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HomeMy WebLinkAbout13 014 Haulage of Leachate (Bluewater Sanitation Inc.) Tender Acceptance By-law THE CORPORATION OF THE MUNICIPALITY OF KINCARDINE KB7 • 4 :. ._ Ida '+Af 909 11I1Y OF KM, BY -LAW NO. 2013 - 014 BEING A BY -LAW TO ACCEPT A TENDER TO HAUL AND DISPOSE OF LEACHATE (BLUEWATER SANITATION INC.) AND WHEREAS Sections 11 (1) and (3) of the Municipal Act, 2001, S.O. 2001, c. 25 as amended gives broad authority to lower -tier municipalities to provide any service or thing that the municipality considers necessary or desirable for the • public and authorizes lower -tier municipalities to pass by -laws respecting public utilities; AND WHEREAS pursuant to the said Municipal Act, Sections 8 (1) and 9 provide that the powers of a municipality under this or any other Act shall be interpreted broadly so as to confer broad authority on the municipality to enable the municipality to govern its affairs as it considers appropriate and to enhance the municipality's ability to respond to municipal issues and a municipality has the capacity, rights, powers and privileges of a natural person for the purpose of exercising its authority under this or any other Act; AND WHEREAS the Council of The Corporation of the Municipality of Kincardine deems it necessary to haul and dispose 2400 cubic metres of leachate at the Bruce Energy Centre Wastewater Treatment Plant; NOW THEREFORE the Council of The Corporation of the Municipality of Kincardine ENACTS as follows: 1. That The Corporation of the Municipality of Kincardine accept a tender from • Bluewater Sanitation Inc., in the amount $24,408 including applicable taxes to haul and dispose 2400 cubic metres of leachate at the Bruce Energy Centre Wastewater Treatment Plant; 2. That the Mayor and Chief Administrative Officer be authorized and directed to sign an execute, on behalf of the Council of The Corporation of the Municipality of Kincardine, any contracts and other documents required to authorize such work to commence. 3. This by -law shall come into full force and effect upon its final passage. 4. This by -law may be cited as the "Haulage of Leachate (Bluewater Sanitation Inc.) Tender Acceptance By -law ". RE1,2 a FIRS nd OND TIME this 13 day of February, 2013. ip Mayor Clerk • READ THIRD TI A an • - NALLY PASSED this 13 day of February, 2013. ifirka.Spocke ayor Clerk Haulage of Leachate (Bluewater Sanitation Inc. Tender Acceptance By -law By -Law No. 2013 - 014 CONTRACT DOCUMENT: BLUEWATER SANITATION INC. Project: KWMC Leachate Haulage Contract Contract No. N/A Reference No. 004074 Refer to Attachment 1 Contract and Exhibit 1 Page 2 for signed contract Between Municipality of Kincardine Owner and BLUEWATER SANITATION INC. Contractor 2590 Bruce Road 15 Tiverton, ON NOG 2T0 Filed under separate cover in Administration File — C01 in Central Records: Titled: Municipality of Kincardine By -Law No. 2013 - 014 BEING A BY -LAW TO ACCEPT A TENDER TO HAUL AND DISPOSE OF LEACHATE (Bluewater Sanitation Inc..) Cited as: Haulage of Leachate (Bluewater Sanitation Inc.) Tender Acceptance By -law Dated: 13 day of February, 2013 CRA 651 Colby Drive, Waterloo, Ontario, N2V 1C2 Telephone: (519) 884 -0510 Fax: (519) 884-0525 www.CRAworld.com CONESTOGA- ROVERS & ASSOCIATES February 27, 2013 Reference No. 004074 Mr. Gagan Sandhu, P.Eng. Director of Public Works Municipality of Kincardine 1475 Concession 5 RR5 Kincardine, ON N22 2X6 Dear Mr. Sandhu: Re: Review of Contract Submission Leachate Hauling from the Kincardine Waste Management Centre Municipality of Kincardine Tender No. PW2013 -01 Conestoga- Rovers & Associates (CRA) has reviewed the signed Contract submission from Bluewater Sanitation Inc. (BWS) for The Corporation of the Municipality of Kincardine, (Municipality). CRA has concluded that BWS has completed the appropriate documentation and has submitted the signed Contract, as requested. CRA recommends that the Municipality signs and executes two copies of the Contract. One copy is to be returned to BWS and one is to be kept for the Municipality's records. CRA has kept a copy of the Contract signed by BWS. Should you have any questions, please do not hesitate to contact us. Yours truly, CONESTOGA- ROVERS & ASSOCIATES � r2i James R. Yardley, P.Eng. RL /Ip /8 Encl. c.c.: Greg Ferraro, CRA Don Campbell, CRA 150 9001 Worldwide Engineering, Environmental, Construction, and IT Services KWMC LEACHATE HAULAGE CONTRACT Tender Date: January 16, 2013 Effective Date: February 14, 2013 Bluewater Sanitation Inc. of 2590 Bruce Road 15, Tiverton, Ontario, NOG 2T0 (CONTRACTOR), shall serve as independent CONTRACTOR to The Corporation of the Municipality of Kincardine of 1475 Concession 5, Kincardine, Ontario (OWNER), in the performance of leachate haulage (Works) from the Kincardine Waste Management Centre (Site) to the Bruce Energy Centre, and if so directed to the Ward 1 Landfill under the following terms and conditions: 1. The terms of the attached Exhibit 1, "CONTRACTOR's Scope of Work and Schedule of Prices" and "Policy GG.2.17, Appendix "G ", Municipality of Kincardine, Notice to Bidders "; shall apply and shall form part of the KWMC Leachate Haulage Contract ( "Contract "). 2. ENGINEER means Conestoga - Rovers & Associates Limited and its duly authorized representatives. Whenever the shortened names "Conestoga- Rovers & Associates" or "CRA" are used, such names each refer to ENGINEER. ENGINEER will be OWNER's representative during performance of the Works. CONTRACTOR shall execute and complete the Works in accordance with the Contract and to the satisfaction of ENGINEER, and shall promptly comply with ENGINEER's instructions on any matter relating thereto. 3. CONTRACTOR shall comply with all applicable Iaws, including safety and health laws, sales and use tax laws, and laws that impose a tax on services. Except as may be provided otherwise in Exhibit 1, CONTRACTOR shall obtain all licenses, and other governmental approvals required for conducting the Works. 4. OWNER shall own all documents it delivers to CONTRACTOR. 5. If CONTRACTOR receives any of OWNER's confidential information which was not previously made public by or to others, it shall use it only for OWNER's benefit and shall not directly or indirectly disdose it to others unless (1) OWNER issues written approval of this disclosure in advance, or (2) the disclosure is to a SUBCONTRACTORS, governmental entity, or some other person or entity that must review it in order for CONTRACTOR to complete the Works under the Contract. If disclosure under (2) is made, CONTRACTOR shall take all actions to assure confidential treatment of the information by the recipients of it. 6. If CONTRACTOR discloses any information, suggestion, idea, or invention t¢DIVNER or- ENGINEER, OWNER or ENGINEER shall receive it on a non - confidential baiiPiturfy, and shall have no liability to CONTRACTOR because of OWNER's or ENGINEER's 457th o'sure or use of it 7. OWNER may order changes in the Works with the Contract Price and ConGa", times under _ Exhibit 1 adjusted accordingly. Claims by CONTRACTOR for extra comperfsatlop due to changes in the Works must be made in writing by CONTRACTOR before it exec44.es^the Works* _— involved. 8. During the performance of the Works, CONTRACTOR shall adequately protect the Works, the public, and the property of OWNER and others, shall minimize interference with OWNER's use CRA 00+074Ruetz-r -Am 1 HAULAGE CONTRACT a EXHIBIT 1 KWMC LEACHATE HAULAGE CONTRACT TENDER DATE: JANUARY 16, 2013 CONTRACTOR's SCOPE OF WORK AND SCHEDULE OF PRICES 1.0 SCOPE OF WORK A. The Works to be performed by CONTRACTOR under the Contract shall be as follows: 1. Loading of leachate at the KWMC, hauling of the leachate, and the unloading of leachate into MH2A at the BEC W WTP and at the discretion of the Municipality, also into PS2 at the Ward 1 Site. Works include: (i) Supply pump or other means to transfer leachate from leachate holding tank to CONTRACTOR haulage vehicle. (ii) Load, haul, and discharge leachate to the BEC WWTP (maximum amount - 40 m per day). (iii) Load, haul, and discharge leachate to Ward 1, at discretion of Municipality (maximum amount - 33 m per day) (Note: The additional discharge to PS2 will depend on existing leachate removal efforts and leachate levels at KWMC. (iv) CONTRACTOR will be given keys for access to the KWMC, the leachate holding tank and the Ward 1 Site (if required). (v) Perform leachate hauling at a minimum of 5 Days per week and at a maximum of 6 Days per week (Sundays excluded). 2. According to the typical procedure as described below: (i) Weigh in tank truck /vac truck (empty) at the KWMC weigh scale (a standard tare weight will be used following one week of continuous weigh -ins). (ii) Load leachate from the leachate holding tank or landfill cell into the tank truck /vac truck. ail) After loading, tank truck /vac truck to weigh -out (loaded) at the KWMC weigh scale. (iv) Complete waste manifest (supplied by CONTRACTOR) and have signed by scale attendant on behalf of the Municipality. Attendant will record day, time, weight, manifest number, and other applicable information. (v) Haul leachate to the appropriate discharge location: (a) BEC WWTP Site (maximum daily discharge volume of 40 m — Discharge leachate from the tank truck /vac truck into MH2A. The leachate discharge rate is not to exceed 17 litres per second (225 imperial gallons per minute). (b) Ward 1 Site (maximum daily discharge volume of 33 m 004074Ruen -i- confect 1 EXHIBIT 1 - SCOPE OF WORK 3.0 SUBCONTRACTORS The major SUBCONTRACTORS to be used by CONTRACTOR in the performance of the Works are only the parties listed below and /or other parties CONTRACTOR will identify to OWNER in writing and to whom OWNER has no objection: Bluewater Sanitation Inc. will not be subcontracting this out. 4.0 CONTRACTOR Provide CONTRACTOR legal name, address, contact person and contact information (phone, fax, email). Name: Bluewater Sanitation Inc., 2590 Bruce Road 15, Tiverton, Ontario, NOG 2T0 Signature: Original signed January 29, 2013 by Al Ruetz, Witnessed by MaryAnne Takken Contact Person Al Ruetz or Mary Anne Takken Phone No.: 519- 368 -5529 Cell Phone No. (Al): 519- 378 -5529 Cell Phone No. (Mary Anne): 226 - 668 -0392 Fax No.: 519 -368 -7817 Email: bws @bmts.com aawaena- cannct 3 EXHIBIT 1 - SCOPE OF WORK s. ATTACHMENT 2 TENDER SUBMISSION DOCUMENTS (AS SUBMI11 ED JANUARY 30, 2013) CRA 004074Ruetr.1 AR TPs t fa- POLICY GG.2.17 APPENDIX "F" MUNICIPALITY OF KINCARDINE NOTICE TO ALL CONTRACTORS CORPORATE STATEMENT OCCUPATIONAL HEALTH AND SAFETY The Corporation of the Municipality of Kincardine is committed to ensuring that a high standard of health and safety is provided and maintained for all employees, visitors, guests, contractors, agents and others on our premises. ALL CONTRACTORS/SUPPLIERS SHALL: 1. Demonstrate establishment and maintenance of health and safety program with objectives and standards consistent with applicable legislation. This information will be documented in a meeting where at least one representative of the municipality and contractor are in attendance. 2. Submit a copy of past accident records and Workers' Compensation Board Number. 3. Include health and safety provisions in their management systems to reach and maintain consistently a high level of health and safety. 4. Ensure that workers in their employ are aware of hazardous substances that may be in use at their place of work and wear appropriate personal protective equipment as may be required. 5. Upon request at any time from award to completion of contract, submit proof of fulfilment of above responsibilities. This proof may but is not limited to a copy of the organization's own Health & Safety Policy, copies of training sessions, copies of logs documenting training/discussions. 6. Must comply with Workplace Safety Insurance Board (WSIB) premiums. 7. The Contractor/Supplier shall sign-off on the corporate occupational health & safety form stating his agreement to comply. Your co- operation and assistance in this matter is appreciated and vital to the Health and Safety of all. 37 4 POLICY GG.2.17 APPENDIX H" MUNICIPALITY OF KINCARDINE OCCUPATIONAL HEALTH AND SAFETY COMPLIANCE FORM I have read Appendix F of Policy #CG.2.1 Purchasing and Procurement "Notice to All Contractors, Corporate Statement of Occupational Health and Safety" and agree to comply with it Contractor's Name Date 39 You are hereby notified that this environmental compliance approval is issued to you subject to the terms and conditions outlined below: TERMS AND CONDITIONS 1. Except as otherwise provided by the conditions of this Environmental Compliance Approval, the waste management system shall be operated in accordance with the conditions contained within this Environmental Compliance Approval and the supporting information submitted with the application far this Environmental Compliance Approval dated November 9, 2012 and the additional information subsequently submitted to the Ministry of the Environment listed below (A) E -mails dated November 29 and November 30, 2012, submitted by Mary Anne Takken, Co- Owner, Secretary- Treasurer, Bluewater Sanitation Inc., providing updated corporate documents, ownerships and certificate of insurance. 2. The operation of this waste management system is limited to the collection, handling and transportation of liquid industrial waste and hazardous waste class no. 149 as described in the "Ministry of the Environment Waste Classes ", as amended, January, 1986. 3. In addition to the collection and transportation of the waste outlined in the previous condition, this waste management system is also approved under this Environmental Compliance Approval to collect and transport waste from food processing//preparation operations. 4. The Company shall promptly take whatever steps are nervsary to contain and clean up any spills of waste which have resulted from the operation of this waste management system. 5. Waste shall only be delivered to a waste disposal site or facility which has an Environmental Compliance Approval, and only where the waste being delivered complies with the Environmental Compliance Approval of the receiving waste disposal site or facility, and at no time shall waste be stored or transferred to your truck storage yard located at 2590 Bruce Road 15, Tiverton, Ontario. 6. All waste shall only be transported in a covered vehicle. 7. Any addition, deletion or other change to the fleet of vehicles, trailers and equipment (i.e., year, make, model, serial number, licence number and ownership of each vehicle, trailer or piece of equipment) in particular those which are leased or rented, shall be reported to the Director within fourteen (14) days of any such change. Page 2 - NUMBER 1901- 92PKZK 2. The reason for conditions 2 and 3 are to ensure that this waste management system is only used to collect, handle and transport waste which it is able to in a suitable manner as the transportation of waste which this waste management system is not able to collect, handle and transport may aeate a nuisance or result in a hazard to the health and safety of any person or the natural environment 3. The reason for condition 4 is to ensure that any waste spilled onto the vehicle is promptly contained and cleaned up to minimize the risk of further spillage or the discharge of waste from the vehicle to the environment and to ensure that the proper officials of the Ministry of the Environment are notified and able to give direction to the Company to ensure the complete decontamination of the vehicle and clean up of the spilled material. 4. The reason for condition 5 is to ensure that this waste management system is used to transport waste only to waste disposal sites or fatalities that have been approved by the Ministry of the Environment to receive the waste which this waste management system is delivering under this Environmental Compliance Approval, and that by accepting the waste being delivered by the waste management system, the waste disposal site and facilities will not be out of compliance with its Environmental Compliance Approval. 5. The reason for condition 6 is to ensure that waste particulates are not emitted to the environment as any such emission may result in a hazard to the health and safety of any person or the natural environment. 6. The reason for condition 7 is to ensure that all vehicles, trailers and equipment including those leased or rented for operation under this Environmental Compliance Approval have been approved as part of a suitable waste transportation system to collect and transport waste as an unsuitable waste transportation system could result in a hazard to the health and safety of any person or the natural environment 7. The reason for condition 8 is to ensure that the collection, handling and transportation of waste is conducted in a safe and environmentally acceptable manner, as outlined in Regulation 347. 8. The reason for condition 9 is to ensure that every vehicle operated under this Environmental Compliance Approval is adequately insured under a vehicle liability policy. The transportation of subject waste in a vehicle that has not been adequately insured under a vehicle liability policy would not be in the public interest 9. The reason for condition 10 is to ensure that all waste carriers have met and are operating in compliance with the standards for waste management systems outlined in Regulation 347. Page 4 - NUMBER 1901- 92PICZK AdUee' Ian Parrott, P.Eng. Director appointed for the purposes of Part 111 of the Environmental Protection Act SS/ c: District Manager, MOE Owen Sound / Barrie Don Campbell, Conestoga Rovers and Associates Page 6 - NUMBER 1901- 92PKZK ` f FdeaTd.IloMdO.lfdga'd'bP PeadealOcoirpecid �••,` \: Pn ..'Yl... `!N!' fGF . .I '.MI. - .Y 'W -* k.iSY�d■Saaa'IaYY A Y abddd Ws sr voids sew Pe.* • . - 'hk _�. ...__ "uv.•. _.. .�. AnwerpekmalS ddrda. - dnilab: VMfTY1 81101114 AWCOGUSMIYYi1611M1p/2 1 - � �. . 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Mar lr QWie .'2011 /0 bbAtisinb Y P144.3er pit ws- Ministry ItittYre Annual Inspection Certificate I.f Ontatl0 frrerhwarLotion Transports Certificat d'fnspection annuepe MYWNamw uVraaw VP4MV H 4679185 Ixww r� VS cI. pawed wOo IWe) elf Whiny .OdafrhaledCa, eur No Nans'Rueaf rP c I -- c 6 ,wcs z� !CaX bswnee PiwinceiSrldRnnraEd tf tai Co drraW Paella ■ Tz� t"e I � Ai r4, 74Z57 Vehicle lypo/Typo da volt* /a.mind =e g=nai tlraelege lastly this yahoo was ilmpeced r accordance :attests qua as vdldade • 4t impend wits Ills Highway Tm6b Ac4 Regulations 111 for coMwmdmenfaux cespw9'm du Code de is ale type of vehicle flkesd and b,nd the Items mute. Rdgrrnent 611. pour le type de Mama listed on the reveres to be m7Nn the prescrbed inditere ve sus rs Atlrndrrs turmaau verso ndey standards. satabs auxnorm's de sea 71 prosodies. ryarll, Sidon Name/Nom du Ooas hwaclon Mnt trr Sot s HE+ -'r 33 'fS_ I 5�R / �N / 1p a dakbrtu In depsme per p � Oe d elves dlnhiurdaN der libraiestiabrAtmilve WahhiraddaarS nimots 5t�T.4O@17 9 430 Cilrlde espies the bai day d the twelfth Le Prdsenf certified( expire r demrrOur du month after month of ampeohon. deodeme mar suirdnr r STOW S (Inspection SREale W04 cn *. aS C/ a . it„ ,,... ,, 1 j• I � �+ FdF . it it it s‘ Atc , i 1 ‘ tit\ 1 3 IN ,‘,. - ikt. t V; \An, St V � t A 9 i li F is . • "DON'T GET CAUGHT WITH YOUR PANTS DOWN" •� BLUEWATER SANITATION INC. P.O. BOX 189, 2590 Bruce Road 15 TIVERTON, ON NOG 2T0 PHONE: (519)368.5529 FAX (519)368.7617 TOLL FREE: 1-888-805-6481 WEB: www.hlurwatrrsanitation.rom Reference No. 004074 -44 QUALIFICATIONS: • MOE Environmental Compliance Approval is included * SUPPORTING DOCUMENTATION PROPOSED EQUIPMENT: On the 2004 Eenworth: • has a tank capacity of 2200 gallons (new & installed April 2008) • the pump is a 553 HRVOA (pumps approx. 450gallons /minute using 3" suction hose) • if using vacuum from a 3" line — shouldn't take any longer than 15 minutes to load 2200 gallons — depends on how much "foam" is created • Spill kit in truck On 2005 International: • has a tank capacity of 3400 gallons (new & installed July 2007) • the pump is a 750 HRVOA (pumps approx. 550 gallons /minute using 3" suction hose) • if using vacuum from a 3" line — shouldn't take any longer than 20 minutes to load 3400 gallons — depends on how much "foam" is created • Spill kit in truck 030015 .sets wwr.�........ ws..atw� F .O. Boa 4115 Premium Remittance Form �YSN7 s Station T r ' .v�'r'er`nsrr Tan ON aaly2V3 Paps 1 of 1 All Information Is strictly confidential. Accord No. Fun No. 1930877 2449138 Due Date law Dale limonite Period 2013 - 01 - 31 2012 - 12 - 16 2012 - 10 - 01 b 2012 - 12 - 31 - 214 Telephone Emery Number (416)344 -1004 %-001 Tr ttratei e,x 1- 800 -387 -0750 s ati 8L LUENATER I C' N p h %VW Ar Axle 7, TIVERTON ON NDE 2TO S ick 1 76 8 1 Pcogit.5...n oC t ppaarge of this torm. you must reborn Ore bottae Z3 w e o in the envelope p prow to 1M wWSW with payment, t� c p age o tt You RIM report your premiwn(c) for 24 g period using to bottom portion or this lam (rte stub). Please snow that you enter Ow premlug(sbmm cola n (C) in Ile eppopriSM bass an the SYA. Enpbyss may pay at moat grrnncial brdadiors. 0.!- ise. please mean tM MIb(IL with yar payment in I1* aweops provided. II the stub(s)am not received by to WSW en or helots Its due deb, aronno pirtw chugs nil be sppOad to pow neap. A mrvconplianw charge dos not relies, you cl your obIOYionb sport Om proem pamam based 0 . 1 YOU maws' asuabs earnings to this period. East y dw eremite') to be reputed is zero, to avoid • non-compliance charge, you oast sill complete are ream to stub. EnW V In the 'W Premium' DWnn of the stub la each preprinted CO and ration the stub in the envelops Provided by the due that Meese Include optional Neurones amounts (ti apphoable) /s this ..patine Peeled In the Insurable earnings caladaaon. For more Information, Me reaea . Complete tide portion to your records. DO NOT SUBMIT this TOP PORTION with your payment Aououd No. 1930877 W (11) (c) W Code 06 W Dsorlpdon Earnings i CU P (8) o ff ` Wx / (e inIum 9919-00D OTHER !WHINER.? RENTAL 7. 03 2.83 )(n ,7 1 Emir tie total of the premiums for all CUs P "Amount Dues. Avant Doe a) 1 I Please enclose one cheque to corer ail CU premiums wing on ibis ■coon t Important Y/ofmatlon about the 2013 Prank= Rates now Awamt Feld s i N 3 I!a -A available on the WEIR webelte www.walb on.ca W3TA(1V12 • nwl *: r itg• i FAx: Mitt= Employees Beporl of injury/Dtuees Mt . a. s,to�nu (Page 1; es far;rain oat dbpwdbw on tennis sir dwMMt please mad eta hnwanone wi We sevens of the Employers Copy (yellow aapy). WSIB use only • pleasn type or prhn firmly In dark Mk. Claim *maw • Do eel told page 2 under page 1 token oompleeag the tone. A. Worker Identification - Please compete In /till nM Nes1• Worker Mlwwaeitumbr •Aims CaIt1Number e Numb r )nwrwrce wynee /. Yen Olps1aa Aearew 7 � l ` _ 1 • - I I I �f 1 ` j In Dmpellan Ocaps0m al Wm, o1 t n ) u r _ ( / A w w e m e e of M e m o s aortwnn _ _ -7 wexnw PaW Cede I �r � ` - ( _. Due of Ilrhh �q( of leas I 714 1' I ��' 1 1 I � I 1 i 1I Worker's Pretested Language of Sent. !� Wynn 1 1 Frwe:h OtXw Iwlp.pe X wakes speaks neither English/Renck F010 W M sew bowel Pall • (em) mnbedor. Independent aperuw, owner, executive Mee Cade TeNlXgne Xumpt, of the Surname resooup arelWeaoflM e yes nne (.;l 1) l J \ // (,.i 8. Employer klentlfleatlon Ei,tlo Finn Humber Rate Numb. Aduap CC 1 /yoyn Province Poed ode ; Swigged Cr (1/4: I „IL : I. • n Area Code TelepRow Nutty Ain FAX tamable I Dppdpem of Beane", Activity ) l N (. Co M I.owasn. aluch DewrknrR Yawn wwkranptar , �Ip`, Do you have n erly return to work, l e ten I wort re 0s n CoaprYM M Mbm to Work program an ye no I br aDede NiMn rke n yea no wassa 1opm pogrom In your workplace? G Temporary DlsaWilty Fallowing the day that the In)ray /awaneesa of drawee occurred, oral the Injured worker be absent from work because e/ We INlury /dleeassT unknwm 0 yes fj no Not: M your .newer N you answered no to the above, will the Inland worker as •mull of the Injury/disease: le 'M• tea et these . mums other wort Wiles because the lyuy/dbew pawned Ihwn from peMmine then remit duller? 0 yea 6 no — gtr.aeans .M r CmpNte gsPUkm earn • n than th their sappier wawa because of lb. lydury /dh ..t ❑ yea y.r 'Earnings ketornatlen' A DeIS. of Iniw/Diseaae Dell od New of bonny /ALe n•p IN _terse or and NOW Reported to EmIlirs Drs and How lean worker Hormel Working Howe n Len Da ep F � i /Pr='=tSI t t PI " � to Date wd How Returned to Work Ann Stews /ptIN Hormel Earnings . ken r ter De you o .1 Immm o.Xn ear the worker could Ins could elm. red 1 1 I I I I I a Worked Der Worked m welt m r orn I so. provide (Welk Pa . 1. Whet happeneddo cams We injury/disease? If ?pap�d M Injury. an or May Lyra end fpecl a .� ry IA mph ' aMM, r . r 1 (.: 1, If f- ?papaws-Rio r IC) C 'a_d . ._.V ' _C/ r. 2 Who was the InJuryfdirM reported lo? .If lrywy /dbe t r.tl Immediately, pre reason for delay. a Describe see wakens arid. at the Rene r ten PoMeva m.de,yp�s al w.ipner p (nuwjre used and ten en and weights ol obleW bkw handled '.� '. +'F Pkd , � f' - . - •N t... _. '...r 1. a. Wore wen the worker when tee njwy /awrrlep of disease ocveded? d the Nosy/disease occurred outside of Ontario, specify province, Hate or country. S. is mere anyone OM who may have witnessed or who may Mow Was Ow Mpey /awel of disease? If so, pale duck below. NoneD) 1 Adllren(es) and phapnumberfel If inhabit 0007A (01/118) Were Copy - Whl. Worker Copy - Pint €arploYer Copy - Yellow Mass and and complete page 2 • a • C Malls 4R of buto/Dboo Roped Mono Rennin 1t ON WV Ot134 � W�'/ •�'o�'n TaomoON ht5f311 OR 1-888.313-7373 Pleas PRINT In black Mk pate Number A. Widow tefaemnln I lob lNle /Gwpatlm (Mae time or aaddmVBMna- do not use eboteiatbutl length of See IRthis position Social Insurance weber while wooing Wpm Please deck if this water is a r . sueadhe [' elected Adel ;2 weer El apopaorteligseoier employer libS i/ a 7,c-7 • Is 11* wvqker�sws by a Worker Reference Number worker Name Unwn/Cdlee9wAlnmerll7 rn R'wc- LT Yes fm' /Ways 'number. scree. ep�. nuke. mill W�o�rker�' ihrelened lmguge peel dd mm yy 37YYS NA1s Co Rgiy LU, r Web °"U 0. U3 hl_ erert.a.n no ore amataae Other Telephone n iv 3_ I v s!5) 'Ho Oda � r .__ Q _— ..........- �— 5a RCLI F Dote of ram l m y R. llrMat teraa.nuan 1 F a o ee 1 iltio Chem FinsFinsOR Provide Number � rit r( omits" �ri,�n-L01. , nC ores Lt member _ retlbe 1 930'6_7 f 7 - Poi. l A9 '°"' q 3 3 Ultra C - ede City �r�-- Y_� 9 - 00 0 l C; Y1 3n-� Pedal ( �5 t9 ) ,Zell 5584 e tpB Dees For tino l.Ne200r FAX amber 1�P�M1TAI Al YY�1 1i► S mamwdmm7 ❑ws yjm l(5/9 13(0% 7600 Baer hAddasstemmorkerIs baed (if tlhrmt hem ma address - no abbreea0aa) CQS9l7 &cur l , VA r( yg 5 �e Ci "Ra.`T"� --oY. • j + ' Al aYO 69 9 Te;) 3" so8 5018_ C. 1MsManl/Ill aos DMus scald Molls 3 1. Date ant how o dd mm Y7 2. Wee th den e aedVlkuss ISMS la b7 Man dtlat) e &PO �a 'Airmen p$ 0-1. & Hof° vn vtss a MR „ Js Date and hmrepakd dd mil y7 by T 6d to employer a 8 04- 09. io:ao rind ( 14 ) s 55a9 3. Was the a skant/Meas 0.iyeel eceident/Ilnne (please cheek aft that app3) ill SpeakEvent/Ocewnee IV 8kttdgCauOd Li Fall 0511p/tdp N Gradually (keening &vfM m a -' Omattlm i _I Nandul Substanw /FPdmtomnw LI Motor WAMeIncident Occupational Mama 0 AepMNm. {{......i� Pasant Fatally L, Are /Explerion L I other AAme ofI*fy Nod7Pa0- Maass etas* all Set splay) Ilmd 11 Teeth r Upper ban tall � R left R left Rllht Leh Rigid fats Nay Shudder Lower tack n i. t er l J✓ G ' I8p Anlde . 1 Eyga) L Chest Aim Nand �✓ No . Abdomen H N � -{ n — r J I . Foot a(N E L PSMS g 1 agals) L i L-: Lower Ll Toe(el Faaaral ' LJ O her S. Meodbewuathappened to ems the accidentalness and what the w'orker doing Male lime OBkiga 50 Ih bra, slipped onsett es, mpe9Bmmovemmm, ere. 4. Includeshmthe injury had ay details el eeuIpenem, materials, emhan.wnki caedMoas (work area, temperature, noise. die Tai, gas, homes, other Person( that may hem rlbuma. Pm a aeasitaea that emmered tadsallv over Rena, plan* anima a daserlpflou of Cs pyalual activity required be ale IM wed. w {hddi�q up back. Pal- M -�rLi� clie q -- /k124- - cd a*G( be in la ge rs. fJ k (:e+ 9 0 - c f-,,c sg dtA , -f - eu -a, -Jo prcF ha-hot up * b + a. 42 . 0007A(07/OS) A ASS to ewml ote tads faro Is ovulate it Page 1 of 3 • • w, B • etIDNmmy /DWma�(Fwm7) CSHft I ■/ Claim Number , ( 1 j Please PRINT in blank irk I Worker Name l - tx - r1(\ I II,C LC P ]LA P) slats. `T� W I Q l id D...» Wadmiliambenemot Information - (Do rat lnd de endear ben) 1. tstbwak rpiss cheek ell that sewn) _ Pena/meet Full lime rl Camd/rrees ` SWded _ Regbtms Apprentice l �'ner00peermaftwrr. Li Pem Partible r nenoael Unpaid/balm _ Optioallasurente (Suh)COnitedor I Tampotay Fel lime Cotem — `: Temporary PmiM. '—' Other 2 RSdderrafi of my S U per ',T E day _ week _ other R. ASWral Wad* IMnamaUw L Net Cairo Code 2. Vendee pay Provide or Amok Federal 1 I Rebgal ! -m eaddIMue7 yes knu pemeoa % 3. MID mdhm4nwded 4.tioni wading hang 5. Ached wefts tW 4. Mann earnings tor t � � (( t0. last daywoded lest day worked test day worked ac OT 01 `O (KAM 8 ea I.-FPM To ` 30 i7411 f I cxBc' $ lab 03 7. Is Atm= an themomrrbekmg� whilehe/dm moms? L: yes Li no gym. karat. FUVRkWfir E Omer S. ass Reminds (Net Regusr Wadnk PtoNde the total of a -mtlanm oaminy lyggr seek krme4 weeks beton the mndenyfness. ' FrROlagpeY Mt Awakes- N the shift cycle m sds4weeks, "�� Use these sgatesiar any cgmrearnings please agath tb oaarbdr fir... lest eepp2n shit - BrtllraY .� m, Differentials, Premiums, eyrie Martel* diesels/re.... mW//8��•CJ Brea. • - L., Me.). —, Prlod WI ;) i l,It4`� ITZ:in - n G1` �il ► eek W W 2 � /_ C) � s � s ,s • . \ \ �s ,© s Week I - '1 S S S $ 1. Work Sobedid (Otobte ether A, ■ or C. De not Include ovammeshifts) I [_ I1) Redder adseeate- Inks. mmMwoddayaanman. IP Fnemdm Madeyta Friday, 40 mars See* • Wesley Tae* Wmmrkgr',. Thursday Wm SehaiW Fr M 1 T • W T : F S I 818. 8'8'8 I et, L R.) RAWe( Notational Shift Worker - Provide MIMBER OF NUMBER OF HOURS , NUMBER OFWEBIS DAYS OSI DAYS OFF I PERSHIFT(s) IN CYCLE err pp. Exaraylr4 days on, 4 days off, 12 haws per shalt, 8 weeks In cydc (C.) Varied w Invader Work tvdheM. Pm4de the Mat number o( regular haws awl ins for each week for the 4weeks ..- per to tse aatli n h,ms. (Do net IMide overtime hours r shifts Item). Week l I Week 2 Week 3 I Week4 Frem/TO Oates (dd/min) 1 I I Totat Ham Wedea I i ' Total ShDs Worked i 1 .1. R is no efface to deliberately make false statements to the Workplace Safety arid Insurance beard. I deduce that all of Ike information provided ea pans 1, 2 and 3 ie true. a SI I, 0J KK +J aril sire al ( 1� T ea. fn m m W L7./�. (J 3c$ J r 0/ 05o) 71E WORKPLACE SAFETY AND RKURANCE ACT REWIRES YOU GIVE A COPY OF TWS FORE TO YOUR WORKER 0007A (07/05) Page 3103 • a OCCUPATIONAL HEALTH & SAFETY FOR BLUEWATER SANITATION INC EMPLOYER'S RESPONSIBILITY 1. Required to take every reasonable precaution to protect the Health & Safety of all employees 2. Ensure that all employees have support, resources and authority to meet their responsibilities 3. Designate a Health & Safety representative 4. Ensure that all machinery and equipment are used safely 5. Ensure that hazardous materials are stored, labeled and used safely, by using appropriate dressing apparel & devices to protect the worker 6. Enforcing safety procedures & policies f o TRAINING ON DISPOSAL OF WASTE AT THE HOLDING TANK (2013) 1. Upon entry into the holding tank area make sure there are no obstacles, such as another vehicle, a toilet, persons, etc 2. ff all clear, then proceed into position to prepare to dispose your waste 3. Prior to disposing, please check level of waste in holding tank, also make sure that there are no cracks in cement casing, make sure the grate is upright to catch the paper, napkins, underwear, gloves, condoms, etc., also make sure grate that collects these items on top, is secure, also check to make sure that the 3" rubber gasket is on end of the disposal suction hose for a pressure seal 4. If all of the above are in place and satisfactory, proceed to release your load 5. After the waste is emptied off your truck, create vacuum so there are no spills when you detach valve cap, and this will ensure the caps will pressure seal 6. check level of waste in tank for peace of mind to avoid overflow 7. Proceed to leave this area in a safe manner 8. All drivers please enter date, tipre and your signature, to acknowledge that you have read & understand the above. DATE I NAME TIME SITURE alact3 Al Ruetz 3 33 M.A. Takken 3 3a v- Mia� " RayTakken 3 t .1/,� . " Carl Ommen 3v9 14,,,A3 Rob Graf , �' a''' Mike Pitre C( Rod Brown t�or 4�tL�e T,l.e.ff (, s l e, Ds. eas°-Q, caxc) a ` WHEN PUMPING A SEPTIC TANK, DO NOT EVER GO INSIDE A TANK By entering name, date & time, you acknowledge the above information DATE NAME TIME SIG E Jan a'ac Al Ruetz 5 pm. !� " M.A. Takken " Ray Takken 5 ° „I Am - 03 Carl Ommen y ,!/ �� ye, Rob Graf 1 S-6 iiezli