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EPA FORM 6100-4 (DBE Subcontractor Utilization Form) <br />OMB Control No: 2090-0030 <br />Approved: 8/13/2013 <br />Approval Expires: 8/31/2015 <br />Disadvantaged Business Enterprise (DBE) Program <br />DBE Subcontractor Utilization Form <br />This form is intended to capture the prime contractor’s actual and/or anticipated use of identified certified DBE1 <br />subcontractors2 and the estimated dollar amount of each subcontract. An EPA Financial Assistance Agreement <br />Recipient must require its prime contractors to complete this form and include it in the bid or proposal package. <br />Prime contractors should also maintain a copy of this form on file. <br />Prime Contractor Name Project Name <br />Bid/ Proposal No. Assistance Agreement ID No. (if known) Point of Contact <br />Address <br />Telephone No. Email Address <br />Issuing/Funding Entity: <br />I have identified potential DBE <br />certified subcontractors ___ YES ___ NO <br />If yes, please complete the table below. If no, please explain: <br />Subcontractor Name/ <br />Company Name <br />Company Address/ Phone/ Email Est. Dollar <br />Amt <br />Currently <br />DBE <br />Certified? <br />1 A DBE is a Disadvantaged, Minority, or Woman Business Enterprise that has been certified by an entity from which EPA accepts certifications as <br />described in 40 CFR 33.204-33.205 or certified by EPA. EPA accepts certifications from entities that meet or exceed EPA certification standards as <br />described in 40 CFR 33.202. <br />2 Subcontractor is defined as a company, firm, joint venture, or individual who enters into an agreement with a contractor to provide <br />services pursuant to an EPA award of financial assistance. <br />Continue on back if needed <br />Bowen Engineering Corporation South Bend Final Clarifiers 1-3 Improvements <br />119-069B Chris Durnil <br />8802 N. Meridian Street, Indianapolis, IN 46260 <br />317.842.2616 cdurnil@bowenengineering.com <br />SRF <br />X <br />TESCO 9955 Crosspoint Blvd, Indpls, IN 46256 <br />317.442.6887 <br />kbowen@tesco-solutions.com <br />$280,000 YES <br />Team Cruiser PO Box 78634 Indpls, IN 46278 <br />317.423.2375 <br />projects@teamcruiser.com <br />$200,000 YES