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Standardized Pre-Qualification Form (PQF)L C S CO N ST RUCT O RS, I N C.West Coast 15205 Alton Parkway Irvine CA 92618 P 949.870-4500 F 949.870-4501 CA License. #640058Gulf Coast 11410 Brittmoore Park Drive Houston TX 77041 P 713.934-7174 F 713.934-7181 M-37865 TACLA2193CGENERAL INFORMATION1. Company Name:Telephone:Street Address:Mailing Address:Fax:Web site:Contact Person:e-mail:Telephone:Fax:2. OfficersYears With CompanyPresident:Vice President:Treasurer:3. How many years has your organization been in business under your present firm name?4. Parent Company Name:4b. Tax ID #:4a. Dun & Bradstreet #:City:State:Zip:Subsidiaries:5. Under Current Management Since (Date):6. Contact for Insurance Information:Title:Telephone:Fax:7. Insurance Carrier(s):NameType of Coverage8. Are you self insured for Worker’s Compensation Insurance? YesTelephoneNo9. Contact for Requesting Bids:Title:Telephone:Fax:Telephone:Fax:10. PQF Completed By:Title:Sub PQF1Rev.2, 07/13/2011
Standardized Pre-Qualification Form (PQF)L C S CO N ST RUCT O RS, I N C.West Coast 15205 Alton Parkway Irvine CA 92618 P 949.870-4500 F 949.870-4501 CA License. #640058Gulf Coast 11410 Brittmoore Park Drive Houston TX 77041 P 713.934-7174 F 713.934-7181 M-37865 TACLA2193C11. Form of Business:Sole OwnerORGANIZATION CorporationPartnershipDate and State of Incorporation:EEO Category:12. Percent Minority/Female Owned:13.A. Describe Services Performed:SIC Code:Original Equipment Manufacturer andConstruction Maintenance Service work (e.g., janitorial, clerical, etc.)Construction DesignManpower and ResourceOriginal Equipment Manufacturer and Installer Other TurnaroundMaintenanceEngineeringSpecialty MaintenanceB. Work Categories - Check the categories in which you are interested in bidding and in which you are qualified to perform work. Feel free to attach additional information clarifying your capabilities and specialities.“C” denotes work done by company employeesC “S” denotes work done by subcontractorsSC1. Air Conditioning/RefrigerationComfort Cooling/HVACProcess Refrigeration 2. BuildingsRemodelingNew (steel, brick, block, other) 3. CleaningIndustrialJanitorial 4. CivilConcreteExcavation/GradingPaving-- Asphalt-- Concrete5. Demolition/Dismantling6. ElectricalGeneralHigh-voltage/High-lineHeat Tracing Cathodic ProtectionGrounding Systems 7. Inspection & Testing General NDTInfared ScanningEddy Current TestingAcoustic Emission Column ScanningCivil/Soils High Voltage ElectricalElectrical Ground InspectionFiberglass InspectionOtherS 11. Field MaintenanceGeneralHot Tap/line stops Leak Sealing (online) Field Machining Tank/Vessel Code Boiler Code Exchanger Retubing Rotating Equipment Valve Cooling Tower High Alloy Welding (list type) Lead Lining Glass Lining Heat Treating Nonmetallic materials Pipe Fabrication Mobil Equipment Repair 12. New Construction13. Painting 14. Refractory/Acid Brick 15. Rigging/Equipment Erection 16. Scaffolding 17. Scale Maintenance 18. Structural Steel Fab/Erection 19. Tanks - Field Erection 20. OtherContinuedSub PQF2Rev.2, 07/13/2011
Standardized Pre-Qualification Form (PQF)L C S CO N ST RUCT O RS, I N C.West Coast 15205 Alton Parkway Irvine CA 92618 P 949.870-4500 F 949.870-4501 CA License. #640058Gulf Coast 11410 Brittmoore Park Drive Houston TX 77041 P 713.934-7174 F 713.934-7181 M-37865 TACLA2193C8. Instrumentation GeneralDCS Control Systems9. InsulationGeneralAsbestos Abatement10. Linings/coatings for:MetalConcrete21. Consulting- Mechanical- Electrical- Chemical- Metallurgical- Controls- Other14.Describe Additional Services Performed:15.List other types of work within the services you normally perform that you subcontract to others:16.A. Do you normally employ? Union PersonnelNon-Union PersonnelLeased PersonnelIf union, list trades/locals:B. Average number of employees for last 3 years17.Annual Dollar Volume forthe Past 3 Years:18.Largest Job During the Last 3 Years:19.Your Firm’s Desired Project Size:Maximum:20.D&B Financial Rating:Net Worth: 21.Bank Line of Credit:22.Major jobs in progress:Customer/Location23.YR : 20 YR :20 Annual SalesBonding CapacityYR :20 Minimum:Bank Reference(s):Type of WorkSize Customer ContactTelephoneSize Customer ContactTelephoneMajor jobs completed in the past three years:Customer/LocationType of Work24.Are there any judgments, claims or suits pending or outstanding against your company?If yes, please attach details.YesNo25.Are you now or have you ever been involved in any bankruptcy or reorganization proceedings?If yes, please attach details.YesNoSub PQF3Rev.2, 07/13/2011
Standardized Pre-Qualification Form (PQF)L C S CO N ST RUCT O RS, I N C.West Coast 15205 Alton Parkway Irvine CA 92618 P 949.870-4500 F 949.870-4501 CA License. #640058Gulf Coast 11410 Brittmoore Park Drive Houston TX 77041 P 713.934-7174 F 713.934-7181 M-37865 TACLA2193CSAFETY & HEALTH PERFORMANCE26.Workers Compensation Experience Modification Rate (EMR) Data: Complete below areas.a.EMR is:b. Interstate rate2010:Intrastate rateMonopolistic State rateDual ratec.EMR for three last years:2009:2008:State of Origin:d.27.Injury and Illness Data:a. Total company employee hours worked lastthree years (excluding subcontractors)Hours / YearEMR Anniversary Date:YR2010YR2009YR2008FieldTotalb.Provide the following data (excluding subcontractor) using your OSHA 300 Forms from the past three (3) years:Notes:(1) Data should be the total company data unless specifically requested by client.(2) Combine injuries and illnesses as reported on 300 Forms(3) If your company is not required to maintain OSHA 300 forms, pleaseYR:provide information form your Worker’s Compensation insurance carrieritemizing all claims for the last 3 years.No.2010RateYR: 2009No.YR: 2008RateNo.RateFatalitiesRate Number of Fatalities x 200,000 / Total Employee HoursLost workday case injuries and illnesses involving days away from work, or daysof restricted work activity, or both.Rate Total LW and restricted cases x 200,000 / Total Employee HoursLost workday case injuries and illnesses involving days away from work.Rate LW cases** x 200,000 / Total Employee HoursInjuries and Illnesses involving medical treatment only.Rate Total injuries and illnesses involving medical treatment only x 200,000 /Total Employee HoursTotal OSHA Recordable Injury and Illnesses RateRate Total Injuries and Illnesses x 200,000 / Total Employee Hours28. Have you received any regulatory (EPA, OSHA, etc.) civil or criminal citations in the last three years?If yes, please attach copies.Sub PQFYesNo4Rev.2, 07/13/2011
Standardized Pre-Qualification Form (PQF)L C S CO N ST RUCT O RS, I N C.West Coast 15205 Alton Parkway Irvine CA 92618 P 949.870-4500 F 949.870-4501 CA License. #640058Gulf Coast 11410 Brittmoore Park Drive Houston TX 77041 P 713.934-7174 F 713.934-7181 M-37865 TACLA2193CSAFETY & HEALTH MANAGEMENT29. Highest ranking safety/health professional in the company:Contact:Title:Telephone:30. Do you have or provide:a. Full time Safety/Health DirectorFax:YesNob.Full time Site Safety/Health SupervisorYesNoc.Full Time Job Safety/Health CoordinatorYesNoYesYesNoNo31. Do you have or provide:a. Safety/Health incentive programb. Company paid safety/health training32. a.SAFETY & HEALTH PROGRAMS & PROCEDURESDo you have a written Safety and Health Program?Yes No b. Does the program address the following key elements?Yes Yes Yes No No No Yes Yes No No Yes Yes No No 1. Ensuring your employees follow the safety rules of the facility? Yes 2. Advising owner of any unique hazards presented by the contractor’swork and of any hazards found by the contractor?Yes No 1. Management commitment and expectations2. Employee participation3. Accountabilities and responsibilities for managers,supervisors, and employees4. Resources for meeting safety & health requirements5. Periodic safety and health performance appraisalsfor all employees6. Safety Recognition Program7. Hazard recognition and controlc. Does the program satisfy your responsibility under the law for:No 33. Does the program include work practices and procedures such as:a.b.c.d.e.f.g.h.i.j.Equipment Lockout and Tagout (LOTO)Confined Space EntryInjury & Illness RecordingFall ProtectionPersonal Protective EquipmentPortable Electrical/Power ToolsVehicle SafetyCompressed Gas CylindersElectrical Equipment Grounding AssurancePowered Industrial Vehicles(Cranes, Forklifts, JLGs, etc.)k. Housekeepingl. Accident/Incident Reportingm. Unsafe Condition Reportingn. Emergency Preparedness, including evacuation plano. Waste Disposalp. Back Injury PreventionSub PQF5Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Yes Yes Yes Yes Yes Yes No No No No No No N/A N/A N/A N/A N/A N/A Rev.2, 07/13/2011
Standardized Pre-Qualification Form (PQF)L C S CO N ST RUCT O RS, I N C.West Coast 15205 Alton Parkway Irvine CA 92618 P 949.870-4500 F 949.870-4501 CA License. #640058Gulf Coast 11410 Brittmoore Park Drive Houston TX 77041 P 713.934-7174 F 713.934-7181 M-37865 TACLA2193C34. Do you have written programs for the following:a.b.c. d.Hearing ConservationRespiratory ProtectionWhere applicable, have employees been: Trained Fit tested Medically approvedHazard CommunicationHave employees been trainedProgram to support the contractor requirements of the OSHAProcess Safety Management of Highly Hazardous Chemicals;Explosives and Blasting Agents Standard (29 CFR 1910).35. Do you have a substance abuse program?Yes Yes No No Yes Yes Yes Yes Yes Yes No No No No No No Yes No N/A If yes, does it include the following?36.37. Pre-placement TestingYes No Random TestingYes No Testing for CauseYes No DOT TestingYes No Post Incident TestingYes No Do your employees read, write, and understand English such thatthey can perform their job tasks safely without an interpreter?Yes No If no, provide a description of your plan to assure that they can safely perform their jobs.Medicala.b.c.38.Do you conduct medical examinations for: Pre-placementYes No N/A Preplacement Job CapabilityYes No N/A Hearing Function (Audiograms)Yes No N/A PulmonaryYes No N/A RespiratoryYes No N/A Describe how you will provide first aid and other medical services for your employeeswhile on-site.Specify who will provide this service:Do you have personnel trained to perform first aid and CPR?Yes No Do you hold site safety and health meetings for:Field SupervisorsYes EmployeesYes New HiresYes SubcontractorsYes No No No No FrequencyFrequencyFrequencyFrequencyAre the safety and health meetings documented?39.Yes No Yes Yes No No Personal Protection Equipment (PPE)a.b.Is applicable PPE provided for employees?Do you have a program to assure that PPE is inspectedand maintained?40.Do you have a corrective action process for addressing individual safety and health performance deficiencies?Yes No 41.Equipment and Materials:a.Sub PQFDo you have a system for establishing applicable health,safety, and environmental specifications for acquisition6Yes No N/A Rev.2, 07/13/2011
Standardized Pre-Qualification Form (PQF)L C S CO N ST RUCT O RS, I N C.West Coast 15205 Alton Parkway Irvine CA 92618 P 949.870-4500 F 949.870-4501 CA License. #640058Gulf Coast 11410 Brittmoore Park Drive Houston TX 77041 P 713.934-7174 F 713.934-7181 M-37865 TACLA2193Cof materials and equipment?42.b.Do you conduct inspections on operating equipment(e.g., cranes, forklifts, JLGs) in compliance withregulatory requirements?Yes No N/A c.Do you maintain operating equipment in compliance withregulatory requirements?Yes No N/A d.Do you maintain the applicable inspection and maintenance Yes certification records for operating equipment? No N/A Subcontractors:Do you use subcontractors?Yes No Yes No N/A Yes No N/A Yes No N/A No No No No N/A N/A N/A N/A (If no, skip to question 43)a.Do you use safety and health performance criteria inselection of subcontractors?b.Do you evaluate the ability of subcontractors tocomply with applicable health and safety requirementsas part of the selection process?c.Do your subcontractors have a written Safety & HealthProgram?d.43.Do you include your subcontractors in: Safety & Health OrientationYes Safety & Health MeetingYes InspectionsYes AuditsYes Inspections and Auditsa.Do you conduct safety and health inspections?Yes b.Do you conduct safety and health program audits?Yes c.Are corrections of deficiencies documented?Yes 44.N/A45.Safety & Health Training No No No SAFETY & HEALTH TRAININGa.Do you know the regulatory safety and health trainingYes No Yes No Yes No Yes No Yes No requirements for your employees?b.Have your employees received the required safety andhealth training and retraining and is it documented?c.Do you have a specific safety and health training programfor supervisors?d.Are all employees trained in the work practices neededto safely perform his/her job?e. Is each employee instructed in the known potential of fire, explosion, or toxic release hazards related tohis/her job, the process and the applicable provisionsof the emergency action plan?CRAFT TRAINING AND ASSESSMENTData as of:NotesSub PQF7Rev.2, 07/13/2011
Standardized Pre-Qualification Form (PQF)L C S CO N ST RUCT O RS, I N C.West Coast 15205 Alton Parkway Irvine CA 92618 P 949.870-4500 F 949.870-4501 CA License. #640058Gulf Coast 11410 Brittmoore Park Drive Houston TX 77041 P 713.934-7174 F 713.934-7181 M-37865 TACLA2193C1. Data should be the best available applicable to the workforce in this region or area2. Skills Assessment means either the National Skills Assessment or the ISAC Skills Assessment. For other areas, ifapplicable, it would be the skills assessment process approved in the area.3. Skill assessment is not required for helper/trainer/laborers or for craft employees who have either1) completed Wheels of Learning (WOL) or Department of Labor Bureau of Apprenticeship Training (DOL BAT) or2) are participating in WOL or DOL BAT.46. WORKFORCENumberPercentagea. Journeymen Craftsmen%b. Helper/Trainees%c. Total Workforce%347. TRAININGYesa. Do you have craft training records for employees?Nob. % of Craft Employees who have completed Wheels ofLearning or DOL Bureau of Apprenticeship Training%c. % of Craft Employees presently enrolled in Wheels of Learningor DOL BAT%d. If employees have not completed or are not enrolled in Wheelsof Learning or DOL BAT have they been trained in appropriateYesNojob skills (attach explanation)48. ASSESSMENTNumberPercentagea. Craftsmen who have been assessed through the%craft skills assessment process (see note 3)b. Craftsmen who have been assessed with “no deficiencies”identified%c. Craftsmen who have been assessed with training needs(WOL modules) identified%d. Craftsmen who have not been assessed throughthe skills assessment%e. Craftsmen assessed with training needs identified who havecompleted upgrade training%f. Where appropriate are training needs being addressedYesNoYesNothrough skill upgrade trainingg. For those employees for whom there is not a skills assessmentavailable, do you have a process to assess the skills of yourworkers to assure they are qualified (attach explanation)1. Internal review of job performance yearly; 2. Training from senior craftsman; 3. Per project follow-uph. Are employees job skills certified where required byYesregulatory or industry consensus standards.No(attach a list of the crafts which have been certified)49. HELPER/TRAINEESa. Helpers who are enrolled in Wheels of Learning or DOLBureau of Apprenticeship Trainingb. Helpers who are not enrolled in WOL or DOL BATSub PQF8NumberPercentage%%Rev.2, 07/13/2011
Standardized Pre-Qualification Form (PQF)L C S CO N ST RUCT O RS, I N C.West Coast 15205 Alton Parkway Irvine CA 92618 P 949.870-4500 F 949.870-4501 CA License. #640058Gulf Coast 11410 Brittmoore Park Drive Houston TX 77041 P 713.934-7174 F 713.934-7181 M-37865 TACLA2193CINFORMATION SUBMITTALPlease provide copies of checked itema with the completed PQF:EMR documentation from your insurance carrierInsurance Certificate(s)OSHA 300 Logs (Past 3 Years)Safety & Health Program (table of contents only)Safety & Health Incentive ProgramSubstance Abuse Program (Include Substances Tested & Levels)Hazard Communication ProgramRespiratory Protection ProgramHousekeeping PolicyAccident/Incident Investigation ProcedureUnsafe Condition Reporting ProcedureSafety & Health Inspection FormSafety & Health Audit Procedure or FormSafety & Health Orientation (Outline)Safety & Health Training Program (Outline)Example of Employee Safety & Health Training RecordsSafety & Health Training Schedule (Sample)Safety & Health Training for Supervisors (Outline)Organization ChartList of major equipment (e.g., cranes, JLGs, forklifts) your company has available for work at this facility.Note: Owner checks items to be provided with PQF.Items have been checked by LCS Constructors.Fill in below Name & Title of Company Officer responsible for assuring the accuracy of thisdocument:TitleNameDatePQF EVALUATION-- OWNER USE ONLY -DO NOT FILL OUT - OWNER USE ONLYContractor is:Acceptable for Approved Contractor ListConditionally acceptable for Approved Contractor ListConditions:ReviewerSub PQFDate:9Rev.2, 07/13/2011
Standardized Pre-Qualification Form (PQF) LCS CONSTRUCTORS, INC. West Coast 15205 Alton Parkway Irvine CA 92618 P 949.870-4500 F 949.870-4501 CA License. #640058 Gulf Coast 11410 Brittmoore Park Drive Houston TX 77041 P 713.934-7174 F 713.934-7181 M-37865 TACLA2193C Sub PQF 6 Rev.2, 07/
