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EPA" 'a Environm ental Protection q Agency <br />0MB Control No: 2090-0030 <br />Approved:8/13/2013 <br />Approval Expires: 8/31/2015 <br />Disadvantaged Business Enterprise (DBE) Program <br />DBE Subcontractor Performance Form <br />This form is intended to capture the DBE1 subcontractor's2 description of work to be performed and the price of <br />the work submitted to the prime contractor. An EPA Financial Assistance Agreement Recipient must require its <br />prime contractor to have its DBE subcontractors complete this form and include all completed forms in the prime <br />contractors bid or proposal package. <br />Subcontractor Name Project Name <br />Team Cruiser Supply South Bend Final Clarifiers 1-3 <br />Bid/ Proposal No. Assistance Agreement ID No. (if known) Point of Contact <br />South Bend Chris Barney <br />Address PO Box 78634, Indianapolis, IN 46278 <br />Telephone No. 317.423.2375 Email Address projects@team cruiser.com <br />Prime Contractor Name Engineering <br />Issuing/Funding Entity: <br />Bowen <br />Contract Item Number Description of Work Submitted to the Prime Contractor Price of Work <br />Involving Construction, Services , Equipment or Supplies Submitted to the <br />Prime Contractor <br />Process Pipe Supply $200,000.00 <br />DBE Certified By: DOT - SBA Meets/ exceeds EPA certification standards? <br />X Other: IN DO T _ YE s NO Unknown - - - <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 services <br />pursuant to an EPA award of financial assistance. <br />EPA FORM 6100-3 (DBE Subcontractor Performance Form)