DL2536 Statement of Intent

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STATEMENT OF INTENT

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Prescribed by: 41 CFR 102-40
Sponsor: Disposition Services

Form Approved
OMB No. 0704-0534
Expires

AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information, OMB 0704-0534, is estimated to average 1.5 hours 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 the burden
estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at whs.
[email protected]. 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.

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 Disposition Services Sales Contracting Officer may use the bidder's failure to provide complete or
accurate information on this basis to deny the award.
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.

DLA FORM 2536, JUN 2018

REPLACES DRMS FORM 1645, WHICH IS OBSOLETE

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PDF (DLA)

STATEMENT OF INTENT

Prescribed by: 41 CFR 102-40
Sponsor: Disposition Services

Form Approved
OMB No. 0704-0534
Expires

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 NONEMERGENCY 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 ACCUR.ATELY COMPLETE THIS BLOCK WITH REQUESTED INFORMATION MAY RESULT IN
YOUR BID BEING NON-RESPONSIVE AND ULTIMATELY NO AWARD.

DLA FORM 2536, JUN 2018

REPLACES DRMS FORM 1645, WHICH IS OBSOLETE

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PDF (DLA)

STATEMENT OF INTENT

Prescribed by: 41 CFR 102-40
Sponsor: Disposition Services

Form Approved
OMB No. 0704-0534
Expires

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 Usage):
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 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.
b. 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
THE UNDERSIGNED BIDDER HEREBY CERTIFIES THAT IF AWARDED A CONTRACT UNDER THIS INVITATION FOR BIDS, THE BIDDER WILL
COMPLY WITH ALL APPLICABLE FEDERAL, STATE, AND LOCAL LAWS, ORDINANCES, AND REGULATIONS WITH RESPECT TO THE
CARE, HANDLING, STORAGE, SHIPMENT, RESALE, EXPORT, OR OTHER USE OF THE MATERIAL HEREBY PURCHASED. THE BIDDER
WILL HOLD THE UNITED STATES HARMLESS FROM AND INDEMNIFY THE UNITED STATES AGAINST ANY OR ALL DEBTS, LIABILITIES,
JUDGEMENTS, COSTS, DEMANDS, SUITS, ACTIONS, OR OTHER CLAIMS OF ANY NATURE ARISTNG FROM OR INCIDENT TO THE
HANDLING, USE, STORAGE, SHIPMENT, RESALE, EXPORT, OR OTHER DISPOSITION OF THE ITEMS PURCHASED.
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 DLA DISPOSITION SERVICES CONTRACTING OFFICER.

I AGREE THAT I WILL NOT EFFECT SUCH CHANGES WITHOUT FIRST RECEIVING THE WRITTEN APPROVAL OF THE DLA DISPOSITION
SERVICES CONTRACTING OFFICER.

DATE OF SIGNING

SIGNATURE OF OFFICIAL BIDDER

PRINT OR TYPE NAME OF BIDDER

DLA FORM 2536, JUN 2018

REPLACES DRMS FORM 1645, WHICH IS OBSOLETE

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PDF (DLA)

STATEMENT OF INTENT

Prescribed by: 41 CFR 102-40
Sponsor: Disposition Services

Form Approved
OMB No. 0704-0534
Expires

SECTION 6. SPECIFIC USAGE
As a purchaser, I will:
(a) Ensure that a minimum of 75% of the hazardous property purchased from DLA Disposition Services 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(s) which records management of hazardous property by one of the following methods for
purchases from DLA Disposition Services: (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 DLA Disposition Services Sales Office with a Semi-Annual Report (See section 7) June 1st and December 1st recording
management of hazardous property received from DLA Disposition Services 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, DLA Disposition Services will not consider releasing
any further property to you until the requirements have been satisfied.

Printed Name of Buyer(s)

Signature of Buyer(s)

DLA FORM 2536, JUN 2018

REPLACES DRMS FORM 1645, WHICH IS OBSOLETE

Date Signed

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PDF (DLA)

STATEMENT OF INTENT

Prescribed by: 41 CFR 102-40
Sponsor: Disposition Services

Form Approved
OMB No. 0704-0534
Expires

SECTION 7. SEMI-ANNUAL REPORT
a. NAME OF ITEM:
b. UNIT OF ISSUE:
c. QUANTITY:
d. CONTRACT NUMBER(s) (where the material came from #):
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:
DLA DISPOSITION SERVICES SALES CONTRACTOR SIGNATURE:

DLA FORM 2536, JUN 2018

REPLACES DRMS FORM 1645, WHICH IS OBSOLETE

Page 5 of 5

PDF (DLA)