DRMS 1645 Statement of Intent

STATEMENT OF INTENT
NOTE: The bidder has a duty to demonstrate responsibility and compliance with federal, state, county, city or local
environmental/safety regulations or ordinances on the use and storage of Hazardous Property (HP) to qualify for an
award. The DRMS Sales Contracting Officer may use the bidder's failure to provide complete or accurate information
on this basis to deny the award.
Completion of ALL information is Mandatory.
SECTION I. BIDDER INFORMATION

If bidder is agent, check here

a. NAME AND PHONE NUMBER OF PRINCIPAL
b. PRINCIPAL'S ADDRESS
c. PLEASE LIST OTHER BUSINESS OR NAMES USED BY THE PRINCIPAL BIDDER
d. NATURE OF BUSINESS
(1) BROKER, MARKETER, RETAILER or WHOLESALER
(2) TREATMENT, STORAGE AND/OR DISPOSAL FACILITY
(3) OTHER (Specify)
e. INDICATE ALL RELEVANT TRAINING AND EXPERIENCE RELATED TO THE USE AND STORAGE OF HAZARDOUS PROPERTY.

BIDDER MUST INDICATE THE ITEM(S) FOR WHICH THE INFORMATION IN THIS SECTION APPLIES.

SECTION 2. DESTINATION OF PROPERTY
NOTE:

.LIST THE ACTUAL STREET ADDRESS WHERE THE PROPERTY IS TO BE DELIVERED. POST OFFICE BOXES ARE NOT ACCEPTABLE.

a.

1. PRINCIPAL BIDDER(S)
2. OTHER (List )

NAME, ADDRESS AND PHONE NUMBER OF DESTINATION

EPA ID NO. AND/OR LICENSE/PERMIT(S) NO.

(Mandatory if facility is regulated by federal/state or local authorities)

TYPE(S) OF ACTIVITY DESTINATION POINT IS LICENSED/PERMITTED FOR:

b. DOES THE PRINCIPAL OWN THE STORAGE FACILITY?

YES

NO

IF THE STORAGE FACILITY IS NOT OWNED BY THE PRINCIPAL, PROVIDE THE NAME AND PHONE NO. OF THE OWNER AND THE
RELATIONSHIP BETWEEN THE PARTIES. IF THE STORAGE FACILITY IS RENTED, DOES THE LEASE SPECIFICALLY INCLUDE THE STORAGE
OF HAZARDOUS PROPERTY?
IF YES, ENCLOSE A COPY OF THE LEASE AGREEMENT.
YES
NO

c. PROVIDE THE NAME, ADDRESS AND PHONE NO. OF THE FEDERAL/STATE ENVIRONMENTAL REGULATORY AGENCIES AND/OR
NON-EMERGENCY PHONE NO. FOR THE LOCAL, STATE, COUNTY, CITY OR OTHER AGENCY THAT HAS JURISDICTION FOR FIRE/SAFETY
INSPECTIONS OR WOULD RESPOND TO EMERGENCIES WHERE THE PROPERTY WILL BE STORED. FAILURE TO ACCURATELY COMPLETE THIS
BLOCK WITH REQUESTED INFORMATION MAY RESULT IN YOUR BID BEING NON-RESPONSIVE AND ULTIMATELY NO AWARD.
(911 Is Not Acceptable)

d. LIST ALL FEDERAL/STATE/LOCAL ENVIRONMENTAL REGULATORY AGENCIES THAT HAVE INSPECTED THE FACILITY/BUSINESS OR THE
DESTINATION SITE DURING THE PAST TWO (2) YEARS. INCLUDE THE NAME OF THE INSPECTORS, AND THE NAME, ADDRESS, AND
PHONE NO. OF EACH AGENCY. FAILURE TO ACCURATELY COMPLETE THIS BLOCK WITH REQUESTED INFORMATION MAY RESULT IN
YOUR BID BEING NON-RESPONSIVE AND ULTIMATELY NO AWARD.

DRMS FORM 1645, OCT 2006 (EF)

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STATEMENT OF INTENT
(CONTINUED)

SECTION 3. SPECIFIC USAGE

(Insert Item Number(s) as Appropriate)

a. AS A PURCHASER, I WILL:
(1) RESELL ITEM(S):
(2) USE ITEM AS INTENDED:
(3) SCRAP ITEM(S) FOR RECOVERY OF CONTENTS:
(4) RE-REFINE/REPROCESS ITEM(S)
(5) OTHER

(Specify Item and

b. IF ITEM(S) ARE RESOLD, LIST ALL CUSTOMERS AND PROVIDE ALL APPLICABLE INFORMATION REQUESTED IN SECTION 2, PARAGRAPHS
C & D OF ABOVE FOR EACH CUSTOMER. USE ADDITIONAL PAPER IF NECESSARY AND ATTACH TO THIS FORM.

SECTION 4. ACKNOWLEDGEMENTS

a. Bidder ackowledges the responsibility to comply with ALL applicable federal/state/local laws, ordinances, and
regulations with respect to processing, storing or using the material 29 CFR OSHA, transporting, handling 49 CFR and
disposal of items with respect to the environment, specifically 40 CFR Part 260 et seq.
b. Bidder acknowledges that no false statements have been made or any information concealed regarding the business,
disposition of the property, or compliance history.
c. Bidder acknowledges that sanctions may be imposed against any persons who knowingly/unknowingly violates any
law relative to environmental protection, illegal transportation or storage/safety requirements/regulations or who
knowingly falsifies or conceals information regarding the business, disposition, violation or use of the property and may
include the denial of any future participation in the DoD Surplus Sales Program.
d. Bidder acknowledges that the information provided in this statement will be considered a part of the bid under the
IFB, and a part of the contract of sale if the bid is accepted by the United States of America.
SECTION 5. CERTIFICATION
I CERTIFY THAT ALL OF THE INFORMATION GIVEN IN THIS STATEMENT IS TRUE AND CORRECT, AND THAT I HAVE NOT KNOWINGLY OMITTED
ANY ADDITIONAL INFORMATION WHICH IS INCONSISTENT WITH THIS STATEMENT. I UNDERSTAND THAT THIS STATEMENT IS INCORPORATED
BY REFERENCE INTO ANY RESULTING CONTRACT OF SALE WITH THE U.S. GOVERNMENT. PRIOR TO EFFECTING ANY CHANGE OF FACT OR
INTENTION FROM THAT STATED HEREIN OR IN ANY PRIOR AMENDMENT, WHETHER OCURRING BEFORE OR AFTER THE RELEASE OF PROPERTY
UNDER CONTRACT, I WILL SUBMIT A WRITTEN REQUEST FOR AMENDMENT OF THIS STATEMENT TO THE DRMS CONTRACTING OFFICER.
I AGREE THAT I WILL NOT EFFECT SUCH CHANGES WITHOUT FIRST RECEIVING THE WRITTEN APPROVAL OF THE DRMS CONTRACTING OFFICER.

DATE OF SIGNING

SIGNATURE OF OFFICIAL BIDDER

PRINT OR TYPE NAME OF BIDDER

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STATEMENT OF INTENT (Continued)
SECTION 6. SPECIFIC USAGE

As a purchaser, I will:
(a) Ensure that a minimum of 75% of the hazardous property purchased from DRMS will be managed by one of the
following methods within 12 months of the purchase date: (Specify Item)
(1) Resell Items:
(2) Use Item as Intended:
(3) Scrap Item(s) For Recovery of Contents:
(4) Re-Refine.Reprocess Item(s):
(5) Other (Specify Item and Use)
(b) Maintain accurate log which records management of hazardous property by one of the following methods for
purchases from DRMS: (Specify Item)
(1) Resell Items:
(2) Use Item as Intended:
(3) Scrap Item(s) For Recovery of Contents:
(4) Re-Refine/Reprocess Items(s):
(5) Other (Specify Item and Use):
(c) Provide DRMS Sales Office with a Semi-Annual Report (See section 7) June 1st and December 1st recording
management of hazardous property received from DRMS by one of the following methods: (Specify Item)
(1) Resell Items:
(2) Use Item as Intended:
(3) Scrap Item(s) For Recovery of Contents:
(4) Re-Refine/Reprocess Items(s):
(5) Other (Specify Item and Use):
NOTE:
If the conditions of these requirements are not met, DRMS will not consider releasing any further property to you
until the requirements have been satisfied.

Printed Name of Buyer(s)

Signature of Buyer(s)

Date Signed

SECTION 7. SEMI-ANNUAL REPORT
a. NAME OF ITEM
b. UNIT OF ISSUE
c. QUANTITY
d. CONTRACT NUMBER(s)
e. STORAGE LOCATION
f. DATE OF REMOVAL (n/a if item stored in original location)
g. POINT OF CONTACT (POC) IF DIFFERENT FROM ORIGINAL DESTINATION:
PRINTED NAME
ADDRESS
TELEPHONE NUMBER
SIGNATURE
h. IF PROPERTY IS RESOLD BUYER(s)
PRINTED NAME
ADDRESS
TELEPHONE NUMBER
DRMS SALES CONTRACTOR SIGNATURE
DRMS FORM 1645, OCT 2006 (EF)

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STATEMENT OF INTENT (Continued)

OMB CONTROL NUMBER: 0704-XXXX
EXPIRATION DATE: XX/XXXX

AGENCY DISCLOSURE STATEMENT
The public reporting burden for this collection of information is estimated to average 75
minutes per response, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing the burden, to
the Department of Defense, Washington Headquarters Services, Executive Services
Directorate, Information Management Division, 4800 Mark Center Drive, East Tower,
Suite 02G09, Alexandria, VA 22350-3100 (0704-XXXX). Respondents should be aware
that notwithstanding any other provision of law, no person shall be subject to any penalty
for failing to comply with a collection of information if it does not display a currently
valid OMB control number.

DRMS FORM 1645, OCT 2006 (EF)

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