.00. GENERAL TERMS AND CONDITIONS Hold Harmless. Contractor shall, to the fullest extent allowed by law, indemnify, defend, and hold harmless the City and its officers, officials, agents, employees and volunteers against any and all liability, claims, stop notices, actions, causes of action or demands whatsoever from and against any of them, including any injury to or death of any person or damage to property or other liability of any nature, arising out of, pertaining to, or related to the performance of this Agreement by Contractor or Contractor's employees, officers, officials, agents or independent contractors. Contractor shall not be obligated under this Agreement to indemnify City to the extent that the damage is caused by the sole or active negligence or willful misconduct of City, its agents or employees. Such costs and expenses shall include reasonable attorneys' fees of counsel of City's choice, expert fees and all other costs and fees of litigation. Subcontracting. Contractor has been retained due to their unique skills and Contractor may not substitute another, assign or transfer any rights or obligations under this Agreement. Unless prior written consent from City is obtained, only those people whose names are listed this Agreement shall be used in the performance of this Agreement. Page 1 of 3 Short Form Agreement Assignment. Contractor may not assign or transfer this Agreement, without prior written consent of CITY. Insurance. Contractor shall file with City a Certificate of Insurance consistent with the following requirements Coverage: Contractor shall maintain the following insurance coverage: (1) Workers' Compensation: Statutory coverage as required by the State of California. (2) Liability: Commercial general liability coverage in the following minimum limits: Bodily Injury: $500,000 each occurrence $1,000,000 aggregate - all other Property Damage: $100,000 each occurrence $250,000 aggregate If submitted, combined single limit policy with aggregate limits in the amounts of$1,000,000 will be considered equivalent to the required minimum limits shown above. (3) Automotive: Comprehensive automotive liability coverage in the following minimum limits: Bodily Injury: $500,000 each occurrence Property Damage: $100,000 each occurrence or Combined Single Limit: $500,000 each occurrence (4) Professional Liability: Professional liability insurance which includes coverage for the professional acts, errors and omissions of Consultant in the amount of at least$1,000,000. Subrogation Waiver. Contractor agrees that in the event of loss due to any of the perils for which it has agreed to provide comprehensive general and automotive liability insurance, Contractor shall look solely to its insurance for recovery. Contractor hereby grants to City, on behalf of any insurer providing comprehensive general and automotive liability insurance to either Contractor or City with respect to the services of Contractor herein, a waiver of any right to subrogation which any such insurer of said Contractor may acquire against City by virtue of the payment of any loss under such insurance. Page 2 of 3 Short Form Agreement Termination of Agreement. The City reserves the right to terminate this Agreement with or without cause with a seven (7)-day notice. The Contractor may terminate this Agreement with or without cause with a seven (7)-day written notice. Non-Discrimination. No discrimination shall be made in the employment of persons under this Agreement because of the race, color, national origin, ancestry, religion, gender or sexual orientation of such person Interest of Contractor. It is understood and agreed that this Agreement is not a contract of employment in the sense that the relationship of master and servant exists between City and undersigned. At all times, Contractor shall be deemed to be an independent contractor and Contractor is not authorized to bind the City to any contracts or other obligations in executing this Agreement. Contractor certifies that no one who has or will have any financial interest under this Agreement is an officer or employee of City. City shall have no right of control as to the manner Contractor performs the services to be performed. Nevertheless, City may, at any time, observe the manner in which such services are being performed by the contractor. The Contractor shall comply with all applicable Federal, State, and local laws and ordinances including, but not limited to, unemployment insurance benefits, FICA laws, and the City business license ordinance. Changes. No changes or variations of any kind are authorized without the written consent of the City. CONTRACT CO-ORDINATOR and representative for CITY shall be: NAME: Albert Salvador, Building Official DEPARTMENT: Community Development This Agreement shall become effective upon its execution by CITY, in witness thereof, the parties have executed this Agreement the day and year first written above. CONTRACTOR: CITY OF CUPERTINO: �l� By • 110 0 By PIM LA' -17://11All>1 �t Title /.��i 7_0 Title: 1✓U1 I�/11'�Cr ( 6� 1�. APPROVALS EXPENDITURE DISTRIBUTION DEPART ENT H ...� / DATE ACCOUNT NUMBER AMOUNT ��,[6 i/� P. 6 a 0 ,3(,2 5- mob'" $ ,2:1-,-2).‘& CITY ' ORNEY AP'ROVE IP AS TO FORM DATE . 1 _k_ .1,1., lf/ 13 — CI LERK: A ES 1 DA 4 ; (o 5--( 3 Page 3 of 3 Short Form Agreement Crime Scene Steri-Clean,LLC EStI 111 ate Corporate Office i' 9785 Crescent Center Dr. Ste.302 Date Estimate# Rancho Cucamonga,CA 91730 STERI-CLEAN 888 577-7206 V31/2013 11693 CA-TSWit0l0 Name/Address City of Cupertino Attn:Julia Kinst 10300 Torre Ave. Cupertino,CA 95014 Job Address 19507 Stevens Creek Blvd.203a Cupertino,Ca 95014 Terms Requested By Estimate Julila Kinst Description/Services Qty Unit I Hourly Total ****ASSESSMENT FINDINGS**** 0.00 0.00 This is a two story condominium with a decomposition of unknown length in the front room at the bottom of the stairs.The decomposition is on the carpet,and it appears tiat it has probably affected the padding and sub flooring as well.There are also personal belongings in the kitchen,downstairs closet,and upstairs too. ****RECOMMENDED SERVICES**** 0.00 0.00 1)Provide a crew of OSHA certified Steri-Clean technicians to perform all services listed below. 2)Remove all materials affected by biological matter such as carpet and padding,and dispose of into a bio bin. 3)If it found that the foundation is affected then it will be cleaned,have a disinfectant applied,and then the affected area will have a sealer applied to protect against OPIM. 4)Remove all personal items in the home including the closets.These items will be taken to a landfill. 5)Clean up all loose debris and wipe down all counter tops in the home. 6)Remove and discard all carpet,padding,and tack strip from the downstairs area. 7)Apply an EPA registered disinfectant to all walls,flooring,and other surfaces in the home to kill viruses,bacterium,and OPIM.All counter spaces and surfaces will be wiped down dry. This residence has been inspected by Mike Mooney Northern California Operations Manager. Total By signing this estimate,I accept financial responsilbiity for the services as described above. Payment in full is due at the end of the work day unless other arrangements are described in the estimate. Please sign and fax to(909)481-4567. Work cannot begin until we have the signed estimate on file. Signature:"454 ��, /.f' Date: Page 1 Any refunds made from funds paid by credit card are subject to a 3%transaction fee. Crime Scene Steri-Clean,LLC Corporate Office Estimate 9785 Crescent Center Dr. Ste.302 Date Estimate# Rancho Cucamonga, CA 91730 STERI-CLEAN 888 577-7206 5/31/2013 11693 CA-TS W#010 Name/Address City of Cupertino Attn:Julia Kinst 10300 Torre Ave. Cupertino,CA 95014 Job Address 19507 Stevens Creek Blvd.203a Cupertino,Ca 95014 Terms Requested By Estimate Julila Kinst Description/Services Qty Unit/Hourly Total ****ESTIMATED COST**** 2,750.00 2,750.00 This estimate is for all services listed above.The estimate includes all labor,drive time, fuel,supplies,materials,equipment,and transport of donation items,e-waste,and disposal costs.This estimate is for 2 OSHA certified technicians,2 bio bins,and all services are estimated to be completed in 4 hours or less.Any additional time or bio bins needed would result in an increase In the final invoice amount. • This residence has been inspected by Mike Mooney Northern California Operations Manager. Total $2,750.00 By signing this estimate,I accept financial responsilbiity for the services as described above.Payment in full is due at the end of the work day unless other arrangements are described in the estimate. Please sign and fax to(909)481-4567. Work cannot begin until we have the signed estimate on file. Signature: �� 0.1? /��' Date:_o0 / Page 2 Any refunds made from funds paid by credit card are subject to a 3%transaction fee. ACOR" CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD YYYY) �� _ 05/31/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY ANA 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). CON AC� PRODUCER 800-585-8887 866-585-8887 NAME: T Insurance Guys Insurance Services Inc. Insurance Guys Insurance Services, Inc. PHO1N •800-585-8887 a No):866-585-8887 PO Box 6823 A op:ess:su ort insurance u s.com Santa Barbara, CA 93160 PRO[QMERIO#: CA License OB53906 INSURER(S) AFFORDING COVERAGE NAICN INSURED 909-481-2285 INSURER A:Westchester Surplus Lines Insurance 10172 Crime Scene Steri-Clean INSURER B:Century National Insurance Company 26905 9785 Crescent Center Drive, Ste 302 INSURER C:State Compensation Insurance Fund 35076 Rancho Cucamonga, CA 91730 _INSURIRD: INSL RER E.' INSL RER F: COVERAGES CERTIFICATE NUMBER: 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 EY 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 ADDL SUBR, POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER _ MM/DDr YW MMIDDIYYYV GENERAL LIABILITY EACH OCCURRENCE $ A COMMERCIAL GENERAL LIABILITY DAMA E PREMISES Ea occurrence $ CLAIMS-MADE ©OCCUR MED EXP(Any one person) s5.00O Contractor's Pollution G24290414 001 6/18/2012 6/18/2013 PERSONAL&ADV INJURY S liability included I GENERAL AGGREGATE .____L444 QQQQQ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $4MGMO POLICY PRO V-11 LOC _ $ B AUTOMOBILE LIABILITY Ea aB deDQ SINGLE LIMIT $1'0001000 ANY AUTO BAP0175920 05/23/2013 05/23/2014 BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) $ - NON-OWNEDAUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE - - $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION -/ WC STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $1,000,000 C OFFICER/MEMBFREXCLI, Y❑ N/A 9022723 09/01/2012 09/01/2019 - (Myandatory in NH) U E.L.DISEASE•EA EMPLOYE $1,000,000 IDESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 A Professional Liability G24290414 001 06/18/2012 06/18/2013 3,000,000 each claim DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schack le,If more space Is required( EVIDENCE OF INSURANCE CERTIFICATE HOLDER 30 Day C ANCELLATION NO CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 'FFIE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN \(LRDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Gwg �td� ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY EDMUND G.BROWN JR.,Govemor DEPARTMENT OF PUBLIC HEALTH MEDICAL WASTE MANAGEMENT PROGRAM 1616 CAPITOL AVENUE,2nd FLOOR-MS 7405 P.O.BOX 997377 SACRAMENTO,CA 95899-7377 Phone:916-449-5671 March 25, 2013 ID Number TSW 10 Mr. Cory Chalmers Crime Scene Steri-Clean, LLC 9785 Crescent Ctr Dr Ste 302 Rancho Cucamonga, CA 91730 Dear Mr. Chalmers: Your Trauma Scene Waste Management Practitioner certificate is shown below. Please retain this for your records. If you have questions regarding this certificate, please call(916)449-5671. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 000ee0000•0000000000000.000000000000000 • •• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •• • e • • •• • • • • . . • • • . • . • • • • • • • • • • • • • • • . • • • • . • • •.00• • ••� ••• •e•• r� OF T 0.00• •••s. yE iunik� NR •••" sa STATE OF CALIFORNIA �� .0000 a ,•• goes.06 =d' a Department of Public Health ..0 0 A �- _ .11 California!) ,r--,,of ••e•• Medical Waste Management Program 00 • 0.0.0® publicHealth '•••0 00 " C'1lI PORN - •00'• Crime Scene Steri-Clean, LLC •'•00 *000 .004pe 0000• Registration No. e••.. ••••- ....e 010 is registered as a ••••e ••"• TRAUMA SCENE WASTE MANAGEMENT PRACTITIONER 0000• ••••e ••0•• Expiration Date 0.00• o•°•. April 16,2014 ••0•e ••0•• 0.0.0 ••°•, The facility named herein is registered pursuant to the provisions of the Medical Waste Management Act, .0000 e•••, Division 104,Part 14,Chapter 5 of the California Health and Safety Code, ••••e ••••, and shall be subject to all applicable provisions of this law. This registration is not transferable and is .6800 0000, valid only in California. .0000 0000• Alison Dabney,Chief •00i0 0000• Date Issued: 3/25/2013 C � Medical Waste Management Program ••••• 0000• i ..e•• 00�ee • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •0 0 0 000000o a•oe•o••eeo4b•000000•o•000•oo•ee • 'Department of Toxic Substances Control: Deborah O.Raphae,Director Matthew Rodriquez 1001 "P"Street Edmund G Brown Jr. Governor secretaryror P.O.Box 806 Ernlropmencai Protection Sacramento,California 95812-0806' ATTN: CORY'CHALMERS EPA ID Number Issued: February 17 2012's CRIME SCENE STERI-CLEAN LLC Location,Address: 9785 CRESCENT CENTER DR 9785 CRESCENT.CENTER DR STE 302 STE 302 RANCHO CUCAMONGA CA 91730 RANCHO CUCAMONG CA 91,730 PERMANENT RECORD - DO'NOT DESTROY YOUR CALIFORNIA EPA IDENTIFICATION NU,MBER,IS: CAL 0003718 '.�` 47 This is to acknowledge that a permanent California Environmental Protection Agency Identification (EPA ID) Number h'as been:assigned'to your place of business. An.EFA ID'Numb'er'is assignedto;a person or business at a specific site: If is only'valid for the location and person or business to which it was assi.4Ined. If your business has multiple . generation sites, each site`must have ifs own unique number. If you stop handling:hazardous waste,',move}your business;change ownership, change mailing address, or change the type or amount,of waste you handle,you must notifythe Department of Toxic sgbstances control, immealiately. if your business has'moved,your EPA ID A'umber must be canceled: Anew number must be,obtained for your new location if you continue t0 generate,haiarabus waste. This EPA ID Number must be-used;for all=:manifesting, record keeping,and reporting requirements: Please retain this notice;in your files. Department.of Toxic Substances Control Generator Information Services Section Telephone;(916)255-1136 or California Only Toll-free Number: (800)618-=6942. Operator's Initials: MEMAAS version:January 2011 Printed on Recycled Paper I. d \� Department of Toxic Substances Control Deborah O. Raphel, Director Linda S.Adams Edmund G.Brown Jr. 8800 Cal Center Drive I Acting Secretary for Governor I Environmental Protection Sacramento, California 95826-3200 I ***HAZARDOUS WASTE TRANSPORTER REGISTRATION*** NAME AND ADDRESS OF REGISTERED TRANSPORTER: j CRIME SCENE STERI-CLEAN, LLC 9785 CRESCENT CENTER DR., SUITE 302 I RANCHO CUCAMONGA, CA 91730 t TRANSPORTER REGISTRATION NO.: 5844 EXPIRATION DATE: SEPTEMBER 30, 2013 THIS IS TO CERTIFY THAT THE FIRM NAMED ABOVE IS DULY REGISTERED TO TRANSPORT HAZARDOUS WASTE IN THE STATE OF CALIFORNIA IN ACCORDANCE WITH THE PROVISIONS OF CHAPTER 6.5, DIVISION 20 OF THE HEALTH AND SAFETY CODE AND TITLE 22 OF THE CALIFORNIA CODE OF REGULATIONS, DIVISION 4.5. THIS REGISTRATION CERTIFICATE MUST BE CARRIED WITH EACH SHIPMENT OF HAZARDOUS WASTE. FOR REGISTRATION INFORMATION, PLEASE C 16) 440-7145. (AUTHORIZED SIGNATURE) (D i i ® Printed on Recycled Paper R ° n 1 R n M n R Western Surety Company DISHONES'T'Y BOND G (FOR ANY TYPE OF BUSINESS) ° ° Bond No. 14744709 v p In consideration of the agreed premium, Western Surety Company, a South Dakota corporation (the "Surety"), hereby ; Fagrees to indemnify Crime Scene Steri-Clean LLC _ 9716 6th Street Rancho Cucamonga, CA 91730 oi (the"Insured'),against any loss of money or other property which the Insured shall sustain or for which the Insured o shall incur liability to any Customer or Subscriber of the Insured through any fraudulent or dishonest act or acts o committed by any Employee or Employees of the Insured acting alone or in Collusion with others, the amount of indemnity on each of such Employees being One Hundred Thousand and 00/100 DOLLARS($100,000-00 ). THE FOREGOING AGREEMENT IS SUBJECT TO THE FOLL DWING CONDITIONS AND LIMITATIONS: TERM OF BOND: SECTION 1. The term of this bond begins with the 6th __day of September 2005 standard time,at the address of the Insured above given, and Ends at 12:00 o'clock night,standard time,on the effective date of the cancellation of this bond in its entirety. EXCLUSION: SECTION 2. This bond does not apply to loss,or to that part of any loss,as the case may be,the proof of which,either as to its factual existence or as to its amount, is dependent upon an inventory computation or a profit and loss computation. In addition, the policy does not apply to the defense of any legal proceedings brought against the Insured, or to fees, costs or expenses incurred or paid by the Insured in prosecuting or defending any legal proceedings whether or not such proceedings results or would result in a loss to the Insured covered by this policy. In addition, the Company shall not be liable for any costs, fees and other expenses incurred by the Irsured in establishing the existence or the amount of loss covered under this policy. DISCOVERY PERIOD: SECTION 3. Loss is covered under this bond only (a) if sustained through any act or acts committed by any Employee of Insured while this bond is in force as to such Employee,and (b) ii'discovered prior to the expiration or sooner cancellation of this bond in its entirety as provided in Section 10, or from i_s cancellation or termination in its entirety in any other manner,whichever shall first happen. DEFINITION OF EMPLOYEE: SECTION 4. The word Employee or Employees,as used in this bond,shall be deemed to mean, respectively, one or more of the natural persons (except directors or trustees of the Insured, if a corporation,who are not also officers or employees thereof in some other capacity)while in the regular service of the Insured in the ordinary course of the Insured's business during the term of this bond,and whom the Insured compensates by salary or wages and has the right to govern and direct in the performance of such service, and who are engaged in such service within any of the States of the United States of America,or within the District of Columbia, Puerto Rico, the Virgin Islands, or elsewhere for a limited period, but not to mean brokers, factors, commission merchants, consignees, contractors, or other agents or representatives of the same general character. o FRAUDULENT OR DISHONEST ACT: SECTION 5. A FRAUDULENT OR DISHONEST ACT OF AN.EMPLOYEE OF THE INSURED SHALL MEAN AN ACT ; WHICH IS PUNISHABLE UNDER THE CRIMINAL CODE IN THE JURISDICTION WITHIN WHICH ACT OCCURRED, FOR WHICH SAID EMPLOYEE IS TRIED AND CONVICTED BY A COURT OF PROPER o JURISDICTION. MERGER OR CONSOLIDATION: d SECTION 6. If any natural persons shall be taken into the regular service of the Insured through merger or consolidation a 6 with some other concern, the Insured shall give the Surety written notice thereof and shall pay an additional premium on s any increase in the number of Employees covered under this bond as a result of such merger or consolidation computed opro rata from the date of such merger or consolidation to the end of the current premium period. NON-ACCUMULATION OF LIABILITY: SECTION 7. Regardless of the number of years this bond shall ontinue in force and the number of premiums which shall be payable or paid,the liability of the Surety under this bond shal l not be cumulative in amounts from year to year or from ° ° period to period. ° Form 1432-10.2002 R E _ V. ,<3M .��.)'. ✓s �ti '�Sn `- "�pt+'�7^�t',.-en - �"xF i' w } k} P nr a Qt {r s�Uare } da�ei��nrot ar peps&ogrenror �U6n of: p i n cent(ca a is §trtran st big°�r1QTis bee tmefUa�S�(�909)"91��,� ° .. �` •r 1!^`.. •�. .. d�' trtt. , l ,. .�'� � u�^ i a �rE" r 3 �'s c .p �Th�`°+. I �(,y b ,'.; � T +. l '•� .. . f � .d'�C nex„as Y •3�+f� £^ k1w'>r�'.,r.�op .y..r�,t `!'�4Fn5,- k ti�v t �° a i0F'i�+,�S�i4�`�3, `,'( s�3 y�1vfi x; �' °tif19F & f fB_I Z2r y�" �a lo-1 t3�I' i` f t`!', `+*t, 4.`` €... •�'Sitie ��.,'a'tsr '�' ikS!,4.,,may ''"� ...r�v - t °'3 x �' ,yx ffills >k�� +�y!, *y le+. �1v' "S.�Lr�'�w' -.,t• F,' '�, � ,�� P� aa. J"Y ro k.y. � � n. ^ IWIIIIYh .iv. l•'•i'Y Yl: y� '�". ��kF R?.Y�'P, �3 L�� '•� ��r' `.,� � � � K R h't ���S �rt�k �4 �. v .�i' r�'�'�,,�.-;zr •r'q�.. 3„ � t+�.. �� 1hF�I��` s"�j '1�'ja�9 -� r�>��' i State of California—Health and Human Services Agency ` 4 California Department of Public Health 9CDPH MARK B NORTON,MD,MSPH Director ARNOLD SCHWARZENEGGER Governor MEDICAL WASTE TRANSPORTER AUTHORIZATION AND CONDITIONS This is to advise you that the Department of Public Health, Medical Waste Management Program, has approved your request to be listed as a medical waste transporter. You are required to maintain your registration as a hazardous waste transporter in order to remain listed as a medical waste transporter. Hazardous Waste Transporter Registration Number: 5844 Company name/address/phone: Crime Scene Steri-Clean 9716 Sixth Street Rancho Cucamonga, CA 91730 (888) 577-7206 Contact Person: Cory Chalmers You are subject to all applicable provisions of Me Medical Waste Management Act, Division 104, Part 14, Chapter 6, of the California Health anc Safety Code and the conditions set forth on the following page. If you have any questions, please contact us at (916) 449-5671. f I /�r 1 Ronald Pilllorin, Chief Waste Management Section I APPROVED OCT 2 9 2009 Medical Waste Management Program P.O.Box 997377(MS 7405),Sacramento,CA 995899 Phone:(916)449-5671/FAX:(916)449-5665 Internet:www.cdph.ca.gov/certlic/Medica[Waste Form W'9 Request for Taxpayer Give Form to the Department 20eas Identification Number and Certification requester.Do not Department of the Treasury send to the IRS. Internal Revenue Service Name(as shown on your income tax return) 1YY1� SCENE SI E�1- lf�h1 N Business name/disregarded entity name,if different from above a> m cL Check appropriate box for federal tax classification: C o C ❑ Individual/sole proprietor F1 C Corporation El S Corporation El Partnership ❑ Trust/estate N a El Exempt payee L o dUmited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=partnership)0. c H d ❑ Other(see instructions)► E Address(number,street,and apt.or suite no.) nn Requester's name and address(optional) L m City,state,and ZIP code a) q A-ocm WC,ia' u'1 --,A Ust account number(s)here(optional) Taxpayer Identification Number(TIN) Enter your TIN in the appropriate box.The TIN provided must match the name given on the"Name"line Social security number to avoid backup withholding.For individuals,this is your social security number However,for a -m - resident alien,sole proprietor,or disregarded entity,see the Part I instructions on n page 3.For other entities,it is your employer identification number(EIN).If you do not have a number,see How to get a TIN on page 3. Note.If the account is in more than one name,see the chart on page 4 for guidelines on whose FEmpioyer identification number number to enter. �14 5 .5 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. 1 am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue Service(IRS)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 I am no longer subject to backup withholding,and 3. 1 am a U.S.citizen or other U.S.person(defined below). 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,you are not required to sign the certification,but you must provide your correct TIN.See the instructions on page 4. Sign Signature of Here U.S.person 11- Date 0, General Instructions Note.If a requester gives you a form other than Form W-9 to request your TIN,you must use the requester's form if it is substantially similar Section references are to the Intern ev ue Code unless otherwise to this Form W-9. noted. Definition of a U.S.person.For federal tax purposes,you are Purpose of Form considered a U.S.person if you are: A person who is required to file an information return with the IRS must •An individual who is a U.S.citizen or U.S.resident alien, obtain your correct taxpayer identification number(TIN)to report,for •A partnership,corporation,company,or association created or example,income paid to you,real estate transactions,mortgage interest organized in the United States or under the laws of the United States, you paid,acquisition or abandonment of secured property,cancellation .An estate(other than a foreign estate),or of debt,or contributions you made to an IRA. •A domestic trust(as defined in Regulations section 301.7701-7). Use Form W-9 only if you are a U.S.person(including a resident alien),to provide your correct TIN to the person requesting it(the Special rules for partnerships.Partnerships that conduct a trade or requester)and,when applicable,to: business in the United States are generally required to pay a withholding tax on any foreign partners'share of Income from such business. 1.Certify that the TIN you are giving is correct(or you are waiting for a Further,in certain cases where a Form W-9 has not been received,a number to be issued), partnership is required to presume that a partner is a foreign person, 2.Certify that you are not subject to backup withholding,or and pay the withholding tax.Therefore,if you are a U.S.person that is a 3.Claim exemption from backup withholding if you are a U.S.exempt partner in a partnership conducting a trade or business in the United payee.If applicable,you are also certifying that as a U.S.person,your States,provide Form W-9 to the partnership to establish your U.S. allocable share of any partnership income from a U.S.trade or business status and avoid withholding on your share of partnership income. is not subject to the withholding tax on foreign partners'share of effectively connected income. Cat.No.10231X Form W-9(Rev.12-2011)