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I <br /> IDISADVANTAGED BUSINESS ENTERPRISE TRUCKING CREDIT FORM <br /> All I` Disadvantaged Business Enterprise <br /> I <br /> Washington State <br /> '; Department of Transportation (DBE)Trucking Credit Form <br /> PART A:TO BE COMPLETED BY THE BIDDER <br /> I This form is in support of the trucking commitment identified on the DBE Utilization Certification Form submitted with the proposal. <br /> Please note that DBE's must be certified prior to time of submittal. <br /> Federal Aid it Contract# Project Name <br /> I If listing items by hours,or by lump sum amounts,please provide calculations to substantiate the quantities listed. <br /> Bid Item Item Description <br /> I AIvte <br /> ' Use additional sheets as necessary. <br /> Bidder Name/Title(please print) <br /> IPhone Fax Signature <br /> Address <br /> II certify that the above information is complete and accurate. <br /> Email Date <br /> IPART B:TO BE COMPLETED BY THE DBE TRUCKING FIRM <br /> Note:DBE trucking firm participation may only be credited as DBE participation for the value of the hauling services,not for the <br /> materials being hauled unless the trucking firm is also recognized as a supplier of the materials used on the project and approved <br /> I for this project as a regular dealer. <br /> 1.Type of Material expected to be <br /> hauled? <br /> ' 2.Number of fully operational trucks Tractor/trailers: Dump trucks: <br /> expected to be used on this project? <br /> 3.Number of trucks and trailers owned by Tractor/trailers:_ _ __ Dump trucks: <br /> the DBE that will be used on this <br /> I project? <br /> 4.Number of trucks and trailers leased by Tractor/trailers: Dump trucks:_ <br /> the DBE that will be used on this <br /> prn]arr? <br /> IDBE Firm Name Name/Title(please print) <br /> Certification Number <br /> IPhone Fax Signature <br /> Address <br /> I I certify that the above information is complete and accurate_ <br /> Email Date <br /> I DOT Form 272-058 <br /> Revised 09/2020 <br /> I 2023 FEDERAL OVERLAY <br /> FEDERAL AID#STBGUL-2715(011) <br /> WO#3788 March 2,2023 133 <br /> irovided to Builders Exchange of WA, Inc. For usage Conditions Agreement see www.bxwa.com - Always Verify Scal <br />