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Home My WebLink AboutOpening of Bids - Byer's Softball Complex Improvements Proj No 123-071 - Premium Concrete ServicesCITY OF SOUTH BEND, INDIANA CONTRACTOR'S BID FOR PUBLIC WORK Project Name Project No. For Bids Due Date: Address: City/State/Zip: Softball Complex Improvements Phase 1 December 10, 2024 (Must be completed for all bids. Please type or print) 12/9/2024 Bidder (Firm): PREMIUM CONCRETE SERVICES 712 RICHMOND ST ELKHART, IN 46M6 Telephone Number: (574 ) 264-0196 Agent of Bidder (if Applicable): Pursuant to notices given, the undersigned offers to furnish labor and/or material necessary to complete the public works project of: BYERS SOFTBALL COMPLEX IMPROVEMENTS PHASE 1 the City of South Bend, Indiana, in accordance with plans and specifications prepared by: DL7 and dated 11/4/24 for the sum of (enter the Total Bid as shown on the Proposal) TI-IREE MILLION SIX HUNDRED TWENTY-ONE THOUSAND EIGHT HUNDRED EIGHTY-TWO DOLLARS ($ 3,621,$$2.00 ) (Enter sum of Total Base Bid plus Alternates shown on Proposal) (Numerical) The undersigned further agrees to furnish a bond or certified check with this bid for an amount specified in the notice of the letting. If alternative bids apply, the undersigned submits a proposal for each in accordance with the notice. Any addendums attached will be specifically referenced at the applicable page. If additional units of material included in the contract are needed, the cost of units must be the same as that shown in the original contract if accepted by the City of South Bend. If the bid is to be awarded on a unit basis, the itemization of the units shall be shown on a separate aa ent. By (Signature) /'?Al y4ct�-a y (Printed Name of Person Signing) ACCEPTANCE The above bid is accepted this Subject to the following conditions: BOARD OF PUBLIC WORKS Elizabeth A. Maradik, President Gary A. Gilot, Member Murray L. Miller, Member 20 Joseph R. Molnar, Vice President Jordan V. Gathers, Member Attest: Theresa Heffner, Clerk Version 07/19/2023 Special Provisions - 2 BID/PROPOSAL CITY OF SOUTH BEND Project Name Byers Softball Complex Improvements Phase 1 Project No. 123-072 For Bids Due: December 10, 2024 Contractor Name: PREMIUM CONCRETE SERVICES BASE BID No Description Quant, Unit Unit Price Extension 1 MOBILIZATION AND DEMOBILIZATION 1.00 IS $247,000 $247,000 2 CLEARING RIGHT OF WAY 1.00 LS $76,500 $76,500 3 EROSION CONTROL 1.00 LS $10,000 $101000 4 TREE PROTECTION 1.00 LS $5,750 $5,750 5 CURB, REMOVE 30.00 LFT $30 $900 6 SIDEWALK, CONCRETE, REMOVE 338,00 SYS $30 $10,140 7 PLAY EQUIPMENT, REMOVE 1.00 LS $12,200 $12,200 8 EXCAVATION, COMMON 11230,00 CYS $112,50 $138,375 9 COMPACTED AGGREGATE NO.53 263.00 TON $67 $17,621 10 HMA PATCHING FULL DEPTH, TYPE B 31.00 TON $240 $7,440 11 PARKING LOT, CRACK SEALAND REPAIR 8,500.00 SYS $6 $51,000 12 CURB, CONCRETE 30.00 LFT $85 $2,550 13 CURB RAMP, CONCRETE 7.00 SYS $265 $1,885 14 DETECTABLE WARNING SURFACES 1.20 SYS $355 $426 15 SIDEWALK, CONCRETE, 4 IN. 241.00 SYS $108 $26,028 16 SIDEWALK, CONCRETE, 6 IN. 768.00 SYS $116 $89,088 17 SIDEWALK, CONCRETE, DECORATIVE 235.00 LFT $120 $28,200 Version 07/19/2023 Special Provisions - 7 BID/PROPOSAL CITY OF SOUTH BEND Project Name Byers Softball Complex Improvements Phase 1 Project No. For Bids Due: Contractor Name: 123-072 December 10, 2024 PREMIUM CONCRETE SERVICES No Description Quant. Unit Unit Price Extension 18 SODDING, NURSERY 10,063.0 0 SYS $22 $2210386 19 MULCHED SEEDING 77329.00 SYS $15 $109,935 20 TRENCH DRAIN 37.00 LFT $350 $12,950 21 PIPE, 8 IN. 13.00 LFT $94 $1,222 22 PIPE, 12IN. 331.00 LFT $44 $14,564 23 PIPE END SECTION, 12 IN. 1.00 EACH $10500 $1,500 24 DRAIN BASIN 4.00 EACH $3,650 $14,600 25 SIGN, SHEET, ACCESSIBLE PARKING 6.00 EACH $670 $4,020 26 SIGN, SHEET, ON DECK BATTER 8.00 EACH $300 $2,400 27 PAVEMENT MARKING, ACCESSIBLE PARKING ISA 6.00 EACH $36,50 $219 28 PAVEMENT MARKING, 4" LINE 4,267.00 LFT $1 $4,267 29 PARKING BLOCK 6.00 EACH $158 $948 30 PLANT, DECIDUOUS TREE, SINGLE STEM, OVER 2 IN, TO 2.5 IN. 19.00 EACH $750 $14,250 31 PLANT, DECIDUOUS SHRUB 10.00 EACH $150 $1,500 32 PLANT, ORNAMENTAL GRASS 39.00 EACH $40 $1,560 33 STEEL LANDSCAPE EDGING 45.00 EACH $65 $2,925 34 MULCH SHREDDED HARDWOOD BARK 20.00 CYS $170 $3,400 35 BORROW 1,039.00 C YS $58 $60,262 Version 07/19l2023 Special Provisions - 8 BID/PROPOSAL CITY OF SOUTH BEND Project Name Byers Softball Complex Improvements Phase 1 Project No. For Bids Due: Contractor Name: 123-072 December 10, 2024 PREMIUM CONCRETE SERVICES No Description Quant, Unit Unit Price Extension 36 FACILITY SIGNAGE 1.00 ALLOW W $50,000 $50,000 37 INTERPRETIVE SIGNAGE 1.00 LS $33,800 $33,800 38 GATEWAY AT ENTRY PLAZA 1.00 LS $99,725 $99,725 39 DECORATIVE GATES 1.00 LS $13,900 $13,900 40 FENCE, CHAINLINK, BOTTOM RAIL RESET 560.00 LFT $37 $20,720 41 FENCE, CHAINLINK, FABRIC REPLACEMENT 825.00 LFT $50 $41,250 42 FENCE, CHAINLINK, OUTFIELD RESET 515.00 LFT $40 $20,600 43 INFIELD 4.00 EACH $88,400 $35300 44 BALLFIELD EQUIPMENT, INFIELD 4.00 EACH $3,000 $12,000 45 BALLFIELD EQUIPMENT, FOUL POLES 4.00 EACH $6,900 $27,600 46 BALLFIELD EQUIPMENT, BULLPENS 4.00 EACH $140850 $59,400 47 BALLFIELD EQUIPMENT, BULLPENS, GRAVEL BASE 4.00 EACH $5,000 $20,000 48 IRRIGATION 1.00 LS $62,650 $62,650 49 FLAGPOLE AND LIGHTING 1.00 EACH $13,000 $13,000 50 SHADE STRUCTURE 4.00 EACH $42,620 $170,480 51 SANITARY SEWER, PVC SDR-35, 6-INCH 65.00 LFT $56 $3,640 52 SANITARY SEWER, PVC SDR-35, 8-INCH 40.00 LFT $92,50 $3,700 53 SANITARY SEWER, MANHOLE 1.00 EACH $6,825 $6,825 Version 07/19/2023 Special Provisions - 9 BID/PROPOSAL CITY OF SOUTH BEND Project Name Byers Softball Complex Improvements Phase 1 Project No. For Bids Due: Contractor Name: 123-072 December 10, 2024 PREMIUM CONCRETE SERVICES No Description Quant, Unit Unit Price Extension 54 SANITARY SEWER, DOGHOUSE MANHOLE 1.00 EACH $3%200 $39,200 55 WATER SERVICE, TYPE K COPPER, 2-INCH 150.00 LFT $69 $10,350 56 WATER SERVICE, TYPE K COPPER, 1-INCH 45.00 LFT $128 $51760 57 BACKFLOW ASSEMBLY 1.0 LS $12,500 $12,500 58 METER PIT 1.00 LS $10,500 $10,500 59 SPLASH PAD 1.00 LS $320,000 $320,000 60 DRINKING FOUNTAIN, SPLASH PAD 1.00 LS $7,900 $7,900 61 BENCH 3.00 EACH $5,000 $15,000 62 BIKE RACK 2.00 EACH $470 $940 63 TRASH RECEPTACLE 1.00 EACH $4,400 $4,400 64 BOLLARD, FIXED 6.00 EACH $1,330 $7,980 65 BOLLARD, REMOVABLE 3.00 EACH $1,330 $3,990 66 GREASE INTERCEPTOR 1.00 LS $25,700 $25,700 67 SECOND FLOOR KITCHENETTE SANITARY AND DOMESTIC SERVICE PLUMBING 1.00 LS $81300 $8,300 68 DRINKING FOUNTAIN, PRESSBOX 2.00 EACH $7,600 $15,320 69 FLUSH VALVE 1.00 LS $850 $850 70 CONDENSATE LINE 1.00 LS $1,825 $1,825 71 LIGHTING, PRESSBOX EXTERIOR 1.00 LS $3,440 $3,440 Version 07/19/2023 Special Provisions - 10 BID/PROPOSAL CITY OF SOUTH BEND Project Name Byers Softball Complex Improvements Phase 1 Project No. 123-072 For Bids Due: December 10, 2024 Contractor Name: PREMIUM CONCRETE SERVICES No Description Quant. Unit Unit Price Extension 72 LIGHTING, PRESSBOX RESTROOMS 1.00 LS $8,120 $8,120 73 LIGHTING, PRESSBOX 1ST FLOOR 1.00 LS $9,550 $%550 74 LIGHTING, PRESSBOX 2ND FLOOR 1.00 LS $8,475 $8,475 75 LIGHTING, ENTRY PLAZA 1.00 LS $3,000 $3,000 76 ELECTRONIC DISPLAYS 1.002.00 ALLOEACHW $10,000 $1000 00 77 ELECTRICAL CIRCUITS, ELECTRONIC DISPLAYS 2.00 EACH $1,1 00 $202 00 78 ELECTRICAL CIRCUITS, CONCESSIONS 1.00 LS $3,730 $3,730 79 ELECTRICAL CIRCUITS, KITCHENETTE 1.00 LS $1,920 $1,920 80 ELECTRICAL PANEL, RELOCATE 1.00 LS $3,840 $3,840 81 SPRAY PAD ELECTRICAL AND BONDING 1.00 LS $7,100 $7,100 82 ELECTRICAL SERVICE, EQUIPMENT 1.00 LS $5,800 $5,800 83 ELECTRICAL SERVICE, CABINET 1.00 EACH $2,850 $2,850 84 ELECTRICAL SERVICE, CONDUIT 120.00 LFT $33 $30960 85 HANDWASH SINK 1.00 LS $1,430 $1,430 86 CONCESSIONS, COUNTERTOPS 70.00 LFT $128 $8,960 87 CONCESSIONS, SELECTIVE DEMOLITION 1.00 LS $8,685 $8,685 88 CONCESSIONS, DOOR HARDWARE 1.00 LS $2,015 $2,015 89 CONCESSIONS, PAINTING 3,600. 00 SFT $6 $21,600 Version 07/19/2023 Special Provisions - 11 BID/PROPOSAL CITY OF SOUTH BEND Project Name Byers Softball Complex Improvements Phase 1 Project No. 123-072 For Bids Due: December 10, 2024 Contractor Name: PREMIUM CONCRETE SERVICES No Description Quant. Unit Unit Price Extension 90 PRESSBOX WINDOW SCREENS 1.00 LS $2,510 $2,510 91 PRESSBOX EXTERIOR MASONRY, RESTROOM WING WALLS 1.00 LS $8,755 $8,755 92 PRESSBOX EXTERIOR MASONRY, CLEANING 1.00 LS $6,650 $6,650 93 PRESSBOX EXTERIOR STAIRS 1.00 LS $17,420 $17,420 94 CONSTRUCTION CONTINGENCY ALLOWANCE, BASE BID 1.00 ALLOLS W $50.000 $50,000 Base Bid Total $ 21902,396 ALTERNATE #1 WEST PARKING LOT OVERLAY AND COLLECTOR SIDEWALK No, Description Quant, Unit Unit Price Extension 1 PARKING LOT, CRACK SEALAND REPAIR -81500.00 SYS $4,40 -$37,400 2 COMPACTED AGGREGATE NO.53 61.00 TON $98 $5,978 3 HMA, SCARIFY 8,500.00 SYS $4.80 $40,800 4 HMA, SURFACE, TYPE B 701.00 TON $147 $103,047 5 SIDEWALK, CONCRETE, 4 IN. 276.00 SYS $104 $2%704 6 PARKING BLOCK 33.00 EACH $158 $5,214 7 CONSTRUCTION CONTINGENCY ALLOWANCE, ALT NO 1 1.00 ALLOLS W $5.000 $5000 AIt.1 Total $151,343 Version 07/19/2023 Special Provisions - 12 BID/PROPOSAL CITY OF SOUTH BEND Project Name Byers Softball Complex Improvements Phase 1 Project No. For Bids Due: Contractor Name: 123-072 December 10, 2024 PREMIUM CONCRETE SERVICES ALTERNATE #2 SPLASH PAD PARKING No. Description Quant, Unit Unit Price Extension 1 COMPACTED AGGREGATE NO.53 5.00 TON $120 $600 2 CURB, REMOVE 110.00 LFT $30 $3,300 3 EXCAVATION, COMMON 150.00 CYS $115 $17,250 4 HMA, SURFACE, TYPE B 18.00 TON $187 HMA, BASE, TYPE B 30.00 TON $130 F$3;3665 6 SIDEWALK, CONCRETE, 4 IN. 93.00 SYS $94 7 CURB RAMP, CONCRETE 12.00 SYS $310 $3,720 8 CURB, CONCRETE 146.00 LFT $65 $%490 9 SIGN, SHEET, ACCESSIBLE PARKING 1.00 EACH $670 $670 10 PAVEMENT MESSAGE MARKING, ACCESSIBLE PARKING 1.00 EACH $50 $50 11 PAVEMENT MARKING, 4" LINE 250.00 LFT $1 $250 12 CONSTRUCTION CONTINGENCY ALLOWANCE, ALT NO 2 1.00 ALLOLS W $5,000 $5000 Alt, 2 Total $56,338 ALTERNATE #3 SPLASH PAD SAFETY SURFACE No, Description Quant, Unit Unit Price Extension 1 SPLASH PAD SAFETY SURFACING 1.00 LS $85,000 $85,000 Alt, 3 Total $850000 Version 07/19/2023 Special Provisions - 13 BID/PROPOSAL CITY OF SOUTH BEND Project Name Byers Softball Complex Improvements Phase 1 Project No. For Bids Due: Contractor Name: 123-072 December 10, 2024 PREMIUM CONCRETE SERVICES ALTERNATE #4 BATTER'S EYE SCREENING No, Description Quant. Unit Unit Extension Price 1 PLANT, UPRIGHT EVERGREEN, B&B 105.00 EACH $395 $41,475 2 MULCH SHREDDED HARDWOOD BARK 36.00 CYS $120 $4,320 3 MULCHED SEEDING -320.00 SYS $5 -$11600 Alt, 4 $44,195 Total ALTERNATE #5 BATTER'S EYE SCREENING No, Description Quant. Unit Unit Extension Price 1 BALLFIELD EQUIPMENT, BARRIER NETTING 1 LS $136,820 $136,820 Alt, 5 $136,820 Total ALTERNATE #6 SOUTHEAST FIELD SUBGRADE REMEDIATION No, Description Quant, Unit Unit Extension Price 1 SUBGRADE REMEDIATION, DEFINITION OF 1 LS $610 $610 LIMITS 2 COMPACTED AGGREGATE NO. 53 4175.00 TON $32 $133,600 SUBGRADE REMEDIATION 3 INDOT TYPE IB GEOGRID 3,130.00 SYS $3,50 $10,995 4 GEOTEXTILE 6,410.00 SYS $2,50 $16,025 5 EXCAVATION, COMMON - SUBGRADE 3,130.00 SYS $20 $62,600 REMEDIATION Alt, 6 $223,790 Total Version 07/19/2023 Special Provisions - 14 BID/PROPOSAL CITY OF SOUTH BEND Project Name Byers Softball Complex Improvements Phase 1 Project No. For Bids Due: Contractor Name: 123-072 December 10, 2024 PREMIUM CONCRETE SERVICES ALTERNATE #7 BULLPEN SURFACING No. Description Quant, Un7it Unit Price Extension 1 BALLFIELD EQUIPMENT, BULLPENS, ARTIFICIAL TURF 4.00 EACH $5,500 $22,000 Alt, 7 Total $22,000 Bidder (Firm): PREMIUM CONCRETE SERVICES Address: 712 RICHMOND ST City/State/Zip: ELKHART, IN 46516 Telephone Number: (574) 264-0196 By dr (Signature) /" lA,t' VrR Kc )/ (Printed Name of Person Signing) Version 07/19/2023 Special Provisions - 15 Wien the prospective Contractor is unable to certify to any of the statements below, it shall attach an explanation to this Affrdavit. CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT, CERTIFICATION REGARDING INVESTMENT WITH IRAN, EMPLOYMENT ELIGIBILITY VERIFICATION, NON- DISCRIMINATION COMMITMENT AND CERTIFICATION OF USE OF UNITED STATES STEEL PRODUCTS OR FOUNDRY PRODUCTS (Must be completed for all quotes and bids. Please type or print) STATE OF D) IgP ) ) SS: X COUNTY ) The undersigned Contractor, being duly swot•n upon his/het•/its oath, affirms under the penalties of perjury that: 1. Contractor has not, nor has any other member, representative, or agent of the firm, company, corporation or partnership represented by him, entered into any combination, collusion or agreement with any person relative to the price to be bid by anyone at such letting nor to prevent any person from bidding or to induce anyone to refrain from bidding, and that this bid is made without reference to any other bid and without any agreement, understanding or combination with any other person in reference to such bidding. Contractor further says that no person or persons, firms, or corporation has, have or will receive directly or indirectly, any rebate, fee, gift, commission or thing of value on account of such sale; and 2. Contractor certifies by submission of this proposal that neither contractor nor any of its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency; and 3. Contractor has not, nor has any successor to, nor an affiliate of, Contractor, engaged in investment activities in Iran. a. For proposes ofthis Certification, "Iran" means the government of Iran and any agency or instrumentality of Iran, or as otherwise defined at Ind. Code § 5-22-16.5-5, as amended from time -to -time. b. As provided by Ind. Code § 5-22-16.5-8, as amended from time -to -time, a Contractor is engaged in investment activities in Iran if either: I. Contractor, its successor or its affiliate, provides goods or services of twenty million dollars ($20,000,000) ot• inore in value in the energy sector of Iran; or ii. Contractor, its successor or its affiliate, is a financial institution that extends twenty million dollars ($20,000,000) or more in credit to another person for forty-five (45) days or more, if that person will (i) use the credit to provides goods and services in the energy sector in Iran; and (ii) at the time the financial institution extends credit, is a person identified on list published by the Indiana Department of Administration. 4. Contractor does not knowingly employ or contract with an unauthorized alien, nor retain any employee or contract with a person that the Contractor subsequently learns is an unauthorized alien. Version 09/29l2024 Contractor's Bid for Public Works - 4 Contractor agrees that he/she/it shall enroll in and verify the work eligibility status of all of Contractor's newly hired employees through the E-Verify Program as defined by I.C. 22-5-1.7-3. Contractor's documentation of enrollment and participation in the E-Verify Program is included and attached as part of this bid/quote; and 5. Contractor shall require his/her/its subcontractors performing work under this public contract to certify that the subcontractors do not knowingly employ or contract with an unauthorized alien, nor retain any employee or contract with a person that the subcontractor subsequently learns is an unauthorized alien, and that the subcontractor has enrolled in and is participating in the E-Verify Program. The Contractor agrees to maintain this certification throughout the term of the contract with the City of South Bend, and understands that the City may terminate the contract for default if the Contractor fails to cure a breach of this provision no later than thirty (30) days after being notified by the City. 6. Persons, firms, partnerships, corporations, associations, orjoint venturers awarded a contract by the City of South Bend through its agencies, boards, or commissions shall not discriminate against any employee or applicant for employment in the performance of a City contract with respect to hire, tenure, terms, conditions, or privileges of contract or employment, or any matter directly or indirectly related to contracting or employment because of race, sex, religion, color, national origin, ancestry, gender expression, gender identity, sexual orientation, or due to age or disability that does not affect that person's ability to perform the work. In awarding contracts for the purchase of work, labor, services, supplies, equipment, materials, or any combination of the foregoing including, but not limited to, public works contracts awarded under public bidding laws or other contracts in which public bids are not required by law, the City, its agencies, boards, or commissions will consider the Contractor's good faith efforts to obtain participation by those subcontractors certified by the State of Indiana as a Minority Business ("MBE") or as a Women's Business Enterprise ("WBE") as a factor in determining the lowest, responsible, responsive bidder. Contractors seeking the award of a City contract cannot be required to award a subcontract to an MWBE; however, they may not unlawfully discriminate against said MBE/WBE. On goal -eligible contracts, Contractors are required to either meet both MBE and WBE utilization goals or demonstrate that the Contractor has made good faith efforts to obtain participation from MBE and WBE subcontractors. A finding of noncompliance or a discriminatory practice shall prohibit that Contractor from being awarded a City contract for a period of one (1) year from the date of such determination, and such determination may also be grounds for terminating the contact to which the discriminatory practice or noncompliance pertains. 7. The undersigned Contractor agrees that the following nondiscrimination commitment shall be made a part of any contract which it may henceforth enter into with the City of South Bend, Indiana or any of its agencies, boards or commissions. Contractor agrees not to discriminate against or intimidate any employee or applicant for employment in the performance of this contract with privileges of employment, or any matter directly or indirectly related to employment, because of race, religion, color, sex, gender expression, gender identity, sexual orientation, handicap, national origin or ancestry. Breach of this provision may be regarded as material breach of contract. I, the undersigned bidder or agent as contractor on a public works project, understand my statutory obligations to the use of steel products or foundry products made in the United States (I.C. 5-16-8-1). I hereby certify that I and all subcontractors employed by me for this project will use steel products or foundry products made in the United States on this project if awarded. I understand I have an affirmative duty to notify the City in my bid that my proposal does not include the use of steel products or foundry products made in the United States. I understand it is my sole obligation and responsibility to provide ajustification to the City, subject to review and approval, why the cost of United States made steel or foundry products is unreasonable. Prior to award and upon submission of bid which does not use steel products or foundry products made in the United States, the City, through its director of public works, shall make a determination if the price of United States made steel or foundry is unreasonable. I understand that violations hereunder Version 09/29/2024 Contractor's Bid for Public Works - 5 may result in forfeiture of contractual payments. I hereby affirm under the penalties of perjury that the facts and information contained in the foregoing bid for public works are true and correct. Dated this Al h day of _D C , 20Cki PREMIUM CONCRETE SERUhCES Cgt�k�a r/Bicjder (Fi )� � n Signature of/Conlraot�•/Bidder or�ts Agent ,j tee-JL4 L Vi'1 eL -/ f IKSI PE41-I' PrinteWine and Title/ Subscribed and sworn to before me this 1 day of My Commission Expires �� a e4�0 �� < 0. $� _� •�l�s7Yu�s Notliry Public County of Residence �t�C(� A JANEE M TOWNER NOTARY PUBLIC SEAL ELKHART COUNTY, STATE OF 1r, tl-h v MY COMMISSION EXPIRES FEBRUr COMMISSION NO.71'Xie JANEE M TOWNER NOTARY PUBLIC SEAL ELKHART COUNTY, STATE OF INDIANA MY COMMISSION EXPIRES FEBRUARY 12,1 COMMISSION NO.710399 Version 09/29/2024 Contractor's Bid for Public Works - 6 AIA Document asi oTM .2010 Bid Bond CONTRACTOR: SURETY: (Name, legal status and address) (Name, legal status and principal place Premium Concrete Services, Inc. of business) Old Republic Surety Company 712 Richmond St P. O. Box 0941 This document has important legal Elkhart, IN 46516 Brookfield, WI 53008-0941 consequences. Consultation with OWNER: an attorney is encouraged with (Name, legal status and address) respect to its completion or City of South Bend Board of Public Works modification. County -City Building Room 1316, 227 West Jefferson Blvd Any singular reference to South Bend, IN 46601 Contractor, Surety, Owner or BOND AMOUNT: other party shall be considered Five Percent of the Total Bid 5 % of Total Bid plural where applicable. PROJECT: (Name, location or address, and Project number, if any) Byers Softball Complex Improvements Phase 1, City Project No. 123-072 The Contractor and Surety are bound to the Owner in the amount set forth above, for the payment of which the Contractor and Surety bind themselves, their heirs, executors, administrators, successors and assigns, jointly and severally, as provided herein. The conditions of this Bond are such that if the Owner accepts the bid of the Contractor within the time specified in the bid documents, or within such time period as may be agreed to by the Owner and Contractor, and the Contractor either (1) enters into a contract with the Owner in accordance with the terms of such bid, and gives such bond or bonds as may be specified in the bidding or Contract Documents, with a surety admitted in the jurisdiction of the Project and otherwise acceptable to the Owner, for the faithful performance of such Contract and for the prompt payment of labor and material furnished in the prosecution thereof; or (2) pays to the Owner the difference, not to exceed the amount of this Bond, between the amount specified in said bid and such larger amount for which the Owner may in good faith contract with another party to perform the work covered by said bid, then this obligation shall be null and void, otherwise to remain in full force and effect. The Surety hereby waives any notice of an agreement between the Owner and Contractor to extend the time in which the Owner may accept the bid. Waiver of notice by the Surety shall not apply to any extension exceeding sixty (60) days in the aggregate beyond the time for acceptance of bids specified in the bid documents, and the Owner and Contractor shall obtain the Surety's consent for an extension beyond sixty (60) days. If this Bond is issued in connection with a subcontractor's bid to a Contractor, the term Contractor in this Bond shall be deemed to be Subcontractor and the term Owner shall be deemed to be Contractor. When this Bond has been famished to comply with a statutory or other legal requirement in the location of the Project, any provision in this Bond conflicting with said statutory or legal requirement shall be deemed deleted herefrom and provisions conforming to such statutory or other legal requirement shall be deemed incorporated herein. When so furnished, the intent is that this Bond shall be construed as a statutory bond and not as a common law bond. Sign d and7411VAOVI led this 9th day of December 2024 N P t ervic//xr09`, (Princ`pa (Seal) ( �) MY Ytallla, Ulu . R�sllho i ness �_ (Title) 0 euit J Old Republic Sur mte v Conanv "°a (Surety) AAL (Wi ness) (Title) Je er L. Kaszn' . Attornev;Ifi-Fact CAUTION: You should sign an original AIA Contract Document, on you should an AlA Contract Document, on wh�is text appears in RED. An original assures **** * OLD REPUBLIC SURETY COMPANY ** * ** POWER OF ATTORNEY KNOW ALL MEN BY THESE PRESENTS: That OLD REPUBLIC SURETY COMPANY, a Wisconsin stock insurance corporation, does make, constitute and appoint: NICOLE L 81CKNELL, MEGAN E RIESENBERG, MARK EDWARD WOBBE, BAReARA E PEARSON, JENNIFER L KASZNIA, SANDRA L JUNK, WILLIAM J CERNEY, III, WESLEY MANTOOTH, THERESA BURNS, JORDAN SCHEIBER, LISA M THOMAS, FAITH HUNT, PAMELA S. HIGGINBOTHAM of SOUTH BEND, IN its true and lawful Attorneys) -in -Fact, with full power and authority for and on behalf of the company as surety, to execute and deliver and affix the seal of the company thereto (if a seal is required), bonds, undertakings, recognizances or other written obligations in the nature thereof, (other than bail bonds, bank depository bonds, moHgage deficiency bonds, mortgage guaranty bonds, guarantees of Installment paper and note guaranty bonds, self-insurance workers compensation bonds guaranteeing payment of benefits, or black lung bonds), as follows: ALL WRITTEN INSTRUMENTS IN AN AMOUNT NOT TO EXCEED TWENTY MILLION ($20,000,000) FOR ANY SINGLE OBLIGATION and to bind OLD REPUBLIC SURETY COMPANY thereby, and all of the acts of said Attorneys -in -Fact, pursuant to these presents, are ratified and confirmed. This appointment is made under and by authority of the board of directors at a special meeting held on February 18, 1982. This Power of Attorney is signed and sealed by facsimile under and by the authority of the following resolutions adopted by the board of directors of the OLD REPUBLIC SURETY COMPANY on February 18,1982. RESOLVED that, the president, any vice-president or assistant vice president, in conjunction with the secretary or any assistant secretary, may appoint attorneys -in -fact or agents with authority as defined or limited in the instrument evidencing the appointment in each case, for and on behalf of the company to execute and deliver and affix the seal of the company to bonds, undertakings, recognizances, and suretyship obligations of all kinds; and said officers may remove any such attorney -in -fact or agent and revoke any Power of Attorney previously granted to such person. RESOLVED FURTHER, that any bond, undertaking, recognizance, or suretyship obligation shall be valid and binding upon the Company (i) when signed by the president, any vice president or assistant vice president, and attested and sealed (if a seal be required) by any secretary or assistant secretary; or (ii) when signed by the president, any vice president or assistant vice president, secretary or assistant secretary, and countersigned and sealed (if a seal be required) by a duly authorized attorney -in -factor agent; or (iii) when duly executed and sealed (if a seal be required) by one or more attorneys -in -fact or agents pursuant to and within the limits of the authority evidenced by the Power of Attorney issued by the company to such person or persons. RESOLVED FURTHER that the signature of any authorized offcer and the seal of the company may be affixed by facsimile to any Power of Attorney or certification thereof authorizing the execution and delivery of any bond, undertaking, recognizance, or other suretyship obligations of the company; and such signature and seal when so used shall have the same force and effect as though manually affixed. IN WITNESS WHEREOF, OLD REPUBLIC SURETY COMPANY has caused these presents to be signed by its proper officer, and its corporate seal to be affixed this 30th day of November 2022 't// ,,��c"BugEl`,,,, OLD REPUBLIC///S///U]RETY COMPANY y� SEAL j� au, ��nt Secreta �" President m"o,,, ,nom.. STATE OF WISCONSIN, COUNTY OF WAUKESHA - SS On this 301h day of November 2022 came before me, Alan Pavlic and Karen J Haffner ,personally , to me known to be the individuals and officers of the OLD REPUBLIC SURETY COMPANY who executed the above instrument, and they each acknowledged the execution of the same, and being by me duly sworn, did severally depose and say: that they are the said officers of the corporation aforesaid, and that the seal affixed to the above instrument is the seal of the corporation, and that said corporate seal and their signatures as such officers were duly affixed and subscribed to the said instrument by the authority of the board of directors of said corporation. 'q,. �otAq��, �Y/ ;AUeI�� M�� Nola`ry Public +ti_vn My Commission Expires: September 28. 2026 CERTIFICATE (Expiration of notary's commission does not invalidate this instrument) I, the undersigned, assistant secretary of the OLD REPUBLIC SURETY COMPANY, a Wisconsin corporation, CERTIFY that the foregoing and attached Power of Attorney remains in full force and has not been revoked; and furthermore, that the Resolutions of the board of directors set forth in the Power of Attorney, are now in force. _�'`°"""""`�°s' 9th December 2024 45-5314 'yp SEAL j "> Signed and sealed at the City of Brookfield, WI this ,/I(d/\ay o�f��/^"��{J�l�� --- . ORSC 22262 (3-06) "'*�"` � t ` 1 Assis:l�t1 Secreta GIBBON INSURANCE AGENCY, INC. PART II or projects of $100,000 or more — IC 36-1-12-4) These statements to be submitted under oath by each bidder with and as part of his/her/its bid. Attach additional pages for each section as needed. SECTION I EXPERIENCE QUESTIONNAIRE 1. Attach information regarding projects your organization has completed for the period of one (1) year prior to the date of the current bid. 2. Attach a listing of public works projects currently in process of construction by your organization. 3. Attach information regarding any failure to complete any work awarded to you and the location thereof. 4. Attach references from private firms for which you have performed work. SECTION II PLAN AND EQUIPMENT QUESTIONNAIRE 1. Attach an explanation of your plan or layout for performing proposed work. (Examples could include a narrative of when you could begin work, complete the project, number of workers, etc. and any other information which you believe would enable the City of South Bend to consider your bid.) 2. Attach a listing of the names and addresses of all subcontractors (i.e. persons or firms outside your own firm who have performed part of the work) that you have used on public works projects during the past five (5) years along with a brief description of the work done by each subcontractor. If you intend to sublet any portion of the work, attach the name and address of each subcontractor, equipment to be used by the subcontractor, and whether you will require a bond. However, if you are unable to currently provide a listing, please understand a listing must be provided prior to contract approval. Until the completion of the proposed project, you are under a continuing obligation to immediately notify the City of South Bend in the event that you subsequently determine that you will use a subcontractor on the proposed project. 4. Attach a listing of equipment you have available to use for the proposed project. 5. Have you entered into contracts or received offers for all materials which substantiate the prices used in preparing your proposal? If not, attach an explanation for the rationale used which would corroborate the prices listed. SECTION III CONTRACTOR'S FINANCIAL STATEMENT Attachment of bidder's financial statement is mandatory. Any bid submitted without said financial statement as required by statute shall thereby be rendered invalid. The financial statement provided hereunder to the City of South Bend awarding the contract must be specific enough in detail so that said City of South Bend can make a proper determination of the bidder's capability for completing the project if awarded. Version 09/29/2024 Contractor's Bid for Public Works - 3 Premium Concrete Services, Inc. 712 Richmond Street Elkhart, IN 46516 (574) 264-0196 SECTION I EXPERIENCE QUESTIONAIRE 1) PUBLIC WORKS PROJECTS COMPLETED IN PAST YEAR: CONTRACT AMOUNT COMPLETION DATE OWNER $ 956,975.00 CURB & SIDEWALK 5/2024 CITY OF SOUTH BEND $ 486,975,50 SPLASHPADS 7/2024 CITY OF SOUTH BEND $ 788,990.00 MULTI -USE PATH 7/2024 CITY OF ELKHART $ 638,543,00 PARK IMPROVEMENTS 9/2024 TOWN OF WINONA LAKE $ 210,200,00 ADA CURB RAMPS 9/2024 CITY OF ELKHART 2) PUBLIC WORKS PROJECTS IN PROGRESS: CONTRACT AMOUNT COMPLETIO N DATE OWNER $ 7,394,177.00 STREETSCAPE 4/2025 CITY OF ELKHART $ 3047630.00 TRAFFIC CALMING 8/2025 CITY OF SOUTH BEND $ 286,754,00 ROAD IMPROVEMENTS 4/2025 CITY OF ELKHART 3) HAVE NEVER FAILED TO COMPLETE ANY WORK THAT WAS AWARDED TO US. 4) REFERENCES: a. NISOURCE - MR. LUKE BRADLEY- 1039 PENNSYLVANIA AVE SOUTH BEND, IN 46601 b. COZIER MANUFACTURING - MR. KEN MURR-402 N MAIN MIDDLEBURY, IN 46540 Premium Concrete Services, Inc. 712 Richmond Street Elkhart, IN 46516 (574) 264-0196 SECTION II PLAN AND EQUIPMENT QUESTIONAIRE 1) Project: Byers Softball Complex Improvements Phase 1 PROJECT # 123-072 -Schedule: After given the notice to proceed, Premium Concrete Services, Inc. will then contact Indiana 811 to locate all utility lines within construction limits. Private locates may be necessary. Layout and staking of sites will be next. Then erosion control, removals, excavation, grading, and subgrade with a 3-5 man crew. All field work will commence as soon as weather allows. Work on pressbox will also begin as soon as weather allows with a 2-4 man crew. After excavation and grading phases are complete, concrete work will commence. Forming and pouring of concrete work will be completed with a 5-man crew. Project will finish with parking lot patching, crack seal, repair & striping. Subs will be utilized on this project to complete electric, plumbing, splash pad equipment, crack sealing & repair, pavement markings, landscaping & trucking. Multiple crews may be working at the same time. Project with be completed on schedule. 2) a) State Barricading Inc.- 24963 US 20 West South Bend, IN 46628 —Traffic Maintenance &Signs b) Acorn Landscaping — 3680 W Sample St South Bend, IN 46619 —Top Soil and Sodding. c) 1'' Class Logistics — 2213 St Charles St South Bend, IN 46614 - Trucking d) Hawk Enterprises —1850 East North St Crown Point, IN 46307 - Electric e) KC Tree, Inc —8913 East US Hwy 20 New Carlisle, IN 46552—Tree Removal f) A-1 Striping Service Inc. — 56825 Spirea Rd, New Carlisle, IN 46552 —Painting g) Slusser's Green Thumb, Inc. —1610 Genesis Dr LaPorte, IN 46350 - Landscaping h) Herrman & Goetz, Inc. — 225 South Lafayette Blvd, IN 46601— Electric & Plumbing Premium Concrete Services, Inc. Does not require bonding for its subcontractors 3) Will supply list of subcontractors soon after award of project. 4) Equipment use for project: Skid Steers, Mini Excavators, Excavators, Compactors, Rollers, Wall< - behind Saws, Cut-off Saws, Friction Screed, Dump Trucl<. Current plan is to used owned equipment, however depending on workload some rental equipment may be necessary. 5) Yes, Premium Concrete Services, Inc. has quotes for all materials in proposal. SOT'+o CITY OF SOUTH BEND MINORITY AND WOMEN BUSINESS ENTERPRISE INCLUSION PROGRAM PLAN FORM MBE-1.0 MBE UTILIZATION PLAN This completed form should be supplied with Bids that pertain to City of South Bend Public Works Projects involving MBE participation. It is the bidder's sole responsibility to verify whether any listed minority -owned business meets the MBE qualifications. ***Goals should be calculated based on the Base Bid only.*** Project Number: Bidder. 123-072 Project Name: Byers Softball Complex Improvements Phase 1 PREMIUM CONCRETE SERVICES Total Bid Amount: $ 2,902,396.00 MBE Goal: 1.74% Name &Address of MBE Primary Contact Person (Name/Telephone) Scope of Work to be Performed (Attach scope/schedule if you need additional space) Dollar Amount of MBE Component Percentage of Total Bid/Proposal 1ST CLASS LOGISTICS 2213 ST CHARLES ST SOUTH BEND, IN 46614 BERNARD COUTEE (574) 993-0071 TRUCKING/HAULING $ 50,568.00 1.74% Submitted by: RACY Print Name Signature Date ***Goals should be calculated based on the Base Bid only.*** Version 07/19/2023 Special Provisions - 16 mcTa eE� CITY OF SOUTH BEND ial MINORITY AND WOMEN BUSINESS ENTERPRISE INCLUSION PROGRAM PLAN / FORM WBE-1.0 WBE UTILIZATION PLAN 11 This completed form should be supplied with Bids that pertain to City of South Bend Public Works Projects involving WBE participation. It is the bidder's sole responsibility to verify whether any listed woman -owned business meets the WBE qualifications. ***Goals should be calculated based on the Base Bid only.*** Project Number: Bidder: Project Name: Byers Softball Complex Improvements Phase 1 PREMIUM CONCRETE SERVICES Total Bid Amount: 2,902,396.00 WBE Goal: Page of Name &Address of WBE Primary Contact Person (Name/Telephone) Scope of Work to be Performed (Attach scope/schedule if you need additional space) Dollar Amount of WBE Component Percentage of Total Bid/Proposal SLUSSER'S GREEN THUMB 125 MONTGOMERY ST LOGANSPORT, IN 46947 JOHN WILLIAMSON (800) 762-7442 LANDSCAPING $ 116,100.00 4.00% Submitted by: /y?t}x KGA%KE/ /�4 �b/2 Print Name Signature Date ***Goals should be calculated based on the Base Bid only.*** Version 07/19/2023 Special Provisions - 17 y>U GII OF J.. O CITY OF SOUTH BEND o MINORITY AND WOMEN BUSINESS ENTERPRISE INCLUSION PROGRAM PLAN FORM MBE-2.0 EVIDENCE OF GOOD FAITH EFFORTS This completed form should be included as part of the Bids documents related to City of South Bend Public Works Projects requiring Good Faith Efforts to obtain MBE participation. Project Number: Project Name: Bidder: Contact Person: Address: City: Email: Date: 12/9/2024 Byers Softball Complex Improvements Phase 1 PREMIUM CONCRETE SERVICES ROB BECKER Telephone: (574) 264-0196 712 RICHMOND ST ELKHART State: IN Zip 46516 RBECKER@PREMIUMSERV ICES. GROUP To determine whether a bidder has demonstrated good faith efforts to reach the MBE utilization goals set forth in the City of South Bend Public Works Project Specifications, the City and its agencies, boards, or commissions, REQUIRE ALL of the following Good Faith Efforts as listed in the table below*: EVIDENCE OF GOOD FAITH EFFORTS MBE LIST(S): The bidder reviewed 1) the City of South Bend's Minority and Women Business Enterprise Inclusion Program Plan; 2) the list of certified MWBEs provided by the City; and 3) the Indiana Department of Administration list of Minority and Women Owned Businesses (both certified and non -certified) found at: htt ://www.in.gov/idoa/. GOOD FAITH EFFORTS TO OBTAIN MBE PARTICIPATION The biddershall initial each item below, as evidence of its good faith efforts to obtain MBE participation in the awarded contract. I affirm that I reviewed the City of South Bend's Minority and Women Business Enterprise r� Inclusion Program Plan and the Indiana Department of Administration's certified list of `j Indiana Minority and Women Business Enterprises, found on their website htt ://www.in. ov/idoa . I affirm that I have made good faith efforts to select portions of the contract work to be performed by MWBEs, including, where appropriate, breaking out contract work items into 'hYY economically feasible units to facilitate MBE participation. /)��yy/,, I affirm that I have made good faith efforts to solicit through all reasonable and available i means the interest of all MBEs in the scopes of work of the contract. I affirm that I attended all pre -bid meetings scheduled by the City of South Bend to inform MBEs of contracting and subcontracting opportunities. I affirm that I advertised in general circulation and/or trade association publications concerning subcontract opportunities and allowed MBEs reasonable time to respond to such advertisements. r•'(/� I affirm that 1 performed any and all necessary steps to provide written notices in a manner reasonably calculated to inform MBEs of subcontracting opportunities and allowed sufficient time for MBEs to participate effectively. I affirm that I followed up on initial solicitations with interested MBEs. I affirm that I negotiated with interested MBEs in good faith, including providing such MBEs ^ 1/1 with adequate information about the plans, specifications and other requirements of the subcontract. I affirm that I have made good faith efforts to assist interested MBEs in obtaining bonding, lines of credit, or insurance as required by the City or the bidder, where appropriate. Version 07/19/2023 Special Provisions - 18 CITY OF SOUTH BEND MINORITY AND WOMEN BUSINESS ENTERPRISE INCLUSION PROGRAM PLAN FORM MBE-2.0 EVIDENCE OF GOOD FAITH EFFORTS IY� I affirm that I have made good faith efforts to assist interested MBEs in obtaining necessary equipment, supplies, materials, or related assistances or services, where appropriate. I affirm that I did not reject any MBEs as unqualified without sound business reasons based on a thorough investigation of their capabilities. CONTRACT RECORDS: The bidder has maintained the following records for each MBE that has bid on the subcontracting opportunity: 1. Name, address, and telephone number; 2. A description of information provided by the bidder or subcontractor; and 3. A statement of whether an agreement was reached, and if not, why not, including any reasons for concluding that the MBE was unqualified to perform the job. *Proper demonstration of Good Faith Efforts requires your initials next to all of the above boxes. Any omissions shall be considered grounds for rejection of the bid by the Board of Public Works. The City of South Bend reserves the right to request additional information. Version 07/19/2023 Special Provisions - 19 irx o n o/ CITY OF SOUTH BEND( o MINORITY AND WOMEN BUSINESS ENTERPRISE INCLUSION PROGRAM PLAN 's FORM WBE-2.0 EVIDENCE OF GOOD FAITH EFFORTS This completed form should be included as part of the Bids documents related to City of South Bend Public Works Projects requiring Good Faith Efforts to obtain MWBE participation. Project Number: 123-072 Date: 12/9/2024 Project Name: Bidder: Contact Person: Address: City: Email: Byers Softball Complex Improvements Phase 1 PREMIUM CONCRETE SERVICES ROB BECKER 712 RICHMOND ST ELKHART State: IN RBECKER@PREMIUMSERVICES.GROUP Telephone: (574) 264-0196 46516 To determine whether a bidder has demonstrated good faith efforts to reach the WBE utilization goals set forth in the City of South Bend Public Works Project Specifications, the City and its agencies, boards, or commissions, REQUIRE ALL of the following Good Faith Efforts as listed in the table below*: EVIDENCE OF GOOD FAITH EFFORTS WBE LIST(S): The bidder reviewed 1) the City of South Bend's Minority and Women Business Enterprise Inclusion Program Plan; 2) the list of certified MWBEs provided by the City; and 3) the Indiana Department of Administration list of Minority and Women Owned Businesses (both certified and non -certified) found at: http://www.in.gov/idoa/. GOOD FAITH EFFORTS TO OBTAIN WBE PARTICIPATION The bidder shall initial each item below, as evidence of its good faith efforts to obtain WBE participation in the awarded contract. I affirm that I reviewed the City of South Bend's Minority and Women Business Enterprise Inclusion Program Plan and the Indiana Department of Administration's certified list of Ij Indiana Minority and Women Business Enterprises, found on their website htt ://www.in. ov/idoa . I affirm that I have made good faith efforts to select portions of the contract work to be performed by WBEs, including, where appropriate, breaking out contract work items into economically feasible units to facilitate WBE participation. I affirm that I have made good faith efforts to solicit through all reasonable and available means the interest of all WBEs in the scopes of work of the contract. I affirm that I attended all pre -bid meetings scheduled by the City of South Bend to inform WBEs of contracting and subcontracting opportunities. I affirm that I advertised in general circulation and/or trade association publications concerning subcontract opportunities and allowed WBEs reasonable time to respond to such advertisements. I affirm that I performed any and all necessary steps to provide written notices in a manner {l/h reasonably calculated to inform WBEs of subcontracting opportunities and allowed sufficient time for WBEs to participate effectively. I affirm that I followed up on initial solicitations with interested WBEs. „ ^ I affirm that I negotiated with interested WBEs in good faith, including providing such WBEs with adequate information about the plans, specifications and other requirements of the subcontract. !l� 1 affirm that I have made good faith efforts to assist interested WBEs in obtaining bonding, Jlines of credit, or insurance as required by the City or the bidder, where appropriate. Version 07119/2023 Special Provisions - 20 CITY OF SOUTH BEND MINORITY AND WOMEN BUSINESS ENTERPRISE INCLUSION PROGRAM PLAN FORM WBE-2.0 EVIDENCE OF GOOD FAITH EFFORTS I affirm that I have made good faith efforts to assist interested WBEs in obtaining necessary equipment, supplies, materials, or related assistances or services, where appropriate. I affirm that I did not reject any WBEs as unqualified without sound business reasons L/ based on a thorough investigation of their capabilities. CONTRACT RECORDS: The bidder has maintained the following records for each WBE that has bid on the subcontracting opportunity: 1. Name, address, and telephone number; 2. A description of information provided by the bidder or subcontractor; and 3. A statement of whether an agreement was reached, and if not, why not, including any reasons for concluding that the MWBE was unqualified to perform the job. *Proper demonstration of Good Faith Efforts requires your initials next to all of the above boxes. any omissions shall be considered grounds for rejection of the bid by the Board of Public Works. The City of South Bend reserves the right to request additional information. Version 07/19/2023 Special Provisions - 21 04 f141 CITY OF SOUTH BEND MINORITY AND WOMEN BUSINESS ENTERPRISE INCLUSION PROGRAM PLAN FORM MBE-2.1 " sJ MBE CONTACTED This completed form should be supplied with Bids that pertain to City of South Bend Public Works Projects requiring Good Faith Efforts to contact MBEs. It is the bidder's sole responsibility to verify whether any listed minority -owned business meets the MBE qualifications. Attach additional pages if necessary. PAGE I OF 1 Project Number: 123-072 MBE Participation Goal 1.74% Project Name: Byers Softball Complex Improvements Phase 1 Bidder: PREMIUM C CRETE SERVI,C/ES By: V j2l/9? 5`� MBE Firm IST CLASS LOGISTICS Owner or Contact at MBE Firm BERNARD COUTEE Telephone: (574) 993-0071 Fax: Email: ISTCLASSI.OGISTICS2013@GMAIL.COM TYPE OF WORK SOLICITED FOR THIS PROJECT: TRUCKING/HAULING RESULTS OF CONTACT WITH THE MBE FIRM: WILL UTILIZE IF AWARDED MBE Firm Owner or Contact at MBE Firm Telephone: Fax: Email: TYPE OF WORK SOLICITED FOR THIS PROJECT: RESULTS OF CONTACT WITH THE MBE FIRM: Version 07/19/2023 Special Provisions - 22 y�U rft p CITY OF SOUTH BEND ` MINORITY AND WOMEN BUSINESS ENTERPRISE INCLUSION PROGRAM PLAN FORM MBE-2.1 bra, WBE CONTACTED This completed form should be supplied with Bids that pertain to City of South Bend Public Works Projects requiring Good Faith Efforts to contact WBEs. It is the bidder's sole responsibility to verify whether any listed woman -owned business meets the WBE qualifications. Attach additional pages if necessary. PAGE I OF 1 Project Number: 123-072 WBE Participation Goal 3.97% Project Name: Byers Softball Complex Improvements Phase 1 Bidder: PREMI ONCRETE SERVICES By: WBE Firm SLUSSER'S GREEN THUMB Owner or Contact at WBE Firm JOHN WILLIAMSON Telephone: (574) 722-3102 Fax: Email: JDW@slussers.com TYPE OF WORK SOLICITED FOR THIS PROJECT: LANDSCAPING RESULTS OF CONTACT WITH THE WBE FIRM: WILL UTILIZE IF AWARDED WBE Firm Owner or Contact at WBE Firm Telephone: Fax: Email: TYPE OF WORK SOLICITED FOR THIS PROJECT: RESULTS OF CONTACT WITH THE WBE FIRM: Version 07/19/2023 Special Provisions - 23 :; 04SDt TH UEyb F I'ILL p pd � el sal 1316 COUNTY-i)ITY BUILDING PHONE 574/235-9251 FAX 574/235-9171 227 W. JEFFERSON BOULEVARD Iflfiv .X SOUTH BEND, INDIAN A 46601-1830 TDD 574/ 235-5567 CITY OF SOUTH BEND, JAMES MUELLER, MAYOR BOARD OF PUBLIC WORKS Date: November 27, 2024 To: All Planholdels From Theresa Heffner, Clerk, Board of Public Works Subject Addendum Number: I Project Name: Byers Softball Complex Improvements Project Number: 123-072 ACKNOWLEDGEMENT OF RECEIPT OF ADDENDUM L Date Received: 2 /�2 a / This addendum is being forwarded to you for the above referenced project. Please sign below and acknowledge receipt of this Addendum by faxing this sheet to the Board of Public Works at (574) 2354171 within 48 hours of receipt. A copy MUST also be included with your bid package upon submittal. THIS ADDENDUM MAY AFFECT YOUR BID. The attached documents are hereby added to the Specifications and Contract Documents and become a part of herein. Authorized Signature: Date: / oe z1 ! a Version 4/2/2015 �45otiTil UEy O d', St'1 1316 COUNTY -CITY BUILDING PHONE 574/235-9251 227 W. JEFFEiSON BOULEVARD 1865 X FAX 574/ 235-9I71 SOUTH BEND, INDIANA4660I-1830 TDD 574/235-5567 CITY OF SOUTH BEND, JAMES MUELLER, MAYOR BOARD OF PUBLIC WORKS Date: December 4, 2024 To: All Planholders From Theresa Heffner, Clerk, Board of Public Works Subject Addendum Number: 2 Project Name: Byers Softball Complex Improvements Project Number: 123-072 ACKNOWLEDGEMENT OF RECEIPT OF ADDENDUM Date Received: 12 A %Z This addendum is being forwarded to you for the above referenced project. Please sign below and acknowledge receipt of this Addendum by faxing this sheet to the Board of Public Works at (574) 2354171 within 48 hours of receipt. A copy MUST also be included with your bid package upon submittal. THIS ADDENDUM MAY AFFECT YOUR BID. The attached documents are hereby added to the Specifications and Contract Documents and become a part of herein. Company: Authorized Signature: Date: Version 4/2/2015 'ourr Bp U d'1 I� }Z CITY OF SOUTH BEND, INDIANA CONTRACTOR'S BID FOR PUBLIC WORK CHECKLIST FOR BIDDERS Project Name Byers Softball Complex Improvements Phase 1 Project No. 123-072 For Bids Due December 10, 2024 From time to time the South Bend Board of Public Works finds it necessary to reject a bid because it does not comply with statutory requirements. In preparing your bid, please use the following checklist in order to make sure that your bid is done in the proper manner. / Proper bid security included. The bidder has the option of providing either a Certified Check ✓ or Bid Bond. Bid prepared on the City of South Bend Contractor's Bid for Public Work Form, completely executed. Contractor's Non -Collusion and Non -Debarment Affidavit, Certification Regarding Investments / with Iran, Employment Eligibility Verification, Non -Discrimination Commitment, and r/ Certification of use of United States Steel Products or Foundry Products. Proof of M/WBE Utilization Plans [MBE-1.0 and WBE-1.0]. Also provide Evidence of Good / Faith Efforts Forms [MBE-2.0 and WBE-2.0] and M/WBE Contacted Forms [MBE-2.1 and [/ WBE-2.1]. Acknowledge Receipt of � Addendum(s) included with the bid. All required additional information is included with the bid. / Proposal statements and other affidavits all signed by the proper party with name either V printed or typed underneath signature. V This checklist submitted with the Bid. This checklist is provided for bidder's use in assuring compliance with required documentation; however, it does not include all specifications requirements and does not relieve the bidder of the need to read and comply with the specifications. Bidder: PREMIUM CONCRETE SERVICES By Authorized Representative: Signature: a p Date: 12/9/2024 Version 07/19/2023 Special Provisions - 1 CITY OF SOUTH BEND, INDIANA CONTRACTOR'S BID FOR PUBLIC WORK RESPONSIBLE BIDDER CHECKLIST Project Name Byers Softball Complex Improvements Phase 1 Project No. 123.072 For Bids Due December 10, 2024 Contractor Name: PREMIUM CONCRETE SERVICES The City seeks to enhance its ability to identify responsive and responsible bidders on all City public works projects by institution of comprehensive submission requirements in compliance with State law. Quality workmanship, efficient operation, safety, and timely completion of projects requires that all bidders meet certain minimum requirements to be responsive and responsible bidders. THIS FORM MUST BE SUBMITTED WITH YOUR BID. If you are apre-qualified bidder, complete Section I only. If you are not a pre -qualified bidder, complete Section II only. Section II acts as an application for pre -qualification. Submission of Section II will allow the bidder to be considered for pre -qualification for bids with the City of South Bend Department of Public Works. Pre - qualified bidders will then be exempt from a portion of the submission requirements outlined in Section 6- 63 of The Responsible Bidding Ordinance No. 10594-18 (hereinafter, "Responsible Bidding Ordinance") for a period of twelve (12) months. Thereafter, contractors who are pre -qualified must submit a complete application for continuation of "pre - qualified" standing, on a form provided by the City ("Responsible Bidder Checklist (1) Pre -Qualified Bidders") by December 3151 for the upcoming calendar year, or within twelve (12) months of obtaining pre - qualified standing. If the status of any item changes within the twelve (12) months, it is the responsibility of the contractor to notify the City. Failure by any pre -qualified contractor to submit its complete application for continuation of "pre -qualified" standing within the time prescribed above shall result in automatic removal of the designation, effective January 1 of the following year, or immediately following the twelve (12) months of pre -qualified standing. However, the "removed" contractor or subcontractor shall still be permitted to bid on City public works projects, though the contractor must submit all required documents under 6-63 until "pre -qualified" status s re-established. Please Note: The City reserves the right to request supplemental information from the bidder, additional verification of any information provided by the bidder, and may also conduct random inquiries of the bidder's current and previous customers regardless of pre -qualified standing. t is the sole responsibility of the potential bidder to comply with all submission requirements applicable to the bidder in Section 6-63 of the Responsible Bidding Ordinance no later than the date of the public bid opening. Version 07/19/2023 General Conditions - 11 POST BID SUBMISSIONS: Post -bid submissions must be submitted in accordance with Section 6-72 of the Responsible Bidding Ordinance. The post -bid submission requirements are as follows: 1. All bidders shall collect, maintain, and provide upon request, a current written list that discloses the name, address, licensing status, and type of work for any subcontractor from whom the bidder has accepted a bid and/or intends to hire on any part of the public work project, including individuals performing work as independent contractors. 2. Each subcontractor, whose portion of the project is estimated to be at least two -hundred fifty thousand dollars ($250,000.00), shall be required to adhere to the requirements of Section I of the Responsible Bidder Ordinance as though it were bidding directly to the City, except that the subcontractor shall submit the required information (including the name, address, and type of work) to the successful bidder prior to the commencement of work. 3. Failure of a subcontractor to submit the required information shall not disqualify the successful bidder from performing work on the project and shall not constitute a contractual default and/or breach by the successful bidder. However, the City may withhold all payment otherwise due for work performed by a subcontractor, until the subcontractor submits the required information and the City approves such information. 4. The disclosure of a subcontractor list ("Disclosed Subcontractor(s)") to the City by a bidder shall not create any rights in the Disclosed Subcontractor(s). Thus, a bidder may substitute another subcontractor for a Disclosed Subcontractor by giving the City, upon request, written notice of the name, address, licensing status, and type of work of the substitute subcontractor. 5. The successful bidder for projects greater than $250,000 and all subcontractors performing work greater than $250,000 on a public works project are required to submit certified payroll utilizing the federal form known as WH-347 or a similar form on a bi-weekly basis, submitted within 10 days after the end of each bi-weekly payroll period. Certified payrolls shall identify the job title and craft for each employee. Certified payrolls shall be submitted electronically. Please Note: Submissions deemed inadequate, incomplete, or untimely by the City may result in the automatic disqualification of the bid. The City, after review of complete and timely submissions, shall, in its sole discretion, after taking into account all information in the submission requirements, determine whether a bidder is responsive and esponsible, and provide a Pre -Qualification Verification Letter. The City specifically reserves the right to utilize all information provided in the contractor's submission and any information obtained by the City through its own independent verification of the information provided by the contractor. Version 5/20/2024 General Conditions - 11 PRE -QUALIFIED BIDDER CHECKLIST (a) Acknowledgements: (i) _ By checking this box, I hereby acknowledge that I am a pre -qualified bidder with the City of South Bend and that I have met the pre -qualification requirements within the last twelve (12) months. A copy of my Pre -Qualification verification letter is attached. By checking this box, I hereby acknowledge that the City reserves the right to request supplemental information, additional verification of any information provided by me, and may also conduct random inquiries of my current and prior customers. By checking this box, I hereby acknowledge that apprenticeship and training programs that I participate in have graduated at least five (5) apprentices in each of the past five (5) years. (iv) _ By checking this box, I hereby acknowledge that all subcontractors performing work greater than $250,000 also meet the qualifications of the Responsible Bidder Ordinance. (b) Attachments (i) _ Indiana Secretary of State's on-line records (ie. Business verification) dated within sixty (60) days of the submission of said document showing that business is in existence, current with the Indiana Secretary of State's Business Entity Report, and eligible for a certificate of good standing. (Not applicable to individuals, sole proprietors or partnerships). Statement on staffing capabilities, including labor sources. This statement indicates and ensures I have sufficient employees on staff to complete the work. It outlines how I intend to meet the staffing needs of the work. (iii) _ List of projects of similar size and scope of work performed in all areas, including the State of Indiana, within the last three (3) years. (iv) _ For every project, submit evidence of participation in apprenticeship and training programs, applicable to the work to be performed on the project, which are approved by and registered with the United States Department of Labor's Office of Apprenticeship, or its successor organization. This includes, but may not be limited to, letters from apprenticeship coordinators detailing the bidder's association with the program, and the United States Department of Labor Office of Apprenticeship Certificates of Registration of Apprenticeship Programs for each type of work to be performed on the project. Version 5/20/2024 General Conditions - 12 11, PRE -QUALIFICATION CHECKLIST (FOR BIDDERS THAT ARE NOT PRE -QUALIFIED) (a) Acknowledgements: (i) X By checking this box, I hereby acknowledge that I am not a pre -qualified bidder with the City of South Bend. (ii) X By checking this box, I hereby acknowledge that the City reserves the right to request supplemental information, additional verification of any information provided, and may also conduct random inquiries of my current and prior customers. The City reserved the right to utilize all information provided in this submission and all information obtained in inquiries or requests to determine if a bidder is responsive and responsible. Additionally, I acknowledge that all information provided to the City shall be regarded as public records. (iii) X By checking this box, I hereby acknowledge that copies of all Applicable apprenticeship certificates or standards for training programs applicable to the work performed on the project may be requested at any time and shall be furnished upon request. (iv) X By checking this box, I hereby acknowledge and ensure that I and all sub- contractors, from whom I have accepted a bid and/or intend to hire to perform work on the public work project, are properly licensed. Furthermore, I acknowledge my understanding that it is my responsibility to ensure that all sub -contractors have the necessary licenses to undertake the work called for in this bid. If a sub- contractor loses their license at any point, it is the responsibility of that sub- contractor to notify the City. (v) X By checking this box, I hereby acknowledge that apprenticeship and training programs that I participate in have graduated at least five (5) apprentices in each of the past five (5) years. (vi) X By checking this box, I hereby acknowledge that all subcontractors performing work greater than $250,000 also meet the qualifications of the Responsible Bidder Ordinance. (b) Attachments: (i) X Indiana Secretary of State's on-line records (ie. Business verification) dated within sixty (60) days of the submission of said document showing that business is in existence, current with the Indiana Secretary of State's Business Entity Report, and eligible for a certificate of good standing. (Not applicable to individuals, sole proprietors or partnerships). (ii) X List identifying all former business names. (III) X Any determinations by a court or governmental agency any violations of federal state, or local laws including, but not limited to, violations of contracting or antitrust laws, tax or licensing laws, environmental laws, Occupational Safety and Health Act (OSHA), or federal Davis -Bacon and related Acts, within the preceding five (5) years. (iv) X Statement about staffing capabilities, including labor sources. This statement indicates and ensures I have sufficient employees on staff to complete the work I am bidding on OR outlines how I intend to meet the staffing needs of the work. (v) X Statement that individuals who will perform work on the public work project on my behalf will be properly classified as an employee or as an independent contractor under all applicable state and federal laws and local ordinances. (v) X For every project, submit evidence of participation in apprenticeship and training programs, applicable to the work to be performed on the project, which are approved by and registered with the United States Department of Labor's Office of Apprenticeship, or its successor organization. This includes, but may not be limited to, letters from apprenticeship coordinators detailing the bidder's association with Version 5/20/2024 General Conditions - 13 the program, and the United States Department of Labor Office of Apprenticeship Certificates of Registration of Apprenticeship Programs for each type of work to be performed on the project. (vi) X Copy of a written plan for employee drug testing that covers all of my employees who will perform work on the public work project and meets or exceeds the requirements set forth in IC 4-13-18-5 or IC 4-13-18-6. (vii) X Evidence that I am utilizing a surety company which is on the Bureau of Fiscal Service "Department of Treasury's Listing of Approved Sureties" as required in the bid specifications or contract. (viii) X Written statement of any federal, state or local tax liens or tax delinquencies owed to any federal, state or local taxing body in the preceding three years. (ix) X List of projects of similar size and scope of work performed in all areas, including the State of Indiana, within three (3) years prior to the date on which the bid is due. Date: 12/9/24 4 (Sign Here) (Print Name Here) PREMIUM CONCRETE SERVICES (Name of Company) 712 RICHMOND ST (Address of Company) ELKHART (City) IN (State) (574)264-0196 (Telephone Number) Version 5/20/2024 General Conditions - 14 Certified Copies To Whom These Presents Come, Greeting: I, DIEGO MORALES, Secretary of State of Indiana, do hereby certify that I am, by virtue of the laws of the State of Indiana, the custodian of the corporate records and the proper official to execute this certificate. I further certify that this is a true and complete copy of this 2 page document consisting of the following records filed in this office: Certification Date: December 05, 2024 Business Name: PREMIUM' CONCRETE SERVICES, INC. Business ID: 2004120100105 Transaction Date Filed No. of pages Business Entity Report 11/12/2024 2 Total No. of oaees 2 In Witness Whereof, I have caused to be affixed my signature and the seal of the State of Indiana, at the City of Indianapolis, December 05, 2024 jo� 0 "6 't'lte'vw� fl/ DIEGO MORALES SECRETARY OFSTATE 2004120100105 / 17245566 All certificates should be validated here: https://bsd.sos.in.gov/ValidateCertificate Expires on January 04, 2025. Page 1 Of 3 CertificateID:17245566 APPROVED AND FILED DIEGO MORALES INDIANA SECRETARY OF STATE 11/12/2024 10:47 AM K BUSINESS ID 2004120I OOI05 BUSINESS TYPE Domestic For -Profit Corporation BUSINESS NAME PREMIUM CONCRETE SERVICES, INC. ENTITY CREATION DATE 11/24/2004 JURISDICTION OF FORMATION Indiana PRINCIPAL OFFICE ADDRESS 712 RICHMOND ST, ELKHART, IN, 46516, USA a � YEARS EFFECTIVE DATF. EFFECTIVE TIME D zoz4/zozs 11/12/202A 0:47 AM REGISTERED AGENT TYPE htdividual NAME MAX A. YBAI{EY ADDRESS 712 Richmond Street, Elkhart, IN, 46516, USA w TITLE President NAME ADDRESS TITLE NAME ADDRESS Becky L. Yeakey 712 Richmond Street, Elkhart, IN, 46516, USA Vice President Max A. Yeakey 712 Riclunond Street, Elkhart, IN, 46516, USA Page 2 Of 3 CerCificatelD:17245566 - Page 1 of 2 - APPROVED AND FILED DIEGO MORALES IlVDIANA SECRETARY OF STATE II/12/2024 10:47 AM IN WITNESS WHEREOF, THE UNDERS[GNED HEREBY VERIFIES, SUBJEC'P TO THE PENALTIES OF PERJURY, TIiAT THE STATEMENTS CONTAINED HEREIN ARE TRUE, THIS DAY November 12, 2024. THE UNDERSIGNED ACKNOWLEDGES THAT A PERSON COMMITS A CLASS A MISDEMEANOR BY SIGNING A DOCUMENT THAT THE PERSON KNOWS IS FALSE IN A MATERIAL RESPECT WITH THE INTENT THAT THE DOCUMENT BE DELIVERED TO THE SECRETARY OF STATE FOR FILING. SIGNATURE /s/ Matthew A. Yeakey TITLE Legal Representative Business ID : 2004120100105 Filing No.: 10572323 Page 3 Of 3 CertificatelD:17245566 -Page2of2- State of Indiana Office of the Secretary of State Certificate of Assumed Business Name of In Witness Whereof, I have caused to be affixed my signature and the seal of the State of Indiana, at the City of Indianapolis, October 12, 2022. HOLLI SULLIVAN SECRETARY OFSTATE 2004120100105 /9591594 To ensure the certificate's validity, go to https://bsd.sos.in.gov/Puhlic8usinessSearch Page 4 Of S CerlificatelD:1G709194 BuslNEssID BUSINESS TYPE BUSINESS NAME PRINCIPAL OFFICE ADDRESS EFFECTIVE DATE EFFEC'CIVE'CIME Premium Services APPROVED AND FILED HOLLI SULLIVAN INDIANA SECRETARY OF STATE 10/12/2022 08:45 AM 2004120100105 Dameslic Fm•-Rofi(Corparation PREMIUM CONCRETE SERVICES, INC, 7l2 RICHMOND ST, ELICHART, IN, 4G51G, USA 10/It/2022 0 *SRPM 712 Richmond Sbeel, Elkhart, IN, 46516, USA IN WITNESS WHEREOF, THE UNDERSIGNED HEREDY VERIFIES, SUDJECT TO THE PENALTIES OF PERILIRY, THAT THE STATEMENTS CONTAINED HEREIN ARE TRUE, THIS DAY October 11, 2022. THE UNDERSIGNED ACKNOWLEDGES THAT A PERSON COMMITS A CLASS A MISDEMEANOR BY SIGNING A DOCUMENT THAT THE PERSON KNOWS ]S FALSE IN A MATERIAL RESPECT WITH THE INTENT THAT 9'HE DOCUMENT BE DELIVERED TO THE SECRETARY OF STATE FOR FILING, SIGNATURE TITLE Seulo I. Delgado Legal Representative business ID : 2004120100105 Filing No, : 959159A Page50f5 CertificutelD:16709194• ,-, Premium Concrete Services, Inc. dba Premium Services 712 Richmond Street Elkhart, IN 46516 574-264-0196 fax 574-266-5392 May 23, 2024 To Whom it May Concern, Premium Concrete Services, Inc. has never been identified by any other business name in the past. As of October 12, 2022, as filed with the Indiana Office of the Secretary of State, Premium Concrete Services, Inc. also conducts business as Premium Services. Max Yeal<ey Vice -President Premium Concrete Services, Inc. dba Premium Services 712 Richmond Street Elkhart, IN 46516 574-264-0196 fax 574-266-5392 Sept. 27, 2024 To Whom it May Concern, Premium Concrete Services, Inc. has had no determinations by a court of governmental agency of any violations of federal, state, or local laws, including but not limited to, violations of contracting or antitrust laws, tax or licensing laws, environmental laws, Occupational Safety and Health Act (OSHA), or federal Davis -Bacon and related Acts, within the preceding five (5) years. Max Yeakey Vice -President Premium Concrete Services, Inc. dba Premium Services 712 Richmond Street Elkhart, IN 46516 574-264-0196 fax 574-266-5392 May 23, 2024 To Whom it May Concern, Premium Concrete Services, Inc. has no federal, state, or local tax delinquencies owed to any of the fore mentioned taxing bodies, nor has owed any in the past three years. Max Yeal<ey Vice -President Premium Concrete Services, Inc. dba Premium Services 712 Richmond Street Elkhart, IN 46516 574-264-0196 fax 574-266-5392 May 23, 2024 To Whom it May Concern, Premium Concrete Services, Inc. currently employs 74 people, 5 of which are field supervisors, 8 concrete finishers, 23 laborers, 10 heavy equipment operators, 2 carpenters and 2 ironworkers. We are signatory to the local Cement Masons, Laborers, Operators, Carpenters, and Ironworkers unions through which extra employees can be pulled from when needed. Individuals who perform work on public work projects on my behalf will be properly classified as an employee or as an independent contractor under all applicable state and federal laws and local ordinances. Max Yeakey Vice -President INDIANA LABORERS' TRAINING TR UST FUND David A. Frye Secretary -Treasurer JerryJ. Bolk Chris Brickey Ricky Henson, Jr. Ramon Mendoza, Jr. Brian Short P.O. Box 758 -Bedford, Indiana 47421 (812)279-9751 June 6, 2024 To Whom It May Concern: Sean Coakley, Director John P. Brown Chairman Kelly Abel Michael Ferrara Stan Meyer Nick Timmerman Jim Wiseman FAX: (812) 279-5545 Toll Free (800) 7424086 This letter is to confirm that "Premium Concrete Services, Inc." is a signatory contractor in good standing with the Indiana Laborers' Training Trust Fund. The above -mentioned company is a participant in the Joint Apprenticeship and Training Committee through this Union and has been an active participant in good standing and is currently eligible to use our apprentices on a project. Further, our organization's program is approved by the U.S. Veterans Administration to participate in the GI educational benefits program. A copy of our approval letters are attached along with the collective bargaining agreement stating the ratios of Journey workers to Apprentices; which is one (1) Apprentice for every four (4) Journey workers and thereafter may not employ more that (1) Apprentice for every (3) Journey workers. Sincerely, (�AV Sean Coakley, Director SC:jb www. indianalaborerstraining. org FutJu uporttututg tAV of INDIANA LABORER'S TRAINING TRUST FUND BEDFORD, INDL9NA for the trade classification of CONSTRUCTION CRAFT LABORER J�e9isfereo� as parf of fie �afional .`�pprenfices�iP J�royram in accoro�ance mif�z fie basic sfano(aroof apprenfieesAip esfa6fisheo( 6y ffie c3ecrefary of Labor December 14, 1995 Dat IN040-0528 9r y;lm6an x - ofraco, i �.. DEPARTMENT OF VETERANS AFFAIRS STATE APPROVING AGENCY 402 WEST WASHINGTON STREET ROOM W-469 INDIANAPOLIS, INDIANA 46204.2738 Jeremy Brewer Apprenticeship Coordinator Indiana Laborers Training Trust Fund -Apprenticeship 439 Patton Hill Rd. Bedford, IN 47421 Dear Jeremy Brewer, Eric Holcomb, Governor James M. Brown, Director January 9, 2019 The Indiana State Approving Agency conducted a supervisory visit on 01/8/2019 at Indiana Laborers Training Trust Fund -Apprenticeship. The purpose of the visit was to provide training to the Certifying Officials and review enrollment certifications, record retention and reporting procedures. The organization demonstrated proper record maintenance and record maintenance and reporting procedures: During the visit, we discussed the importance of reporting hours on a monthly basis, good record keeping techniques, and how to report a leave of absence or completion via VA Form 22-1999b. We also updated the Certifying Officials via VA Form 22-8794, work processes, and wage scale. If you need any assistance or have any questions regarding this technical visit please contact me directly at tgriffin@dva.in.gov or (317) 232-3916. Thank you for the courtesy extended during my visit. The education and training opportunities that your organization continues to provide veterans and their dependents are appreciated. Sincerely, Taniqua Griffin Program Director �vq `�9 �a Phone (317)-234-6062 Toll Free (800)-400-4520 Fax (317)•234-8744 STATE UF INDIANA DEPARTMENT OF VETERANS AFFAIRS STATE APPROVING AGENCY 402 WEST WASHINGTON STREET ROOM W469 INDIANAPOLIS, INDIANA 46204-2738 Jeremy Brewer Apprenticeship Coordinator Indiana Laborers Training Trust Fund -Apprenticeship 439 Patton Hill Rd. Bedford, IN 47421 Dear Jeremy Brewer, Eric Holcomb, Governor James M. Brown, Director January 9, 2019 This will acknowledge receipt of your updated Wage Scale for the Construction Craft Laborer program offered by Indiana Laborers Training Trust Fund -Apprenticeship. The State Approving Agency has reviewed the document as listed below: Wage Scale: Construction Craft Laborer FACILITY CODE: 30004114 To the best of my knowledge Indiana Laborers Training Trust Fund -Apprenticeship doesmot utilize erxoneous or misleading advertisement, either by actual statement, omission, orinumation. It is understood by Indiana Laborers Training Trust Fund -Apprenticeship that they will maintain a complete record of all advertising utilized by or on behalf of the Indiana Laborers Training Trust Fund -Apprenticeship in regards to their training programs during the preceding 12 months. Indiana Laborers Training Trust Fund-Apprenticesbip`s advertising will be available for review by any and all future supervisory visits by the SAA, or the U. S. Department of Veteran Affairs. Please Review the entire packet for content and accuracy. Approval is granted pursuant to the provisions of Title 38, U.S. Code 3687, with an effective date of April 1, 2018. If you have any questions, please feel free to give me a call at 317-232-3916 or email me at tgriffin@dva.in.gov. Thank you for what you do for our Veterans, and have a great day! Sincerely, Taniqua Griffin Program Director State Approving Agency Cc: VARO/ELR rNof��q � 9 2019 Siq�gPpRO�NC/�4�%� STATE OF INDIANA DEPARTMENT OF VETERANS AFFAIRS STATE APPROVING AGENCY 402 WEST WASHINGTON STREET ROOM W-469 INDIANAPOLIS, INDIANA46204-2738 Jeremy Brewer Apprenticeship Coordinator Indiana Laborers Training Trust Fund -Apprenticeship 439 Patton Hill Rd. Bedford, IN 47421 Dear Jeremy Brewer, Eric Holcomb, Governor James M. Brown, Director January 9, 2019 This will aclmowledge receipt of your revised Work Processes for the Construction Craft Laborer program offered at Hoosier Energy, located in Bedford, Indiana. The State Approving Agency has reviewed the document as listed below: TRAINING PROGRAM LENGTH DOT CODE Construction Craft Laborer FACILITY CODE: 30004114 4,000-7800 hours 47-2061.00 To the best of my Iflrowledge Indiana Laborers Training Trust Fund -Apprenticeship does not utilize erroneous or misleading advertisement, either by actual statement, omission, or intimation. It is understood by Indiana Laborers Training Trust Fund -Apprenticeship that they will maintain a complete record of all advertising utilized by or on behalf of the company in regards to their training programs during the preceding 12 months. The company's advertising will be available for review by any and all future supervisory visits by the SAA, or the U.S. Department of Veteran Affairs. This approval is made pursuant to and under the provisions of Title 38, U. S. Code 3687, with an effective date of January 8, 2019. If you have any questions, please contact me at 317-232-3916. Sincerely, Taniqua GriGriffinProgram Director State Approving Agency CC:VARO/ELR AAA ryO�a Jgti �O`*F Yq y40 �q� c'pJ9 '9pA c9 c �ry Phone (317)-234-6062 To1lFree(800)-400-4520 Fax (317)-234-8744 Apprentice Status Report By Indenture Date Apprentices Indentured Between 1/1/2019 And 12/31/2023 Apprentice Program: IN2 Year Apprentice Status Apprentices Percentage 2019 2020 Active i 26 4 2 84 % Adv. to Journeyman 96 10.47 % Deceased 9 098 % Graduated 110 12.00 % Inactive 11 'i 120 % Journeyman 121 1,31 % Med. susp. 1 0,11 ^/o Reinstate 2 0.22 % Suspended 1 - till Terminated 578 63.03 % Voluntary tKhdraw 71 ' 7.74 % Total Indentured 917 Active _ 32 4.95 % Adv. to Journeyman 72 11.15%0 Deceased 2 0,31 % Graduated 59 9.13 % Journeyman 1 Otis % Not Registered 1 0.15 % Reinstate 2 Q 31 Suspended 1 01150/0 Terminated 431 66.72 0$ Voluntary withdraw 45 6.97 % Total Indentured 646 Printed: etlnesday, May 29, 2024 Page 1 or 3 Apprentice Status Report By Indenture Date Apprentices Indentured Between 1/1/2019 And 12/31/2023 Apprentice Program: IN2 Year Apprentice Status Apprentices Percentage 2021 2022 Active 99 1307% Active Duty 1 043 % Adv. to Journeyman 68 9 07 "/o Deceased 2 0427 0/6 Graduated 65 867 % Reinstate Idil 0653 % Suspended 2 0 27 "/o Terminated 467 62.27 % Voluntarywithdrawi 01 5i73'0/0 Total Indentured 750 Active 341 3556 %: Adv, to Journeyman 70 7.30 %° Deceased 5 OM; % Graduated 23 2:40 % ]ounneyman 1 Or10'%o Med, Susp. 21 0.21 % Not Registered Reinstate 10 1.04 % Suspended 9 094 % Terminated 467 48.70 %° Voluntary withdraw 30 - 313 % Total Indentured 959 Printed: Wednesday, May28, 2024 Paga 2 0! 3 Apprentice Status Report By Indenture Date Apprentices Indentured Between 1/1/2019 And 12/31/2023 ApprenOce Program: IN2 Year Apprentice Status Apprentices Percentage 2023 1 010 % Active 597 57.90 % Acdye Duty 1 010 elo Adv. to Joumeyman 35 3,39 % Receased 2 019 % Graduated 1 Oslo % m Jaueyman 9 0 29 % Med, Susp, 3 0.29 % Not Registered 14 003M Reinstate 34 330 % Suspernied 4 Terminated 3251 31.52 % Voluntary withdraw'" 21 s 204 % Total Indentured 1031 Printed: watlnesday, May 29; 2024 Page 30/ 3 Plasterers° & Cement Masons' Apprenlioeship Coordinator Local Union #692 To Whom it May Concern: Phone: (219) 707-7767 Email: bkristoff@plcmlocal682.org June 60 2024 This letter is to certify that Premium Services, Inc. is and has been a signatory contractor with OPCMIA Local 692 and has participated in the Plasterers & Cement Masons Apprenticeship Training Program for many years. Premium Services Inc. is a valued Contractor in good standing with Local 692 and the JATC. All our apprentices are registered with the United States Department of Labor. I may be reached at (219) 707-7767 if additional information is needed. Further, our organization's program is approved by the U.S. Veterans Administration to participate in the GI Education Benefit Program, Thank you, Brian Kristoff Apprentice Coordinator Plasterers & Cement Masons 9�00 Louitiiana Strt�ot IVierrilfvillo, fndiana 464t0 Plasterers & Cement Masons' Apprenticeship Coordinator Local Union #692 Local 692 Apprenticeship Summary ANOc�r 4 O � "y 1864 - NAI ASSoc. Year 1St 2na 3a NEW Grads Total 2016 31 14 26 25 3 71 2017 35 20 21 61 20 76 2018 30 36 19 52 16 85 2019 30 26 16 13 13 78 2020 30 34 22 52 15 86 2021 25 28 23 16 12 76 2022 22 35 36 35 10 93 Phone: (219)707-7767 Email: bkristoff@plcmlocal692,org 9200 Louisiana Street Merrillville, Indiana 46410 WWW.PLCMLOCAL692.ORG .Lv 4a'�IdIg Y,. ,51 au 1fI%, p�}(h "3K�a zC�1IF r !f'� 1�=1-�'e Z,�;uf h�sT=�^s�3a S 4P$ �"�� '� Y t 4 ..I a,.� •.I d � n ��_ r��r. ,��• E�• �a>�s � �,, �'F� ��9 �� a r+q^Z -rTHE -AS i^'-i:AT0NSL5 CEAVIEN, MASON: P:-rLSTERE ., 1€sn 1113 PENSION TRUST FUND • WELFARE FUND • RETIREE WELFARE PLAN ® VACATION SAVINGS PLAN • RETIREMENT ENHANCEMENT FUND 6150 JOLIET ROAD, COUNTRYSIDE, IL 60525-3994 PHONE: (708) 482-7300 FAX: (708) 482-3056 MIDWEST OPERATING ENGINEERS FRINGE BENEFIT FUNDS JAMES M. SWEENEY CHAIRMAN / DAVID M. SNELTEN, SECRETARY -TREASURER June 7, 2024 Premium Concrete Services, Inc Becky Yeakey: 712 Richmond Street Elkhart, IN 46516 Dear Becky Yeakey, This letter• serves as formal notification that as of the date of this letter, Premium Concrete Services, Inc 44180 is in "Good Standing" with the Midwest Operating Engineers Fringe Benefit Funds for fringe benefit contribution reports and payments. Our records indicate that Premium Concrete Services, Inc has accurately reported hours and payments to the Fund Office, The Midwest Operating Engineers Fringe Benefit Funds reserves the right to withdraw Premium Concrete Services, Inc "Good Standing" status if our assumption is found to be incorrect. If you have airy questions, please contact Premiwn Concrete Services, Inc. Sincerely, �en,i.e JJzon4nti Jerrie Brown Accounts Receivable Manager SON INS IN! 111111 SIEMENS: NINE IN 11 ! IN I ISO I NONE IN I ANTI -DRUG AND ALCOHOL MISUSE PREVENTION PLAN, U.S. DEPARTMENT OF TRANSPORTATION PIPELINE He HAZARDOUS MATERIALS SAFETY ADMINISTRATION (PHMSA) PREPARED IN ACCORDANCE WITH THE REQUIREMENTS OF: 49 CFR PART 199 49 CFR PART 40 Premium Concrete Services, Inc. 712 Richmond St; Elkhart, IN 46516 574-264-0196 Original Date of Implementation: 2/15/2004 New Effective Date: 2/15/2022 PLAN REVISION DATE: April :1,'12021. REVISION DATE MODIFIED BY NCMS ONLY. ©NATIONAL COMPLIANCE MANAGEMENT SERVICE, INC. (NCMS) 2011 Copyright Cor ihcato of Registration TX 8<1FT18 Table of Contents I. INTRODUCTION 4 1. Development of "Combined" Plan 4 2. Approach 4 3. Background 5 II. GENERAL 5 1. Scope 5 2. Applicability 5 3. Compliance 6 4. "DOT' vs. 'PHMSA 6 5. DOT Procedures 6 6. Stand -down Waiver 6 7. Preemption of State and Local Laws 6 8. Definitions 7 III. POLICY AND RESPONSIBILITIES 12 1. Company Policy 12 2. Responsibilities of Key Personnel 12 3. Responsibilities of Covered Employees 13 4. Use of Service Agents 13 5. Critical Service Agent Positions 14 6. "NON -DOT" Testing Program 15 IV. DOT PROGRAM REQUIREMENTS 15 1. Employees Subject to Testing 15 2. Acknowledgement/Receipt Form 15 3. History Check Requirement 16 4, Employee Notification of Tests 16 5. DOT Drug Violations 17 6. DOT Alcohol Violations and Prohibited Conduct 17 7. Violation Consequences and Company Actions 18 V. ANTI -DRUG PROGRAM 18 1. DOT- Required Drug Tests 18 2., Drug Tests That Require Direct Observation Procedures 21 3. Specimen Collection Procedures 21 4. PHMSA Inspection Protocol for Specimen Collection Sites 23 5. Drug Testing Laboratory 24 6. Laboratory Retention Period and Reports 26 7. Laboratory Quality Control 26 8. MRO Review of Drug Test Results 26 9. Split Specimen Testing 27 10. Medical or Recreational Marijuana 28 Premium Concrete Services, Inc.- PNMSA DRUG/ALCOHOL PLAN C,' NATIONAL COMPt.IANCE MANAGEMENT SERVICE, INC. tNCMSf 2011 (u�dale 2021). Tlie NCMS plan is 2 Ihie subecl ota reylsteretl copyright end is pralectad by copyright laws in the U.S. and elsevihere All riyhls eserved. VI. ALCOHOL MISUSE PREVENTION PROGRAM 28 1. DOT- Required Alcohol Tests 28 2. Alcohol Test 30 3. PHMSA Inspection Protocol for Alcohol Testing Sites 31 VII. PROGRAM ELEMENTS COMMON TO DRUG AND ALCOHOL 33 1. Substance Abuse Professional 33 2. Employee Assistance Program 34 3. Supervisor Training 34 4. Contractor Monitoring 35 5. Recordkeeping 35 6. Management Information System 37 VIII. APPENDIX A Acknowledgement/Receipt Form 38 IX, APPENDIX B Designated Personnel and Service Agents 39 X. APPENDIX C Covered Positions 40 XI. APPENDIX D Company Disciplinary Actions and Additional Procedures 41 XII. APPENDIX E PHMSA Anti -Drug and Alcohol Misuse Prevention Program Inspection Protocol Form, Substance Abuse Program Comprehensive Audit and Inspection Protocol Form Specimen Collection Sites, Alcohol Testing Sites and Changes to Model Plan 43 XIII. APPENDIX F Post -Accident or Reasonable Cause/Suspicion Supervisor Written Record 56 XIV, APPENDIX G Reasonable Cause/Suspicion Observation Checklist 57 Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN (�� NATIONAL COMPLIANCE MANAGEMENT SERVICE., LNG. rNCMS� 2011 (uptlate 2�21). The NCMS plan is 3 the subJecl of e reglsterad roPYrt9ht antl Is Vmtecletl ny copyright laws In rho U.S. antl olsewhera NI rlgh�s reserved. I. INTRODUCTION 1. Development of "Combined" Plan The Pipeline and Hazardous Materials Safety Administration (PHMSA) is the agency within the Department of Transportation (DOT) that regulates operators in the natural gas and hazardous liquid pipeline industry. PHMSA's Drug and Alcohol Testing Regulation, 49 CFR Part 199' requires each operator to develop, maintain, and follow an Anti -Drug and an Alcohol Misuse Prevention Plan. Historically, companies have produced these plans as two separate documents. This "combined" Anti- Drug and Alcohol Misuse Prevention plan, merges both PHMSA-required plans into a single document. Authorization for a combined plan was granted by PHMSA's Office of Pipeline Safety stating: "PHMSA will allow the combining of the two plans into one written plan, as long as all requirements of each regulation are met." The "requirements of each regulation" means the requirements of Part 199 and the requirements of DOT's "Procedures for Transportation Workplace Drug and Alcohol Testing," 49 CFR Part 40'. The Anti -Drug and Alcohol Misuse Prevention Plan henceforth referred to as the "Plan," meets the requirements of Part 199 and Part 40. 2. Approach The Plan will use the generic word "Company" in reference to the operator or contractor, as applicable, for which t is written. PHMSA's requirement for plan development and implementation applies equally to each operator and contractor that performs covered safety -sensitive operations, maintenance, or emergency- response functions on a pipeline or LNG facility within the natural gas and hazardous pipeline industry. The Plan will describe how the Company will comply with government requirements. The Plan will identify "Company -additional" requirements - those that go beyond the minimum requirements of DOT. Company -additional requirements will be underscored. Therefore, consider anything that is not underscored a requirement of DOT or a process put in place by the Company to meet a DOT requirement. Appendix D outlines the Company disciplinary actions and additional procedures. The Plan is written in "plain language" and follows the requirements of each rule. However, the Plan does not repeat the language of either Part 40 or Part 199. Doing so would require the Company to produce a new plan every time DOT or PHMSA issued a change to their respective rule. The goal of DOT is to know that the company understands the requirements of the rules and how the Company will go about achieving compliance. The Plan makes use of existing DOT language in places where summaries are used to explain a more detailed process (e.g., specimen collection and alcohol test procedures are extracted from DOT's "Employee Guide").' Appendix E. of the Plan includes references to the PHMSA Inspection Protocol Forms' for the purposes of assisting inspectors with specific areas of Plan compliance. � "Citle 49 Cade of Federa( Regulations (CFR), fart 199, "Dmg and Alcohol Testing Requirements," Pipeline and Hazardous Materials Safety Administration, Deparhnent of Transportation. 2 Title 49, Code of Federal Regulations (CFR), Part 40, "Procedures far Transportation Workplace Ding and Alcohol Testing Programs," Office of the Secretary, Department of'rransportation. 3 "What Employees Need To Know About DOT Drug & Alcohol Testing," ODAPC, DOT. Premium Concrete Services, Inc.-PHMSA DRUG/ALCOHOL PLAN lJ NATIONAI. COMPLIAIJCE MANAGEMENT SERVICE. INC. (NCMSI 2011 (update 2021). Tire NCMS plan Is the silblec� of a registered copyrgh� and Is pm�cc�etl by copynghl lav,s in the U 5. and els'ev�l�ere. All rigFis eservetl 3, Background Safety. The DOT requires transportation employers to develop and implement drug and alcohol testing programs n the interest of public safety. Safety is the highest priority for DOT. One of the means by which the DOT helps ensure safety is by subjecting those workers responsible for transportation safety to drug and alcohol testing. Workers tested under the DOT program have a direct impact on the safety of the traveling public or the safety of those potentially affected by the transportation of hazardous products, such as natural gas, liquefied natural gas (LNG) and hazardous liquids. Test Procedures. The overall responsibility for management and coordination of the DOT program resides within the Office of the Secretary of Transportation's (OST), Office of Drug and Alcohol Policy and Compliance (ODAPC). ODAPC issues Part 40. Whether the transportation employee is a pipeline worker, truck driver, or airline pilot, their drug and alcohol tests are conducted using the same Part 40 procedures. This consistency benefits all employees affected by DOT regulations in each agency's regulations must adhere to DOT's testing procedures. Better known simply as "Part 40", this rule has become the standard for workplace testing in the United States. Compliance Enforcement. Regulation and enforcement within the different transportation industries is the responsibility of the DOT agency that has authority over the particular industry. The regulatory authority requiring drug and alcohol testing of safety -sensitive employees in aviation, trucking, railroads, and mass transit industries is the Omnibus Transportation Employee Testing Act of 19915 (OTETA). The OTETA did not specifically address the pipeline industry. PHMSA has regulatory authority over the pipeline industry and conveyed their authority, for drug and alcohol testing, through the issuance of their regulation - Part 199, Part 199 spells out who is subject to testing, when and in what situations. Operators, and in turn, 'their associated contractors, implement the regulations. II. GENERAL 1. Scope Operators of pipeline facilities subject to 49 CFR Parts 1928, 1937, or 1958 are required to test covered employees for the presence of prohibited drugs and alcohol. Contractors doing similar work on the behalf of their operators are subject to the same requirements. Part 199, requires of each operator the assurance that any contractor performing any DOT covered safety -sensitive work for that operator, under Parts 192, 193, or 195, is in full compliance with the provisions of the DOT's drug and alcohol program, as applicable. 2. Applicability Part 199, and the provisions of the Plan, applies to operators and contractors only with respect to their employees located within the territory of the United States, including those employees located within the limits of the "Outer Continental Shelf'. Part 199 and the provisions of the Plan do not apply to covered functions performed on master meter systems or pipeline systems that transport only petroleum gas or petroleum gas/air mixtures. s Public Law t02-143, October 28, 1991,'I'itle V—Omnibus'Cransportation Employee Testing, 105 Stat 952-965; 49 O.S.C. 45104(2). e Part 192 — "Cransportation of Natm'a( and Other Gas by Pipeline: Minimum Federal Safety Standards Part 193—Liquefied Natural Gas Facilities: Federal Safety Standards s Part 195 —Transportation of Hazardous Liquids by Pipeline Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN �� NATIONAL GOMPLIAi10E MANAGEMENT SERVICE. ING. (NGMS) 2011 (uptlate 10Zi I. Tlie rICMS plan is Itie subject of a registe,'etl copyrtght and is proteued Uy cupyrlghl Isws in Ue U.S. entl elseviM1ei'e. All �glils esErved 3. Compliance Plan Development. The Plan meets the requirements of Part 199, paragraphs §199.101 and §199.202, respectively, to develop a written anti -drug and a written alcohol misuse prevention plan. The Plan describes the methods and procedures for compliance with the drug and alcohol program requirements of the DOT, including the employee assistance program. The Plan covers the operational, day-to-day requirements that are found in Part 199, and the procedural, testing requirements that are found in Part 40. The Plan provides appendices for the name and address of each laboratory that analyzes specimens for the Company, the Company's Medical Review Officer, and Substance Abuse Professionals. The Plan communicates to employees, Company officials, and DOT officials the path that the Company will follow in order to comply with the requirements for a successful DOT drug and alcohol program. Plan Availability. The Plan will be posted in a common place, selected by the Company, for employee review and feedback. A copy of the Plan will be made available to all covered safety -sensitive employees. Any covered safety - sensitive employee desiring a copy of Part 40 and/or Part 199 must contact the Designated Employer Representative (see Appendix B). The Plan provides a basic description of the rules and testing requirements, and shows how the Company implements and follows them. The Plan is not meant as a substitute for the detail provided in either rule. If there is any difference in instruction or interpretation between the Plan and the rules, the rules prevail. The Plan will be updated at any time its language, or the intent of its language, differs from that of either Part 40 or Part 199. Employees are encouraged to obtain and read Part 40 and Part 199 on their own. 4. "DOT" vs. "PHMSA" All DOT testing procedures will follow Part 40 requirements. All ,DOT procedural responsibilities for pipeline operators and contractors will follow Part 199. In the Plan, the term) "DOT" will be used for reference to general requirements (e.g., testing procedures) placed on all transportation employers, including operators and contractors. The use of the term "PHMSA" will be to distinguish specific, unique administration requirements versus general, DOT requirements (e.g., random alcohol testing is not authorized by,PHMSA). 6. DOT Procedures The company will assure that the procedures of Part 40 are followed for drug and alcohol testing conducted under the requirements and authority of Part 199; a violation of Part 40 is a violation of Part 199. If the Company employs a Consortium/Third-Party Administrator;(C/TPA) to assist in program development, implementation, and management, the C/TPA will, likewise, follow all the requirements of Part 40 and Part 199. It is the Company's goal to establish and maintain compliance with the DOT drug and alcohol program. 6. Stand -down Waiver DOT "stand -down" is not in effect for this Company. The Company does not hold a stand -down waiver under Part 40, and has not applied for one. Should this status change, the Company will notify all covered safety -sensitive employees and Company officials, in accordance with Part 40 requirements. 7. Preemption of State and Local Laws Part 40 and Part 199 are Federal laws. Federal law preempts any state or local law, rule, regulation or order to the extent that: (a) compliance with both the state or local requirement and Part 40 or 199 is not possible; or (b) compliance with the state or local requirement is an obstacle to the accomplishment and execution of any equirement of Part 40 or 199; or (c) the state or local requirement is a pipeline safety standard applicable to nterstate pipeline facilities. This provision does not preempt provisions of state criminal law that impose sanctions for reckless conduct leading to actual loss of life, injury, or damage to property, whether the provisions apply specifically to transportation employees or employers or to the general public. Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN CJ NATIONHL COMPLIANCE MANAGEMENT SERVICE, INC. (NCMS) 2011 (u��tl"le t021). The NCMS plan Is the subjaG o[ a registered ct,pY�lgh! entl Is protedeU by copyrig[il Ix,vs in the U S. 2nd else,vhe,e. /111 ngM1ls eserved 8. Definitions Definitions from Parts 40, 191, 195, and 199 have been combined in alphabetical order and are provided in a single listing. For purposes of the Plan, the following definitions apply: Accident/Incident - An incident reportable under Part 191 involving gas pipeline facilities or LNG facilities or an accident reportable under Part 195 involving hazardous liquid pipeline facilities. a) (§191.3) — An accident on a gas pipeline or LNG facility is defined as an "incident," as follows: (1) An event that involves a release of gas from a pipeline, gas from an underground natural gas storage facility, liquefied natural gas, liquefied petroleum gas, refrigerant gas, or gas from an LNG facility, and that results in one or more of the following consequences: (a) A death, or personal injury necessitating inpatient hospitalization; (b) Estimated property damage of $122,000* or more, including loss to the operator and others, on both, but excluding the cost of gas lost.; or (c) Unintentional estimated gas loss of three million cubic feet or more; *For adjustments for inflation observed in calendar year 2021 onwards, changes to the reporting threshold will be posted on PHMSA's website. These changes will be determined in accordance with the procedures in Appendix A to Part 191 (2) An event that results in an emergency shutdown of an LNG facility or an underground natural gas storage facility. Activation of an emergency shutdown, system for reasons other than an actual emergency does not constitute an incident. (3) An event that is significant, in the judgment of the operator, even though it did not meet the criteria of paragraphs (1) or (2). b) (§195.50) — An accident report is required for each failure in a pipeline system in which there is a release of the hazardous liquid or carbon dioxide transported resulting in any of the following: (1) Explosion or fire not intentionally set by the operator. (2) Release of 5 gallons (19,liters) or more of hazardous liquid or carbon dioxide, except that no report is required for a release of less than 5 barrels (0.8 cubic meters) resulting from a pipeline maintenance activity if this release is: (a) Not otherwise reportable under this section; (b) Not one described in §195.52(a)(4); (c) Confined to Company property or pipeline right-of-way; and (d) Cleaned up promptly; (3) Death of any person. (4) Personal injury necessitating hospitalization; (5) Estimated property damage, including cost of clean-up and recovery, value of lost product, and damage to the property of the operator or others, or both, exceeding $50,000. Administrator- The Administrator, Pipeline and Hazardous Materials Safety Administration (PHMSA) or his or her delegate. Adulterated specimen - A specimen that has been altered, as evidenced by test results showing either a substance that is not a normal constituent for that type of specimen or showing an abnormal concentration of an endogenous substance. Affiliate -Persons are affiliates of one another if, directly or indirectly, one controls or has the power to control the other or a third party controls or has the power to control both. Indicators of control include, but are not limited to: nterlocking management or ownership; shared interest among family members; shared facilities or equipment; or common use of employees. Following the issuance of a Public Interest Exclusion (PIE), an organization having the same or similar management, ownership, or principal employees as the service agent concerning who public interest exclusion is in effect is regarded as an affiliate. This definition is used in connection with the public interest exclusion procedures of Part 40, Subpart R. Premium Concrete Services, Inc: PHMSA DRUG/ALCOHOL PLAN C; NATIONAL COMPLIAIICE MANAGEMENT SERVICE, INC. (NCMS) 201 I (update 2021). The NCMS plan'is Itte subject o(a �eyis�e�ed copyright and Is pmlodetl by wpyrigh� to\US In the U S. and elsu,vhore. All ngM1ls served. Air blank - In evidential breath testing devices (EBTs) using gas chromatography technology, a reading of the device's internal standard. In all other EBTs, a reading of ambient air containing no alcohol. Alcohol - The intoxicating agent in beverage alcohol, ethyl alcohol or other low molecular weight alcohols, including methyl or isopropyl alcohol. Alcohol concentration - The alcohol in a volume of breath expressed in terms of grams of alcohol per 210 liters of breath as indicated by a breath test under this part. Alcohol confirmation test - A subsequent test using an EBT, following a screening test with a result of 0.02 or greater, that provides quantitative data about the alcohol concentration. Alcohol screening device (ASD ) - A breath or saliva device, other than an EBT, that is approved by the National Highway Traffic Safety Administration (NHTSA) and appears on ODAPC's Web page for "Approved Screening Devices to Measure Alcohol in Bodily Fluids" because it conforms to the model specifications from NHTSA. Alcohol screening test - An analytic procedure to determine whether an employee may have a prohibited concentration of alcohol in a breath or saliva specimen. Alcohol testing site - A place selected by the employer where employees present themselves for the purpose of providing breath or saliva for an alcohol test. Alcohol use - The drinking or swallowing of any beverage, liquid mixture or preparation (including any medication), containing alcohol. Aliquot - A fractional part of a specimen used for testing. It is taken as a sample representing the whole specimen. Breath Alcohol Technician (BAT) A person who instructs and assists employees in the alcohol testing process and operates an evidential breath testing device. Cancelled test - A drug or alcohol test that has a problem identified that cannot be or has not been corrected, or which Part 40 otherwise requires to be cancelled. A cancelled test is neither a positive nor a negative test. Chain -of -custody (or Custody and Control Form (CCF) - The procedure used to document the handling of the urine specimen from the time the employee gives the specimen to the collector until the specimen is destroyed. This procedure uses the Federal Drug Testing Custody and Control Form (CCF) as approved by the Office of Management and Budget. Collection .Container - A container into which the employee urinates to provide the specimen for a drug test Collection Site - A place selected by the employer where employees present themselves for the purpose of providing a urine specimen for a drug test. Collector - A person who instructs and assists employees at a collection site, who receives and makes an initial nspection of the specimen provided by those employees, and who initiates and completes the CCF. Confirmatory drug test - A second analytical procedure performed on a different aliquot of the original specimen to identify and quantify the presence of a specific drug or drug metabolite. Confirmation (or confirmatory) validity test - A second test performed on a different aliquot of the original urine specimen to further support a validity test result. Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN �i NATIONAL COMPLIANCE MFlNFlGEMENT SERVICE, INO. (MOMS) 2Ct� (updele 2021�. Tl,a hICMS f>lau is rho subjeG of a rogisterod copyrlyhl end Is proloc�etl by copyriydt laws in the U S. end elso�vhere Ail dyM1ts r.. served. Confirmed drug test -A confirmation test result received by an MRO from a laboratory. Consortium/Third-Party Administrator 1Q I PA) - A service agent that provides or coordinates the provision of a variety of drug and alcohol testing services to employers. C/TPAs typically perform administrative tasks concerning the operation of the employers' drug and alcohol testing programs. This term includes, but is not limited to, groups of employers who join together to administer, as a single entity, the DOT drug and alcohol testing programs of its members. C/TPAs are not "employers" for purposes of Part 40, Covered function (or safety -sensitive function) - An operations, maintenance, or emergency- response function regulated by 49 CFR Part 192, 193, or 195 that is performed on a pipeline or on an LNG facility. Designated employer representative (DER) - An employee authorized by the employer to take immediate action(s) to remove employees from safety -sensitive duties, or cause employees to be removed from these covered duties, and to make required decisions in the testing and evaluation processes. The DER also receives test results and other communications for the employer, consistent with the requirements of Part 40, Service agents cannot act as DERs. Dilute specimen - A urine specimen with creatinine and specific gravity values that are lower than expected for human urine. DOT Procedures (or Part 40) - The Procedures for Transportation Workplace Drug and Alcohol Testing Program published by the Office of the Secretary of Transportation in 49 CFR Part 40. DOT, The Department, DOT agency - These terms encompass all DOT agencies, including, but not limited to, the Federal Aviation Administration (FAA), the Federal Railroad Administration (FRA), the Federal Motor Carrier Safety Administration (FMCSA), the Federal Transit Administration (FTA), the National Highway Traffic Safety Administration (NHTSA), the Pipeline and Hazardous Materials Safety Administration (PHMSA), and the Office of the Secretary (OST). For purposes of this part, the United States Coast Guard (USCG), in the Department of Homeland Security, is considered to be a DOT agency for drug testingpurposes only since the USCG regulation does not incorporate Part 40 for its alcohol testing program. These terms include any designee of a DOT agency. Drugs- The drugs for which tests are required under Part 40 and DOT agency regulations are marijuana, cocaine, amphetamines, phencyclidine (PCP), and opioids. Employee (covered employee) - Any person who is designated in a DOT agency regulation as subject to drug testing and/or alcohol testing. The term includes individuals currently performing safety- sensitive functions designated in DOT agency regulations and applicants for employment subject to pre -employment testing. For purposes of drug testing under Part 40, the term employee has the same meaning as the term "donor" as found on CCF and related guidance materials produced by the Department of Health and Human Services, For the purposes of regulation under Part 199, the term employee means a person who performs a covered function, ncluding persons employed by operators, contractors engaged by operators, and persons employed by such contractors. This includes full-time, part-time and temporary employees. It also includes any applicant for a covered function. Employer - A person or entity employing one or more employees (including an individual who is self-employed) subject to DOT agency regulations requiring compliance with Part 40. The term includes an employer's officers, representatives, and management personnel. Service agents are not employers for the purposes of Part 40. Error Correction Training - Training provided to BATS, collectors, and screening test technicians (STTs) following an error that resulted in the cancellation of a drug or alcohol test. Error correction training must be provided in person or by a means that provides real-time observation and interaction between the instructor and trainee. Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN CJ NATIONAL COMPIJANCE MANAGEMENT SERVICE.. INC. (NGLIS) 20� � (update 202t). iM1a NCMS plan is the subjeG o[ a registered �upyrtgM1t and is protected by copyiighl laws in Iho U S and vlse,Riore All nghls osmcd. Evidential Breath Testing Device (EBT) - A device that is approved by the National Highway Traffic Safety Administration (NHTSA) for the evidential testing of breath at the .02 and .04 alcohol concentrations, and appears on ODAPC's Web Page for "Approved Evidential Breath Measurement Devices' because it conforms with the model specifications available from NHTSA, HHS, Department of Health and Human Services - The Department of Health and Human Services or any designee of the Secretary, Department of Health and Human Services. Initial drug test (also known as a "Screening drug test") - The test used to differentiate a negative specimen from one that requires further testing for drugs or drug metabolites. Initial specimen validity test - The first test used to determine if a urine specimen is adulterated, diluted, substituted. or invalid. Invalid drug test —The result reported by an HHS-certified laboratory in accordance with the criteria established by HHS Mandatory Guidelines when a positive, negative, adulterated, or substituted result cannot be established for a specific drug or specimen validity test. Laboratory - Any U.S. laboratory certified by HHS under the National Laboratory Certification Program as meeting the minimum standards of Subpart C of the HHS Mandatory Guidelines for Federal Workplace Drug Testing Programs; or, in the case of foreign laboratories, a laboratory approved for participation by DOT under this part. Limit -concena can , assays) the concentration cannot be accurately calculated. Limit of Quantitation - For quantitative assays, the lowest concentration at which the identity and concentration of the measurand can be accurately established. of Detection (LOD) The lowest tration at which measurand be identifiedbut (for quantitative Medical Review Officer IMROI - A person who is a licensed physician and who is responsible for receiving and reviewing laboratory results generated by an employer's drug testing program and evaluating medical explanations for certain drug test results. Negative result - The result reported by an HHS-certified laboratory to an MRO when a specimen contains no drug or the concentration of the drug is less than the cutoff concentration for the drug or drug class and the specimen is a valid specimen. Non-neqative specimen - A urine specimen that is reported as adulterated, substituted, positive (for drug(s) or drug metabolite(s)), and/or invalid. Office of Drug and Alcohol Policy and Compliance (ODAPC) -The office in the Office of the Secretary, DOT, that is responsible for coordinating drug and alcohol testing program matters within the Department and providing information concerning the implementation of Part 40. Operator - A person who awns or operates pipeline facilities subject to 49 CFR Part 192, 193, or 195. Oxidizing adulterant - A substance that acts alone or in combination with other substances to oxidize drugs or drug metabolites to prevent the detection of the drug or drug metabolites, or affects the reagents in either the nitial or confirmatory drug test. Premium Concrete Services, Inc.- PHMSA DRUGIALCOHOL PLAN 10 l%IJATIONAL GOMRLIANCE MANAGEMENT SERVICE, INC. (NCMS) 2011 (update 2021). Tl,e NCMS plan Is the subj¢ct of a ro9islerotl copyright and is proloctod by copynyht laws In the U.S. and elsewhere All rlghls eserved Performs a covered function - Actually performing, ready to perform, or immediately available to perform a covered function. Pipeline or Pipeline System - All parts of those physical facilities through which gas, hazardous liquids or carbon dioxide moves in transportation, including, but limited to, pipe, valves, and other appurtenance attached to pipe, compressor units, metering stations, regulator stations, delivery stations, holders, pumping units, breakout tanks and fabricated assemblies. Pipeline facility —New and existing pipelines, rights -of -way, and any equipment, facility, or building used in the transportation of gas or in the treatment of gas, or transportation of hazardous liquids or carbon dioxide during the course of transportation. Positive rate for random drug testing -The number of verified positive results for random drug tests conducted under Part 199, plus the number of refusals of random drug tests required by Part 199, divided by the total number of random drug tests conducted plus the number of refusals of random tests under Part 199. Positive result -The result reported by an HHS-certified laboratory when a specimen contains a drug or drug metabolite equal to or greater than the cutoff concentrations. Primary specimen - In drug testing, the urine specimen bottle that is opened and tested by a first laboratory to determine whether the employee has a drug or drug metabolite in his or her system; and for the purpose of validity testing. The primary specimen is distinguished from the split specimen, defined in this section. Prohibited drug — Means any of the substances specified in 49 CFR Part 40. Qualification Training - The training required in order for a collector, BAT, MRO, SAP, or STT to be qualified to perform their functions in the DOT drug and alcohol testing program: Qualification training may be provided by any appropriate means (e.g., classroom instruction, internetapplication, CD- ROM, video). Reconfirmed -The result reported for a split specimen when the second laboratory is able to corroborate the original result reported for the primary specimen. Refresher Training - The training required periodically for qualified collectors, BATS, and STTs to review basic requirements and provide instruction concerning, changes in technology (e.g., new testing methods that may be authorized) and amendments, interpretations, guidance, and issues concerning Part 40 and DOT agency drug and alcohol testing regulations (e.g., Part 199). Refresher training can be provided by any appropriate means (e.g., classroom instruction, internet application, CD-ROM, video). Refusal to submit, refuse, or refuse to take -Behavior consistent with Part 40 concerning refusal to take a drug test or refusal to take an alcohol test. Rejected for testing - The result reported by an HHS-certified laboratory when no tests are performed for a specimen because of a fatal flaw or a correctable flaw that is not corrected. Screening drug test - See Initial drug test definition above. Screening Test Technician (STT) - A person who instructs and assists employees in the alcohol testing process and operates an ASD. Secretary -The Secretary of Transportation or the Secretary's designee. Service agent Any person or entity, other than the employee of the employer, who provides services to employers and/or employees in connection with DOT drug and alcohol testing requirements. This includes, but is not limited to, collectors, BATS and STTs, laboratories, MROs, substance abuse professionals, and GTPAs. To act as service agents, persons and organizations must meet DOT qualifications, if applicable. Service agents are not employers for purposes of this part. Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN 11 (.--� NATIONAL COMPLIA�IGE MA�IAGEME�IT SFRVIGF, ING. (�ICMS7 2011 (update 2�21). The IVGMS Plan is the subject ofa reglsteretl caPyrlghl antl Is protaclad ny copyrlgiil laws in the U S'. end else,vhere. All rigiils e sewe, d. Shipping container - A container that is used for transporting and protecting urine specimen bottles and associated documents from the collection site to the laboratory. Specimen bottle - The bottle that, after being sealed and labeled according to the procedures in Part 40, is used to hold the urine specimen during transportation to the laboratory. Split specimen - In drug testing, a part of the urine specimen that is sent to a first laboratory and retained unopened, and which is transported to a second laboratory in the event that the employee requests that it be tested following a verified positive test of the primary specimen or a verified adulterated or substituted test result. Split specimen collection - A collection in which the urine collected is divided into two separate specimen bottles, the primary specimen (Bottle A) and the split specimen (Bottle B). State apencv - An agency of any of the several states, the District of Columbia, or Puerto Rico that participates under the pipeline safety laws (49 U.S.C. 60101 et seq.) Stand -down -The practice of temporarily removing an employee from the performance of safety- sensitive functions based only on a report from a laboratory to the MRO of a confirmed positive test for a drug or drug metabolite, an adulterated test, or a substituted test, before the MRO has completed verification of the test result. Substance Abuse Professional (SAP) - A person who evaluates employees who .have violated a DOT drug and alcohol regulation and makes recommendations concerning education, treatment, follow-up testing, and aftercare. Substituted specimen - A specimen with creatinine and specific', gravity values that are so diminished or so divergent that they are not consistent with normal human urine. Verified test - A drug test result or validity testing result from an HHS-certified laboratory that has undergone review and final determination by the MRO. III. POLICY AND RESPONSIBILITIES 1. Company Policy Policy Statement, The Company has along -standing commitment to maintain the highest standards for employee substances or alcoholic beverages while on Companv property, or in any Companv vehicle, or prohibited. DOT Compliance, The Company is aware that it is ultimately responsible for meeting the requirements of Part 40 and 199. The DOT authorizes transportation employers to use a service agents) to perform tasks necessary to comply with the Plan. The Company understands that, under the DOT regulations, it is responsible for the actions of its service agents. The Company is responsible for developing and implementing a successful and comprehensive DOT drug and alcohol program. Components of the Company's program include clear policies, provisions for education and training, drug and alcohol testing, and when needed, referral for evaluation, education, and treatment. The Company shall ensure that all covered safety -sensitive employees are aware of the provisions and coverage of the Plan. 2. Responsibilities of Key Personnel The Company will convey to responsible individuals -- the Designated Employer Representatives) and affected supervisors -that, to the best of their ability, the privacy and confidentiality of any covered safety -sensitive employee subject to the an must be maintained at all times. Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN 12 Q� NAiIONAI..GOMPLIANCF MANAGEMENT SERVICE, INC. (NCMSI 2011 (update 2021). The NCMS plan Is the subject of fl reglstaretl copyright bntl Is prolecletl by copynghl la,vs in the U.S. end elsewhere. III �iyM1is eseNed Designated Employer Representative (DER). Appendix B contains the name, address, and phone number of the DER(s). The DER is: a. the key employee for the Company's drug and alcohol program functions, and has the knowledge and authority to make decisions about the testing process and answer questions about it. b, not a service agent. C. one or more employees of the Company assigned to ensure adequate coverage on all shifts and at all locations. d, responsible for the preparation of the Plan, as well as providing oversight and evaluation on the Plan. e. responsible to review all adverse personnel action or discipline applied under the Plan for consistency and conformance to human resources policies and procedures, f, responsible for scheduling random, return -to -duty and follow-up testing, as applicable, and is authorized to receive and maintain, in a secure file system, all drug and alcohol testing results. g. responsible for providing answers to employee questions regarding the testing program, and information on the resources available for drug and alcohol counseling. h, responsible for overseeing the employee assistance program (EAP). Supervisor. A Company individuals) responsible for observing the performance and behavior of employees that is suggestive enough to lead to reasonable suspicion/cause drug and/or alcohol testing. Supervisors who will determine whether an employee must be drug tested and/or alcohol tested based on reasonable suspicion/cause will be trained in the "signs and symptoms" of each substance. The supervisor is required to document a reasonable suspicion/cause event. The supervisor may also be responsible for requests as the second supervisor for substantiation and concurrence for reasonable suspicion/cause drug test, if applicable. 3. Responsibilities of Covered Employees Compliance. Each covered safety -sensitive employee must comply with the requirements of the Plan, and the DOT drug and alcohol rules it pertains to; in order to remain 'eligible to work in a DOT covered safety - sensitive position. Each covered safety -sensitive employee has the responsibility to read, be knowledgeable of, and comply with, the requirements of the Plan, and Parts 40 and 199. Committing a DOT violation will result n the employees' immediate removal from the covered function, and remain so until successfully completing the DOT return -to -duty conditions of Part 40. The Plan describes circumstances for being tested, violations, prohibited conduct and their subsequent consequences. The Plan describes what is available to each covered safety -sensitive employee as services (e.g., EAP) in such cases where the employee has a potential problem with drugs or alcohol prior to a drug or alcohol test. It is a condition of employment for all covered safety - Failure to comply with this condition may result in disciplinary action up to and including termination 4. Use of Service Agents Compliance, The Company will contract with service agents to accomplish many of the requirements of Parts 40 and 199. Appendix B (Designated Personnel and Service Agents) provides the names and addresses of service agents that are under contract. Service agents, including C/TPA's, will comply with Parts 40 and 199 in the services provided. The work of any service agent providing services to the Company will be open to inspection by the Company. The service agent must allow access to property and records by the operator, the Administrator, and if the operator is subject to the jurisdiction of a state agency, a representative of the state agency for the purpose of monitoring the operator's compliance with the requirements of Part 199. No service agent will serve as DER for this Company. Public Interest Exclusion. The Company will not use a service agent against whom a Public Interest Exclusion (PIE) has been issued. The Company will stop using the services of a service agent no later than 90 days after the DOT has published the decision in the Federal Register or posted it on its web site that a PIE has been issued. The Company may apply to the ODAPC Director for an extension of 30 days if it is demonstrated that a substitute service agent cannot be found within 90 days. Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN 13 « NATIONAL COMf'LIANGE MANAGEMENT SERVICE. INC. (MCM57 2011 (update 2021 � Tl,a NCMS plan Is Il,e subject of a regstnrotl copyright entl is prolecletl by copynyhl laws in the U S. and else,vhoro All rghls eS0WQd Consortium/Third Party Administrator. The Company may employ the service of a Consortium/Third Party Administrator (C/TPA) to assist the DER with overall program management and consultation on any program ssue. While the C/TPA will not serve as the DER, the C/TPA may support the DER by explaining the regulations and offering guidance on program -compliance issues. Service Agent Limitations. Service agents are subject to the following limitations concerning activities in the DOT' drug and alcohol testing program, (9 5. Critical Service Agent Positions Compliance. The Company recognizes the significance of critical service agent positions within the DOT drug and alcohol program. The Company understands the importance of each service agent meeting their initial qualifications, as applicable, and then maintaining compliance throughout the conduct of their program functions, all in accordance with Part 40 and Part 199 requirements. The Company will ensure that the follow critical positions meet DOT rule requirements. a) Medical Review Officer (MRO) (§40.121 and §199.109(b)); (See Plan Section V:8) b) Substance Abuse Professional (SAP) (§40.251); (See Plan Section VIL1) c) Urine Specimen Collector (§40.33); (See Plan Section VA.) d) Screening test Technician (§40.213); and (See Plan Section VI. 2 & 3.) e) Breath Alcohol Technician (§40.213) (see Plan Section VI.2-& 3) Premium Concrete Services, Inc.- PHMSA DRUGIALCOHOL PLAN 14 �� NATIONAL COMPLIANCE MANAGEMENT SERVICE, INC. (NCMS) 20�� (u�dele 2021). The NCMS plan is the subject of a reglstared copyriyh! antl is protecletl by copyrignl lor•is in the U.S. end elsewhere. All rights eservetl 6. "Non -DOT" Testing Program Compliance, The Company may implement an additional drug and/or alcohol testing program, referred to as a "non -DOT program", Any additional testing program would be completely independent of the DOT testing program. Such a testing program would be developed under the Company's own authority and kept separate from the DOT program. All DOT testing would be accomplished first; the Company's non -DOT program would commence afterwards. The non -DOT program would use different forms and not use the Federal Custody and Control Form or the DOT Alcohol Testing Form. The non -DOT program could test different people for different drugs and different reasons -for -testing. If the Company implements its own non -DOT testing program the Company will define the program and notify all employees through a non -DOT Program Plan IV. DOT PROGRAM REQUIREMENTS Employees Subject to Testing Compliance. Any employee who would perform an operations, maintenance, or emergency -response function, regulated by Part 192, 193, or 195, on a pipeline or LNG facility, is subject to mandatory DOT drug and alcohol testing under this program. Such individuals are subject to DOT testing because their job functions have been determined to be a covered, safety -sensitive, transportation function. Appendix C (Covered Positions) provides specific employee titles, for this Company, of those subject to testing under this program. However, it is the work that an individual performs, not their title of their job, which determines whether their work is covered and therefore subject to drug and alcohol testing Operator or Contractor. Covered employees may be employed by the operator, be a contractor engaged by the operator, or be employed by such a contractor; this includes full-time, part-time and temporary employees and includes any applicant for a covered function. 2. Acknowledgement/Receipt Form Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN 15 i'� NATIONAL COMPLIANCE MANAGEMENT SERVICE, I�IG. (�ICMS) LOi t (update 2021). The NCMS plan Is the subjoG of a reglsteretl copyriyht antl is prolodatl by copyright laws rn the U S. antl elsewhere All rlghls servetl 3. History -check Requirement Compliance. Prior to the first time that the Company uses an employee to perform covered safety -sensitive duties (i.e., a new hire or an employee transferring into a covered safety -sensitive position) the Company will require a "history check" of the employee. The history check will look back into the employee's past two years of DOT employment for DOT violations. History checks are conducted only after obtaining the employee's written authorization to do so. Any employee refusing to provide written consent will not be permitted to perform covered safety -sensitive functions. The Company will not allow the covered safety -sensitive employee to perform their functions after 30 days from the date on which the employee first performed safety- sensitive functions, unless the Company has obtained or made and documented a good faith effort to obtain alcohol and drug testing information from previous DOT -regulated employers. Information request. The Company will request the following information about the employee: a) Alcohol tests with a result of 0.04 or higher alcohol concentration; b) Verified positive drug tests; c) Refusals to be tested (including verified adulterated or substituted drug test results); d) Other violations of DOT agency drug and alcohol testing regulations; and e) With respect to any employee who violated a DOT drug and alcohol regulation, documentation of the employee's successful completion of DOT return -to -duty and follow- up testing requirements. The Company will make at least two attempts by telephone, e-mail or fax, and maintain documentation associated with the attempts to obtain history -check information (e.g., date and time of the attempt, persons contacted). If the Company finds evidence of oast DOT violations those violations may be used as the reason for not hiring the individual or for termination. Violation Consequences. The Company will not use any employee in a DOT covered safety -sensitive position that has had a past DOT violation and has not complied with DOT eligibility standards for returning to covered safety -sensitive work. The Company will also ask the employee if they had any pre -employment test that was positive for which the previous employer did not hire them. The employee's answer to this question will be maintained as part of the employee's history -check information. 4. Employee Notification of Tests Employees will be notified directly when a test must be conducted. While the circumstances for a test will differ by its reason -for -test, the Company will endeavor to conduct all tests with only a limited number of Company personnel having knowledge of the reason for the test. All testing will be unannounced until the last possible moment. The timing will vary in conjunction with the reason - for -test. For example, a pre -employment test will be announced during the job application; a random test is announced within the test period, but just prior to the test, to maintain the element of surprise; and, announcements of post -accident or reasonable suspicion tests are controlled by the circumstances that come to light around the time of the event (e.g., accident). All alcohol tests will be conducted just prior to, during, orjust after the performance of covered safety -sensitive duties. Drug tests may be conducted anytime the employee is at work. The DER and Company supervisors will be responsible for notifications and to help maintain the element of confidentiality. When an employee is notified for a test, the employee must proceed to the collection site mmediately. Immediately means that after notification, all the employee's actions must lead to an immediate specimen collection (or test). The Company considers "travel time to the collection site. plus 30 minutes" as the maximum acceptable interval of time between notification and testing. Premium Concrete Services, Inc: PHMSA DRUGlALCOHOL PLAN 16 l-J NATIONAL COMPLIANC[ MANAGEMENT SERVICE, ING. (NCMS) 2011 (update 2021i. iM1a NCMS plan is Iho subjoct of e registered copyngdi antl is proloclsd by wpy,igM1t la,vs in IM1e U S. anti elsa,vtiere All rights roserved In test situations such as post -accident and reasonable suspicion/cause, where the employee's job performance s called into possible question, supervisors will use their discretion and training to minimize further confrontation. A reasonable attempt will be made by the supervisors to isolate and inform the employee of the decision to test, the steps that must be taken to accomplish the test, and the consequences of refusing the test. If possible, for post -accident and reasonable suspicion tests, the Company will have the DER or a supervisor accompany the employee to the collection site. 5. DOT Drug Violations Drug Violations. The following provides a listing of DOT drug violations prohibited of covered safety -sensitive employees: a) A verified positive drug test result; b) A refusal to be tested, determined by: (1) Having a verified adulterated or substituted drug test result; (2) Failing to appear for any drug test (except a pre -employment test) within a reasonable time, as determined by the Company, after being directed to do so by the Company; (3) Failing to remain at the drug testing site until the testing process is complete; (4) Failing to provide a urine specimen for any drug test; (5) Failing to allow a directly observed or monitored collection in a drug test that requires such a collection procedure; (6) Failing to provide a sufficient amount of urine for a drug test when directed, and it has been determined, through a required medical evaluation, that there was no adequate medical explanation for the failure; (7) Failing or declining to take an additional drug test the Company or collector has directed the employee to take; (8) Failing to undergo a medical examination or evaluation, as directed by the MRO as part of the verification process, or as directed by the DER; or, (9) Failing to cooperate with any part of the testing process (e.g., refuse to empty pockets or failure to wash hands when so directed by the collector, behave in a confrontational way that disrupts the collection process, tampering with a specimen). (10) For an observed collection, fail to follow the observer's instructions to raise clothing above the waist, lower clothing and underpants, and to turn around to permit the observer to determine if there is any type of prosthetic or other device that could be used to interfere with the collection process. (11) Possess or wear a prosthetic or other device that could interfere with the collection process; (12) Admit to the collector or MRO that a specimen has been adulterated or substituted. 6. DOT Alcohol Violations and Prohibited Conduct Alcohol Violations. The following provides a listing of DOT alcohol violations prohibited of covered safety -sensitive employees: a) A test result of 0.04 or higher alcohol concentration; b) A refusal to be tested, determined by: (1) Failing to appear for any alcohol test (except a pre -employment test) within a reasonable time, as determined by the Company, after being directed to do so by the Company; (2) Failing to remain at the alcohol testing site until the testing process is complete; (3) Failing to provide an adequate amount of saliva or breath for an alcohol test; (4) Failing to provide a sufficient amount of breath for an alcohol test when directed, and it has been determined, through a required medical evaluation, that there was no adequate medical explanation for the failure; (5) Failing to undergo a medical examination or evaluation, as directed by the DER; (6) Failing to sign the certification statement on the Alcohol Testing Form; or, (7) Failing to cooperate with any part of the testing process. Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN 17 G NATIONAL COMPI.IANGE MANAGEMENT SEftVIGE, ING (�IGMS) 2011 (update 2�2t). ilia NCMS plan Is the subiBo� of a registered copyrght antl is proloclotl by copyright le,vs'in Ii�e U. S'. antl else,vhara All rghls Qservetl c) On -duty use of alcohol while performing covered functions. d) Pre -duty use of alcohol within four (4) hours prior to performing covered functions, or if the employee is called to duty to respond to an emergency, within the time period after the employee has been notified to report for duty. e) Use of alcohol within eight (8) hours following an accident in which the performance of covered functions has not been discounted by the Company as a contributing factor to the accident, unless the employee has already been given a post -accident alcohol test. Alcohol Prohibited Conduct. The following is prohibited conduct of DOT covered safety -sensitive employees: a) A test result of 0.02 or greater alcohol concentration, but less than 0.04. Violation Consequences and Company Actions After DOT Rule Violations. The Company will not allow any covered employee who has. a DOT drug or alcohol violation to perform covered safety -sensitive duties for the Company. Immediately upon learning of the violation, the DER shall assure the removal of the employee from all covered safety -sensitive duties, That employee will be ineligible to work in any DOT covered safety -sensitive function for the Company until the employee has successfully completed the DOT return -to -duty process; however, whether or not to do so is a business decision of the Company, not DOT. The company will refer the employee to a Substance Abuse Professional (SAP) as soon as practicable after the verified violation report. If the Company has a zero tolerance policy, any covered safety -sensitive employee who has a DOT drug or alcohol violation will be terminated upon such violation (refer to Appendix D, Company Disciplinary Actions and Additional Procedures). However, the employee will be referred to a SAP. The employee will be made aware that they must complete the DOT return -to -duty process prior to again performing covered safety -sensitive work for a company that is subject to the DOT alcohol and drug testing regulations. After DOT Alcohol Prohibited Conduct. The Company will not allow any covered safety -sensitive employee to perform, or continue to perform, any function covered by Part 199 when the employee is found to have an alcohol concentration of 0.02 or higher, but less than 0.04. The Company may continue testing the employee until the alcohol concentration is less than 0.02, or the Company may not use the employee in a covered safety -sensitive function until the start of the employees next regularly scheduled shift, which must be not less than eight hours follow the test that indicated, "prohibited conduct". V. ANTI -DRUG PROGRAM DOT -Required Drug Tests Compliance. The Company will ensure that each employee who performs aDOT-covered function will be drug tested for the following reasons when called for by Part 199: All drug tests will be conducted following the procedures of Part 40. Only urine specimens screened and confirmed at HHS certified laboratories are allowed for drug testing. Point -of -collection urine testing or instant tests are not authorized. Pre -Employment Testing. Apre-employment drug test will be conducted before an individual is hired or contracted into a covered position and when an individual is transferred or promoted from anon- covered to a covered position. This includes when an individual switches back and forth from a covered position to a non -covered position and back again. This also applies to employees returning from a leave of absence greater than 30 days who have not been participating in the Company's drug program and subsequently subiect to the random selection process. A negative DOT urine drug test results is required prior to performing a covered functions. DOT does not allow the use of a "quick test" (e.g., a urine test that produces an immediate test results) or any other methodology other than urine. Pre -employment tests are normally unobserved by the collector. However, provisions will be available at the collection site for a directly observed collection to take place should the circumstances requires such action. Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN 78 �� NATIONAL COMPIIAIVCE MANAGEMENT SERVICE, INC. (NCH15) 201� (update 2021). the NCMS plan is no subierA ofa registered copyngh� and is pio.ected by copyright laws in the U S. entl elservhero. Ail rights served Post -Accident Testing. As soon as possible but no later than 32 hours after an accident, the Company will drug test each surviving covered safety -sensitive employee whose performance of a covered function either contributed to the accident or cannot be completely discounted as a contributing factor to the accident. The Company may decide not to test under this paragraph but such a decision will be based on specific information that the covered employee's performance had no role in the cause(s) or severity of the accident. The Company will document the decisions that support the determination not to conduct a post -accident drug test. If a test required by this section is not administered within the 32 hours following the accident, the company will prepare and maintain its decision stating the reasons why the test was not promptly administered. If a test required by the above paragraph of this section is not administered within 32 hours following the accident, the Company will cease attempts to administer a drug test and will state in the record the reasons for not administering the test. Refer to Appendix F: Post -Accident or Reasonable Cause/Suspicion Supervisor Written Record The Company must take all reasonable steps to obtain a urine specimen from an employee after an accident, but any injury should be treated first. Nothing in this section shall be construed to require the delay of necessary medical attention for injured people following an accident, to prohibit a covered safety -sensitive employee from leaving the scene of an accident for the period necessary to obtain assistance in responding to the accident or to obtain necessary emergency medical care. The affected employee will not be allowed to proceed alone to or from the collection site. An employee who is subject to post -accident testing who fails to remain readily available for such testing, including notifying the Company or Company's representative of their location if they leave the scene of the accident prior to submission to such a test, may be deemed by the Company to have refused to submit to testing. Post -accident tests are normally unobserved by the collector. However, provisions will be available at the collection site for a directly observed collection to take place should circumstances require such action. Depending on the circumstances of the accident, and if feasible, the employee will not be allowed to perform covered functions pending, the results of the drug test. Random Drug Testing: The company will conduct a number of random tests each calendar year that meets or exceeds the current minimum' annual percentage random testing rate. The current annual random drug testing late is 50'percent The Company may use the services of the C/TPA to manage all aspects of the Company's random testing program. If the Company conducts random testing through a C/TPA, the number of employees to be tested may be calculated for each individual Company or may be based on the total number of covered safety -sensitive employees covered by the C/TPA who are subject to random testing (e.g., consortium random testing pool). All covered safety -sensitive employees will be immediately placed in the random pool after obtaining a negative result on their pre -employment test. Covered safety -sensitive employees will remain in the random selection pool at all times, regardless of whether or not they have been previously selected for testing. The selector of employees shall be made by using a computer -based, scientifically valid method (e.g., random number generator or equivalent random selection method) that is matched with an employee's social security or employee ID number, When requested during an audit or inspection, the DER will provide the name of the computer -based application that is The DER will assure the pool contains employee social security number or employee ID numbers that are current, complete, and correct. Employees will have an equal chance of being selected for testing. Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN 19 �J NATIONAL COMPLIANCE MANAGEMENT SERVIGF, INC. (NGMS) 201 � (updele 2021). The NCMS plan is` the suojacl of a rogistomtl wpyrlght and Is protected by copynghl I�nvs In the U.S. and elsewhere FlII rights eserved Random testing will occur on a quarterly basis. Prior to selection, the DER shall ensure that the random testing pool has been updated to include all current covered employees in the Company's workforce. The number of tests to be conducted will be based on the number of covered employees at the beginning of each quarter's test cycle. The DER, or C/TPA, shall use the random selection procedures to compile a list of covered employees selected for testing in each testing cycle. The number of employees selected shall be sufficient to assure that the minimum number of required tests can be achieved. The list of employees selected will be retained by the DER in a secure location until the time of testing when the list will be provided to the appropriate division manager, department head, or supervisor who will, in turn, notify the employee(s) to report for testing. Random testing is unannounced, with employees being notified that they have been selected for testing after they have reported for duty on the day of collection. Specimen collection will be conducted on different days of the week throughout each test cycle to prevent employees from matching their drug use patterns to the schedule for collection. Random tests are normally unobserved by the collector. However, provisions will be available at the collection site for a directly observed collection to take place should circumstances require such action. Once notified by the appropriate Company official, employees will be instructed to report immediately to the collection site. Reasonable Suspicion/Cause Testing. The Company will conduct reasonable suspicion testing, also known as reasonable cause testing, based on the Company's observation of "signs and symptoms" of specific, contemporaneous, articulable observations concerning the appearance, behavior, speech or body odors of the employee. At least two Company supervisors, one of whom is trained in detection of the possible signs and symptoms of drug use, shall substantiate and concur in the decision to test an employee. The concurrence between the two supervisors may be by telephone. If the Company,has 50 or fewer employees subject to testing under PHMSA regulations, only one supervisor, trained in detecting, possible drug use signs and symptoms, is needed to make the decision to test. The supervisor making the determination to test shall document, in writing, the behavioral signs and symptoms that support the determination to conduct a reasonable suspicion/cause test. This documentation of the employee's conduct shall be prepared and signed within 24 hours of the observed behavior or before the results of the test are released, whichever is earlier. Refer to Appendix G: Reasonable Cause/Suspicion Observation Checklist. The potentially affected employee should not be allowed to proceed alone to or from the collection site. In addition to the safety concerns for the employee, accompanying the employee also assures that there is no opportunity in route to the collection site for the employee to compromise the test through any method of tampering that could affect the outcome of the test results. Reasonable suspicion/cause tests are normally unobserved by the collector. However, provisions will be available at the collection site for a directly observed collection to take place should circumstances require such action. The employee shall not perform a covered function pending the receipt of the drug test results. The employee should make arrangements to be transported home. The employee should be instructed not to drive any motor vehicle due to the reasonable belief that the employee may be under the influence of a drug. If the employee insists on driving a supervisor should notify the proper local law enforcement authority that an employee believed to be under the influence of a drug is leaving the Company premises driving a motor vehicle. Return -to -Duty Testing, The Company will conduct areturn-to-duty test prior to an employee returning to covered safety -sensitive duty following a DOT violation. When an employee has a DOT violation the employee cannot work again in any DOT covered safety -sensitive function until successfully completing the Substance Abuse Professional (SAP) return -to -duty requirements. Only after the SAP has reported to the Company that the employee s eligible to return to covered safety -sensitive duties is the Company authorized to return the employee to a covered function. However, whether or not to do so is a business decision of the Company, not the DOT. When the Company makes the decision to return the employee to covered safety -sensitive duty, the Company will initiate the order for the return -to -duty test. All return -to-duty tests will be conducted using direct -observation collection procedures. Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN 20 L� NATIONAL GOMPIIANCE NIANAOEMENT SERVICE ING. (NOM812011 (upMte 2021) The NGMS plan is the sub�ecl of a reglstere<t coPYh9tit antl Is pmtecled by copyright laws in Iho U S. antl elsewhere. All hghts esetve( A return -to -duty test, as a minimum, will be for the substance associated with the violation. A return -to- duty test may, however, be for both drugs and alcohol. The decision belongs solely to the SAP from information gained during the SAP-evaluation/treatment processes. The results of a return -to -duty drug test must be negative in order "to count" and allow the employee to return to work. A cancelled test must be recollected; a positive test or refusal -to -test will be considered as a new, separate violation. When the employee "passes" their return -to -duty test, their name is immediately placed into the Company's random testing pool. If the Company has a zero tolerance policy, any covered safety -sensitive employee who has a DOT drug or alcohol violation will be terminated upon such violation (refer to Appendix D, Company Disciplinary Actions and Additional Procedures). However, the employee will be referred to a SAP. The employee will be made aware that they must complete the DOT return -to -duty process prior to again performing covered safety -sensitive work for a company that is subject to the DOT alcohol and drug testing regulations. Follow-up Testing. The Company will conduct follow-up testing, as a series of tests that occur after an employee returns to covered safety -sensitive work, following a negative result on the return -to -duty drug and/ or alcohol tests. Follow-up testing, as a minimum, will be for the substance associated with the violation. In addition, follow- up testing may be for both drug and alcohol, as directed by the SAP's written follow-up testing plan. Follow-up testing is the Company's responsibility to conduct. Follow-up testing will run concurrently with random testing. All follow-up tests will be conducted using direct -observation collection procedures. The number and frequency of the follow-up tests will be determined by the SAP, but shall consist of at least six tests in the first 12 months following the covered employee's return to duty. The follow-up plan will give both the number of tests and their frequency; the Company will select the actual day and time of the test and the tests are unannounced. Follow-up testing shall not exceed 60 months from the date of the covered employee's return to duty. The SAP may terminate the requirement for follow-up testing at any time after the first six tests have been administered, if the SAP determines that such testing is no longer necessary. Even if the Company has a zero tolerance policy, in the case where the Company hires an employee who previously had a positive test and successfully completed the return -to -duty process and has an acceptable SAP evaluation, the Company must follow the follow-up testing procedure in accordance with the DOT alcohol and drug testing regulations. 2. Drug Tests That Require Direct Observation Procedures Compliance, The Company will conduct all return -to -duty and follow-up drug tests using the direct observation collection procedures specified by Part 40. Pre -employment, post -accident, reasonable suspicion/cause and random drug tests are normally conducted by giving the employee the privilege of privacy when providing the urine specimen. However, should it become required that these collections be conducted under direct observation procedures, the Company will explain to the employee the reason(s) and convey instructions to the collector to ensure that this done. Direct observation procedures will also be used for collections when a specimen is provided and the temperature is out of range, when the specimen appears to have been tampered with or when a previous specimen has been reported as invalid, adulterated, substituted or negative -dilute with a creatinine concentration greater than or equal to 2 mg/dL but less than or equal to 5 mgrl as defined in Part 40. If a service agent is aware that a directly observed collection should have been collected but was not, the service agent will inform the Company to direct the employee to have an immediate recollection under observation. 3. Specimen Collection Procedures Compliance. The Company will follow the requirements of Part 40 for its DOT collections. A full description of DOT collection requirements that collectors will follow can be found in Part 40, Subpart C ("Urine Collection Personnel"), and Subpart D ("Collection Sites, Forms, Equipment and Supplies Used in a DOT Urine Collection"), and Subpart E ("Urine Specimen Collections"). Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN 21 «) NATIONAL COMPLIANCE MANAGEMENT SERVICE, INC. (NCMS) 2011 (update 2021). The NCMS plan is the subject of a registered copyright and Is protected by copyright talus in trip U.S. and elsewhere All rights reserved Collection Site Personnel, The Company will ensure that collection sites utilized by its employees are aware of their responsibilities with regard to the DOT specimen collection process. These responsibilities are to collect urine specimens using Part 40 procedures, current "DOT Urine Specimen Collection Guidelines" and applicable DOT agency regulations, ship the specimens to a Department of Health and Human Services (HHS) certified laboratory for analysis, and distribute copies of the Federal Drug Testing Custody and Control Form (CCF) to the laboratory, Medical Review Officer, employer or employer's C/TPA and employee in a confidential manner. All attempts are made to use collectors who have been trained in accordance with Part 40. The Company, or the Company's C/TPA, will ask the collection sites conducting DOT collections to attest to the fact that they comply with DOT standards of practice. The direct supervisor of a covered safety -sensitive employee shall not serve as a collector in conducting any required drug test unless it is otherwise mpracticable. Collectors will complete requalification/certification every five years. Collectors will subscribe to the ODAPC list -serve website to keep current on any changes to the DOT alcohol and drug testing regulations. Collection Site, Forms, and Specimen. The Company will provide the employee with the specific location of the collection site where the drug test will take place. The collector will select or allow the employee to select an ndividually wrapped or sealed collection container from collection kit materials. In most cases, the Company will provide the employee with a drug testing kit, which includes the CCF, to present to the collector. The only specimen that will be conducted for any DOT collection is urine; the only form that will be used is the Federal CCF. Collections. The Company will inform every employee that they are required to carry and present a current valid photo ID, such as a driver's license, passport, or employer -issued picture ID to the collection site. The employee will be advised that the collector will ask them to empty their pockets, remove any unnecessary garments (the employee may retain their wallet) and wash and dry their hands prior to the collection. The employee will be instructed to follow the collector's instructions throughout the collection process. Normally, the employee will be afforded privacy to provide a urine specimen, Exceptions to the rule generally surround issues of attempted adulteration or substitution of a specimen or any situation where questions of specimen validity arise, like an unusual specimen temperature. After the employee has provided the specimen (a minimum of 45 mL) of their urine into a collection container, the collector will check the temperature and color of the urine. All DOT collections are "split specimen collections." The collector will pour the urine into two separate bottles (bottle "A" as the primary specimen and bottle "B" as the split specimen), seal them with tamper -evident tape, and then ask the employee to initial the seals after they have been placed on the bottles. (Remember: Neither the employee nor the collector should let the specimen out of their sight until it has been poured into two separate bottles and sealed.) Next, the employee will write their name, date of birth, and daytime and evening phone numbers on the MRO Copy (Copy 2) of the CCF. This is so the MRO can contact the employee directly if any questions arise about their test. Lastly, the collector will complete the necessary documentation on Copy 1 of the CCF and package the CCF and the two specimen bottles in the plastic bag and seal the bag for shipment to the laboratory. Copies of the CCF will be distributed: Copy 2 to the MRO and Copy 4 to the employer or the employer's C/TPA; the collector keeps Copy 3 and the employee gets Copy 5. The employee may list any prescription and over-the-counter medications they may be taking on the back of their copy of the CCF (this may serve as a reminder for the employee n the event the MRO calls to discuss their test results). Possible collection issues. If the employee is unable to provide 45mL of urine on the first attempt, the time will be noted, and they will be required to remain in the testing area under the supervision of the collection site personnel, their supervisor, or a representative from their Company (e.g., supervisor accompanying the employee). Leaving the testing area without authorization may be considered a refusal to test. The employee will be urged to drink up to 40 oz. of fluid, distributed reasonably over a period of up to three hours, and asked to provide a new specimen (into a new collection container). If the DER is contacted, the DER should instruct the employee to remain at the collection site to complete the collection process. If the employee does not provide a sufficient specimen within three hours, the DER, in consultation with the MRO, will direct the employee to obtain a medical evaluation within five days to determine if there is an acceptable medical reason for not being able to provide a specimen. If it is determined that there is no acceptable physiological or pre-existing psychological reason for not providing a urine specimen, it will be considered a refusal to test. Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN 22 �NATIONAL COMPLIANCE MANAG[MENT SEP.VICE, INC. (NCM57 2011 (uodale 20211. The NCMS plan is Iha subfoU of a reystered copyrght antl is pmtecletl by copyright laves In Iho Il S. and elsa,vhere NI riyM1ls reserved. Directly observed collections. If a direct observation collection is required of the employee, the Company will ensure that the DOT requirements (i.e., direct observation by the same -sex collector, observation of body - to -bottle urination, and use of full turn -around observation) procedures are followed. 4. PHMSA Inspection Protocol for Specimen Collection Sites Compliance. "PHMSA's Substance Abuse Program Comprehensive Audit and Inspection Protocol Form, Specimen Collection Sites, Form No,: 3.1.7 (Revision':2)" provides a separate inspection protocol for Specimen Collection Sites. The Company provides this protocol to correspond with the detail found in the PHMSA Inspection Form. As previously stated, the Company will ensure that all DOT drug tests comply with Part 40 requirements. Collection Personnel. The Company will ensure that only qualified collectors are used to conduct Company DOT tests. An immediate supervisor of an employee may be used in cases where there are no qualified collectors available, and where their use is the only way to get the test conducted. Collectors will maintain documentation to verify they meet training requirements and will make that documentation available to the Company on request. If an error occurs causing a test to be cancelled and the error is directly attributed to the collector, the collector will undergo error -correction training within 30 days of the date of notification of the error that led to the need for training. Collection Sites, Forms and Supplies. The Company will use designated collection sites that meet DOT requirements. If the collection site uses a facility normally used for other purposes, the collector will ensure that it meets DOT standards before continuing the collection. Access to collection materials and specimens will be restricted, and the facility will be secured against access during the procedure to ensure privacy to the employee and prevent distraction of the collector. Limited -access signs will be posted as necessary. The collector will maintain personal control over each specimen and CCF throughout the collection process and will prevent unauthorized personnel from entering any party of the site in which urine specimens are collected or stored. The current CCF and a collection kit, that meets the requirements of Appendix A to Part 40, will be used for DOT collections. Specimen Collections. Collectors will explain the basic collection procedures to the employee, including showing the employee the instructions on the back of the CCF. In most all collections, the Company will provide the employee with a kit and CCF to carry to the collection site. In other collections, collectors will provide the employee with an ndividually wrapped or sealed collection container from the collection kit materials. Precautions will be taken to ensure that unadulterated specimens are obtained and correctly identified. Specimen integrity will be maintained by: bluing agents being added in the toilet tank and all water sources secured; positive photo identification of the employee for collection, notification of the DER if the employee fails to arrive at the assigned time; having the employee remove any unnecessary outer garments (purses or briefcases will remain with the outer garments); having employees wash and dry their hands; and, to the greatest extent possible, the collector will keep an employee's collection container within view of both the collector and the employee between the time the employee has urinated and the specimen is sealed. Any unusual behavior will be noted on the CCF. Following the collection, the specimen will be checked for sufficient volume (i.e., 45 mL), acceptable temperature range (i.e., between 90-100 degrees F), and shows no signs of tampering (e.g., color, odor). Having problematic ssues with specimen volume, the collector will follow DOT's "shy bladder" procedures; problems with temperature or tampering will result in the collector conducting a second collection under direct observation (see Section V.2, "Drug Tests That Require Direct Observation Procedures"), Direct observation procedures will be used for all collections where the reason -for -test is either return -to -duty or follow-up. Direct observation procedures will also be used for collections when a specimen is provided and the temperature is out of range, when the specimen appears to have been tampered with or when a previous specimen has been reported as invalid, adulterated, substituted or negative -dilute with a creatinine concentration greater than or equal to 2 mg/dL, but less than or equal to 5mg/dL, as defined in Part 40. If the collector does a monitored collection, same gender monitors will be used if the monitors are non -medical personnel. Premium Concrete Services, Inc.- PHMSA DRUGlALCOHOL PLAN 23 C� NATIONAL COMPLIANCE M�NAGEME�IT SERVIGF, INC. (NCNB) 2011 (update 2021). TM1e NCMS plan is Iha subjerA of a regisieretl copyngh� entl Is proleGlad by copyM1ght 16�vs'in the U.S. aptl else,vhoro All nghls e. All collections are completed by the specimens being sealed and labeled, the CCF being properly executed, and the specimens and the CCF being sealed in a plastic bag for shipment to the laboratory. 5. Drug Testing Laboratory Compliance. " PHMSA's Substance Abuse Program Comprehensive Audit and Inspection Protocol Form, Specimen Collection Sites, Form No.: 3.1.7 (Revision 2)" provides a separate inspection protocol for Specimen Collection Sites. The Company provides this protocol to correspond with the detail found in the PHMSA Inspection Form. As previously stated, the Company will ensure that all DOT drug tests comply with Part 40 requirements. Laboratory. The Company shall ensure that all DOT testing is conducted only by a laboratory that is certified by the Department of Health and Human Services (HHS) under the National Laboratory Certification Program (NLCP). Doing so ensures that the Company complies with the requirements of Part 40 and with all applicable requirements of HHS in testing DOT specimens, whether or not those requirements are explicitly stated in the Plan. The laboratory used by this Company is specified in Appendix B. The laboratory will report the certified results to the MRO and only to the MRO, at the address provided on the Federal CCF. Results will not be reported directly to the Company or to or through another service agent, such as the C/TPA. Specimen. Urine is the only specimen that is authorized for DOT drug testing. The Company will not use any other specimen (e.g., hair or saliva) for a DOT -required drug test. A "quick test" (e.g,, a urine test that produces an immediate test result) is also prohibited by DOT. Drug Testing. The laboratory will ensure that, on each DOT test, each specimen is tested for marijuana, cocaine, amphetamines, opioids, and phencyclidine (PCP). (See, Table 1) The testing is a "two step" process: all presumptive positive results on the initial test must be confirmed, by a confirmation test. The initial and the confirmation tests use different chemical principles, and separate portions of the original specimen, for test. DOT specimens will not be tested for any other drugs. DOT specimens will not be subjected to DNA testing. Validity Testing. The laboratory will ensure that, on each DOT test, each specimen is also subjected to "validity testing". The purpose of validity testing is to determine if the employee tampered with their specimen during the collection process. Validity testing measures the creatinine concentration and specific gravity to detect a diluted or substituted specimen; ph is measured as one criterion established to detect an adulterated specimen. Validity testing also incorporates HHS criteria (used by DOT) in testing for specific adulterants such as nitrites, chromates, surfactants, and other active chemical compounds. Laboratory Specimen Handling and Reporting. When the laboratory receives a DOT specimen they will unpack and enter it into the testing process. Part of that process is to examine the condition of the specimen bottles and accompanying CCF. The laboratory will look closely for any specific reason to stop the testing process (e.g., "fatal flaws"). If the laboratory determines a fatal flaw exists, the specimen is rejected for testing and the test is cancelled by the MRO. If a fatal flaw does not exist, the specimen will be tested. The following are DOT "fatal flaws": a) There is no CCF; b) Ih cases where a specimen has been collected, there is no specimen submitted with the CCF; c) There is no printed collectors name and no collectors signature; d) Two separate collections are performed using one CCF; e) The specimen ID numbers on the specimen bottle and the CCF do not match; f) The specimen bottle seal is broken or shows evidence of tampering (and a split specimen cannot be re- designated, (see §40.83(h)); and g) Because of leakage or other causes, there is an insufficient amount of urine in the primary specimen bottle for analysis and the specimens cannot be re -designated, (see §40.83(h)). The laboratory will open only the primary specimen (Bottle "A") to conduct the two tests (initial and confirmatory). If the specimen tests negative in either test and does not have any specimen validity issues, the result will be reported to the MRO as negative. Only if the specimen test results are positive, adulterated, substituted, and/or invalid under both tests will the specimen be reported to the MRO as positive, adulterated, substituted, and/or invalid, respectively. These results are also referred to as "non -negative" results. Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN 24 C',NATIONAL COMPLIANCE MANAGEMEM SERVIC[, INC. (NCMS) 2011 (update 2021). Teo NCMS olan'is the subjeG of a raglstereU wVY��9h� and Is protectetl by copyriyhl laws in Ille U.S. and elsevihare. All �igM1ls esMetl Required DOT Drug Tests & Cutoffs TYPE OF DRUG INITIAL TEST CONFIRMATORY TEST CONFIRMATORY TEST Initial Test Analyte Cutoff Concentrations Analyte Cutoff Concentration Marijuana metabolites THCA 10 50 n /mL" THCA 15 ng/ml- Cocaine metabolite 150 ng/mL" Benzoylecgonine 100 ng/ml- Benzo lec onine Opioids: Codeine/Morphine 2000 ng/mL Codeine 2000 ng/mL Morphine 2000 ng/mL Hydrocodone/Hydromorphone 300 ng/ml- Hydrocodone 100 ng/mL Hydromorphone 100 ng/ml- Oxycodone/Oxymorphone 100 ng/ml- Oxycodone 100 ng/mL Oxymorphone 100 ng/ml- 6-Acet Imor hine 10 n /ml- 6-Acet Imor hine 10 n /mL ' Phencyclidine 25 n /mL Phenc clidine 25 n /mL Amphetamine/Methamphetamine 500 ng/mL Amphetamine 250ng/mL Methamphetamine 250 ng/ml- MDMA'2/MDA13 500 ng/mL MDMA 250 ng/ml- MDA 250 n /ml- Table 1 9 For grouped analytes (i.e, two or more analytes Chat are in the same drug class and have the same initial test cutoff): Lmnunoassay, The test must be calibrated with one analyte from the group identified as the target analyte. The cross -reactivity of the immunoassay to the other analytes) within the group must be 80 percent or greater. If not, separate immunoassays must be used for the analytes within the group. Alternate technology: Either one analyte or all analytes from the group must be used for calibration, depending on the technology. At least one analyte within the group must have a concentration equal to or greater than the initial test cutoff or, alternatively, the sum of the analytes present (i.e,, equal to or greater than the laboratory's validated limit of quantification) must be equal to or greater than the initial test cutoff. 10 An innnunoassay must be calibrated with the target analyte Delta-9-tetrahydroeannabinol-9-carboxylic acid (THCA) Alternate technology (THCA and benzoyleegonine): When using alternate technology to test for THCA and Benzoylecgonine, the screening and confirmatory test cutoff concentrations must be the same respectively (i.e., 15 ng/mL for THCA and 100 ug/mL for Benzoyleegnine). iz Metlrylenedioxymethamphetamine (MDMA) Methylenedioxyamphetamine (MDA) Premium Concrete Services, Inc.- PHMSA DRUGIALCOHOL PLAN 25 C IJA riONHI C04f PLIANCE MA�WGEMENT SERVICE, I�IC_ (�ICMS)'20r 1 (upUale 2°217. The NGMS plan is the subject of a registeretl copyriyM1t entl is p,olectetl by copy�igM1t 13,vs In Ilse 11 $. antl elsewhere. All +igl,�s e.ervQd 6. Laboratory Retention Periods and Reports Specimen Retention. Specimens that are confirmed by the laboratory to be positive, adulterated, substituted, or nvalid will be retained by the laboratory in properly secured, long-term, frozen storage for at least one year. Any employee split specimen not sent to another laboratory for testing, will be retained by the laboratory for the same period of time that the primary specimen is retained and will be maintained under the same storage conditions. Within this one-year period, the MRO, the employee, the Company, PHMSA or other state agencies with jurisdiction, may request in writing that the specimens be retained for an additional period. If the laboratory does not receive the request to retain the specimen within the one-year period, the specimen will be discarded. Record Retention. All laboratory records pertaining to any test for this Company on its covered safety -sensitive employees will be retained for two years. The employer -specific data that is created by the laboratory for the laboratory statistical summary will be retained for two years. Within this two-year period, the MRO, the employee, the Company, PHMSA or other state agencies with jurisdiction, may request in writing that the records be retained for an additional period. If the laboratory does not receive the request to retain the records within the two-year period, the records will be discarded. Semi-annual Reports. The laboratory will prepare and send to the Company the aggregate employer- specific summary on a semi-annual basis. The format for this report is found in Part 40, Appendix B. Laboratory Quality Control Inspections. The laboratory shall permit inspections by the Company, the PHMSA Administrator, or if the Company s subject to the jurisdiction of a state agency, a representative of the state agency. Additionally, if the Company uses a C/TPA. that C/TPA may conduct a periodic inspection of the laboratory on the behalf of the companies that are clients of the C/TPA. 8. MRO Review of Drug Test Results Compliance. The Company will have, on staff or contract for the services of, an MRO who is a licensed physician with knowledge of drug abuse and is qualified under Part 40. The MRO will follow the requirements of Part 40 in carrying out the functions of the "independent and impartial gatekeeper of the drug testing process'. A full description of the DOT MRO requirements can be found in Part 40, Subpart G ("Medical Review Officers and the Verification Process", and Subpart H (Split Specimen Testing). The MRO will complete requalification/certification training every five years. The MRO will subscribe to the ODAPC list -serve website to keep current on any changes to the DOT alcohol and drug testing regulations. The MRO will act to investigate and correct problems where possible and notify appropriate parties (e.g., HHS, DOT, employers, service agents) where assistance is needed (e.g., cancelled or problematic tests, incorrect results). Duties. All :confirmed drug test results for the Company are received by the MRO directly from the laboratory. The MRO is responsible for the review of both negative and non -negative test results, review of the CCFs associated with each test, and to conduct quality control reviews of the MRO staff. The MRO will review and nterpret confirmed positive, adulterated, substituted, and invalid test results. The MRO will verify a confirmed positive test result for marijuana, cocaine, amphetamines, semi -synthetic opioids (i.e., hydrocodone, hydromorphone, oxycodone and oxymorphone), and/or PCP unless the employee presents a legitimate medical explanation for the presence of drug(s)/metabolite(s) in his or her system. In carrying out this responsibility, the MRO shall examine alternate medical explanations for any positive, adulterated, substituted or invalid test result. This action would include conducting a medical interview with the employee and review of the employee's medical history, or review of any other relevant biomedical factors, such as the results of a physical examination following an opioid positive. If the MRO determines that it is necessary, the MRO will request the laboratory test for D, L stereoisomers of amphetamine and methamphetamine or testing for tetrahydrocannabivarin (THC-V) when verifying lab results. Premium Concrete Services, Inc: PHMSA DRUG/ALCOHOL PLAN 26 CJ NATIONAL COMt''LIANCE MANAGEMENT SERVICE, INC. (NCMS) 2011 (update 20211. Tt,e MCMS plan is No &ubiad of e registpretl wpynyhl and is proloctatl by wpyright laws in the U.S. and elsa,vhere All n9hls eserved. The MRO shall review and take all reasonable and necessary steps to verify the authenticity of all medical records made available by the tested employee when the source of the confirmed result could have been from legally prescribed medication. The MRO shall not, however, consider the results of urine or other specimens that are not obtained or processed in accordance with DOT regulations. Results. The MRO will use staff under his direct supervision to handle administrative processes for negative test results including receiving the result from the laboratory, reviewing the paperwork for accuracy, and reporting of the result to the DER. The MRO will personally review at least 5 percent of all CCFs reviewed by their staff, on a' quarterly basis, not to exceed more than 500 negative results in a quarter. The MRO staff may make the initial contact with employees having confirmed positive, adulterated, substituted, and invalid test results, for the purposes of setting up an interview for the MRO. The MRO will personally conduct the interview with the employee to determine whether there is a legitimate medical explanation for these results. This interview will be conducted, in most cases, before the Company is notified. If the result is confirmed positive by the laboratory, and a legitimate medical explanation is established, the MRO will report the result to the DER as negative. If not, the MRO will report the result to the DER as positive. If the confirmed result is adulterated or substituted, and a legitimate medical explanation is established, the MRO will report the result to the DER as cancelled and notify ODAPC, in accordance with Part 40 procedures. if not, the MRO will report the result to the DER as a refusal to test. If the result is invalid, and an acceptable reason is established, the MRO will report the result to the DER as cancelled and the process will stop, unless a negative test; result is needed (e.g., pre -employment, return -to -duty and follow-up). If an acceptable reason is not established, the MRO will report the result to the DER as cancelled and order an immediate recollection under direct observation. Reports. All drug test results will be reported to the Company 'DER in a confidential and timely manner. Before reporting any results, the MRO will have received a copy of the CCF showing where the employee has signed the form. The time period from collecting the specimen to reporting the verified test result is generally shorter for negatives than for non -negatives. Non -negatives will not be reported to the DER until all information required for the employee interview is received and approved by the MRO. The MRO will transmit the report(s) of verified tests to the Company DER within two days of verification by the MRO. The Company may use a C/TPA as its intermediary in receiving drug test results. If so, those reports will be handled in accordance with Part 40 requirements. If the MRO does not use Copy 2 of the CCF for reporting results, the MRO will maintain a copy of the signed or stamped report in addition to the signed or stamped and dated Copy 2. If the MRO uses an electronic data file to report negatives, the MRO will maintain a retrievable copy of that report in a format suitable for inspection and auditing by a DOT representative. 9. Split Specimen Testing Split Specimen. When the MRO has verified a result as positive, adulterated, or substituted, the MRO will notify the employee of their right to have the split specimen tested. The employee must notify the MRO within 72 hours of the result being verified in order to have this testing conducted. If the employee requests that the split specimen be tested within the 72-hour period, the MRO will ensure that the split specimen is tested. Testing of the split specimen is only conducted at the request of the employee, and then only after using the MRO as the requesting agent for the employee. The MRO will select the second laboratory. The MRO will immediately provide written notice to the laboratory that tested the primary specimen, directing the laboratory to forward the split specimen to the second HHS-certified laboratory. The MRO will document the date and time of the employee's request. The Company is responsible for making sure that the MRO, first laboratory, and second laboratory perform the functions noted in Part 40 in a timely manner, once the employee has made a timely request for a test of the split specimen (e.g., by establishing appropriate accounts with laboratories for testing split specimens). The Company must not condition compliance with these requirements on the employee's direct payment to the MRO or laboratory or the employee's agreement for reimbursement of the costs of testing. For example, if the Company's asks the employee to pay for some or all of the cost of testing the split specimen, and the employee s unwilling or unable to do so, the Company must ensure that the test takes place in a timely manner, which means that the Company will pay for the split testing. Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN 27 CJ NATIONAL COMPLIANCE MANFlCEMEpn SFRVIGE, I�IC. (pICMS) 2011 (update 2p21). the NCMS plan is the sub;ect of a regis�oretl copyrtyht and Is prolecletl by copyright le,vs in the U S. antl elsewhere. Ail rghis osorvotl. The Company may seek payment or reimbursement of all or part of the cost of the split specimen from the employee. Part 40 takes no position on who ultimately pays the cost of the test, so long as the Company ensures that the testing is conducted as required and the results released appropriately. Laboratory. The testing of the split specimen will be conducted at another HHS-certified laboratory, different from the original laboratory. The MRO will select the second laboratory. The split specimen will be tested for the same substance or condition that was found in the primary specimen. The MRO will report back to the DER and the employee whether the split reconfirms the primary. If the test of the split does not reconfirm the primary, both tests will be cancelled as if they never occurred. 10. Medical or Recreational Marijuana The DOT does not accommodate the use of medical or recreational mariivana by DOT -covered safety -sensitive employees. VI. ALCOHOL MISUSE PREVENTION PROGRAM DOT -Required Alcohol Tests Compliance. The Company will ensure that each employee who performs a'DOT-covered function will be alcohol tested for the following reasons when called for by Part 199. All alcohol tests will be conducted following the procedures of Part 40. Pre -Employment Testing. PHMSA does not mandate apre-employment alcohol test for covered sensitive employees employees in the pipeline industry. PHMSA does give operators and contractors who wish to conduct a pre- employment alcohol test the authority to do so. If the Company decides to conduct pre- employment alcohol testing, all applicants will be advised of the test prior to the test occurring, and all tests will be conducted before the first performance of covered functions by every covered safety -sensitive employee (whether a new employee or someone who has transferred to a position involving the performance of covered functions). The Company will treat all covered safety -sensitive employees the same for the purpose of pre- employment alcohol testing; the Company will not test some covered safety -sensitive employees and not others. The Company will conduct the pre -employment tests after making a contingent offer of employment or transfer, subject to the employee passing the pre -employment alcohol test. A result of less than 0.02 alcohol concentration is required prior to performing covered functions. Post -Accident Testing. As soon as possible, the Company will alcohol test each surviving covered safety -sensitive employee whose performance of a covered function either contributed to the accident or cannot be completely discounted as a contributing factor to the accident. The Company may decide not to test under this paragraph but such a decision will be based on specific information that the covered safety -sensitive employee's performance had no role in the cause(s) or severity of the accident. The Company will document the decisions that support the determination not to conduct a post -accident alcohol test. If a test required by this section is not administered within the 8 hours following the accident, the Company will prepare and maintain its decision stating the reasons why the test was not promptly administered. If a test required by the above paragraph of this section is not administered within 8 hours following the accident, the Company will cease attempts to administer an alcohol test and will state in the record the reasons for not administering the test. Refer to Appendix F: Post -Accident or Reasonable Cause/Suspicion Supervisor Written Record If the alcohol test is not completed within 2 hours the Company will prepare and maintain a written statement documenting the reason the test was not conducted. If the test is not completed within 8 hours, the Company shall cease attempts to do so. The Company will take all reasonable steps to obtain a breath test from an employee after an accident, but any injury should be treated first. Nothing in this section shall be construed to require the delay of necessary medical attention for injured people following an accident, to prohibit a covered safety -sensitive employee from leaving the scene of an accident for the period necessary to obtain assistance in responding to the accident, or to obtain necessary emergency medical care. Premium Concrete Services, Inc.-PHMSA DRUG/ALCOHOL PLAN 28 C� NATIONAL COMPLIANCE MANAGEMENT SERVICE, I�IC. (NCMS) 2011 (update 2021). TM1a NCMS plan is lne subject of a re9istored ra�yright entl Is prolecletl by copyriyM1l lawsin Ilse V.S. and elsewhpro All n9hls a50NE, The affected employee will not be allowed to proceed alone to the testing site. A covered safety -sensitive employee who is subject to post -accident testing who fails to remain readily available for such testing, including notifying the Company or Company's representative of their location if they leave the scene of the accident prior to submission to such test, may be deemed by the Company to have refused to submit to testing. Random Testing. PHMSA does not authorize random alcohol testing of covered safety -sensitive employees within the natural gas and hazardous liquids pipeline industry. The Company will not conduct DOT random alcohol testing of their PHMSA-regulated employees. Reasonable Suspicion/Cause Testing. The Company will conduct reasonable suspicion testing, also known as reasonable cause testing, based on the Company's observation of "signs and symptoms' of specific, contemporaneous, articulable observations concerning the appearance, behavior, speech, or body odors of the employee. A supervisor trained in detection of the possible signs and symptoms of alcohol use shall make the decision to test an employee. The decision to test will only be made on an employee during, just before, or just after his performance of DOT functions. The supervisor making the determination to test shall document, in writing, the behavioral signs and symptoms that support the determination to conduct a reasonable suspicion/cause test. This documentation of the employee's conduct should be prepared and signed within 24 hours of the observed behavior or before the results of the tests are released, whichever is earlier. Refer to Appendix G: Reasonable Cause/suspicion Observation Checklist. The potentially affected employee should not be allowed to proceed alone to or from the test site. If the reasonable suspicion test is not administered within 2 hours following the determination, the Company will prepare and maintain on file a record stating the reasons the test was not promptly administered. If a test s not administered within 8 hours, the Company will cease attempts to administer an alcohol test and record the reasons for not testing. Reqardless of whether or not a reasonable susoicion alcohol test is conducted. the Companv It the test results are 0.02 or greater the emplovee should make arrangements to be transported home. The emplovee should be instructed not to drive any motor vehicle due to the reasonable belief that he may be under the influence of alcohol. If the employee insists on driving a supervisor should notify the proper local law enforcement authority that an employee believed to be under the influence of alcohol is leaving the Company premises driving a motor vehicle. Return -to -Duty Testing. The Company will conduct areturn-to-duty test prior to an employee returning to covered safety -sensitive duty following a DOT violation. When an employee has a DOT violation the employee cannot work again in any DOT covered safety -sensitive function until successfully completing the SAP/return-to-duty requirements. Only after the SAP has reported to the Company that the employee is eligible to return to covered safety -sensitive duties is the Company authorized to return the employee to a covered function. However, whether or not to do so is a business decision of the Company, not the DOT. When the Company makes the decision to return the employee to safety- sensitive duty, the Company will initiate the order for the return -to -duty test. A return -to -duty test, as a minimum, will be for the substance associated with the violation. Areturn- to- duty test may, however, be for both drugs and alcohol. The decision belongs solely to the SAP from information gained during the SAP-evaluation/treatment processes. The results of a return -to- duty alcohol test must be less than 0.02 in order "to count" and allow the employee to return to work. A cancelled test does not meet this criterion and requires a retest; a result greater than 0.02 but less than 0.04 must be retested until the result is less than 0.02; a result of 0.04 or greater is a new, separate violation. If the Company has a zero tolerance policy, any covered safety -sensitive employee who has a DOT drug or alcohol violation will be terminated upon such violation (refer to Appendix D, Company Disciplinary Actions and Additional Procedures). However, the employee will be referred to a SAP. The employee will be made aware that they must complete the DOT return -to -duty process prior to again performing covered safety -sensitive work for a company that s subject to the DOT alcohol and drug testing regulations. Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN 29 C�) NATIONAL COMPLIANCE MANAGEME�Ii SERVICE, I�IC. (�ICMS) 2011 (update 2021i. the NCMS olan is iha eubiecl of a raylsteretl copyright antl is pmtoclod t,y copy,ight laws in the U.S. antl elsc,vh¢ro. Ali rlghls Servetl Follow-up Testing, The Company will conduct follow-up testing, as a series of tests that occur after an employee eturns to covered safety -sensitive work, following a negative result on the return -to -duty drug and/or alcohol tests. Follow-up testing, as a minimum, will be for the substance associated with the violation. In addition, follow-up testing may be for both drugs and alcohol, as directed by the SAP's written follow-up testing plan. Follow-up testing is the Company's responsibility to conduct. The number and frequency of the follow- up tests will be determined by the SAP, but shall consist of at least six tests in the first 12 months following the covered safety -sensitive employee's return to duty. The follow-up plan will give both the number of tests and their frequency; the Company will select the actual day and time of the test and the tests are unannounced. Testing will only be conducted for an employee during, just before, or after his/herperformance of DOT functions. Follow-up testing shall not exceed 60 months from the date of the covered employee's return to duty. The SAP may terminate the requirement for follow-up testing at any time after the first six tests have been administered, if the SAP determines that such testing is no longer necessary. 2. Alcohol Test Compliance. The Company will follow Part 40 procedures for alcohol testing. A full description of DOT alcohol testing requirements can be found in Part 40, Subpart J ("Alcohol Testing Personnel"); Subpart K ("Testing Sites, Forms, Equipment and Supplies Used in Alcohol Testing"); Subpart L ("Alcohol Screening Tests'); Subpart M ("Alcohol Confirmation Tests'); and, Subpart N ("Problems in Alcohol Testing"). These procedures apply to all DOT alcohol tests regardless of the reason for the test. Personnel and Testing Devices. The Company will only use qualifie Alcohol Technicians (BAT) for DOT alcohol tests. Technicians training every five years. The technicians will subscribe to the on any changes to the DOT alcohol and drug testing regulatic test using DOT -approved devices. Devices are approved by the M (NHTSA), an agency of DOT, and placed on the Conforming Prod Company will be maintained according to the particular manufac Plan (CAP). External calibration checks will be performed at the Screening Test Technicians (STT) or Breath 11 complete requalification/certification ID list -serve website to keep current s. These technicians will only conduct the onal Highway Traffic Safety Administration cts List (CPL).14 The devices used by the ire specifications in the Quality Assurance ntervals specified in the manufacturer's Testing Site, Forms, and Specimen. The Company will provide the employee with the specific location where the test will take place. Tests will be conducted in an area to prevent unauthorized people from hearing or seeing the employee's test result, The Company will remind the employee that failure to sign the DOT Alcohol Testing Form (ATF) at the instruction of the testing technician will be viewed as a refusal to test. The alcohol screening test may be conducted with breath or saliva, as applicable for the device used by the testing technician. Only breath will be used for the confirmation test, which is conducted by a BAT using an EBT. Test. The Company will inform the employee that they are required to carry and present a current valid picture ID, such as a driver's license, passport, or employer -issued picture ID to the testing site. The testing technician will perform a screening test and show the employee the test result. If the screening test result is an alcohol concentration of less than 0.02, no further testing is authorized, and there is no DOT action to be taken. The technician will document the result on the ATF, provide the employee a copy and also provide the Company and/or the Company's C/TPA a copy. If the screening test result is 0.02 or greater, the employee will be required to take a confirmation test, which can only be administered by a BAT using an EBT. The BAT will wait at least 15-minutes, but not more than 30 minutes, before conducting the confirmation test. During that time, the employee will not be allowed to eat, drink, smoke, belch, put anything in their mouth or leave the testing area. Leaving the testing area without authorization may be considered a refusal to test. The BAT will perform an "air blank" (which must read 0.00) on the EBT device to ensure that there is no residual alcohol in the EBT or in the air around it. The confirmation test result is the final result of the test, and the will be shown to the employee and on the printout from the EBT. If the result is less than 0.02, no action is taken under Part 199. Any result of 0.02 or greater will be mmediately reported to the Company. �� National Highway Traffic Safety Administration, Conforming Products List for Evidential Breath Measurement Devices. Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN 30 C) NATIONAL GOMPI IANCE NA�IAGEP,AE�IT SERVICE, INC. (NCMS) 2011 (update 2021). the NCMS plan is Iho subjoG of e registered copY�yht dnA Is prolecled by copyriyht laws in the U $. antl elserRiare. FII ,9his BseNed 3. PHMSA Inspection Protocol for Alcohol Testing Sites Compliance. PHMSA's Substance Abuse Program Comprehensive Audit and Inspection Protocol Form, Alcohol Testing Sites, Form No.:3.1.8 (Revision 2)" provides a separate inspection protocol for Alcohol Testing Sites. The Company provides this protocol to correspond with the detail found in the PHMSA Inspection Form. As previously stated, the Company will ensure that all DOT alcohol tests comply with Part 40 requirements. Alcohol Testing Personnel. The Company will ensure that only qualified STTs and BATs are used to conduct Company DOT tests. STTs and BATs are responsible to maintain their own verification documentation and will make it available to the Company on request. A supervisor of an employee may not be used to conduct a reasonable suspicion/cause test if that supervisor was the one who made the determination to test. Alcohol Testing Sites, Forms and Supplies. The testing site will ensure visual and aural privacy to the employee being tested to prevent unauthorized persons from seeing or hearing test results. The site will have the needed personnel, materials, equipment, and facilities to provide for the collection and analysis of breath and/or saliva samples, and a suitable clean surface for writing. The site will be able to prevent unauthorized personnel from entering the testing site, and ensure no unauthorized employee has access to an unsecured EBT, and that when an EBT or ASD is not being used for testing, it is stored in asecure place, Testswill beconducted on onlyone employee at a time. Only EBTs and ASDs listed on the NHTSA CPL will be used for DOT alcohol testing, and only an EBT must be used for conducting the confirmation tests. The OAP and associated manufacturer's instructions will be followed for all EBTs and ASDs used by the Company. It is the responsibility of the testing sites used by the Company to carry out this responsibility for the Company. Alcohol Screening Tests. Only the DOT -approved ATF will be used for all Company alcohol tests. The employee will provide a positive identification through the use of photo ID or by employer representative prior to the test. The BAT or STT shall explain the testing process to the employee, including showing the employee the instructions on the back of the ATF. If the employee has a designated testing time and does not appear, the BAT or STT will notify the DER. Testing will begin without undue delay. An alcohol test will be given prior to a drug test and medical attention, if it is required, will not be delayed in order to conduct a test. The testing technician will explain the testing procedure to the employee, including showing the employee the instructions on the back of the ATF. The ATF will be completed and the employee will be asked to sign the ATF. Failure to sign is a refusal to test. The BAT or STT will select, or allow the employee to select, an individually wrapped or sealed mouthpiece from the testing materials and insert it into the device in accordance with the manufacturer's instructions. The employee will be instructed to blow steadily and forcefully into the mouthpiece for at least six seconds or until the device ndicates that an adequate amount of breath has been obtained. The employee will be shown the displayed test result. The device will print alabel with, or the technician will write, the result and pertinent information on the ATF. Alcohol Screening with an ASD. It is not the intent of the Company to use an ASD for an alcohol test. However, t is possible that, when necessary, one may have to be used to conduct the test. In those cases, the STT or BAT will follow the manufacturer's instructions, and only use a device that has been under their control. The ASD may be either a saliva device or a breath tube. The expiration date will be shown to the employee. A device will not be used after its expiration date. The device will be opened in the presence of the employee, and the employee will be offered the opportunity to use the device, according to instructions. In any case, where the technician uses the device, the device will be inserted into the employee's mouth and gather saliva, with the technician wearing single -use examination gloves while doing so and change them following each test. Assurance will be made that the device has properly activated and that the correct amount of time will be allowed to elapse before reading the result. If problems occur (e.g., the device does not activate, it is dropped on the floor), it will be discarded and a new test will be conducted using a new device. Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN 31 l) NATIONAL CO,Y,PLIANCE MANAGEML�rt 5[RVICE, INC (�ICMS�2011 (update 2021�. The NCMS plan Is the subjeG of a registered copyright find is p,oteeled by wpyright la,ss in the U.S. antl el�,vhore. All nghis served The STT or BAT will note on the ATF the reason for the new test. If efforts to get the ASD to work properly fail, the technician will direct the employee to take a new test immediately, using an EBT for the screening test. Devices, swabs, gloves or other materials used in the prior saliva or breath tube testing will not be used in subsequent tests. Alcohol Screening Results. A result with an alcohol concentration of less than 0.02 will be recorded on the ATF; the result will be transmitted, in a confidential manner, to the DER with the test concluded without consequence. A result with an alcohol concentration of 0.02 or higher requires the employee to take a confirmation test. If the same BAT who conducted the alcohol screening test will also conduct the confirmation test, the test will begin immediately. If a different BAT will conduct the confirmation test, the technician conducting the screening test will direct the employee to the site where the test will take place. The technician will also advise the employee not to eat, drink, put anything (e.g., cigarette, chewing gum) into the employee's mouth, or belch, during the 15-minute waiting period until the test occurs. The different BAT will require positive identification of the employee, explain the confirmation procedures, and use a new ATF. The BAT will note on the "Remarks' line of the ATF that a different BAT or STT conducted the screening test. The employee will be observed by the technician or an employer representative on the way to the confirmation testing site. The employee will be directed not to attempt to drive a motor vehicle to the confirmation testing site. Alcohol Confirmation Test All alcohol confirmation tests will be conducted by BATS using EBTs. The BAT will ensure that the time since the screening test has been at least 15 minutes, and the employee has been advised not to eat, drink, put anything (e.g., cigarette, chewing gum) into the employee's mouth, or belch. The BAT will conduct an air blank on the EBT in the presence of the employee. The reading must be 0.00 for the test to proceed. If the reading is greater than 0.00, another air blank must be conducted; the EBT must not be used (taken out of service) if the second reading is greater than 0.00. The EBT cannot be used for testing until it is found to be within tolerance limits on an external check of calibration. A new sealed mouthpiece will be opened, in view of the employee, and used for the test. The employee will be instructed to blow steadily and forcefully into the mouthpiece for at least six seconds or until the device indicates that an adequate amount of breath has been obtained. The results will be shown to the employee and printed for application to the ATF. Alcohol Confirmation Results. If the alcohol confirmation test result is lower than 0.02, nothing further is required of the employee. If the alcohol confirmation test result is 0.02 or higher, the BAT will immediately transmit the result directly to the DER in a confidential manner. Problems in Alcohol Testing. The Plan addresses the situations in which an employee has refused to take an alcohol test. See Section IV.6, "DOT Alcohol Violations and Prohibited Conduct." In situations where an employee is unable to provide sufficient saliva to complete a screening test, the Company will ensure that the employee takes a breath test immediately. In situations where an employee is unable to provide sufficient breath to complete a test, the employee will be sent for an evaluation, within five days, by a licensed physician who is acceptable to the Company. The physician will have expertise in the medical issues raised by the employee's failure to provide a breath specimen, as well as be apprised of the consequences of the appropriate DOT agency regulation for refusing to take the required alcohol test. The physician will provide the Company with a signed statement of their conclusions. If it is the reasonable medical judgment of the physician, that a medical condition has, or with a high degree of probability could have, precluded the employee from providing a sufficient amount of breath, the test will be canceled by the Company. If there is not an adequate basis for determining that a medical condition has, or with a high degree of probability could have, precluded the employee from providing a sufficient amount of breath, this constitutes a refusal to test. Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN 32 �I NATIONAL COMPLIl�NGE MANAGEMENT SERVIOE, INO. (NCM612011 (update 2021J. The NCMS plan is the sub�eU of o re9lslerotl copYrlyht and Is protacled by copyright laws in the U 5. and else�vhero. All rlyhts vsaNed Canceling an Alcohol Test. The Company will ensure that an alcohol test is canceled if a fatal flaw occurs. Fatal flaws are: 1) in the case of a screening test conducted on a saliva ASO or a breath tube ASD, the STT or BAT reads the result either sooner than or later than the time allotted by the manufacturer; the saliva ASD does not activate; the device is used for a test after its expiration date; or, in the case of a screening or confirmation test conducted on an EBT, the sequential test number or alcohol concentration displayed on the EBT is not the same as the sequential test number or alcohol concentration on the printed result; 2) in the case of a confirmation test the BAT conducts the confirmation test before the end of the minimum 15-minute waiting period; the BAT does not conduct an air blank before the confirmation test; there is not a 0.00 result on the air blank conducted before the confirmation test; the EBT does not print the result; or, the next external calibration check of the EBT produces a result that differs by more than the tolerance stated in the QAP from the known value of the test standard. In this case, every result of 0.02 or above obtained on the EBT since the last valid external calibration check is canceled. The Company will ensure that an alcohol test is canceled if a correctable flaw occurs and is not corrected. Correctable flaws are: the BAT or STT does not sign the ATF; the BAT or STT fails to note on the "Remarks" line of the ATF that the employee has not signed the ATF after the result is obtained; and, the BAT or STT uses a non - DOT form for the test. Corrected Alcohol Problems. The Company will ensure that BATs and STTs will try to successfully complete each alcohol test for an employee. If they become aware of a problem that will cause the test to be canceled, they will try to correct the problem promptly, if practicable. Repeating the test is an acceptable part of this process. If repeating the testing process is necessary, a new test (new ATF, new device) must begin as soon as possible. If repeating the testing process is necessary, the technician is not limited in the number of attempts to complete the test, provided that the employee is making a good faith effort to comply with the testing process. If another testing device is not available for the new test at the testing site, the technician will immediately notify the DER and advise the DER that the test could not be completed. The DER will make all reasonable efforts to ensure that the test is conducted at another testing site as soon as possible. If the Company or its service agent administering the testing process becomes aware of a correctable flaw that has not been corrected, all practicable action will be taken to correct the problem so that the test is not cancelled. If the problem resulted from the omission of required information, the person responsible for providing the information must supply in writing the missing information and a signed statement that it is true and accurate. If the problem is the use of a non -DOT form, the technician must, as the person responsible for the use of the incorrect form, certify in writing that the incorrect form contains all the information needed for a valid DOT alcohol test. The technician must also provide a signed statement that the incorrect form was used inadvertently or as the only means of conducting a test, in circumstances beyond the technician's control, and the steps the technician has taken to prevent future use of non -DOT forms for DOT tests. The technician must supply this information on the same business day on which the collector was notified of the problem, transmitting it by fax, e-mail or courier. If the technician cannot correct the problem, the technician must cancel the test. VII. PROGRAM ELEMENTS COMMON TO DRUG AND ALCOHOL 1, Substance Abuse Professional Compliance. The Company will follow the requirements of Part 40 for its Substance Abuse Professional (SAP) obligations. A full description of the SAP requirements is in Part 40, Subpart O ("Substance Abuse Professionals and the Return -to -Duty Process"). Qualifications. The Company will refer employees only to SAP's who have the credentials, basic knowledge, and qualification training, including fulfilling obligations for continuing education courses, for DOT violations. The SAP will subscribe to the ODAPC list -serve website to keep current on any changes to the DOT alcohol and drug testing egulations. The SAP will not be an advocate for the Company or the employee. The SAP's function is to protect the public interest in safety by professionally evaluating the employee and recommending appropriate education/treatment, follow-up tests, and aftercare. Premium Concrete Services, Inc.- PHMSA DRUGIALCOHOL PLAN 33 IVAiIOIVAL COMPLIANCE MAIL\GEM[NT SERVICE, INC. (NCMS) 2011 (uptlate 2�217. Thv IJCMS plan Is the suU�eG of a registered copyrigM1� a�itl is prolecletl by copyngM1� lave in IM1e U.S. and olsavfiale. Ail llytils BS, Netl. SAP Referral. The Company will provide to each employee who violates a DOT drug and alcohol regulation a isting of SAP's readily available to the employee and acceptable to the Company. The list will include SAP names, addresses, and telephone numbers. There will not be a charge to the employee for compiling or providing this list. The Company may use its C/TPA orother service agent to provide this information. Any covered safety -sensitive employee who has violated DOT drug and alcohol regulations cannot again perform any DOT covered safety - sensitive duties far this Company until and unless the employee successfully completes the SAP evaluation, referral, and education/treatment process. Payment. The Company is not required to pay for a SAP evaluation or any subsequent recommended education or treatment for an employee who has violated a DOT drug and alcohol regulation. Company Responsibility. The Company is only bound by DOT to ensure that if the employee is provided an opportunity to return to a DOT covered safety -sensitive duty following a violation, that the Company ensure that the employee receives an evaluation by a SAP meeting the requirements of Part 40 and that the employee successfully complies with the SAP's evaluation recommendations before returning to the covered safety -sensitive job. Even if a SAP believes that the employee is ready to return to safety- sensitive work, the Company is under no obligation to return the employee to work. Under the DOT regulations, hiring and reinstatement decisions are left to the employer. The DOT leaves all payment issues for SAP evaluations and services to the Company and the employee to resolve. SAP Process. The SAP will make aface-to-face clinical assessment and evaluation to determine what assistance is needed by the employee to resolve problems associated with alcohol and/or drug use. The SAP will refer the employee to an appropriate education and/or treatment program. At the completion of the education and/or treatment, the SAP will conduct a face-to-face follow-up evaluation to determine if the employee actively participated in the education and/or treatment program and demonstrated successful compliance with the initial assessment and evaluation recommendations. Reports will be provided to the Company on both the initial requirements and the outcome of the follow- up evaluation. The report will be specific and will include all of the Part 40 requirements of a written SAP report. The SAP will provide the DER with a written follow-up drug and/or alcohol testing plan for the employee and, if deemed necessary, will also provide the employee and the Company with recommendations for continuing education and/or treatment. 2. Employee Assistance Program The Company will provide an Employee Assistance Program (EAP) for its employees and supervisors. The EAP may be established "in house," as part of internal personnel service or may be contracted to an entity that provides EAP services at other locations. The function of the EAP will be to provide employees with informational material on the awareness and danger of drug and alcohol use. General EAP-information material, such as the availability of brochures or videos, and community service "hotline" telephone numbers will be displayed in common areas and distributed to employees. Employees will be encouraged to call the hotline if needed. Additionally, this Plan will be displayed and made available to all employees. The Plan contains the employer's policy regarding the use of prohibited drugs and alcohol misuse. The areas and places in which the above material will be displayed nclude employee bulletin boards, break rooms, locker rooms, or other areas designated by the Company. If applicable, the Company will provide written notice to representatives of employee organizations of the availability` of drug and alcohol education materials. 3. Supervisor Training Each supervisor who will determine whether an employee must be drug tested and/or alcohol tested based on reasonable suspicion/cause will be trained in the "signs and symptoms' of each substance. Each supervisor will receive one 60-minute period of training on the specific, contemporaneous physical, behavioral, and performance ndicators of probable drug use and one 60-minute period of training on the specific, contemporaneous physical, behavioral, and performance indicators of probable alcohol use. The two 60-minute training periods may run concurrently equaling 120-minutes. Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN 34 C� NATIONAL GOMPLIFlNGF MANAGEMENT 6ERVICE, INC. (NCMS) 2U1 I (update 2021i. Tho NCM6 plan Is the subjocl of o regsletod copyright and Is p,oleGed by copyright lav,s in the U.S. antl elea�vhote All rigi,is esmed 4. Contractor Monitoring Compliance. Operators are responsible for ensuring that contractors and contractor employees working for, and/or on the properties of, the operator are in compliance with the requirements of Part 40 and 199. With respect to those covered safety -sensitive employees who are contractors or employed by a contractor, an operator may provide by contract that all requirements of Part 40 and 199 will carried out by the contractor. To assure that the contractor is in full compliance, the contractor will allow access to property and records by the operator, the operator designee, the Administrator, any DOT agency with regulatory authority over the operator or covered safety -sensitive employee, and, if the operator is subject to the jurisdiction of a state agency, a representative of the state agency for the purposes of monitoring the operator's compliance with the requirements of Part 40 and 199. The operator will ensure that all contractors are qualified prior to commencing, as well as during the performance of, covered functions for the operator. Qualifying Potential Contractor. Qualifications of the potential contractor as it pertains to drug and alcohol testing policies and procedures are assured by requesting the potential contractor to submit a copy of its Plan for review and compliance with PHMSA regulations. After review of the Plan is completed, written correspondence to the contractor will advise whether or not it is acceptable or in need of further additions, deletions, revisions or clarifying language. The review of the contractor Plan shall be completed utilizing the criteria established by PHMSA. Monitoring Contractor's Compliance. The contractor may be required to provide information on their employees who will perform covered functions for the operator. This information will include, as a minimum, the name, type of test and test date of the employees who will perform any work or functions covered by Part 199 under that contract. A list of each contractor's covered safety -sensitive employees may be distributed to appropriate Company field management. All contractors will be required to submit drug and alcohol testing statistical nformation on a periodic basis, which may be based on the duration of the contract. Typically, this requirement will be on a semi-annual basis. The Company may require a more frequent schedule for submission of drug and alcohol testing data should they determine a need for such statistics. The Company shall maintain a complete file on each contractor's statistical drug and alcohol testing reports. The Company shall make these reports available when requested by a PHMSA agency -designated representative, or representatives of those state agencies under which jurisdiction the Company operates. The operator will also submit contractor Management Information System (MIS) reports to PHMSA by March 1511 each year. The contractor will cooperate with the operator, or the operator's designee, if additional information is requested to further verify compliance of the regulations. 5. Recorclkeeping Compliance. The Company will ensure that all records required by the DOT are maintained in a location with controlled access. The Company is not required to keep records related to a program requirement that does not apply to Part 40 or 199. The Company or its C/TPA will maintain the records in a locked file system and will be accessed only on a strict "need to know" basis. The Company or its C/TPA will not release an employee's drug and alcohol records to third parties without the employee's specific written consent. A "third party' is any person or organization to whom Parts 40 or 199 do not explicitly authorize or require the transmission of information in the course of the drug and alcohol testing process. "Specific written consent' means a statement signed by the employee that he or she agrees to the release of a particular piece of information to a particular, explicitly dentified, person or organization at a particular time. Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN 35 C-� NATIONAL COMPLIANCE MMIAGFME�n SERVICE, I<,IC. (NCMS) LOt t (update 2021�. TM1e NCNIS plan is IFo subjoq of e ragisierotl wpYrlght end Is prolecled by nopynght la,vs in Itte U S. a,ttl elsotvhoro. All ngttls serve( The Company or its C/TPA will release the employee's information without consent to DOT, PHMSA, or other government agency having regulatory authority over the Company or employee without consent. The Company or is C/TPA will release the employee's information without consent as a part of an accident investigation by the National Transportation Safety Board. The Company or its C/TPA will release the employee's information without consent in certain legal proceedings. These proceedings include a lawsuit, grievance, administrative proceeding (e.g., an unemployment compensation hearing brought by or on behalf of an employee resulting from a positive drug or alcohol test or refusal to test), a criminal or civil action resulting from an employee's performance of covered safety -sensitive duties, in which a court of competent jurisdiction determines that the drug or alcohol test information sought is relevant to the case and issues an order directing the Company to produce the information. In such a proceeding the information will be released to the decision maker in the proceeding with a binding stipulation that the decision maker to whom it is released will make it available only to parties to the proceeding. After releasing the information, the Company or its C/TPA will notify the employee. If the Company uses a C/TPA to maintain the records, the Company will ensure that the C/TPA can produce these records at the Company's principal place of business in the time required by the DOT agency for an nspection. The records will be provided within two business days after receipt of the request. Most records will be stored electronically, where permitted by Part 40 and 199, The Company will ensure that the records are easily accessible, legible, and formatted and stored in an organized manner. If electronic records do not meet these criteria for the DOT inspector, the Company will convert them to printed documentation in a rapid and readily auditable manner, at the request of DOT agency personnel. Records and Retention Periods. The Company or its C/TPA will maintain the following records for the noted time periods, as a minimum: a) Records kept for five years: (1) Records of alcohol test results indicating an 'alcohol concentration of 0.02 or greater; (2) Records of the inspection, maintenance, and calibration of EBTs; (3) Records of verified positive drug test results; (4) Documentation of refusals to take required alcohol and/or drug tests (including substituted or adulterated drug test results); (5) SAP reports; (6) Follow-up tests and schedules for follow-up tests; and, (7) Statistical data related to the Company's testing program, entitled "Management Information System," will be available to a representative of DOT, PHMSA, or a state agency having regulatory authority over the Company upon request. b) Records kept for three years (1) Records of information obtained from previous employers under Part 40 concerning drug and alcohol test results of employees; (2) Records that demonstrate the drug -testing collection process; and, (3) Records related to "signs and symptoms' alcohol and drug training for supervisors; (4) Records related to employee education and training; (5) Records of decisions not to administer post -accident covered employee alcohol and drug tests. c) .Records kept for two years: (1) Records related to the alcohol collection process (i.e., calibration documentation for evidential breath testing devices, documentation of breath alcohol technician training, documents generated in connection with decisions to administer reasonable suspicion alcohol tests, documents generated in connection with decisions on post -accident tests, and documents verifying existence of a medical explanation of the inability of a covered employee to provide adequate breath for testing); and, d) Records kept for one year: (1) Negative and cancelled drug test results. (2) Alcohol results less than 0.02. Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN 36 tJATIONAL COMPLIANCE MA�IAGEME�IT SERVICE, I�IC. (�ICMS) 2011 (uptlate 2021). iFe NCMS plan Is ilia subject of a registered copyright antl Is pro�e:�ed by copyright la,vs in IM1e tl S. antl elsewhere Ail dghls smed Employee Request for Records. All employees have the right to request and obtain copies of any records pertaining to the employee's use of alcohol and/or drugs, including records of the employee's DOT -mandated drug and/or alcohol tests, and copies of SAP reports. Requests for records must be made in writing to the DER. A laboratory must provide, within 10 business days of receiving a written request from an employee, and made through the MRO, the records relating to the results of the employee's drug test (i.e., laboratory report and data package). Service agents providing records may charge no more than the cost of preparation and reproduction for copies of these records. SAPS must redact follow-up testing information from the report before providing it to the employee. 6. Management Information System Compliance. The Company will prepare and maintain the DOT Management Information System (MIS) report for its drug and alcohol testing program. This report will be submitted to PHMSA in accordance with annual submission requirements. If the Company uses a C/TPA then the C/TPA may prepare and maintain the MIS, reporting the MIS as the Company requires. The DER will certify each report submitted by a C/TPA for accuracy and completeness. The MIS report will be submitted electronically through the DAMIS portal on or before March 15th Contractor Reporting for MIS. If the Company is an operator, it will verify and identify all contractors who performed covered functions, as defined under Part 199, for this Company in a given calendaryear. If required, by either mandated annual or PHMSA written request, the Company will submit an MIS report for each of these contractors. The contractor MIS reports will be submitted electronically through the DAMIS portal on or before March 15th Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN 37 C�J NATIONAL (';UMPIJANCE MANAGEMEM' S[RVICL, I�IG. (NChI$) 201� (uodale 20211. the NCMS plan is the subjecA of a regis�rrotl copYriglit end Is prolecletl by copydgh� laws in the U S. and elflawhere. All dgh�s served VIII. Appendix A - Acknowledgement/Receipt Form acknowlegeT y signinq this form that my full compliance with the Anti -Drug and Alcohol Misuse Prevention Plan (the "01an111 and DOT drug and alcohol regulation , duirements is a condition of my initial and continued emplovment with the Company. I understand and agree that I may be discharged or otherwise disciplined for anv drug and/or alcohol violation committed by me as cited in the Plan and/or in the DOT drug and alcohol regulatory requirements also acknowledge by signinq this form that a copy of the Plan has been made available to me and that I have read and understand the requirements of the Companv and DOT drug and alcohol program I have also been provided with informational materials on the dangers and problems of drug abuse and alcohol misuse. Signed,thisthe day of , 20 Employee Name (Please Print) Employee Signature Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN 38 ':-J NATIONAL COMPLIANCE MANAGEMENt SERVICE, It,IG. (NCNIS)'2011 (update 20217. Th¢ �ICMS plan is ido subJec( ofa reyistered copyright antl is proioclotl by copyright Imes in the U S. antl elsswliere. All rights rese,ved_ X. Appendix B - Designated Personnel and Service Agents CONSORTIUM/THIRD PARTY ADMINISTRATOR (C/TPA) Name: Drug and Alcohol Testinq Compliance Services Address: 4000 US HWY 259 N. Longview TX 75605 Phone Number: 903-234-1136 DESIGNATED EMPLOYER REPRESENTATIVE (DER)/ALCOHOL &DRUG PROGRAM MANAGER Name: Jim Rodino Address: 712 Richmond St, Elkhart, IN 46516 Phone Number: 712 Richmond St, Elkhart, MEDICAL REVIEW OFFICER (MRO) Name: Donald S. Freedman, MD Address: PO Box 550749, Jacksonville, FL 32255 Phone Number: 904-332-0472 SUBSTANCE ABUSE &MENTAL HEALTH ADMINISTRATION ($AMHSA/HHS) LABORATORY Name: Alere Laboratories Address: 1111 Newton, Gretna, LA 70053 Phone Number: 800-433-3823 COLLECTION SITE(s) -DRUG AND BREATH ALCOHOL Collection site procedures, processes and personnel requirements will follow Part 40, Subpart C, Subpart D, Subpart E, Subpart J, Subpart K, Subpart L, Subpart M and Subpart N. A list of collection site facilities, utilized by the Company, will be available upon request. LIST OF APPROVED EVIDENTIAL BREATH TESTING DEVICES (EBTS) UTILIZED: The Company will only utilize alcohol testing technicians who conduct the testing using DOT -approved devices. These devices are approved by the National Highway Traffic Safety Administration. A list of breath testing devices, utilized by the Company, will be available upon request. SUBSTANCE ABUSE PROFESSIONAL (SAP) Name: Pamela Forsev Address: 2319 Edison Rd, South Bend, IN 46615 Phone Number: 574-233-4183 EMPLOYEE ASSISTANCE PROGRAM (EAP) Name: Pamela Forsev Address: 2319 Edison Rd, South Bend, IN 46615 Phone Number: 574-233-4183 Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN ti� IVY\TIONhL COMPI.IA�ICE MANAGEMENT SERVICE, IIIC. (IICMS12011 (uptlale 2021). The tJCMS plan is 39 Iho subject o(a reylslereU copYrf9ht antl i s' protectetl Uy wpyrighl laws in It,e U S. and elsevArere. All ngl,ts served X. Appendix C - Covered Positions EMPLOYEE/SUPERVISOR* POSITIONS SUBJECT TO ALCOHOL & DRUG TESTING JOB CLASSIFICATIONS/TITLES SUBJECT TO 49 CFR PART 192, 193 or 195) "SUPERVISOR POSITIONS THAT HAVE RECEIVED ALCOHOL AND DRUG TRAINING (60 MINUTES DRUG, 60 MINUTES ALCOHOL) Title Employee Supervisor Title Employee Supervisor Yes No Cement Masons Yes No Laborers Yes No Operators Yes No DER No Yes Safety Manager No Yes Supervisor No Yes Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN U NAl'IONAL COMPLIANCE MANAGEMENT SERVICE_ INC (NCMSJ 2d11 (update 2�21). Ttie NCMS plan Is QD the subject of a ragistem�d copyright antl Is protected by copyright laws In the U.S. antl elsawhore All n9hts eserved XI. Appendix D - Company Disciplinary Actions and Additional Procedures 1. Company Discipline Employees violating this Plan will be subject to disciplinary actions up to and including termination 2. Additional Company Procedures Compliance with All Laws This policy statement will be amended from time to time to comply with changes in Federal and State laws The Company reserves the right to revise or amend this policy with or without notice at any time Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN 41 'Sr �I�TIONAL COMPUANGE MANAGEMENT SERVICE. INC. (NCMSi?01� (up�ata 2021J_ The NCMS plen is the siibjed of a rnglslered copyrf9ht e,id is prolecled by wpyn9h� laves in Ilse U.S. antl elsav�hare. v\II ngiils eserved THIS PAGE HAS BEEN INTENTIONALLY LEFT BLANK TO ADD ADDITIONAL COMPANY DISCIPLINARY ACTIONS AND PROCEDURES IF NEEDED. Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN 42 L� NAiIOhIAL GOMPLIAhICE MANAGEMENT' SERVICE INC. (NGMS) 2011 (update 2021J. Tho tJCMS plan is the subject of a registered wpyrlght and Is prol2cted by copyright lags in the U 5 and elsewhere. All rights served XIII Al2pendix E PHMSA Anti -Drug and Alcohol Misuse Rro9ram Inspection Protocol Form, Form No:: 4.1; Revision 3 (dated March 1,'2021) Protocol Area A - General Drug & Alcohol (D&A) Program Requirements A-1: Designated Employer Representative (DER) Has the operator appointed a Designated Employer Representative (DER)? §40.3, §40.15(d), §40.355(k), Verify that a service agent is not used to fulfill the function of a DER. §40.3, §40.15(d), §40.355(k) Plan: IX: Appendix B - Designated Personnel and Service Agents, ill. Policy and Responsibilities - 2. Responsibilities of Key Personnel, Designated Employer Representative (DER), 4. Use of Service Agents, Compliance, Consortium/Third Party Administrator. A-2: Employer Responsibilities for Officials Representatives and Service Agents Does the operator's D&A program have a process to ensure the operator remains responsible for all actions of its officials, representatives, and service agents, including a Consortium/Third Party Administrator (C/TPA),'to ensure compliancewhen these officials, representatives, and service agents carry out the requirements of Parts 199 and 40? §40.11(b), §40.15(c), §40.341 Plan: Ill. Policy and Responsibilities - 4. Use of Service Agents, Compliance, A-3: Qualification Requirements Verify the operator's D&A program positions and/or service agents meet the applicable qualification requirements of Part 40 and Part 199: Medical Review Officer (MRO) §40.121 and §199, 109(b), Urine Specimen Collector §40.33, Substance Abuse Professional SAP) §40.281, Laboratories certified by the Department of Health and Human Services (HHS) National Laboratory Certification program (NLCP) §40.81(a) and §199.107(a), Screening Test Technician (STT) §40.213, Breath Alcohol Technician (BAT) §40.213 Plan: V. Anti -Drug Program - 3. Specimen Collection Procedures, 4. PHMSA Inspection Protocol for Specimen Collection Sites, S. Drug Testing Laboratory, 8, MRO Review of Drug Test Results, VI. Alcohol Misuse Prevention Program- 2. Alcohol Test, VII. Program Elements Common to Drug and Alcohol- 1, Substance Abuse Professional A-4: Service Agent Limitations Verify the operator's D&A program ensures its service agents: Do not require an employee to sign a consent, release, waiver of liability, or indemnification agreement with respect to any part of the DOT D&A testing process (including, but not limited to, collections, laboratory testing, MRO and SAP services). §40.355(a), Do: not act as an intermediary in the transmission of laboratory drug test results direct from the laboratory to the MRO, operator, or to another service agent, or in the transmission of alcohol test results of 0.02 or higher direct from the STT or BAT to the DER. §40.355(b-d), Do not make decisions to test an employee based upon reasonable suspicion/cause, post -accident, return -to -duty, and follow-up determination criteria. While a service agent may provide advice and information, these are duties the operator cannot delegate to a C/TPA. §40.355(g) - see §40.355(h) for exceptions, Do not make determinations that an employee has refused a drug or alcohol test. While a service agent may provide advice and information, these are duties the operator cannot delegate to a C/TPA. §40.355g) - see §40.3550) for exceptions, Do not impose conditions or requirements on the operator, such as the DOT D&A testing of non -covered employees, that DOT regulations do not authorize. §40.355(m), Do not intentionally delay the transmission of drug or alcohol testing -related documents concerning actions the service agent performed because of a payment dispute or other reasons. §40.355(n) Plan: ill. Policy and Responsibilities - 4. Use of Service Agents, Service Agent Limitations, A-5. Supervisory Personnel Training Does the operator require a 60-minute period of training on the specific, contemporaneous physical, behavioral, and performance indicators of probable drug use under the EAP for supervisory personnel who will determine whether an employee must be drug tested based on reasonable cause? §199.113(c), Does the operator require a 60-minute period of training on the physical, behavioral, speech, and performance indicators of probable alcohol misuse for supervisors designated to determine whether reasonable suspicion exists to require a covered employee to undergo alcohol testing? §199.241. Plan: bill. Program Elements Common to Drug and Alcohol - 3. Supervisor Training A-6: Covered Employees�- Does the operator have a process to ensure the operator properly identifies the covered employees who are required to be DOT tested for the presence of prohibited drugs and alcohol? §199.3, Verify the operator does not conduct DOT tests for the presence of prohibited drugs and/or alcohol on any individual who is not a covered employee. §199.1, §199.3 and §40.347(b)(2) Plan: X. Appendix C- Covered Positions, ill. Policy and Responsibilities- 6. 'WO/r Testing Program, IV. DOT Program Requirements - 1. Employees Subject to Testing, Compliance A 7: Employee DOT D&A Testing Record Checks For an employee seeking to perform covered functions for the first time (i.e., new hire or an employee transferring into a safety - Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN NA I ONAL COMPLIANCE NIANAGEM ENT SERVICE, INC. (NCMS) 2011 (update 2021). The NCMS plan is the subject of a registered copyright and is protected by copyright terns in the U.S. and elsewhere. All rights reserved 43 sensitive position): Does the operator obtain the employee's written consent prior to requesting DOT D&A testing information from prior DOT regulated employers? §40.25(a), §40.27, §40,321(b), §40.351(d), Note: a wet ink signature and separate request is required for each prior employer, Does the operator request DOT D&A testing information from each DOT regulated employer who has employed the employee during any period during the two years before the date of the employee's application or transfer? §40.25(b), Verify the operator does not permit an employee to perform a covered function after 30 days from the date on which the employee first performed a covered function, unless the operator has obtained, or made and documented, a good faith effort to obtain the DOT D&A testing information from prior DOT regulated employers. §40.25(d), Verify the operator does not permit an employee who has violated any DOT agency D&A regulation to perform a covered function unless the operator also obtains information that the employee subsequently complied with the return -to -duty requirements in Part 40, Subpart O and PHMSA's drug and alcohol regulations. §40.25(e) Plan: IV. DOT Program Requirements— 3, History Check Requirements, A-8: DOT vs. Non -DOT Tests If a pipeline operator has a non -DOT drug and alcohol testing program: Does the operator have a process to ensure that all DOT D&A tests are completely separate from all non -DOT D&A tests in all respects? §40.13, Does the operator have a process to ensure that all DOT D&A tests take priority and must be conducted and completed before a non -DOT test is begun? §40.13(b) Plan: Ill. Policy and Responsibilities — 6. "NON -DOT" Testing Program, A-9: Contractor Anti -Drug and Alcohol Misuse Prevention Programs If a pipeline operator allows contractors who perform covered functions on the operator's regulated pipeline or LNG facility to conduct their own D&A Programs: Does the operator have a process to oversee contractors to ensure they comply with Parts 199 and 407 §199.115, §199.245, Do the contractors allow access to property and records by the operator, PHMSA, and a representative of a state agency (if applicable) to allow for the monitoring the operator's compliance with Part 199? §199.115(b) Plan: VII. Program Elements Common to Drug and Alcohol— 4. Contractor Monitoring, Protocol Area B — AntiDrug Program B-1: Written Anti -Drug Program Does the operator maintain and follow a written Anti -Drug Plan that conforms to the requirements of Part 199 and Part 40? §199.101(a), Ensure the Anti Drug Plan contains, at a minimum, the following: Methods and procedures for compliance with all the requirements of Part 199, including the Employee Assistance Program (EAP) §199.101(a)(1), The name and address of each laboratory that analyzes the specimens collected for drug testing.§199.101(a)(2), The name and address of the operator's Medical Review Officer (MRO), and Substance Abuse Professional (SAP) §199.101(a)(3), Procedures for notifying employees of the coverage and provisions of the plan §199.101(a)(4) Plan: ll. General — 3. Compliance, Plan Development, Plan Availability, VII. Program Elements Common to Drug and Alcohol 2. Employee Assistance Program, Vlll. Appendix A— AcknowledgmenUReceipt Form, IX Appendix B —Designated Personnel And Service Agents B-2: Prohibited Drugs—ry-- m Does the operator conduct DOT drug tests only for the "prohibited drugs" specified in Part 40? §199.1-5, §199.105 and §40.1-3 Marijuana, Cocaine, Amphetamines, Phencyclidine (PCP), Opioids Plan: 11. General — S. Definitions, Drugs, V, Anti -Drug Program— 5, Drug Testing Laboratory, Drug Testing, Table 1 Required DOT Drug Tests and Cutoffs B-3a: Pre -Employment Drug Testing3�- Does the operator have a process to ensure it does not hire or contract for the use of any person as a covered employee (e.g. new hire or transferred employee) to perform a covered function unless that person first passes a DOT drug test or is covered by an anti- drug program that conforms to Part 199? §199.105(a), Note: The anti -drug programs of the other DOT agencies and the USCG meet the requirements for an anti -drug program that conforms to Part 199, Does the operator have a Process to ensure that a covered employee removed from the random drug test pool (for any length of time) passes a pre -employment DOT drug test before being placed back into the random drug test pool? §199.105(a) Plan: II. General— 8. Definitions, DOT, The Department, DOTAgency, V. Anti -Drug Program — 1. DOT -Required Drug Tests, Pre -Employment Testing B-3b: Post -Accident Drug Testing Does the operator have a process to ensure it completes a DOT post -accident drug test as soon as possible but no later than 32 hours after an accident of each surviving covered employee whose performance of a covered function either contributed to the accident or cannot be completely discounted as a contributing factor to the accident? §199.105(b)(1), If the operator did not administer a DOT drug test within the 32 hours following an accident, does the operator have a process to ensure it ceases attempts to administer a drug lest and states in the record the reason for not promptly administering the test? §199.105(b)(2)2 If the operator decides not to conduct a post -accident drug test of a covered employee, does the operator have a process to ensure it makes that decision based on specific information that the covered employee's performance had no role in the cause(s) or severity of the accident? §199.105(b)(1), If the operator decided not to conduct a post -accident drug test of a covered employee, does the operator have a process to ensure that it documents the decision and keeps that record for at least 3 years? §199.117(a)(5) Premium Concrete Services, Inc.- PHMSA DRUGIALCOHOL PLAN U NATIONAL COMPLIANCE MANAGEMENT SERVICE. INC. (NCMS 2011 (uptlale 2021). The NCMS plan is the subject of a registered copyright and Is protected by copyright lav,s in the U.S. and elsewhere. All rights rese,vnd m' Plan: V Anti•Orug Program - 1. DOT -Required Drug Tests, Post -Accident Testing, Ift Program Elements Common to Drug and Alcohol - 5. Recordkeeping, Records and Retention Periods, Xlll. Appendix F - Post -Accident or Reasonable Cause7Suspicion Supervisor Written Record B-3c: Random Drug Testing ��- ry �� •� ��- _ �, Does the operator use a scientifically valid selection method, such as a random number table or a computer -based random number generator that is matched with the employees' Social Security numbers, payroll identification numbers, or other comparable identifying numbers? §199.105(c)(5), Does the operator's selection method ensure that each covered employee has an equal chance of being selected each time selections are made? §199.1051 Does the operator have a process to ensure it selects a sufficient number of covered employees for random drug testing during each calendar year to equal an annual rate not less than the required minimum annual percentage rate? §199.105(c)(6), Does the operator have a process to ensure that random drug tests are unannounced and that the dates for administering the tests are spread reasonably throughout the calendar year? §199.105(c)(7), Note: Do not confuse random selection dates with lest dates. For example, an operator may select once each quarter (i.e. 4 days a year) but the drug tests themselves must be reasonable spread throughout the calendar year. Plan: V. Anti -Drug Program- 1, DOT•Required Drug Tests, Random Drug Testing Bad: Reasonable Cause Drug Testing •-- �� ,-, - • •�� •�-� �, �n__. _ �� Does the operator have a process to ensure that DOT drug tests are performed when there is reasonable cause to believe the employee is using a prohibited drug? §199.105(d), Does the operator have a process to ensure the operator's decision to test is based on a reasonable and articulable belief that the employee is using a prohibited drug based on specific, contemporaneous physical, behavioral, or performance indicators of probable drug use. §199.1061 Does the operator have a process to ensure at least two of the employee's supervisors, one of whom is trained in detection of the possible symptoms of drug use, shall substantiate and concur in the decision to lest an employee. The concurrence between the two supervisors may be by telephone. §199.105(d), Note: In the case of operators with 50 or fewer employees subject to testing, only one supervisor of the employee trained in detecting possible drug use symptoms shall substantiate the decision to test. §199.105(d), Does the operator have a process to ensure service agents do not make decisions to drug lest an employee based upon reasonable cause? While a service agent may provide advice and information, these are duties the operator cannot delegate to a C/TPA. §40.355(g). (See §40.355(h) for exceptions.) Plan: V. Anti -Drug Program - 1. DOT -Required Drug Tests, Reasonable 'Suspicion/Cause Testing, ill. Policy and Responsibilities, 4. Use of Service Agents, Service Agent Limitations (iJ. B-3e: Return -to -Duty �,a ,. _�.....-.,-,,,r � „r,.,�.,.� x , .� w, a....,,•..�. ...- .,-..._.- .�..z... .,.-,..,, Drug Testing Does the operator have a process to ensure that a covered employee who refuses to take a drug test, or has a positive drug test, does not return to duty in any covered function until the covered employee completes a SAP evaluation, referral, and education/treatment process? §199.105(e) &part 40, Subpart O, Does the operator have a process to ensure that a covered employee who refuses to take or has a positive drug test does not return to duty in any covered function until the covered employee successfully completes a return -to -duty drug test? §40.21 §40.289(b), §40.305(a) and §199.105(e), Does the operator have a process to ensure that all return -to -duty drug testing is performed under direct observation? §40.67(b) Plan: V Anti•Drug Program - 1. DOT -Required Drug Tests, Return -to -Duty Testing, 2, Drug Tests That Require Direct Observation Procedures, Compliance, B-3f: Follow -Up Drug Testing �� --��- -� - • • ��-� Does the operator have a process to ensure that a SAP establishes a follow-up testing plan for a covered employee who refused to take a drug test, or had a positive drug test, before allowing the covered employee to return to duty? §40.307, §40.309 and §199.11 Does the operator have a process to ensure that follow-up testing is performed on an unannounced basis, at a frequency established by the SAP, for a period of not more than 60 months and that at least six tests must be conducted within the first 12 months following the covered employee's return to duty? §40.307, §40.309 and §199.105(f), Does the operator have a process to ensure that all follow- up drug testing is performed under direct observation? §40.67(b) Plan: V Anti -Drug Program - 1. DOT•Required Drug Tests, Follow-up Testing, 2. Drug Tests That Require Direct Observation Procedures, Compliance. Does the laboratory report drug test results directly, and only, to the MRO at his or her place of business? Lab test results must not be reported to or through the DER or a service agent such as a C/TPA. §40.97(b), Does the laboratory Transmit an aggregate statistical summary, by operator, of the drug lest data listed in Part 40, Appendix B to the operator on asemi-annual basis? Plan: V. Anti -Drug Program - 5. Drug Testing Laboratory, Laboratory, 6, Laboratory Retention Periods and Reports, Semi - Annual Reports, ill. Policy and Responsibilities, Use of Service Agents, Service Agent Limitations (b)(c) B-5: MRO Review of Drug Testing Results Does the operator have a process to ensure its MRO provides quality assurance reviews of the drug testing process, including ensuring the review of the Custody and Control Form (CCF) on all specimen collections for the purposes of determining whether there is a problem that may cause a test to be canceled? §199.109 and §40.123(b), Does the operator have a process to ensure its MRO performs the review functions required by §40.127 for negative drug test results received from a laboratory, prior to verifying the result and reporting it to the operator's Designated Employer Representative (DER)? §199.109 and §40.163, Does the operator have a process to ensure its MRO performs the review functions required by §40.129 for confirmed positive, adulterated, substituted, or invalid drug test results received from a laboratory, prior to verifying the result and reporting it to the DER? §199.109 and §40.163, Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN TJ NATIONAL COMPLIANCE MANAGEMP IT SERVICE, INC. (NCMS( 2011 (update 2021). The NCMS plants the subject of a registered copyright and Is prolectod by copyright lav,s in 1ho U.S. and elselvhere. All rights reserved 45 Does the operator have a process to ensure that when its MRO has verified a drug test as positive for a drug or drug metabolite, or as a refusal to test because of adulteration or substitution, the MRO notifies the employee of his or her right to have the split specimen tested and how to request the test? §199.109 and §40.153 Plan: V. Anti -Drug Program - 8. MRO Review of Drug Test Results, Compliance, Duties, Results, Reports, 9, Split Specimen Testing, Split Specimen, Laboratory B-6: MRO Drug Test Reports to the Operator < - -�- •� < <� w ��-�� - Does the operator have a process to ensure its MRO reports all drug test results to the DER in accordance with the requirements in §40.163, §40.165, §40.167 and §199.109(d)? These requirements include: -reporting all drug test results to the DER, except in the circumstances provided for in §40.345, when a C/TPA may act as an intermediary §40.165(a); -reporting the results in a confidential manner §40.167(a); and, -reporting the results within the required time constraints §40.167(b) and (c), Does the operator have a process to ensure its MRO reports all drug test results to the DER unless the operator elects to receive drug test results through a C/TPA, acting as an intermediary, in which case the MRO reports the drug lest results through the designated C/TPA? §199.109(d)5 §40.165, & §40.345 Plan: V, Anti•Drug Program - 8. MRO Review of Drug Test Results, Reports, B-7: Drug Regulation Violations Verify that the operator does not stand down an employee based on laboratory tests results before the Medical Review Officer (MRO) completes the drug test verification process unless an approved waiver has been granted. §199.7, §40.21, Does the operator have a process to ensure that a "covered employee" who violates a PHMSA/DOT drug regulation is removed from performing "covered functions'? §199.103, §40.23, Does the operator have a process to ensure it provides a listing of Substance Abuse Professionals (SAPS) that are readily available to an employee who violates a PHMSA/DOT drug regulation? §40.287, Note: Averified positive DOT drug lest result or a refusal to test (including adulterating or substituting a urine specimen) constitutes a violation of a PHMSA/DOT drug regulation. §40.285(b) and §199.103(a) Plan: 11, General- 6. Stand -down Waiver, IV, DOT Program Requirements- 7. Violation Consequences and CoinpanyActions, After DOT Rule Violations B-8: Employee Assistance Program (EAP) Does the operator have an EAP for its employees and supervisory personnel who will determine whether an employee must be drug tested based on reasonable cause?, The operator may establish the EAP as part of its internal personnel services or the operator may contract with an entity that provides EAP services. §199.113(a), Does the education under the EAP include at least the following elements: display and distribution of informational material; display and distribution of a community service hot-line telephone number for employee assistance; and display and distribution of the operator'spolicy regarding the use of prohibited drug? §199.113(b) Plan: Vll, Program Elements Common to Drug and Alcohol -'.2, Employee Assistance Program, 3. Supervisor Training Protocol Area C - Alcohol Misuse Prevention Program C-1: Written Alcohol Misuse Plan Does the operator maintain and follow a written Alcohol Misuse Plan that conforms to the requirements of Part 199 and Part 40 and which contains methods and procedures for compliance with required alcohol testing, recordkeeping, reporting, education and training elements? §199.202 Plan: L Introduction - 1. Development of "Combined" Plan, VI. Alcohol Misuse Prevention Program C-2: Alcohol Misuse Program Educational Materials - va ��.. � ��•m~ <y�<tt Does the operator have a process to provide educational materials that explain alcohol misuse requirements and the operator's policies and procedures with respect to meeting those requirements? §199.239(a), Does the operator provide a copy of these materials to each covered employee prior to the start of alcohol testing and to each person subsequently hired or transferred into a covered position? §199.239(a)(1). Does the operator provide written notice to representatives of employee organizations of the availability of this information? §199.239(a)(2) Plan: Ill. Policy and Responsibilities, 1, Company Policy, DOT Compliance, VII, Program Elements Common to Drug and Alcohol, 2. Employee Assistance Program C-3: Alcohol Misuse Program Educational Mat me .�..__. -� - Materials Content ��-� ��-••�� «�-�-� Does the operator ensure educational materials are made available to covered employees and that the materials include detailed discussion of at least the following? §199.239(b), The identity of the person designated by the operator to answer covered employee questions about the materials, The categories of employees who are subject to the alcohol testing regulations in Part 199, Subpart C, Sufficient information about the covered functions performed by those employees to make clear what period of the work day the covered employee is required to be in compliance with Part 199, Subpart C, Specific information concerning covered employee conduct that is prohibited by Part 199, Subpart C., The circumstances under which a covered employee will be tested for alcohol under Part 199, Subpart C, The procedures that will be used to test for the presence of alcohol, protect the covered employee and the integrity of the breath testing process, safeguard the validity of the test results, and ensure that those results are attributed to the correct employee, The requirement that a covered employee submit to alcohol tests administered in accordance with this Part 199, Subpart C, An explanation of what constitutes a refusal to submit to an alcohol test and the attendant consequences, The consequences for covered employees found to have violated the prohibitions under Part 199, Subpart C, including the requirement that the employee be removed immediately from covered functions, and the procedures under §199.243, The consequences for Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN NATIONAL COMPLIANCE MANAOEM ENT SERVICE, INC. (NCMS) 2011 (update 2021). The NCM3 plan is the subject o[ a registered copyright and Is protected by copyright laves In the U.S. and elsewhere. All rights teserved m covered employees found to have an alcohol concentration of 0.02 or greater but less than 0.04, Information concerning the effects of alcohol misuse on an individual's health, work, and personal life; signs and symptoms of an alcohol problem (the employee's or a coworker's); and including intervening evaluating and resolving problems associated with the misuse of alcohol including intervening when an alcohol problem is suspected, confrontation, referral to any available EAP, and/or referral to management. Plan: Ill. Policy and Responsibilities, 2. Responsibilities of Key Personnel, Designated Employer Representative (DER), 3. Responsibilities of Covered Employees, IV. DOT Program Requirements, 4, Employee Notification of Tests, 6, DOT Alcohol Violations and Prohibited Conduct, 7, Violation Consequences and Company Actions, VI. Alcohol Misuse Prevention Program, 1. DOT -Required Alcohol Tests, 2. Alcohol Test, 3. PHMSA Inspection Protocol for Alcohol Testing Sites, Vll. Program Elements Common to Drug and Alcohol, 2. Employee Assistance Program, IX Appendix B -Designated Personnel and Service Agents, X. Appendix C - Covered Positions C-4: Alcohol -Related Prohibited Conduct Does the operator have a process to ensure that a covered employee is not permitted to perform covered functions if the employee has engaged in conduct prohibited by §§199.215 through 199.223 as shown below or an alcohol misuse rule of another DOT agency? §199,233, Prohibited conduct includes: Alcohol Concentration - having an alcohol concentration of 0.04 or greater while on duty. §199.215, §40.23(c) and §40.285, On -Duty Use - using alcohol while performing covered functions. §199.217, Pre -Duty Use - using alcohol within 4 hours prior to performing covered functions, or, if an employee is called to duty to respond to an emergency, within the time period after the employee has been notified to report for duty. §199.219, Use Following an Accident - a covered employee who has actual knowledge of an accident in which his or her performance of covered functions has not be discounted by the operator as a contributing factor to the accident, is prohibited from using alcohol for 8 hours following the accident, unless he or she has been given a post -accident test under §199.225(a), or the operator has determined that the employee's performance could not have contributed to the accident. §199.221, Refusal to Submit to a Required Alcohol Test - the refusal of a covered employee to submit to a post -accident alcohol test required under §199.225(a), a reasonable suspicion alcohol test required under §199.225(b), or a follow- up alcohol test required under §199.225(d). §199.223 and §40,285 Plan: IV DOT Program Requirements - 6. DOT Alcohol Violations and Prohibited Conduct C-5: Available Resources for Employees Does the operator have a process to ensure that each covered employee who hasengaged in conduct prohibited by §§199.215 through 199.223 shall be advised of the resources available to the covered employee in evaluating and resolving problems associated with the misuse of alcohol? This includes the names, addresses, and telephone .numbers of substance abuse professionals and counseling and treatment programs. §40.285(b) and §199.243(a) Plan: IV. DOT Program Requirements - 7. Violation Consequences and Company Actions, After DOT Rule Violations., Vll, Program Elements Common to Drug and Alcohol - 1. Substance Abuse Professional, SAP Referral C-6: Alcohol Concentration of 0.02 or Greater Does the operator have a process to ensure that a covered employee is prohibited from performing or continuing to perform covered functions when found to have an alcohol concentration of 0.02 or greater but less than 0.04, until the employee's alcohol concentration measures less than 0.02 in accordance with a test administered under §199.225(e) or the start of the employee's next regularly scheduled duty period, but not less than 8 hours following administration of the lest? §40.23(c) and §199.237(a) Plan: IV. DOT Program Requirements - 7. Violation Consequences and Company Actions, After DOT Alcohol Prohibited Conduct. C-7: Alcohol Screening Test Devices Does the operator use only Alcohol Screening Devices (ASDs) listed on ODAPC's web page for "Approved Screening Devices to Measure Alcohol in Bodily Fluids" or Evidential Breath Testing Devices (EBTs) listed on ODAPC's web page for "Approved Evidential Breath Measurement Devices' to conduct alcohol screening tests? §40.229, Does the operator use ASDs only for screening tests for alcohol and must not be used for alcohol confirmation tests? §40.229, Note: an ASD can only be used for DOT alcohol screening tests iI there are instructions for its use in Part 40, With respect to breath ASDs, verify the operator follows the device's use and care requirements listed in§40.233. §40.235 Plan: VI. Alcohol Misuse Prevention Program - 3. PHMSA Inspection Protocol for Alcohol Testing Sites, Alcohol Screening with an ASD C-8: Alcohol Confirmation Test Devices Does the operator use only Evidential Breath Testing Devices (EBTs) listed on ODAPC's web page for "Approved Evidential Breath Measurement Devices" to conduct alcohol confirmation tests? §40.231, Does the operator ensure that the inspection, maintenance, and calibration of the EBTs are performed by its manufacturer or a maintenance representative certified either by the manufacturer or by a state health agency or other appropriate state agency? §40.233, Does the operator perform external calibration checks at the intervals and using the methods specified in the manufacturer's instructions for any EBT used for DOT required alcohol confirmation testing? §40.233 Plan: VI, Alcohol Misuse Prevention Program - 2. Alcohol Test, Personnel and Training Devices C-9a: Pre Employment Alcohol Testing (not required) If the operator chooses to conduct pre -employment alcohol testing: Does the operator have a process to ensure it conducts a pre- employment alcohol test before the first performance of a covered function by every covered employee (whether a new employee or Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN C-) NATIONAL COMPLIANCE MANAGEMENT SERVICE, INC. (NC NIS) 2011 (update 2021). The NCM5 plan is the subject of 9 registered copyright and is protected by copyright laws In the U.S. and elsewhere All rights reserved 47 someone who has transferred to a position involving the performance of covered functions)? §199.209(b)(1), Does the operator have a process to ensure it treats all covered employees the same with regards to pre -employment alcohol testing (i.e. must not test some covered employees and not others)? §199.209(b)(2), Does the operator have a process to ensure it conducts the pre -employment test only after making a contingent offer of employment or transfer, subject to the employee passing the pre -employment alcohol test? §199.209(b)(3) Plan: Vl. Alcohol Misuse Prevention Program — 1. DOT -Required Alcohol Tests, Pre -Employment Testing, C-9b Post -Accident Alcohol Testing Does the operator have a process to ensure it completes a DOT post -accident alcohol test as soon as practicable following an accident of each surviving covered employee whose performance of a covered function either contributed to the accident or cannot be completely discounted as a contributing factor to the accident? §199.225(a)(1), If the operator did not administer a DOT alcohol test within 2 hours following an accident, does the operator have a process to ensure it prepares and maintains on file a record stating the reasons the test was not promptly administered? §199.225(a)(2)(i), If the operator does not administer a DOT alcohol test within 8 hours following an accident, does the operator have a process to ensure it ceases attempts to administer the test and prepares and maintains on file a record stating the reasons the test was not administered? §199.225(a)(2)(i), If the operator decides not to conduct a post -accident alcohol test of a covered employee, does the operator have a process to ensure it makes that decision based on specific information that the covered employee's performance had no role in the cause(s) or severity of the accident? §199.225(a)(1), If the operator decided not to conduct a post -accident alcohol test of a covered employees, does the operator have a process to ensure it documents the decision and keeps that record for at least 3 years? §199.227(b)(4) Plan: VI. Alcohol Misuse Prevention Program— 1. DOT -Required Alcohol Tests, Post -Accident Testing, Vll. Program Elements Common to Drug and Alcohol — 5. Recordkeeping, Records and Retention Periods, XIII. Appendix F — Post•Accident or Reasonable Cause/Suspicion Supervisor Written Record C-9c: Reasonable Suspicion Alcohol Testing Does the operator have a process to ensure that DOT alcohol tests are performed when there is reasonable suspicion to believe the employee has violated the alcohol use prohibitions in Part 199, Subpart C? §199.225(b), Does the operator have a process to ensure the operator's determination that reasonable suspicion exists is based on specific, contemporaneous, articulable observations concerning the appearance, behavior, speech, or body odors of the employee and that the observations must be made during, just preceding, or just after the period of the work day the employee is required to be in compliance with Part 199, Subpart C? §199.225(b)(2)&(3), Does the operator have a process to ensure that a covered employee is directed by the operator to undergo reasonable suspicion testing for alcohol only while the employee is .performing covered functions; just before the employee is to perform covered functions; orjust after the employee has ceased performing covered functions? §199.225(b)(3), If the operator does not administer a DOT alcohol testwithin 2 hours following the determination of reasonable suspicion, does the operator have a process to ensure that it prepares and maintains on file a record staling the reason the test was not promptly administered? §199.225(b)(4)(i), If the operator does not administer a DOT alcohol test within 8 hours following the determination of reasonable suspicion, does the operator have a process to ensure that if ceases attempts to administer the lest and prepares and maintains on file a record stating the reasons the test was not administered? §199.225(b)(4)(i), Regardless of whether or not a reasonable suspicion alcohol test is conducted, verity the operator does not permit a covered employee to report for duty or remain on duty performing covered functions while the employee is under the influence of, or impaired by alcohol, as shown by the behavioral, speech, or performance indicators of alcohol misuse. §199.225(b)(4)(iii), Regardless of whether or not a reasonable suspicion alcohol test is conducted, verily the operator does not permit a covered employee to perform or continue to perform a covered function while the employee is under the influence of, or impaired by alcohol, as shown by the behavioral, speech, or performance indicators of alcohol misuse until: An alcohol test is administered and the employee's alcohol concentration measures less than 0.02. §199.225(b)(4)(iii)(A) OR The start of the employee's next regularly scheduled duty period, but not less than 8 hours following the determination that there is reasonable suspicion to believe the employee has violated the alcohol misuse prohibitions in Part 199, Subpart C. §199.225(b)(4)(iii)(3), Does the operator have a process to ensure it does not take any action under Part 199, Subpart C, against a covered employee based solely on the employee's behavior and appearance in the absence of an alcohol test? §199.225(b)(4)(iv), Note: This does not prohibit an operator from taking any action under its own authority and otherwise consistent with the law. Plan: VI, Alcohol Misuse Prevention Program — 1. DOT•Required Alcohol Tests, Reasonable Suspicion/Cause Testing, IV, DOT Program Requirements — 6. DOT Alcohol Violations and Prohibited Conduct, 7. Violation Consequences and Company Actions, XIV. Appendix G — Reasonable Cause/Suspicion Supervisor Written Record C 9d: Return -to -Duty Process and Alcohol Testing Does the operator have a process to ensure that a covered employee who engages in conduct prohibited by §199.215 through §199.223 may not return to duty to perform a covered function until the employee has complied with the SAP's evaluation, referral, and education/treatment process? §40.285(a), §40.305(a), Does the operator have a process to ensure that a covered employee who engages in conduct prohibited by §199.215 through §199.223 does not return to duty to perform a covered function until the employee undergoes a return -to -duty alcohol lest with a result indicating an alcohol concentration of less than 0.02? §40.305(a), §199.225(c), §199.243(c), Does the operator have a process to ensure that all return -to -duty testing is performed under direct observation? §40.67(b). Plan: VI. Alcohol Misuse Prevention Program-1. DOT -Required Alcohol Tests, Return -to -Duty Testing, V, Anti•Drug Program 2, Drug Tests That Require Direct Observation Procedures, All alcohol testing is direct observed. C-9e: Follow -Up Process & Alcohol Testing Does the operator have a process to ensure the SAP has established a written follow-up testing plan after the SAP determined that the employee successfully complied with the SAP's return -to -duty recommendations for education and/or treatment and that a copy Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN ff) NATIOtJAL COMPLIANCE MANAGEMENT SERVICE, INC. (NCNIS) 2011 (update 2021). The NCMS plan is Iho subjact of a rogistered copyright and is protected by copyright lays In the U.S. and alsowhore. All rights reserved 48 of the follow-up testing plan is presented to the DER? §40.307(a)t(b), Does the operator have a process to ensure that follow-up testing is conducted on an unannounced basis, at a frequency established by the SAP, for a period of not more than 60 months? At least six tests must be conducted within the first 12 months following the covered employee's return to duty. §40.307, §40.309, §199.225(d) and §199.243(c)(2)(ii), Does the operator have a process to ensure that follow-up testing is conducted when the covered employee is performing covered functions; just before the employee is to perform covered functions; or just after the employee has ceased performing such functions? §199.225(d) Plan: VL Alcohol Misuse Prevention Plan - 1. DOT -Required Alcohol Tests, Follow -Up Testing, IV, DOT Program Requirements - 4. Employee Notification of Tests C-10 BAT Alcohol Test Reports to the Operator Does the BAT or STT transmit alcohol screening test results to the DER in a confidential manner for concentrations or less than 0.02 using the DOT procedures described in §40.247 (refer to the code for specific requirements)? §40.247, Does the BAT immediately transmit alcohol confirmation test results directly to the DER in a confidential manner using the DOT procedures described in §40.255 (refer to the code for specific requirements)? §40.247 Plan: Vl. Alcohol Misuse Prevention Program - 3. PHMSA Inspection Protocol for Alcohol Testing Sites, Alcohol Screening Results, Alcohol Confirmation Test Protocol Area D - Drug and Alcohol Test Reporting g m. D. Reporting of Drug and Alcohol Test Results to PHMSA If the operator has more than 50 covered employees, verify that it submits an annual MIS report of its anti -drug and alcohol testing results in accordance with the form and instructions located in Part 40, Appendix H. not later than March 15 of each year for the prior calendar year. §40.26, §199.119(a) and §199.229(a), If the operator has 50 or fewer covered employees (includes contractor employees), verify that it submits an annual MIS report of its anti -drug and alcohol testing results in accordance with the form and instructions located in Part 40, Appendix H, not later than March 15 of each year for the prior calendar year when requested to do so by PHMSA notice. §40.26, §199.1191 and §199.2291 Does the operator have a process to ensure it identifies all contractors who performed covered functions for the operator in a given calendar year; and, if required by either mandated annual or PHMSA written request, submitted a MIS report for each of these contractors? §40.26, §199.119(a) and §199.229(a), If a service agent (e.g., C/TPA) prepares the MIS report on behalf of an operator, verify that each report is certified by the operator's anti -drug manager/alcohol misuse prevention manager or designated representative for accuracy and completeness. §199.119(f) and §199.229(d) Plan: VII. Program Elements Common to Drug and Alcohol- 6, Management Information System Protocol Area E - Drug and Alcohol Program Records E-1: Drug and Alcohol Program Recordkeeping Does the operator maintain the required drug and alcohol program records in a secure location with controlled access? §191 and §40.333(c), If the operator allows a service agent to maintain its required drug and alcohol program records, verify that the operator can produce these records at its principal place of business upon request by PHMSA or by a representative of a state agency. §199.117(b) and §40.333(d), If the operator stores records electronically, ensure the records are easily accessible, legible, formatted and stored in an organized manner. §40.333(e), Note: If electronic records do not meet these criteria, the operator must convert them to printed documentation in a rapid and readily auditable manner, at the request of PHMSA or by a representative of a state agency. §40.333(e), Verify that upon a signed written request from an employee that the operator provides to the employee all records of drug and alcohol use, testing results, and rehabilitation. §199.117(b) and §199.231(b) Plan: VII, Program Elements Common to Drug and Alcohol- 5, Recordkeeping, Compliance E 2. Reouired Drug Test Records Retention period - Five years Records of verified positive drug test results. §40.333(a)(1) and §199.117(a)(2), Documentation of refusals to take required drug tests (including substituted or adulterated drug test results). §40.333(a)(1), SAP reports and records that demonstrate compliance with SAP recommendations. §40.333(a)(1) and §199.117(a)(2), All follow-up drug test results and schedules for follow-up drug tests. §40.333(a)(1), MIS annual report data - regardless of whether or not an annual MIS report was submitted. §199.1171 Retention period - Three years Information obtained from previous operators under §40.25 concerning drug test results of employees. §40.333(a)(2). Records that demonstrate the collection process conforms to Part 199. §199.117(a)(1), Records confirming that supervisors and employees have been trained as required by Part 199, §199.117(a)(4), Records of decisions not to administer post -accident drug tests. §199.117(a)(5) Retention Period - One year Records of negative and cancelled drug test results. §40.333(a)(4) and §199.117(a)(3) Plan: VII, Program Elements Common to Drug and Alcohol- 5, Recordkeeping, Records and Retention Periods E 3: Required Alcohol Test Records Retention period - Five years Records of alcohol test results indicating an alcohol concentration of 0.02 or greater. §40.333(a)(1) and §199.227(b)(1), Documentation of refusals to take required alcohol tests. §40.333(a)(1) and §199.227(b)(1), SAP reports, employee evaluations and referrals. §40.333(a)(1) and §199.227(b)(1), All follow-up alcohol test results and schedules for follow-up alcohol tests. §40.333(a)(1), MIS annual report data - regardless of whether or not an annual MIS report was submitted. §199.2271 Calibration Documentation -supersedes the DOT two-year requirement found in §40.333(a)(3) and §199.2271 Retention period - Three years Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN 0 NATIONALCOMPLIANCE MANAGE ME N'r SERVICE, INC. tNCri 2011 (update 2021t. The NCMS plan Is the sugocl of e reglshred copyright and Is protected by copyright laws In the U.S. and elsewhere All rights reserved Information obtained from previous operators under §40.25 concerning alcohol test results of employees. §40.333(a)(2), Records of decisions not to administer post -accident alcohol tests. §199.227(b)(4) Retention Period - Two years Records confirming that supervisors and employees have been trained as required by Part 199. §199.227(b)(2), Records related to the collection process (except calibration of EST devices). §199.227(b)(2) Retention Period - One year Records of all test results with a concentration below 0.02 as defined in Part 40. §40.333(a)(4) and §199.227(b)(3) Plan: VII. Program Elements Common to Drug and Alcohol- 5, Recordkeeping, Records and Retention Periods PHMSA Substance Abuse Program Comprehensive Audit and Inspection Protocol Form, Specimen Collection Sites, Form No.: 3.1.7, Revision 2 (Dated September:1, 2017) Protocol Area O: Specimen Collection Sites 0.01 Urine Collection Personnel Verify that training and usage of personnel is in compliance with the applicable requirements of Part 40. 0.01.a. Does the operator ensure that, unless no other collector is available, an immediate supervisor of an employee does not serve as a collection site person? §40.31(c) Plan: V. Anti -Drug Program, 3. Specimen Collection Procedures, Collection Site Personnel, 0.01.b. Do collectors meet the training requirements of §40.33 and is documentation available showing that currently all requirements are met? §40.33(g). Plan: V. Anti -Drug Program, 4. PHMSA Inspection Protocol for Specimen Collection Personnel, Collection Personnel. 0.01 c. Does the operator provide error correction training as required by §40 33(o and does the training occur within 30 days of the date of notification of the error that led to the need for training? Plan: VA ti Program, 4. PHMSA Inspection Protocol for Specimen Collection Personnel, Collection Personnel 0.02 Collection Sites. Forms and Supplies Verify that collection sites, forms and supplies are in compliance with the appiicable,physical and security requirements of Part 40, 0.02.a. Has the employer designated a collection site that meets the requirements of §40.41. Plan: V Anti -Drug Program, 4. PHMSA Inspection Protocol for Specimen Collection Sites, Collection Sites, Forms and Supplies. 0.02.b. If the collection site uses a facility normally used for other purposes, are procedures in place to ensure before the collection that: (1) access to collection materials and specimens is effectively restricted; and (2) the facility is secured against access during the procedure to ensure privacy to the employee and prevent distraction of the collector? Also, are limited -access signs posted? §40.43(c) Plan: V. Anti -Drug Program, 4. PHMSA Inspection Protocol for Specimen Collection Sites, Collection Sites, Forms and Supplies. 0.02.c. Are procedures in place to assure the collector maintains personal control over each specimen and CCF throughout the collection process and to prevent unauthorized personnel from entering any part of the site in which urine specimens are collected or stored? §40.43(d)(5) and §40.43(e) Plan: V. Anti -Drug Program, 4. PHMSA Inspection Protocol for Specimen Collection Sites, Collection Sites, Forms and Supplies. 0.02.d Is the current Federal Drug Testing Custody and Control Form (CCF) or equivalent being used? §40.45 Plan: V, Anti -Drug Program, 4. PHMSA Inspection Protocol for Specimen Collection Sites, Collection Sites, Forms and Supplies. 0.02.e Is a collection kit used that meets the requirements of Appendix A to Part 40? §40.49 Plan: V Anti -Drug Program, 4. PHMSA Inspection Protocol for Specimen Collection Sites, Collection Sites, Forms and Supplies. 0.03 Urine Specimen Collections Verify that procedures for collection of urine specimens are in compliance with the applicable requirements of Part 40. 0.03.a. Do collection site personnel explain the basic collection procedure to the employee, including showing the employee the instructions on the back of the CCF? §40.61(c) Plan: V. Anti -Drug Program, 4. PHMSA Inspection Protocol for Specimen Collection Sites, Specimen Collections. 0.03.1h. Do collection site personnel provide the donor with an Individually wrapped or sealed collection container from the collection it materials? §40.63(c) Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN O NATIONAL COMPLIANCE MANAGEMENT SERVICE, INC. (NCMS) 2011 (update 2021). The NCMS plan is the Subject of a registered copyright and is protected by copynghl laves In the U S. and elseveheor All rights reserved 50 Plan: V Anti•Drug Program, 4. PHMSA Inspection Protocol for Specimen Collection Sites, Specimen Collections- 0.03 c Are precautions taken to ensure that unadulterated specimens are obtained and correctly identified that meet the following requirements: Bluing agents in toilet tank and all water sources secure. §40.43(b)(1) and (2), Individual positively identified (photo ID, etc.). §40.61(c), Proper authority contacted if individual fails to arrive at the assigned time. §40.61(a), The donor shall remove any unnecessary outer garments. Purses or briefcases shall remain with outer garments. §40.61(f), Donor shall wash and dry his/her hands. §40.63(b), To the greatest extent possible, the collector must keep an employee's collection container within view of both himself/herself and the employee between the time the employee has urinated and the specimen is sealed. §40.43(d)(2), Any unusual behavior noted on the CCF. §40.63(e) Plan: V. Anti -Drug Program, 4. PHMSA Inspection Protocol for Specimen Collection Sites, Specimen Collections. 0.03 d. Are procedures being followed at the collection site after the specimen has been provided in compliance with the requirements of §40.65? Plan: V. Anti -Drug Program, 4, PHMSA Inspection Protocol for Specimen Collection Sites, Specimen Collections. 0.03.e. Have provisions been made 1f the donor is unable to provide at least 45 milliliters of urine? §40.65(a) Plan, V. Anti -Drug Program, 4. PHMSA Inspection Protocol for Specimen Collection Sites, Specimen Collections. 0.03 f. Are procedures in place for Immediately collecting urine specimens under direct observation for the situations identified in §40.67(c)? 1. As of August 31, 2009, verify that all collections for return -to -duty and follow-up testing were performed under DER directed direct observation §40.67(b) Plan: V. Anti -Drug Program, 4. PHMSA Inspection Protocol for Specimen Collection Sites, Specimen Collections. 0.03.g. Are same gender collection personnel used if a collection is monitored under direct observation by non -medical personnel? §40.69(b) Plan: V. Anti -Drug Program, 4. PHMSA Inspection Protocol for Specimen Collection Sites, Specimen Collections. 0.03.h. Is the CCF properly executed by authorized collection site personnel upon receipt and transfer of a urine specimen? §40.73(a) Plan: V. Anti•Drug Program, 4. PHMSA Inspection Protocol for Specimen Collection Sites, Specimen Collections, PHMSA Substance Abuse Program Comprehensive Audit and Inspection Protocol Form, Alcohol Testing Sites, Form No.r3.1:8,1 Revision 2 (Dated Septemberl, 2017) Protocol Area P. Alcohol Testing Sites — Audit Information P.01 Alcohol Testing Personnel Verify that training and usage of personnelis in compliance with the applicable requirements of Part 40. P.01.a. Does the operator's plan specify training for BATS and STTs that is in compliance with §40.213 and does the documentation certify that all requirements are met? §40.213(g) Plan: Vl, Alcohol Misuse Prevention Program, 3, PHMSA Inspection Protocol for Alcohol Testing Sites, Alcohol Testing Personnel P.01.1gDoes the plan specify that a supervisor shall not serve as the BAT or STT if that supervisor makes the reasonable cause determination? §40.211(c) §199.225(b)(2) Plan: VI. Alcohol Misuse Prevention Program, 3, PHMSA Inspection Protocol for Alcohol Testing Sites, Alcohol Testing Personnel P.02 Alcohol Testing Sites Forms and Supplies Verify that alcohol testing sites, forms and supplies are in compliance with the applicable physical and security requirements of Part 40, P.02.a. Does the alcohol testing site comply with the applicable physical and security requirements of §40.221 and §40.223? Plan: VI, Alcohol Misuse Prevention Program, 3. PHMSA Inspection Protocol for Alcohol Testing Sites, Alcohol Testing Sites, Forms and Supplies. P.02.b Does the plan specify that only EBTs and ASDs listed on the NHTSA CPL will be used for DOT alcohol testing §40 229? Also, does the plan specify that an EST must be used for conducting the confirmation tests §40.231(a)? Plan: Vl, Alcohol Misuse Prevention Program, 3, PHMSA Inspection Protocol for Alcohol Testing Sites, Alcohol Testing Sites, Forms and Supplies- P.02.c. Does the operator follow the Quality Assurance Plan (QAP) for the EST that is used §40.233(c)(1)? If this service 1s contracted out does the operator ensure that the CAP is being followed §40.233(c)? Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN 0 NATIONAL COMPLIANCE MANAGEMENT SERVICE, INC. lNCII 2011 (dandle 2021(. Tire frCMS plan Is the subject of a registered copyrightann Is protected by copynghl laws In the U.S. and elsewhere All rights reserved 51 Plan: Vl. Alcohol Misuse Prevention Program, 3. PHMSA Inspection Protocol for Alcohol Testing Sites, Alcohol Testing Sites, Forms and Supplies. P.02 d. Does the plan specify that the operator or Its agents shall comply with the OAP and manufacturer's Instructions and does the operator follow the OAP for the ASD that is used §40.235 and §40.235(c)? Plan: VI, Alcohol Misuse Prevention Program, 3. PHMSA Inspection Protocol for Alcohol Testing Sites, Alcohol Testing Sites, Forms and Supplies. P.03 Alcohol Screening Tests Verify that alcohol screening tests are performed in compliance with the applicable requirements of Part 40. P.03.a. Does the plan prescribe that only the DOT -approved Alcohol Testing Form (ATF) shall be utilized §40.225(a)? Plan: Vl, Alcohol Misuse Prevention Program, 3. PHMSA Inspection Protocol for Alcohol Testing Sites, Alcohol Screening Tests, P.03.b. Does the plan specify that the employee shall provide a positive Identification through of photo ID orr e use p � representative §40.241(c)? by the employer Plan: Vt, Alcohol Misuse Prevention Program, 3, PHMSA Inspection Protocol for Alcohol Testing Sites, Alcohol Screening Tests. P.03.c. Does the plan indicate that the BAT or STT shall explain the testing process to the employee §40.241(e)? Plan: VI, Alcohol Misuse Prevention Program, 3. PHMSA Inspection Protocol for Alcohol Testing Sites, Alcohol Screening Tests. P.03.d. Does the plan contain specific instructions for conducting alcohol screening tests In compliance with §40 241 and §40.243 requirements? - Plan: Vt. Alcohol Misuse Prevention Program, 3, PHMSA Inspection Protocol. for Alcohol Testing Sites, Alcohol Screening Tests. P.03.e Does the plan contain specific Instructions for conducting alcohol screening tests using a saliva ASD in compliance with §40.246 requirements? Plan: Vl, Alcohol Misuse Prevention Program, 3. PHMSA Inspection Protocol for Alcohol Testing Sites, Alcohol Screening with an ASD. P.03.f. Does the plan specify actions that are taken after receipt of alcohol screening test results that are in compliance with §40.247? Plan: Vl, Alcohol Misuse Prevention Program, 3. PHMSA Inspection Protocol for Alcohol Testing Sites, Alcohol Screening Results, P.04 Alcohol Confirmation Tests Verify that alcohol confirmation tests are performed in compliance with the applicable requirements of Part 40. P.04.a. Does the plan provide guidance for the actions a new BAT must complete to conduct a confirmation test in compliance with §40.251(b)? Plan: VI, Alcohol Misuse Prevention Program, 3. PHMSA Inspection Protocol for Alcohol Testing Sites, Alcohol Confirmation Test. P.04.b Does the plan specify procedures to be followed in conducting a confirmation test that are in compliance with §40.253 and §40.255? Plan: VI, Alcohol Misuse Prevention Program, 3, PHMSA Inspection Protocol for Alcohol Testing Sites, Alcohol Confirmation Test. P.05 Problems in A T e Alcohol Testing A — Verify that procedures for addressing problems in alcohol testing are in compliance with the applicable requirements of Part 40, P.05.a. Does the plan address the situations for which the employee is considered to have refused to take an alcohol test §40.261(a)(1) o (7)? Plan: Vt. Alcohol Misuse Prevention Program, 3. PHMSA Inspection Protocol for Alcohol Testing Sites, Problems in Alcohol Testing, P.05.b Does the plan specify procedures concerning an employees inability _„tt— ti ..�..,__ �__..-S�M.,...._-.. to provide an adequate amount off saliva saliva for testing and instructions for requiring the employee to attempt again to provide adequate amount of saliva for testing §40.263? Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN v NATIONAL COMPLIANCE MANAGEMENT SERVICE-INC.(rd t 2011(update 2021) The NCMS plan is the subject of A registered copyni and Is protected by copyright lays In the U.S_ and elsewhere. All fights reserved 52 Plan: Vl. Alcohol Misuse Prevention Program, 3, PHMSA Inspection Protocol for Alcohol Testing Sites, Problems in Alcohol Testing. P.05.c. Does the plan specify procedures concerning an employee's inability to provide an atlequate amount of breath for testing in compliance with §40.265? Plan: Vl, Alcohol Misuse Prevention Program, 3. PHMSA Inspection Protocol for Alcohol Testing Sites, Problems in Alcohol Testing. P.05.d. Does the plan specify under what conditions that an alcohol test shall be cancelled §40.267 and §40.269? Plan: Vl. Alcohol Misuse Prevention Program, 3. PHMSA Inspection Protocol forAlcohol Testing Sites, Cancelling an Alcohol Test, P.05.e. Does the plan specify procedures concerning (he potential inability to complete an alcohol test antl trying to successfully complete the lest §40,271? Plan: Vl. Alcohol Misuse Prevention Program, 3. PHMSA Inspection Protocol for Alcohol Testing Sites, Correcting Alcohol Problems. ChangeslUpdates to the Model Plan -Revision Dates: 111/2018, 111/2020, 411/2021 Section Title Change Reason Section II. General — 8. Definitions Updated Accident/Incident Part 191 Update 191.31 &2, 191.39b Section 11. General — 8. Definitions Updated Administrator: Clarification Definition Section II General — 8. Definitions Updated Alcohol Screening Part 40 Update Device Definition `. Section 11, General-8. Definitions Removed Blind Sample Part 40 Update Definition Section It. General — 8. Definitions Updated Chain -of -Custody Added OMB Approval Definition Section 11. General — 8. Definitions UpdatedContinuing Removed reference to MRO. Education Definition Section II. General — 8. Definitions Updated DOT, The Part 40 Update Department, DOT agency Definition Section II. General- 8. Definitions: Updated DOT, :The'. Added USCG has not Department, DOT agency incorporated Part 40 for Definition alcohol testing. Section It. General — 8. Definitions Updated the Drugs Definition Part 40 Update — Opiates to Optoids, Prohibited drug Opiates to 0 ioids Section II. General — 8. Definitions Updated Evidential Breath Part 40 Update Testing Device Definition Section 11, General — 8. Definitions Added Invalid result Part 40 Update Section IL General —8. Definitions Updated Prohibited Drug'. Part 199 Update Definition Section IL General-8. Definitions Service Agent Definition Part 40 Update Section III. Policy and Responsibilities — 4. Use of Added Service Agent. PHMSA Inspection Form Service Agents, Service Agent Limitations Limitations Section Update. Section 111. Policy and Responsibilities — 5. Critical Added: Reference to Clarification Service Agent Positions Additional Sections within the'. Plan, Section IV. DOT Program Requirements — 3 History- Last Paragraph, two attempts Clarification check Requirement, Information Request Section IV. DOT Program Requirements — 7. Violation Added 2nd Paragraph Clarification Consequences and Company Actions, After DOT Rule Violation Section V. Anti -Drug Program, 1. DOT -Required Drug Added two sentences to end Part 40 Update Tests Compliance of 1st Paragraph. Section V. Anti -Drug Program, 1. DOT -Required Drug Updated 151 and 2nd Part 199 update Tests- Post -Accident Testing Paragraph Section V. Anti -Drug Program, 1. DOT -Required Drug Revised 1s' Paragraph, added' Clarification and PHMSA Tests — Random Drug Testing last sentence to 3rd-Paragraph Inspection Form Update. Section V. Anti -Drug Program, 1. DOT -Required Drug Added 4T Paragraph Clarification Tests - Return-To-Dut Testing Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN l� NATIONAL COMPLIANCE MANAGEMENT SERVICE, IrIC. (Ni 2011 (update 2021). The NGMS plan Is the subject of a regisisrotl w)yrighi antl Is pmteoletl by wpynghit aws In iho US and eleewhera. All rlghls eselved 53 Section V. Anti -Drug Program, 1. DOT -Required Drug Added 4'" Paragraph Clarification Tests - Follow -Up Testing Section V. Anti -Drug Program, 2. Drug Tests That 30 Sentence, Added Clarification, Part 40 Update Require Direct Observation Procedures, Company will Explain to the Compliance Employee Reasons) for Direct Observation, Added 2nd Paragraph Section V. Anti -Drug Program, 3. Specimen Collection Updated 2nd Sentence, Added Part 40 Update Procedures, Collection Site Personnel Last Sentence Section V. Anti -Drug Program, 3. Specimen Collection Added 2nd Sentence Clarification Procedures, Collection Site, Forms and Specimen Section V. Anti -Drug Program, 3. Specimen Collection Removed 4'^: Sentence of 1s' Part 40 Update Procedures, Possible collection issues Paragraph, Deleted 2114 Paragraph Section V. Anti -Drug Program, 5. Drug Testing Updated Opiates to Diploids, Part 40 Update Laboratory, Drug Testing, Required DOT Updated Table 1 and Drug Tests and Cutoffs Footnotes Section V. Anti -Drug Program, 5. Drug Testing Updated 1s' Paragraph, Last Part 40 Update Laboratory, Laboratory specimen handling Sentence and Items a-g and reporting. Section V. Anti -Drug Program, 6. Laboratory Retention Added 2nd Sentence to Update and Clarification Periods and Reports, Specimen retention Specimen retention, Added and Record retention last two Sentences to Record retention Section V. Anti -Drug Program, 7. Laboratory Quality Removed Quality Part 40 Update Control, Quality Control, Reporting Control/Blind Specimen Discrepancies requirements. '. Section V. Anti -Drug Program, 8. MRO Review of Drug Added last two sentences to Part 40 Update Test Results, Compliance First Paragraph, Added 2nd Paragraph. Section V. Anti -Drug Program. 8. MRO Review of Drug Added 4111 Sentence. to is' Part 40 Update Test Results, Duties Paragraph, Changed Opiate to Opioid, Added Last Sentence to IN Paragraph, Revised 1" Sentence of 2nd Paragraph, Section V. Anti -Drug Program, 8. MRO Review of Drug First Paragraph, added Addition requested by Test Results, Results : second sentence. State/Federal Inspector. Section V. Anti -Drug Program. 8.i MRO Review of Drug Added 5"' Sentence Clarification Test Results, Reports Section V. Anti -Drug Program. 9. Split Specimen 15' Paragraph, updated 511h, 616 MRO notification and Testing & 7'h Sentence documentation. Section V. Anti -Drug Program - 9. Split Specimen Updated 2nd Sentence MRO will select the second Testing — Laboratory laboratory Section V. Anti -Drug Program- 10. Medical or Added Recreational Changes in State Laws Recreational Marijuana Section VI.: Alcohol Misuse Prevention Program, 1. DOT- Updated 1°' and 2nd Part 199 update Required Alcohol Tests - Post -Accident Paragraph Testing Section VI. Alcohol Misuse Prevention Program. 1. DOT- Revised 3'dParagraph PHMSA Inspection Form Required Alcohol Tests — Reasonable Update. Suspicion/Case Testing Section VI. Alcohol Misuse Prevention Program, 1. DOT- Added 3'd Paragraph Clarification Required Alcohol Tests - Return -to -Duty Testing Section VI. Alcohol Misuse Prevention Program, 2. Added 20d and 3'd Sentence, Part 40 Update Alcohol Test, Personnel and Testing Devices added last Sentence Section VI. Alcohol Misuse Prevention Program, 3. Added gin & 71n Sentence Clarification PHMSA Inspection Protocol for Alcohol Testing Sites, Alcohol Screening Results Section VI. Alcohol Misuse Prevention Program, 3. Added "Within five days" to 4'" Clarification PHMSA Inspection Protocol for Alcohol Sentence Testing Sites, Problems in Alcohol Testing Section VIL Program Elements Common to Drug and Added 2nd Sentence Part 40 Update Alcohol, 1. Substance Abuse Professional, Qualifications Section VII. Program Elements Common to Drug and Added last sentence PHMSA Inspection Form Alcohol. 2. Employee Assistance Program I Update. Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN (i� NATIONAL COMPLIANCE MANAGEMENT SERVICE, INC. (NCMS) 2011 (updata 2021). The NCMS plan Is the subJacl of e registered copyright and Is protected by copyright laws In the U.S. and elsewhere. All rights ese,ved 54 Section VI I. Program Elements Common to Drug and 1st Paragraph, 1st Sentence, Clarification Alcohol, 5. Recordkeeping, Compliance added "in a location with controlled access'. Section VI I. Program Elements Common to Drug and Added(4)and(5) Part 199 update and Alcohol, 5. Recordkeeping - Records and clarification. Retention Periods, b Section VI I. Program Elements Common to Drug and Added "cancelled drug test Clarification Alcohol, 5. Recordkeeping — Records and results" to (1) Retention Periods, d Section VII. Program Elements Common to Drug and Added last sentence Part 199 update Alcohol, 6. Management Information System Compliance Section VII. Program Elements Common to Drug and Added last sentence Part 199 update Alcohol, 6. Management Information System - Contractor Reporting of MIS Section VIII, Appendix A— Acknowledgement/Receipt Removed Company; Signature not required Form Representative Signatureg Section X. Appendix C — Covered Positions Added, to Job Clarification Classifications/Titles, "Subject to 49 CFR Part 192, 193 or 195 Section XII. Appendix E— PHMSA Inspection Plan Cross- Added table to track changes Clarification Reference and Changes to Model Plan and updates to Model Plan Section XIII. Appendix F — Post -Accident or Reasonable Previously an attachment. Clarification Cause/Suspicion Supervisor Written Records Incorporated into written Plan Section XIV. Appendix G — Reasonable Cause/Suspicion Previously an attachment. Clarification Observation Checklist Incorporate into written Plan. Several Several Sections of the Plan Added Covered to Safety- Clarification. PHMSA refers Sections Sensitive to employees performing PHMSA-regulated work as "covered". ODAPC/Part 40 refers to modal coverage as "safet -sensitive". Several Removed Endnotes In Reference to 2017 Added 2021 PHMSA -Anti- PHMSA released a new Sections PHMSA HQ Inspection Form Drug and Alcohol Misuse'. inspection form 3/1/2021 and Program Inspection Protocol replaced the Comprehensive Form, 2017 Comprehensive Anti-Drug and Alcohol Audit and Inspection Protocol'. Misuse Program HQ Forms -Specimen Collection Inspection Form. Sites and Alcohol Testing Sites (included references to Plan Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN U NATIO�WL COMPLIAI+ICE MANAGEMENT SERVICE, INC. (NGMS) 2011 (uptlale 20211. The NCMS plan Is the su�lect of e regtsteratl wpyright antl Is protecteU by copyright laves In the U S. antl else�vhera. All rights eseNetl. 55 XIII. Appendix F Post -Accident or Reasonable Cause/Suspicion Supervisor Written Record (Check one): ❑Pipeline (PHMSA) ❑Driver(FMCSAI Employee's Name Employee Id# Describe Accident/Incident: Dept. Job I Date Time Was EBT Breath Alcohol testing completed within two (2) hours of the accident, or the reasonable cause/suspicion situation? _Yes No If not, why? (Examples — received notification too late, employee emoved from the scene for medical treatment, EBT device not available, injuries precluded testing, breath alcohol technician not available) 2. Was EBT Breath Alcohol testing completed within eight (8) hours? Yes No If not, why? (Examples — received notification too late, employee removed from the scene for medical treatment, EBT device not available, injuries precluded testing, breath alcohol technician not available) 3. Was urine drug testing completed within thirty-two (32) hours of the accident or reasonable cause/suspicion situation? _Yes No If not, why? Supervisor's Name: Second Supervisor's Signature (if applicable): Date: *** IMPORTANT *** The above report is required in Post -Accident or Reasonable Cause/Suspicion testing when the tests) times were not met. The written report of Post -Accident or Reasonable Cause/Suspicion testing must be completed and signed by the supervisor within 48 hours of the incident and subsequently faxed or e-mailed to the Company Designated Employer Representative (DER). Premium Concrete Services, Inc.-PHMSA DRUG/ALCOHOL PLAN NATIONAL COMPLIANCE MANAGEMENT SERVICE, INC. (NCMS) 201� (update 2021J. Tlie t,ICMS plan is the subject of a rugisterntl copyright entl Is protected �y wpyrlgl�t lervs in Ilse U S. and elser•,Fere. All rigM1ls eserved XIV. Appendix G Reasonable Cause/Suspicion Observation Checklist (STRICTLY CONFIDENTIAL) PERIOD OF EVALUATION: SUPERVISOR #1, NAME AND TELEPHONE: SUPERVISOR #2, NAME AND TELEPHONE: This checklist is intended to assist a supervisor in referring a person for drug and/or alcohol testing. Has the employee manifested any of the following behaviors? Indicate (X) if observation and/or documentation exists. A. QUALITY AND QUANTITY OF WORK YES NO 1. Clear refusal to do assigned tasks 2 Significant increase in errors 3. Repeated errors in spite of increased guidance 4. Reduced quantity of work 5. Inconsistent, "up and down" quantity/quality of work 6. Behavior that disrupts workflow 7. Procrastination on significant decisions or tasks 8. More than usual supervision necessary 9. Frequent, unsupported explanations for poor work performance 10.Noticeable change in written or verbal communication 6. INTERPERSONAL WORK RELATIONSHIPS YES NO 1. Significant change in relations with co-workers, supervisors 2 Frequent or intense arguments 3. Verbal/Physical abusiveness 4. Persistently withdrawn or less involved with people _ 5. Intentional avoidance of supervisor 6. Expressions of frustration or discontent 7. Change in frequency or nature of complaints 8. Complaints by co-workers or subordinates _ 9. Cynical, "distrustful of human nature" comments 10. Unusual sensitivity to advice or critique of work 11. Unpredictable response to supervision 12. Passive -aggressive attitude or behavior, doing things "behind your back" C. GENERAL JOB PERFORMANCE 1. Excessive unauthorized absences -number in last 12 months _ 2. Excessive authorized absences -number in last 12 months _ _ 3. Excessive use of sick leave in last 12 months 4. Frequent Monday/Friday absence or other pattern 5. Frequent unexplained disappearances 6. Excessive "extension" of breaks or lunch 7. Frequently leaves work early -number of days per week or month 8. Increased concern about (actual incidents) safety offenses involving the employee 9. Experiences or causes job accidents Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN Ca NATIONAL COMPLIANCE MANAGEMENT SENVICE, INC. (NCMS) 2011 (update 2021). The NCMS plan Is file Ridect of registered copyright and is protected by copyright laws In the U.S. and elsewhere. All rights ,eserved 57 10. Major change in duties or responsibilities 11. Interferes with or ignores established procedures 12. Inability to follow through on job performance recommendation D. PERSONALMATTERS 1. Changes in or unusual personal appearance (dress, hygiene) 2. Changes in or unusual speech (incoherent, stuttering, loud) 3. Changes in or unusual physical mannerisms (gesture, posture) 4. Changes in or unusual facial expressions 5. Changes in or unusual level of activity -much reduced/increased 6. Changes in or unusual topics of conversation 7. Engages in detailed discussions about death, suicide, harming others 8. Increasingly irritable or tearful 9. Persistently boisterous or rambunctious 10. Unpredictable or out -of -context displays of emotion 11. Unusual fears or lacks appropriate caution. 12. Engages in detailed discussion about obtaining/using drugs/alcohol 13. Has personal relationship problems (spouse, girl/boyfriend, children, in-laws) 14. Has received professional assistance for emotional or physical problems 15. Makes unfounded accusations toward others, i.e., has feelings of persecution 16. Secretive or furtive 17. Memory problems (difficulty recalling instructions, data, past behaviors) 18. Frequent colds, Flu, excessive fatigue, or other illnesses 19. Makes unreliable or false statements 20. Unrealistic self -appraisal or grandiose statements 21. Temper tantrums or angry outbursts 22. Demanding, rigid, inflexible 23. Major change in physical health 24. Concerns about sexual behavior or sexual harassment E. PHYSICAL INDICATORS YES NO 1. Smell of alcohol on breath or person? 2. Speech: Slurred? Confused? Fragmented? _ Slow? Unusually soft? _ Unusually loud? _ _ 3. Disorientation: Is employee confused about; Where he or she is? What day it is? What time it is? _ 4. Apparent inability to focus on work? 5. Unusual or unexplained resistance to authority or refusal to follow reasonable directions? 6. tack of motor coordination 7. Mood: Belligerent? _ Moody? _ Ecstatic? _ More nervous than usual? Giddy? _ Talkative? Drowsy? _ 8. Skin color: Pale? _ Flushed? _ 9. Excessive perspiration? 10. Excessive trips to the restroom? 11. Bloodshot eyes? 12. Dilated pupils? 13. Pinpoint pupils? 14. Traces of alcohol in containers? 15, Confession by employee that he/she was drinking alcohol or ingesting drugs? Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN NATIONAL COMPLIANCE MANAGEMENT SERVICE. INC. (NCMS) 2011 (update 2021). The Ni plan Is the subject of e registered Copyr�ghl and is protected by copyright laws In [tie U 5- and elsewhere. All rlgl is reserved 16. Confirmation by other employees? 17. Presence of substances with the appearance of drugs? 18. Presence of drug paraphernalia? 19. Smell of marijuana? 20. Congregation of employees in remote areas of the company's facilities or in areas not usually frequented by employees? 21. Weariness, fatigue, or exhaustion? 22. Deteriorating physical appearance? E. PHYSICAL INDICATORS ICon't) YES NO 23. Yawning excessively? 24. Blank stare or expression? 25. Sudden and/or unpredictable change in energy level? 26. Unusually energetic? 27. Shaking or trembling of hands? 28. Sunglasses worn at inappropriate times? 29. Changes in appearance after lunch break? 30. Breathing or swallowing difficulties? 31. Unusual sneezing/nasal congestion? _ 32. Needle marks on arms? 33. Prolonged lunch hours? 34. Tardiness? Other informationlobservations - (Please be specific &attach additional sheet as SUPERVISOR #1 (print name) SUPERVISOR #1 (signature/date) SUPERVISOR #2 (print name) SUPERVISOR #2 (signature/date) Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN R? IVAiIONAL COMPLIANCE MANAGEMENT SF.RVIGE, ING (MCMS) 2011 (update 2�21). the NCMS plan is the suhjoc� of e rogislered wpyright and is protected by copyright laves In the U.S. and elsewhoro All ri9h�s eserved 59 July 2, 2024 City of South Bend, Indiana, Board of Public Works County/City Building, Room 1316 227 West Jefferson Blvd South Bend, IN 46601 RE: Premium Concrete Services, Inc. Job: 2024 Curb and Sidewalk Program, Project No. 124-009 To Whom It May Concern: In compliance with the United States Department of Treasury's Listing of Certified Companies, this letter will serve to confirm that at this time the surety company Old Republic Insurance Company is listed with the United States Department of Treasury's Listing of Approved Sureties according to Department Circular 570, OLD REPUBLIC INSURANCE COMPANY SU JJ nifer L. Kasznia SEAL r€: MPL IYtd f``fi ttorney in Fact J K/ Premium Concrete Services, Inc. dba Premium Services 712 Richmond Street Elkhart, IN 46516 574-264-0196 fax 574-266-5392 May 23, 2024 To Whom it May Concern, Premium Concrete Services, Inc. has no federal, state, or local tax delinquencies owed to any of the fore mentioned taxing bodies, nor has owed any in the past three years. Max Yeakey Vice -President E PC 3 3w 3 3 3 3 3PP. 3 L F " - - E Pd 3 G _ PO E a 30 a 0a 3 o 3 'o_ 3 E 3 3 3 3 _ > PC PCE _C Q o _ _ _ 0 PO > - > - > > < > m r 3 C 3 ti - z0 z z _ PC PC 3 3 3 PC 3 3 C Cm r PC PC PC PC PC 0 0 0 m PC PC 75 PC U' 3 C PC —PC 3 E - e 46 PC PC PC u u PC -PPP o ow o 0 POP) 0 zz u—