Contract No. 1584-14299Vender Name: MANSFIELD DIL COMPANY

AMENDMENT NO, 1

This Amendment modIes Contract No. 1584-14299, for Motor Fuels (Unleaded Fuel, Diesel and Bio-Diesel Fuel) byand between the County of Cook, illinois, herein referred to as "County" and Mansfield Oil Company, authorized to dobusiness in the Stale of illinois hereinalter referred to as "Contractor":

RECITALS

Whereas, the County and Contractor have entered into a Contract approved by the County Board on April 29, 2015,(hereinafter referred to as the "Contract" ), wherein the Contractor is to provide Motor Fuels (Unleaded Fuel, Dieseland Bio-Diesel Fuel) (hereinaRer referred to as ths "Supplies" ) from May 1, 2015 through April 30, 2015, with one,one-year renewal option, in an amount not to exceed $2,085,721.00;and

Whereas, the Contract will expire April 30, 2016, and ths agreed upon Supplies are still required; and

Whereas, a renewal is desired for the continuation of Supplies; and

Whereas, an increase in the amount of $1,241,0D0.50 is required for the continuation of Supplies; and

Whereas, the County and Contractor desire to renew the Contract for twelve months beginning on May 1, 2016through April 30, 2017.

Now therefore, in consideration of mutual covenants contained herein, it is agreed by and between the parges toamend the Contract as follows'.

I, The Contract is renewed through Apdil 30, 2017.

2. The Contract is increased by $1,241,000.50and the Total Contract Amount is revised to $3,325,721.50.

3. The attached Identification of Subcontractor/Supplier/Subconsultant, Economic Disclosures Statement andMBE/WBE Utilization Plan forms are Incorporated and made a part of this Contract

4. All other terms and conditions remain as stated in the Contract

In witness whereof, the County and Contractor have caused this Amendment No. 1 to be executed on the date andyear last written below.

County of Cook, illinois

Signed P

Doua Hauah /

Type or print name

PresidentTitle

Date: March 7, 2016

RGY 1/1/1 5

Contract No. 1584-142ggVendor Name: MANSFIELD OIL COMPANY

ATTACHMENT

Rev t/t/15

CONTRACT NO 158rs-14299

Cook CountyOfgce of the Chief Procmement OfFtcer

idi ntificafion of SubcontrsctorISuppliarlSubconsuitant Form

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lraclor; Subconsultantfyyt,@r <PizMl (() i'~(s wc r added or sobs

I Authorized Conorized Contact

~7M 4 /)cs<% dr) SubconsultantI «:nieii Address, 11, Email Address

ii cntracto.i. te))rgtrTO)/) g~(bk)g s), 4 at(, tetr i'Subcontractosr

; Ccmpsiiy Add e- l Company Add(Subcontractor) %4~(. )d/ ttl~( 4()Cbv

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and I City, State and ZipI'is.i...,cneand Fsx I 1'eiephone and Fax

~Ccntracto;> Ii«SSFsrrrrEstimated Sisrl end i Estimated Stan andCompbtion Dates I Completion Dates

, /Coersctor) 'Ct J~('(,- V4O- I /t ~ (Subcontractor) g~(-( ( 30"(7Note: Upon request. a copy of all vndtten subcontractor agresmenis must be provided to ihe OCPO.

Ths Bidder/proposer/Respondent ("the Contractorn, v/ill fully complete and execute and submit an tdentificatiod ofsulicontractowsuppiisr/subccnsi!ilant Form ('IsF") with each sid, Requesl for Proposal, and Pequsst forQL!atlficaricn. The Contractor must complete the ISF for each Subcontractor, Supplier or Subconsultant vvhichshall b used on ths Contract. in the event that there are any changes in the utilizaidon of Subcontractors,Suppliers or Subccnsuitsnts, the Contractor must Sle an updated ISF,

Descriudion of Services or Supplies+otal Pdcs of

Subconttac~tfoS~erv'cas i/r Sunni

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T11e subcontract cocilniel1ts 1'rifi .'pcc 'pc/etc a!!requkamenu of ihs Contract awarded to th,. Contractu; as af(pficable.The SubrOnlraCt .ill in nO Way hisnder the Subocntraotor/Sugolier/Subocneultant fram maintaining ite Prcgreee On anyother contract on which it is elthe s Subcontmctor/Supplier/Subconsultant or principal contractor. This disclosure ismade with the underslar dine thai the Contra@or is not unde! any circumstances relieved of ih abiliiies sndobligations, anc is responsible for lhe organization, performance, and ouality of work. This form doss not approveany proposed changes, revisions or modlgirations to tlha contract approved fi/ISE/WBE Utilization Plan. Anychanges to the contract's approved t'dBE/WBE/Utilizadon Plan inust be submitted to the Office of theConb'act Compliance.

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0(~~~Prime Cgntra<or~Signatureb

OFFICE OF CONTRACT COMPUANCE

JACQUELlNS GrqiSSIEZ

DIRECTOR

116N. Qark, Countr Building, Room 1020 o Chicago, Illinois 60602 o i312i 603-5502

April 8, 2016

TONI rsltaCICVVINKLS

PRESIDENT

Cook County Bsani

of Commissionos

RICHARD R. BOYKIN

1st Distrirct

ROBERT STEELE

2nd District

JERRY BUTLER

3rd District

Ms. Shannon E.Andmws

Chief Procurement Oflicer

118N. Qark Street

County Buitding Jgoom 1016

Chicago, IL 60602

Re: Contract No.1584-14299 (Amendment No.1)

Molor Fuels

Department of Transportation and Highway

Dear Ms. Andrews:

STANLEY MOORE

4th Distrirct

DEBORAH SariS

5th District

JOAN PATRICIA MURPHY

6th District

JESUS G. GARCIA

7th Dlstricr

LUIS ARROYO, JR

8th District

PETER N. SILVESTRI

9th District

BRIDGET GAINER

10th District

JOHN P. DALEY

11th District

JOHN A FRITCHEY

12th District

5 ~pliance is in mceipt of the above-reference contract amendmem d h

it for compliance with the Minority- and Women- owned Business Enterpdses (MBE/WBE) Ordinance. Aftercareful review, it has been determined this amendment is responsive to the Onfinance,

Bidder. Mansfield Oil Company

Original Contract Value: $2,085,721.00l~ Contract Value: 81,241,000.50(Amendment No. 1)New Contract Value: $3,326,721.50

Contract Extension. 'l2 months

Nsw Contract Term: May 1, 2016 through April 30, 2017

Contract Goal: 12.5%MBE, 5% WBE

Full Waver Granted: Due to lack of suiiicmnt qualified MBEs and/or WBEs capable of prowding the goods orssrvhes required by the contmct; Prices quoted by potential MBEs and/or WBEs are above competidve levels

and incmase cost of doing business and would make acceptance of such MBE and or WBE economically

impracficable, taking into consideration gte percentage of total contract pdoe represented by such MBE and/or

WBE bsl.

The Oflice of Contract Compliance has been advised by the Requesting Department that no other bidders ans

being recommended for award. Origitudi MBE/WBE forms were used in the dstwmination of gte

responsiveness of this contract.

IARRY SUFFREDIN

13th District

GREGG GOSUH

14th District

Sincerely

'lgGomez

TIMOTHY O. SCHNGDER

15th District

Contract Compliance Director

JG/smp

JEFFREY R. TOBOLSKI

16th District

SEAN M. MORSEOR

17th District

cc: Barbie Flock, OCPO

John Yonan, DOTH

$ Fiscal Responsibility g rnnovativa Leadership IIITransparency st JScssruntabillty IIiimpioved sanacss

CONTRACT NO. 1aee tease

PETITION FOR REDUCTIOWWAIVER OF MSBWBE PARTICIPATION -'FORM 3

A, BIDDERIPRDPDSERHEREBYREQUESTS:

~FIILLMBEqyAhrER ~FULLWBEwAIVER

Q REDUCTIDM(PARTIAL MBE andlor WEE PARTCIPATIOM}

%of Rsducgon for MBE Pmgclpsgon

M of ftsducfkm for WSE Pargclpstton

B. REASOMFOR,FULUREDUCTIOMWAIVERREQUEST

EMdsr/pmpocer shag check each item appikmbls to its reason fore waiver csquest. Addigonegy, suppodlcgdocumeidagon shtg be submigsd wgh gds relusst,

l3 {I} Lack of sughhmtqualilisd MBEa and/or WBEs cspsMe of prowiing the goods or sendces cequhed

by the conkacL (Phmes explain)

(2} ths sps~ txtdnctnttxxy mqulmmerdsforperfonnlng the conkacl make it impossible oreconomhsgylnfsssible to dkkhiihs contracltoetudde Etc conrsctor to ukllzs MBEs atugur wBEsin emnhnu witb the applicsMe partidpalion. (Please explain)

(3} Prioe(s} quoktd by pokmgal MSEs and/cr WBEs srs above compsRlve Isvsis snd increase cost ofdoing bunhuxm and sxxddmske ttcceptattce of such MBE sndior WBE Md sconotnically

impwwlhsMe, bddng Iido ctxxddemgon the percentage of total conlrsct pdcs repretmnktdby suchMBE andfct WSE bM. (Please explain}

{4)There areoguu relevant fsctots making it knpcsdMe or econcndcstty infemibts to ugthe MBEand/or WBE firms. (Please explain)

C. ROOD FAITH EFFORTB TOOBTAIMMBEIWBE PARTICIPATIOM

(1) blade timely wrgten soliclialkm h IdentRed h!BEsand wSEs for dgtutgon ofgoods endhrservices; and prtniided ldSEs and WSEs vtdt s Rmely opporlungy to mdew snd obhin a!avant

cpecRcagotw, htnns end cctxggons of the proposal fo enable MSEs and WBEs to pmpare an

Irdortned response to solhItsgcn. (Attach of copy wrlRen sogciMions nmde)

(2) Used the sen/toes and~of Ihs Ofhce of Conlrsct Compliance slaif. (Please explain)

Q (3) Timely nogfisd snd used the services and assistance of communily, minorily snd womenbusiness

organizsgons, {Attach of copy written solldfagone made)

(4) Foliowsdup on ingial sogcihlkm el MSEs and WBEsto determine if grms are Inhnesktd in doingbusiness. {Attach supporting documsntsgon}

{5) Engaged MBEs 8 WBEs for direcmndkect pa Wcipa5on. {Please explain}

D. OTHER RELEVAMT INFORMATION

A5ach any other documentagon relsgve lo Good Faith Efforts In complying wgh MBE/WBE pwgclpagcn.

Revised: 01/xs/tattvt/WSE Reduction/Waiver Request - Form S

MansfhNFeels. Simplified.

April 6, 2016

Office of Contract ComplianceCook County Government118N. Clark St. Room 1020Chicago; 1L60602

RE:Contract No. 1584-14299Motor Fuels ~,,Dear Sir/Mahdi:

Please accept the amended Foun $i Petition for Waiver ofMBE/WBE Participation. Mansfieldhas made good faith effotls reeadfilI to offer participation in this contract for local MWBEs. Theefforte and documentation'es''e'nclosed.

1. Requested from Diversified Energy Services, a Georgia WBE with nationwide

operations. Due to them still not being Chicago or Cook County certified, this companywmot be utlhxed.

2. Mansfield'reached out to West Fuels again for participation and rates for fuel anddelivery. There was no change in their rates, at $.60per gallon, which far exceedsacceptable iates. This would soundly create a loss of$.40 cents per gallon. Profitabilityon this account is less than .05 cents per gallon for perspective,

3, Msnsfield has reached out to Black Dog Corporation. Results of those efforts areencloseIL 'he'prior y'ear this was requested, no response wss ever received other thanthey had received the request, same as this year.

please note the;-,'jifurmatfon provided in iten ¹4 of the request for waiver. This contract is basedou the National;lIIig:.,pooperafive contract that does not have M%BE requirements, therefore theeconomics to suppo'iet MWBE participation, Within the past year, as noted when this sameinformation was provided, four MWBR compstues were solicited for then participation. Theyeither did not respond, were ineligible or their pricing Sir exceeded a reasonable and competitiveoffer, which would significantl and adversely affect the finaucial performance of thiscontract. Although I undesstsnd the County's desire to include diverse businesses in itepurchasing goals, the existing finailcial offer to provide these services did not include the costsrequired to support one of the two functions requhed to support this contract through anMWBE. Those functions are 1) fuel supply and 2) defiivery of fuel products.

Mansfield respectfully requests that the MWBE participation request be waived due to lack ofcompetitive participants or ineligible participants available. Should you decide that thisrequhemmt cannot be waived, Mausfield will request that pricing be adjusted to support the

vcicatrch 3, 2016

Office of ConT"acl, CornpilaniceCook County Govennnenti i 8 5 C»aii- ct R.o"»'0»0CI(!caco 1'06i!2

RE: Co!"i»act 1'"o. i 684-;--:2cr-;.'victor Fuels Addend.un i i'.enevvai

pea»'!T01'aoa»'I'!ease

accept til»'. {!lcoseo i 0'r ll .», I {'nit!On;, !' ediu( t!0(1Wa!ve!'f iÃiEB Ei W BE partlc!pai! On,y!ansF(aid h! cs ronde»'oon fa!th etio«s»i the previot!s >car to mclu{ie lbe use o'I a V»(BE andiliBE in dlis orretl Those steps hal e beeni as foliole s",

i. I.equesned (lie uSe Of DiVeraii!Sd E.!ei'81 gcl»V!CCSI a Cecrg.a WBF tilat haS natiOT(Widea(ceptance. ',n!e T»o thein '.lol being Chicag't Cook Colin(y certit!ed. i»his suggestion ~»asQe!!ied,

2, Mansf eid reach {lut to West Fue!s. a certified Chicago WBE on Jvfarch 27'". Quotationsfor product an{1 deliverc {vere provided on April 1". EII:e to price heir. g ecor!onlicai! 3u(.aooeptabie. ~iansqleid requeSteid a Vlcai Ver On the WEB requireineni Sc Lle Ci St tosuppot( tile V% BE pa!dc!Dc!!onIs Intreasortabie. Pricing cr{ceecl »10 {e!uris pe!'a(lon illIT!Osl smal! !I1{deli.er!.", Iuldi eaceeds,i 2 cent. per galion ior large deliveries, „yp!c 1

protitabiiity on fuel is $ .016 cer!ts per gallotn io ;"i.03 ce!its pel'PJlon for a!Mnlonlalv iloiesaier like )Ha@afield. A requested requote did not make sui'ficient change hl thepe!cola!a iansf!eld reached out to!'etrox ("1'sv, ci I as Bia"k Doa Corp on Apri!?" ir: oi oer lollieetl the .'(i BF naraicipaiiou goals of the comracl. Biil Ke!!zenbe! <ier vvith petrohi! expi!oned and. advised I ilai he v»oui d supply bl !vpril 10"of?01 5. Amii Cruari froln Balcl{13og C(,rp sept Tal e(nai!. tha'I he ic, v» oui{! senti tbe infoinletlon. 1 have s't'ill hei e noi

Cool{Con(I» ha»rennes!ed, (I co!lilt»ense Q tr X!"-A i on'{rect ti",;!1(n»c Tlo'lt»l»BE

iti",e il»II li!," o, i(lb», '.':!T"{tas il ',",ns !i o!Oticll«i Ic:I oi(1 pi'!l.cla nr I'!'sl'n,

P]cRS'ccc'pi 0111''C(!Rest lo Ir RiVC:lIC Vr% L4L IrOCls ci Ilrie Cro!'Irrr'RCI 88 die !IRtIOIRRi Orjr„iOROOCS llol fi!IRIIrliRLtI'UpOOI t I!IC Roul';!OI181 COSl 0: .'VN'F lIRI'tlolpRtloll.

Sittce: el,.

ir ij rr (Q~ ~J

II,IGSl'I FPjICi SO .Director. tioI «rot!Ic!It ~ter! iccsMRDS(ICJd 0«', {11rrO'rr

CONTRACT NO 1584-14299

COOK COUNTYECONOMIC DISCLOSURE STATEMENT

AND EXECUTION DOCUMENTINDEX

Section Description Pages

Instructions for Completion of EDS EDS i — ii

Certifications

Economic and Other Disclosures, Affidavit of Child

Support Obligations, Disclosure of Ownership Interestand Familial Relationship Disclosure Form

Cook County Affidavit for Wage Theft Ordinance

EDS 1-2

EDS 3 —12

EDS 13-14

Contract and EDS Execution Page

Cook County Signature Page

EDS 15-17

EDS 18

CONTRACT NO, 1584-14299

SECTION 1INSTRUCTIONS FOR CoiylPLETION OF

ECONONIIC DISCLOSURE STATENIENT AND EXECUTION DOCUNIENT

This Economic Disclosure Statement and Execution Document ("EDS") is to be completed and executedby every Bidder on a County contract, every Proposer responding to a Request for Proposals, and everyRespondent responding to a Request for Qualifications, and others as required by the Chief ProcurementOflicer. The execution of the EDS shall serve as the execution of a contract awarded by the County. TheChief procurement Officer reserves the right to request that the Bidder or Proposer, or Respondentprovide an updated EDS on an annual basis.

Definitions, Terms used in this EDS and not otherwise defined herein shall have the meanings given tosuch terms in the Instructions to Bidders, General Conditions, Request for Proposals, Request forQualifications, as applicable.

Affiliate means a person that directly or indirectly through one or mors intermediaries, Controls isControlled by, or is under common Control with the Person specified.

Applicant means a person who executes this EDS.

Bidder means any person who submits a Bid.

Code means the Code of Ordinances, Cook County, illinois available on municode.corn

Contract shall include any written document to make Procurements by or on behalf ofCook County.

Contractor or Contracting Parly means a person that enters into a Contract with theCounty.

Control means the unfettered authority to directly or indirectly manage governance,administration, work, and all other aspects of a business.

EDS means this complete Economic Disclosure Statement and Execution Document,including all sections listed in the Index and any attachments.

Joint Venture means an association of two or more Persons proposing to perform a for-profit business enterprise. Joint Ventures must have an agreement in writing specifyingthe terms and conditions of the relationship between the partners and their relationshipand respective responsibility for the Contract

Lobby or lobbying means to, for compensation, attempt to influence a County official orCounty employee with respect to any County matter.

Lobbyist means any person who lobbies.

Person cr Persons means any individual, corporation, partnership, Joint Venture, trust,association, Limited Liability Company, sole proprietorship or other legal entity,

Prohibited Acts means any of the actions or occurrences which form the basis fordisqualification under the Code, or under the Certifications heminafter set forth.

Proposal means a response to an RFP.

Proposer means a person submitting a Proposal.

Response means response to an RFQ

Respondent means a person responding to an RFQ.

RFP means a Request for Proposals issued pursuant to this Procurement Code.

RFQ means a Request for Qualifications issued to obtain the qualifications of interested parbes.

EOS-i sl201 5

CONTRACT NO. 1584-14236

INSTRUCTIONS FOR COMPLETION OFECONOMIC DISCLOSURE STATEMENT AND EXECUTION DOCUMENT

Section 1: Instructions. Section 1 sets forth the instructions for coinpleting and executing this EDS,Section 2: Certifications. Section 2 sets forth certifications that are required for contracting parties underthe Code and other applicable laws. Execution of this EDS constitutes a warranty that all the statementsand certifications contained, and sll the facts stated, in the Certifications are true, correct and complete asof the date of execution,

Section 3: Economic and Other Disclosures Statement, Section 3 is the County's required Economicand Other Disclosures Statement farm. Execution of this EDS constitutes a warranty that all theinformation provided in the EDS is true, correct and complete as of the date of execution, and binds theApplicant to the warranties, representations, agreements and acknowledgements contained therein.

Required Updates. The Applicant is required to keep all Information provided in this EDS current andaccurate. In the event of any change in the information provided, including but not limited to any changewhich would render inaccurate or incomplete any certification or statement made in this EDS, theApplicant shall supplement this EDS up to the time the County takes action, by filing an amended EDS orsuch other documentation as is required.

Additional Information: The County's Governmental Ethics and Campaign Financing Ordinancesimpose certain duties and obligations on persons or entities seeking County contracts, work, business, ortransactions, and ths Applicant'is expected to comply fully with these ordinances. For further informationplease contact the Director of Ethics at (312) 603-4304 (69 W, Washington St. Suite 3040, Chicago, IL60602) or visit the web-site at cookcountyil. govlethics-board-of.

Authorized Signem of Contract and EDS Execution Page. If the Applicant is a corporation, thePresident and Secretary must execute the EDS. In the event that this EDS is executed by someone otherthan the President, attach hereto a certified copy of that section of the Corporate By-Laws or otherauthorization by the Corporation, satisfactory to the County that permits the person to execute EDS forsaid corporation. If the corporation is not registered in the State of illinois, a copy of the Certificate ofGood Standing from the state of incorporation must be submitted with this Signature Page.

If the Applicant is a partnership or joint venture, all partners or joint venturers must execute the EDS,unless one partner or joint venture has been authorized to sign for the partnership or joint venture, inwhich case, the partnership agreement, resolution or evidence of such authority satisfactory to the Officeof the Chief Procurement Officer must be submitted with this Signature Page.

If the Applicant is a member-managed LLC all members must execute the EDS, unless otherwiseprovided in the operating agreement, resolution or other corporate documents. If the Applicant is amanager-managed LLC, the manager(s) must execute the EDS. The Applicant must attach either acertified copy of the operating agreement, resolution or other authorization, satisfactory to the County,demonstrating such person has the authority to execute the EDS on behalf of the LLC. If the LLC Is notregistered in the State of illinois, a copy of a current Certificate of Good Standing from the state ofincorporation must be submitted with this Signature Page.

if the Applicant is a Sole Proprietorship, the sole proprietor must execute the EDS.

A "Partnership" "Joint Venture" or "Sole Proprietorship" operating under an Assumed Name must beregistered with the illinois county in which it is located, as provided in 805 ILCS 405 (2012), anddocumentation evidencing registration must be submitted with the EDS.

EDS-ii 8/2015

CONTRACT NO 1584 14299

SECTION 2

'ERTIFICATIONS

THE FOLLOWING CERTIFICATIONS ARE MADE PURSUANT TO STATE LAW AND THE CODE. THE APPLICANT ISCAUTIONED TO CAREFULLY READ THESE CERTIFICATIONS PRIOR TO SIGNING THE SIGNATURE PAGE. SIGNINGTHE SIGNATURE PAGE SHALL CONSTITUTE A WARRANTY BY THE APPLICANT THAT ALL THE STATEMENTS,CERTIFICATIONS AND INFORMATION SET FORTH WITHIN THESE CERTIFICATIONS ARE TRUE, COMPLETE ANDCORRECT AS OF THE DATE THE SIGNATURE PAGE IS SIGNED. THE APPLICANT IS NOTIFIED THAT IF THE COUNTYLEARNS THAT ANY OF THE FOLLOWING CERTIFICATIONS WERE FALSELY MADE, THAT ANY CONTRACT ENTEREDINTO WITH THE APPLICANT SHALL BE SUBJECT TO TERMINATION

PERSONS AND ENTITIES SUBJECT TO DISQUALIFICATION

No person ar business entity shall be awarded a contract or sub-contract, for a penod of ffve (5) years from the date ofconviction or entry of a plea or admission of guilt, idvil or criminal, if that person or business entity;

1) Has been convicted of an act committed, within the State of glinois, of bribery or attempting to bribe an officeror employee of a unit of state, federal or local government or school district in the State of illinois in thatofficef s or employee's oflicial capacity;

Has been convicted by federal, state or local government of an act of bid-rigging or attempting to rig bids asdefined in the Sherman Anti-Trust Act and Claytan Act Act. 15 U.S.C. Section 1 ei seqri

3) Has been convloted of bid-rigging or attempting to rig bids under the laws of federal, state or localgovernment;

4) Has been convicted of sn act committed, within the Stats, of price-fixing or attempting to fix prices as definedby the Sherman Anti Trust Act and the Clayton Act. 15 U S C. Section 1, eiseqri

5) Has been convicted of price-fixing or attempting to fix prices under the laws the State;

6) Has been convicted of defrauding or attempting to defraud any unit of state or local government or schooldistrict within ths State of fflinols;

7) Has made an admission of guilt of such conduct as set forth in subsections (1) through (6) above whichadmission is a matter of record, whether or not such person or business entity was subject to pmsecution forthe offense or offenses admitted to; or

8) Has entered s plea of nolo contendere to charge of bribeqi, price-fixing, bid-rigging, or fraud, as set forth insub-paragraphs (1) through (6) above.

In the case of bribery or attempting to bribe, a business entity may not be awarded a contract if an offfclat, agent oremployee of such business entity committed the Prohibited Act on behalf of the business entity and pursuant to thedirection or authorization of an officer, director or other responsible offidal of the business entity, and such ProhibitedAct occurred within three years prior to the award of the contract. In addiTion, a business entity shall be disqualified if anowner, partner or shareholder controlling, directly or indirectly, 20% or more of the business entity, or an oflicer of thebusiness entity has performed any Prohibited Act within five years prior to the award of the Contract

THE APPLICANT HEREBY CERTIFIES THAT The Applicant has read the provisions of Section A, Persons andEntities Subject to Disqualification, that the Applicant has not committed any prohibited Act set forth in Section A, andthat award of the Contract to the Applicant would nat violate the provisions of such Secgan or of the Code.

BID-RIGGING OR BID ROTATING

THE APPLICANT HEREBY CERTIFIES THAT: In accordance with 720 ILCS 5/33 E-11, neiiher the Applicsni nor snyAffiiieied Enffiy is bermd fiam sward of this Confrsci as a result of e conviction for the violation of State isws prohibiffngbid-rigging or bid mieiing.

DRUG FREE WORKPLACE ACT

THE APPLICANT HEREBY CERTETES THAT: The Applicant will provide a drug free workplace, as required by (30 ILCS580/3).

EDS-1 8/2015

CONTRACT NQ 1584 142gg

D. DELINQUENCY IN PAYMENT OF TAXES

THE APPLICANT HEREBY CERTIFIES THAT: The Applicant Is not sn owner or s party responsible for the payment oiany tex or les administered by Cook County, hy e local municipality, or by the illinois Deperhnent of Revenue, which suchtsx or fee is delinquent such as bar award of e contract or subcontract pursuant to the Code Chapter 34 Section 34 171,

E. HUMAN RIGHTS ORDINANCE

No person who is a party to a contract with Cook County ("County" ) shall engage in unlawful disatmlnation or sexualharassment sgsinsi any individual in ths terms or conditions of employment, credit, pubfic accommodations, housing, orprovision of County facilities, services or programs (Code Chapter 42, Section 42 30 e( seq ).

F, ILLINOIS HUMAN RIGHTS ACT

THE APPLICANT HEREBY CERTIFIES THAT: Itis in compliance with the illinois Human Rights Act (775 ILCS 5I2-105),snd agrees to abide hy the requirements of the Act es pert ofits contractual obligations.

G. INSPECTOR GENERAL (COOK COUNTY CODE, CHAPTER 34, SECTION 34-174 and Section 34-250)

The Applicant hes not willfully failed to cooperate in an investigation by ihe Cook County Independent Inspector Generalor to report to the Independent Inspector General any and sll information concerning conduct which they imow to involve

corruption, or other criminal activity, by another county employee or officia, which concerns his or her office ofemployment or County related transaction.

The Applicant has reported direcfiy and without any undue delay any suspected or known fraudulent adivity in theCounty's Procurement process to the Office of the Cook County Inspector General.

H. CAMPAIGN CONTRIBUTIONS (COOK COUNTY CODE, CHAPTER 2, SECTION 2-685)

THE APPI.ICANT CERTIFIES THAT: It hss read and shall comply with the Cook County's Ordinance concerning

campaign contiibulions, which is codified at Chapter 2, Division 2, Subdivision II, Secfion 685, snd can be read In its

entirety at www.municode. corn.

I. GIFT BAN, (COOK COUNTY CODE, CHAPTER 2, SECTION 2-574)

THE APPLICANT CERTIFIES THAT: It has read and shall comply with the Cook County's Ordinance concerning

receiving and solicifing glffs snd favors, which is codified at Chapter 2, Division 2, Subdivision II, Section 574, and can bereed in its entirety st www.municode.corn.

J. LIVING WAGE ORDINANCE PREFERENCE (COOK COUNTY CODE, CHAPTER 34, SECTION 34-160

Unless expressly waived by the Cook County Board of Commissioners, the Code requires Ihat a living wage must be paid

to individuals employed by a Contractor which has a County Contract snd by all subcontractors of such Contractor under aCounty Conirach throughout the duration of such County Contract. The amount of such living wage is annually by theChief Finandial Officer of the County, end shall be posted on the Chief Procurement Officefs website.

The term "Contract" as used in Section 4, I, of this EDS, specifically exdudes contracts with the following:

Not-For Pmfit Organizations (defined as s corporation having tsx exempt status under Section 501(C)(3) of the

United State Internal Revenue Code and recognized under the illinois State not-for -profit law) I

2)

3)

4)

Community Development Block Grants;

Cook County Works Department;

Sheriifs Work Alternative Program; and

Department of Correction inmates

EDS-2 8/2015

CONTRACT NO. 1584-14299

SECllON 3

REQUIRED DISCLOSURES

1, DISCLOSURE OF LOBBYIST CONTACTS

List afi persons that have made lobbying contacts on your behalf with respect to this contract:

Name

N/AAddress

2. I.OCAL BUSINESS PREFERENCE STATEMENT (CODE, CHAPTER 34, SECTION 34-230)

Local business means a Person, including a foreign corporation authorized to transact business in Illinois, having a bona fideestablishment located within the County at which it is transacting business on the date when a Bid is submitted to the County,and which employs the majority of its regular, full-time work force within the County, A Joint Venture shall constitute a LocalBusiness if one or more Persons that qualify as a "Local Business" hold interests totaling over 50 percent in the Joint Venture,even if the Joint Venture does not, at the time of the Bid submittal, have such s bona fide establishment within the County.

a) Is Applicant a "Local Business" as defined above?

Yes: No X

b) If yss, list business addresses within Cook County:

c) Doss Applicant employ the majority of its regularfull time workforce within Cook County?

Yes: No: X

3, THE CHILD SUPPORT ENFORCEMENT ORDINANCE (CODE, CHAPTER 34, SECTION 34-172)

Every Applicant for a County Privilege shall be in full compliance with any child support order before such Applicant is entitled toreceive or renew a County Privilege. When delinquent child support exists, the County shall not issue or renew any CountyPrivilege, and may revoke any County Privilege.

All Applicants are requimd to review the Cook County Affidavfi of Child Suppok Obligations attached to this EDS (EDS-6)and complete the Affidavi, based on the instructions in the Affidavit.

EDS-3 6)2015

CONTRACT NO. 1584-14299

4, REAL ESTATE OWNERSHIP DISCLOSURES.

The Applicant must indicate by checking the appropriate provision below end providing sll required information that either:

a) The following is a complete list of all real estate owned by the Applicant in Cook County:

PERIIIIANENT INDEX NUMBER(S):

(ATTACH SHEET IF NECESSARY TO LIST ADDITIONAL INDEX

NUMBERS)

OR:

b) The Applicant owns no real estate in Cook County.

e. EXcEPTIONS TO CERTIFICATIONS QR DISDLOSURES.

If the Applicant is unable Io cwtify to any of the Certlflcations or any other slatements contained in this EDS and not explained

elsewhere in this EDS, the Applicant must explain below:

N/A

lf the letters, "NA", the word 'None" or "No Responsrt" appears above, or if the space is left blank, it will be conclusively presumedthat the Applicant certified to sll Certifications and other statements contained in this EDS.

EDS-4 ergot b

CONTRACT NO. 1664H4ggg

COOK COUNTY DISCLOSURE OF OWNERSHIP INTEREST STATEMENT

C ks

typed

fodl ii2610 t qi qd 0 \ yAppll tf ys tyAti tdi I ifconcerning ownership Interests in lhs Applicant. This Disclosure of Ownership Interest Statement must be completed withinformation current ss of the date this Statement is signed. Furthermore, this Statement must bs kept current, by filing an amendedStatement, until such time as the County Board or County Agency shall take action on the application. The information contained inthis Statement will be maintained in a database and made available for public viewing.It you are asked to list names, tiut there are no applicable names tc list, you must state NONE, An incomplete Statement will bereturned and any action regarding this contract will be delayed. A failure to fully comply with the ordinance may result in the actiontaken by the County Board or County Agency being voided.

"App//cani" means any Entity or person making an application to the County for any County Action.recon/y Action" means any action by a County Agency, a County Department, or the County Board regarding an ordinance orordinance amendment, a County Board approval, or other County agency approval, with respect to contracts, leases, cr sale orpurchase of real estate."person" "Entity" or "Legal En¹ty" means a sole proprietorship, corporation, partnership, association, business trust, estate, two ormore persons having a joint or common interest, trustee of a land trust, other commercial or legal entity or any beneficiary orbeneficiaries thereof.

This Dlsclosum of Ownership Interest Statement must be submitted by:1.An Applicant for County Acfion and2, A Person that holds stock or a beneficial interest in the Applicant and is listed on the Applicant's Statement (a "Holder" ) must file aStatement and complete ¹I only under Ownership Interest Declaration.please print or type responses clearly and legibly. Add additional pages if needed, being careful to identify each portion of the form towhich each additional page refers.

]Applicant or [

] Original Statement or [

State Georgia

This Statement is being made by the [

This Statement is an: [Identifying Information:

Name Mansfield Oil Companv of Gainesville, Inc.

D/B/A Mansfield Oil Company of Gainesville, Inc.

street Address: 1025 Airport Parkway, SW

city; Gainesville

Phone Nox (678) 450-2000 Fax Number.

) Stock/Beneficial Interest Holder

] Amended Statement

FEIN Nox 58-1091383

Zip Code: 30501-6813

Email:

Cook County Business Registration Number;(Sole Pmpristor, Joint Venture Partnership)

Corporate File Number (if applicable):

Form of Legal Entity:

( ) Sole Proprietor [ )

[ ) Business Trust [ ]

[ ) Other (describe)

Partnership

Estate

[X] Corporation [ ] Trustee of Lend Trust

[ ] Association [ ] Joint Venture

Ownership Interest Declaration:

1. Ust ths name(s), address, and percent ownership of each Person having a legal or beneficial interest (indudingownership) of more than five percent (6%) in the Applicant/Holder,

Name

Manfield Energy Corp.

Address

1025 Airport Parkway, SW

Percentage Interest in

Applicant/Holder

100%

EDSui 8/2016

GEORGIA Page I of 2

GEORGIA

'i'i~kfjjAE) CORPORATIONS

DIVISION

GEORGIA SECRETARY OFSTATE

BRIAN P, KEMP

BUSINESS SEARCH

BUSINESS INFORMATION

MANSFIELD OIL

Business Name: COMPANY OF

GAINESVILLE, INC.Control Number: H500624

HOME (/I

Domestic ProfitBusiness Type:'orporation

Business Purpose:

1025 AIRPORTPrinc'Pal Office

PKWY, GAINESVILLE,Ad

GA, 30501-6813,USA

State of Formation: Georgia

Business Status; Active/Compliance

Date of Formation /Registration Date:

Last Annual

Reg i strati on Yea r:

REGISTERED AGENT INFORMATION

Registered AgentB d pBrad Puryear

Name:

Physical Address: 1025 Airport Parkway SW, Hall, Gainesville, GA, 30501, USA

OFFICER INFORMATION

Name Title Business Address

Wm. Puryear, Brad

I Alexander

Wm. Puryear, Brad

1025 Airport Parkway SW, Gainesville, GA, 30501, USA

CFO 1025 Airport Parkway SW, GAINESVILLE, GA, 30501, USA

Secretary 1025 Airport Parkway SW, GAINESVILLE, GA, 30501, USA

Michael Mansfield, F. Sr. CEO 1025 Airport Parkway SW, Gainesville, GA, 30501, USA

Filing History Name HistoryBack

Office of the Georgia Secretary of State Aitken'%%iIEk',uII".IBFs. %Bi%'313, Floyd West Tower Atlanta, GA 30334-1530, Phone:(404) 656-2817 WEBSITE: http: //www.sos.ga.gov/

2015 PCC Technology Group. All Rights Reserved. Version 2.1.2a Report a Problem?

https://ecorp.sos.ga.gov/Business Search/BusinessInformation?businessid=52592Mbusine... 3/14/2016

GEORGIA Page 2 of 2

Office of the Georgia Secretary of State Attn: 2 MLK, Jr. Dr. Suite 313, Floyd West Tower Atlanta, GA 30334-1530, Phone:(404) 656-2817 WEBSITE: http: //www.sos.ga.gov/

2015 PCC Technology Group. All Rights Reserved. Version 2.1.2a Report a Problem?

https://ecorp.sos.ga.gov/Business Search/Businessinformation?businessid=5259258'cbusine... 3/14/2016

CONTRACT NO- 1584-14299

2, If the interest of any Person listed in (1) above is held as an agent or agents, or a nominee or nominees, list the nameand address of the principal on whose behalf the interest is held.

Name of Agent/Nominee Name of Principal Principal's Address

NOT APPLICABLE

Is the Applicant constructively controlled by another person or Legal Entity7 [ ] Yes [ ] No

If yes, stats the name, address and percentage'of beneilclal Interest of such person, and the relationship under whichsuch control is being or may be exercised.

Name Address Percentage ofBeneficial Interest

Michael Mansfield 1025 Airport Parkway, SW 100%

Relationship

Member

Corporate Officers, Members and Partners Information:

For all corporations, hst the names, addresses, and terms for all corporate officers. For all limited liability companies, list thenames, addresses for all members. For all partnerships and joint ventures, list the names, addresses, for each partner or jointventure.

Name

See Attachment A

Address Title (specify title ofOffice, or whether manageror partner/joint venture)

Term of Office

Declaration (check the applicable box):

[ l I state under oath that the Applicant has withheld no disclosure as to ownership interest in the Applicant nor reservedany information, data or plan as to the intended use or purpose for which the Applicant seeks County Board or other

County Agency action.

[X [ I state under oath that the Holder has withheld no disclosure as to ownership interest nor reserved any informationrequired to be disclosed.

Doug HaughName op uthoriz nt/H der Representative (please print or type)

Signature Phrussej[@mansfi&oil.cornE-mail address sttllfllfyay

Subscribed to and sworn before ms

PresidentTitle

March 7, 2016Date

678-450-2000Phone Number

My commission expires; November 11, 2018

EDS-7

NotaryPublicfignature ~jsf[@fff[lj(BLto'g Q~

/fflilttt

Notary Seal

8/2015

CONTRACT NO. 1554-142gg

COOK COUNTY BOARD OF ETHICS69 W. WASHINGTON STREET, SUITE 3040

CHICAGO, ILLINOIS 60602312/603-4304 Office 312/603-9988 Fax

FAMILIAL RELATIONSHIP DISCLOSURE PROVISION

Nenotism Disclosure Reuuirementi

Doing a significant amount of business with the County requires that you disclose to the Board of Ethics the existence of anyfamilial relationships with any County employee or any person holding elective office in the State of Illinois, the County, or inany municipality within the County. The Ethics Ordinance defines a significant amount of business for the purpose of thisdisclosure requirement as more than $25,000 in aggregate County leases, contracts, purchases or sales in any calendar year.

If you are unsure of whether the business you do with the County or a County agency will cross this threshold, err on the sideof caution by completing the attached fitmilial disclosure form because, among other potential penalties, any person foundguilty of failing to make a required disclosure or knowingly filing a false, misleading, or incomplete disclosure will beprohibited from doing any. business with the County for a period of three years. The required disclosure should be filed withthe Board of Ethics by January 1 of each calendar year in which you are doing business with the County and again with eachbid/proposal/quotation to do business with Cook County. The Board of Ethics may assess a late filing fee of $ 100 per day afteran initial 30-day grace period.

The person that is doing business with the County must disclose his or her familial relationships. If the pemon on the Countylease or contract or purchasing fiom or sefiing to the County is a business entity, then the business entity must disclose thefamilial relationships of the individuals who are and, during the year prior to doing business with the County, were:

~ its board of directors,~ its officers,~ its employees or independent contractors responsible for the general administration of the entity,~ its agents authorized to execute documents on behalf of the entity, and~ its employees who directly engage or engaged in doing work with the County on behalf of the entity.

Do not hesitate to contact the Board of Ethics at (312) 603-4304 for assistance in determining the scope of any requiredfamilial relationship disclosure.

Additional Definitions:

"Familial relationship" means a person who is a spouse, domestic partner or civil union partner of a County employee or State,County or municipal oflicial, or any person who is related to such an employee or official, whether by blood, marriage oradoption, as a:

.!Parent,I) Child!J BrotherD SisterG Aunt

C UncleI'ieceI7 Nephew

!'1 GrandparentU GrandchildG Father-in-lawJJ Mother-in-lawG Son-in-lawO Daughter-in-lawi".Brother-in-lawL'ister-in-law

.!Stepfather' Stepmother,I Stepson'] Stepdaughter::!Stepbrother'

StepsisterCJ Half-brotheriJ Half-sister

EDS-8 8/2015

CONTRACT NO. 158a-1<2gg

COOK COUNTY BOARD OF ETHICSFAMILIAL RELATIONSHIP DISCLOSURE FORM

A. PERSON DOING OR SEEKING TO DO BUSINESS WITH THK COUNTY

Name of Person Doing Business with the County: Mansfield Oil Comoanv of Gainesville~lnc.

Address oi'Person Doing Business with the County: 1025 Airport Parkway, SW, Gainesvllle, GA 30SOLB813 - Hall

Phone number ofPerson Doing Business with the County: (866) 275 7338

Email address of Person Doing Business with the County: JepperSOnemansfieldoil.corn

If Person Doing Business with the County is a Business Entity, provide the name, title and contact information for theindividual completing this disclosure an behalf of the Person Doing Business with the County:Josh Ennerson. Director. Government Services. (4701 333-1475.

iepperson@mansfieldoil.corn

DESCRIPTION OF BUSINESS WITH THE COUNTYAppend additional pages as needed and for each County lease, contract, purchase or sale sought and'orobtained during the calendar year of this disclosure (or the proceeding calendar year ifdisclosure is madeon January I), identify:

The lease number, contract number, purchase order number, request for proposal number and/or request forqualification number associated with the business you are doing or seeking to do with the County:

Contract No. 1584-14299

The aggregate dollar value of the business you are doing or seeking to do with the County: g 830.000

The name, title and contact information for the County officia(s) or employee(s) inyolved in negotiating the businessyou are doing orseekingto do withthe County; Barbie Flock, Specitications Engineer

(312) 603-6828, barbie. flock(Rcookcountyil.gov

The name, title and contact information for the County official(s) or employee(s) involved in managing the businessyou are doing orseekingto do withthe County: Glenn Divita. DOTH. (7081 388-2116

glenn.divitaecookcountyil.gov

C. DISCLOSURE OF FAMILIAL RELATIONSHIPS WITH COUNTY EMPLOYEES OR STATE. COUNTYOR MUNICIPAL ELECTED OFFICIALS

Check the box that applies and provide relatedinformation where needed

El The Person Doing Business with the County is an individual and there is no familial relationship between thisindividual and any Cook County employee or any person holding elective office in the State of illinois, Cook County,or any municipality within Cook County.

D The Person Doing Business with the County is a business entity and there is no familial relationship between anymember of this business entity's board of directors, offlcers, persons responsible for general administration of thebusiness entity, agents authorized to execute documents on behalf of the business entity or employees directlyengaged in contractual work with the County on behalf of the business entity, and any Cook County employee or anyperson holding elective office in the State of Illinois, Cook County, or any municipality within Cook County.

EDS-9 8/2015

CONTRACT NO. 15SS-142gg

COOK COUNTY BOARD OF ETHICSFAMIl IAL RELATIONSHIP DISCLOSURE FORM

P The Person Doing Business with the County Is an individual and there is a familial relationship between thisindividual and at least one Cook County employee and/or a person or persons holding elective office in the State ofillinois, Cook County, and/or any municipality within Cook County. The familial relationships are as follows:

Name of individual Doing

Business with the County

N/A

Name of Refatixl County Title and Position of Related Nature af FamilialEmployee or State, County or County Employee or State, County Relationshiplvlunicipal Elected OfFicial or Municipal Elected Official

/f more space is needed aaach an additional sheet following the above formal.

The Person Doing Business with the County is a business entity and there is a familial relationship between at leastone member of this business entity's board of directom, officers, persons responsible for general administration of thebusiness entity, agents authorized to execute documents on behalf of the business entity and/or employees directlyengaged in contractual work with the County on behalf of the business entity, on the one hand, and at least one CookCounty employee and/or a person holding elective office in the State of Illinois, Cook County, and/or anymunicipality within Cook County, on the other, The familial relatiouships are as follows:

Name of Member of Boardaf Director for BusinessEntity Doing Business with

the County

N/A

Name of Related County Title and Positian of Related Nature of FamilialEmployee or State, County or County Employee or State, County RelationshipMunicipal Elected Official or Municipal Elected Official

Name of Officer for Business Name of Related County Title end Position of RelatedEntity Doing Business with Employee ar State„County or County Einploycc or State, Countythe County Municipal Elected Official ar Municipal Elected Oiticial

N/A

Natum of FamilialRelationship

EDS-10 8/2015

CONTRACT 1'lO. 155r(-tdEBB

Niinie of Person Re-ponerlefor thc OineiaiAdmiuistmtion of thef>usinem Pniity Doing

Nmne of Re!a!er!Count, I'nie and Post(ion of Re!atedEreployce or 9',atc. (.crmiy or County Employee or 6!eie, Coun!1Municipal lRected Oiicial cr Municipal Elected OA!cia!

Natulv. oi rani!hatRela(ion(hip

1'erne of II<,.n'I Auihori acdI: Execute Dosumei vt forBusiness Entie, iloingBusirctsri itt: Iiic. County

X'*me of Related CountsEmployee oi S(ate. Ct uu(y or.'vtuaiotpat Eie tee OITici 1

Title and Position of Rela(edCourny Employe= w State., Couutyor!Eiunicipal Elected Official

Nature of Familialigelationshi Ip

N (me iif Enip'Dice oluis!ucss Hniity f)irecclErgaa "'c Doing Bosli

Name i.i!',enued Cmmb Title ai il Pen(on of Related !datura of Panri!ialEm!in; o!Stritc, Cem;t> ~." C!univ Employee or State, Ccimty Re!adonshipdin!(Iten i hot':1 IETI "2 ce teliii''!pal Elected Otpiclst

,'fn ore space,is needed, attach(at additionalsheet olio!ting the above for!oat.

TER)F)Cy('f')Opt: To the best of my haunt)edge, thc information! have provdded on this disclosure form is accurate acdcomp!2;e. ! acknoue!edge dnet an inacmuate or ircon!piete disclosure ic pun!shab!a by!aw, inch!ding but not limited to fines

.9:.=-.=-Iu-t'ai: Rec:9.$4 (Oats

ELBN(I'i OO'(lpl.ETED FORM TO: CoaL County Bomd of Ethics69 'Vest Washington Stree!, Suite 3060. Chicago. il!hioi( 606(!2O!Tice j3!2)603I-630< -Fau(3!2) 603-99ggCoot(()our.tt.k!thine(iicouticoun() il,gmi

gruuir. hi!it:.'.ic artner. civil uuion panner or uaenh chiid, ib'ing, aunt. uncle. niece, nephietv., grandpmont or pean(ichildio'i(in I, mmr'ag tt 2. III!2(VS 2nd siep I'I!2!Ious) o('doptiorr.

eEDE-': 0/2015

CONTRACT NO. 1584-142gg

SECTION 4

COOK COUNTY AFFIDAVIT FOR WAGE THEFT ORDINANCE

Effective May 1, 2015, eveiy person, inc/cd/no subsrsnds/ owners, seeking s contract with Cook County must coiiiply witli the Cook county wage TheftOrdinance set forth in Chapters), Article IV, Secficn 179. Any Person/Substantial Owner, who fails to comply with Cook County Wage Theft Ordinance,may request thai the Chief Procurement Officer grant s reduction or waiver in accordance with Section 34-179(d).

"Ocnirecf'eans any written document tc make Procvrements by or on behalf of Cook County.

"person" means any individual, corporation, partnership, Joint Venture, trust, association, limited liability company, sole proprietorship or other legal enfity

"procuremenl" means obtaining supplies, ecluipment, goods, cr services of any kind.

"substantial owner" means any person or persons who own or hold s twenty-fwe percent (254A) or more percentage'of interest in any business entayseeking e County Privilege, induding those shareholders, general or limiled partners, bsneficisries snd principals; except wiiere a business entity ie anindividual or sofir proprietorship, Substantial Owner means that individual or sole proprietor.

Afi Persons/Substantial Owners are required to complete this affidavit snd comply with the Cock County Wage Theft Ordinance before any Contract Isawarded, signature cf this form constitutes s certification the information provided below is correct snd complete, snd that the Individual(s) sifining this formhas/have personal knowledce ofsuch mfcrmetion.

I. Contract Information:

Contract Number: 1584-14299

County Using Agency (requesting Procurement); DOT & Forest Preserve

ll. Person/Substantial Owner Information:

Person (Corporate Entity Name): Mansfield Oil Company of Gainesville, Inc,

Substantial Owner Complete Name: Mansfield Enal'Ey Corp

FEIN¹ 58-1091383

Date of Birth:

Street Address: 1025 Airport Parkway, SW

city Gainesville

Home Phone: ~678 450-2000

ill. Compliance with Wage Laws:

E-mail address:

State; Georgia Zip 30501 6813

Driver's License No:

Within the past five years has the Person/Substantial Owner, in any judicial or administrative proceeding, been convicted of,entered a plea, made an admission of guilt or liability, or had an administrative finding made for committing a repeated or willfulviolation of any of the following laws:

I/ffnois VI/age Payment and Cc//eclion Acf, 820 ILCS 115/1 et ssq., YES orO

///ino/s Minimum Wage Acf, 820 ILCS 105/1 et seq., YES o~NO

////nois Worker Adjustment and Re/re/ning No//ficsffon Act, 820 ILCS 85/1 et seq., YES o~NO

Employee C/ass/ffce//cn Act, 820 ILCS 185/1 el seq., YES or~0

Fair Labor 8/endsrds Ac/ of 1938, 29 I/.S.C. 201, sf seq., YES a+03

Any compsrab/e state sta/u/e or regu/sf/cn of any state, wh/ch governs the payment of wages YES o~O

If the Person/Substantial Owner answered "Yes" to any of the questions above, it is ineligible to enter into a Contract with CookCounty, but can request a reduction or waiver under Section IV.

EDS-12 8/2015

CONTRACT NO. 1584-14299

IV, Request for Waiver or Reduction

If Parson/Substantial Owner answered "Yes" to any of ths questions above, it msy request a reduction or waiver inaccordance with Section 34-179(d), provided that the request for reduction cl waiver is made on the basis of one prmore of the following actions that have taken place:

There has been a bona fide change in ownership or Control of the ineligible Person or Substantial ownerYES orrttfgt

Discfplinanr sclion hss been taken against the individual(s) responsible for the acts giving rise to the violationYES ortIDI

Remedial action hss been taken to prevent a rscunsnce of the acts giving rise to the disqualificagon or defaultYES o~O

Other factors lhst lhe Person or Substantial Owner believe sre relevant.YES or(

The Person/Substantial Owner must submil documentalion to suooori the basis of its reauest fora reduction or waiver, TheChief Procursmeni Ofhcer reserves the riohl to make additional inauiries and reauest additional documentation.

day oi March

V. AffirmationThe Person/Subsla

' 0 effl that all statements contained in the Affidavit are true, accurate and complete,

Signature: Date: March 7, 2016

N f P 'G(tI (Pyt( D H h Title: President

~ubscribsd and sworn to before me this, 20t6

x/Q7~>~~ t. JV~> t«lllllllts,Notary Public Signature Julia Tittle

Note: The above informatlonis subject to verification prior ta the award sf the contracgt trj>v'h+I~ +OTtgA Cs

fliiill tl'I

EDS-13 8/2015

Jun 03 2005 12:25PM MANSFIELD OIL COMPANY 770-297-8989

COOK COUNTYDEPARThfENT OF REVENUE

GASOLINE AND DIESEL FUEL TAX

This is to certify that Mansfie d, IQ25 Airport Parkway, GainesIYdi

i",:.,Cook Coanty"Department of~,'the'.Cook;County Gasogne . ax3 amended.

CKRTIFIC TK OF REGISTRATION

Oil Company nf Ghdncsvilfe, I'nc. located at'

GA 30501 is properly registered with theevenie pursuant to applicahle provisions of

Ordinance" effective October 1, 19'16, as

Registration No.: 2990993 Registration Date: October 1, 1999

W~(4ZOIIN H. STab CX

RESIDENT COOK COUNTYOF COMMBSIUNERS

A ~BRUlVOREVENUE

(TO BE POSTED IN A CONSPICUOUS LOCATION

Client¹: 78626 14MANSFIELD

ACORD CERTIFICATE OF LIABILITY INSURANCEi 3/28/2016

INsURER/s) AFFORIMIGCOYENAGE

INsURER A, Nationwide Agribusiness Ins. CoMSIJRPR a Lexington insurance CompanyMEUNEE c:Allied World Assurance Compania

MsuNER c:Evanston Insurance Company

INsURER E: Endurance American Insurance

NAIC e2822319437194893537810641

MSUREO

Mansfield Oil Companyof Gainesville, Inc.1025 Airport Parkway, SWGainesville, GA 30501

MSURER P:COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE INSURED NAMED ABOVE FORTHE POL/CY PERIODINDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITIONOF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THISCERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS ANO CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REOUCEO BY PAID CLAIMS.

INSR AGO L EU BR POLICY EPP POLICY EXPLYN TYPE OF INSURANCE INSR WVb POLICY NUMBER /MM/ccfyym LMMocnyyn I

UM/rs

X COMMERCIAL GENERAL L/ABIUYY CPP119529A 07/01/2015 07/01/2016 EACH GGCURRENCE $ 1,000,000CLAIMS. MADE X OCCUR 9()N(I/EÃb 1 $300.000

MEG Exp (Any ons us/son) $ 10,000PERSONAL 4ADV INJURY $ 1,000,000

GEN'L AGGREGATE LIMIT APPLIES PElt GENERAL AGGREGATE $2,000,000~ PRO-POLICY ~ JECT ~ LOC PROOUGTS-COMP/OPAGG $2,000,000OTHER $

A AUToMoBILE LIAB/k/ry CPP119529A 07/01/2015 07101/2016, „" "; „,8 UM 1,000,000X ANYAUi'0 BODILY INJURY (Pef Poison) $

AUTOSALL OWNED

AUTOSSCHEDULED

BODILY INJURY (Pel scddsni) $

X NON-OWNED PROPERTY DAMAGEHIRED AUTOS AUTOS /Per accident)

UMBRELLA UAS ~X GGCUR 07/01/2015 07/01/2016 EXON occURRENGE $5,000,000EXCESS LIAB

I I CIA/MSMADE AGGREGATE $5,000,000GEG I XI RETENTloN$ 10000 $

A WORKElls COMPENSATION WCC119529A 07/01/2015 07/01/2016 X I.:!."Nn,Y/N

ANY PROPR/ETORIPARTNE/VEXECUT/VE~ E.L.EAcH AccIDENT $1,000,000OFFICER/MEh/SEN EXCLU DE Do N/A(Mandatory in NH) E.L.OISEASE - EA EMPLOYEE $1,000,000If yes, descnbe underDESCRIPTION OFOPERAT/ONS below EL. OISEASE- POLICY LIMIT $1,000,000

C Pollution 03059391 11/17/2014 11/17/2017 $5M Ealncident/$ 10M AggD Excess Umbrella MKLV40LE102184 DTI01/2015 07/01/2016 $5M XS $5ME Excess Umbrella EXC10005109001 DTI01/2015 07/01/2016 $15M XS $10MGEscRl pl/ON oF opERATloN8 / LocATloNs / vEHlcLEs (Ado ND 1el, Addi canal Remarks schedule, may be sdached if more snace ls reuuirsd)

15375502

THIS CERTIFICATE IS ISSUED AS A ISATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THISCERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIESBEI OW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BEIWEEN THE ISSUING INSURER(S), AUTHORIZEDREPRESENTAllVE OR PRODUCER, AND THE CERTIFICATE HOLDER.

IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, Subject tothe terms End conditions of the pcgcy, certain policies may require an endorsement. A stslement on this certificate does not confer rights to thecertificate holder In lieu of such endorsement(s).

PROOUCER GUN/ACYNAME:J.Smith Lanier 6 Co.-Atlanta 770 476-1770 770 476-3651

11330Lakefield Drive E-MAILADDRESS:

Bldg 1, Suite 100Duluth, GA 30097

Cook County Government, IL is included as additional insured when required by written contract but onlywith respects to the general liability insurance and subject to the provisions and limitations of thepolicy.

CERTIFICATE HOLDER CANCELLATION

Cook County Government118N. Clark StreetRoom 1018Chicago, IL 60602

SHOULD ANY OF THE ABOVE DESCRIBEO POLICIES BE CANCELLED BEFORETHE EXPIRATION DATE THEREOF, NOTICE WILL BE OELIVEREO IN

ACCORDANCE WITH THE POLICY PROVISIONS.

AUTHORIZEG REPRESENTATIVE

ACORD 25 (2S14/B1) 1 of 1¹S2979469/M2688203

$$ 19!lFR14ACORD CORPORATION. AB rights reserved.The ACORD name end logo are registered marks of ACORD

KWW

CONTRACT NO. 1564-14299

SECTION 6

CONTRACT AND EDS EXECUTION PAGEPLEASE EXECUTE THREE ORIGINAL COPIES

The Applicant hereby certifies and warrants that all of the statements, certiiicstions and representations set forlh in this EDS sretrue, complete and correct; that the Applicant is in full compliance snd will continue to be in compliance throughout the term of theContract or County Privilege issued to the Applicant with all the policies and requirements set forth in this EDS; and that all factsand information provided by the Applicant in this EDS ere true, complete snd correct. The Applicant agrees to inform ths Chiefprocurement Office In writing if sny of such statements, csrlifications, representations, facts or information becomes or is found tobe untrue, incomplete or incorrect during the term of ths Contract or County Privilege.

Mansfield Oil Company ofCorporation's Name

(800) 255-$89,9

f/Jy&ISKIAVSecretary Signature (

Execution byCor paretic

G i s,I . /~/ /f /g1/Pres ice nf s Piirjfftd Name anpdgnature

dhaughLRInansfieldojij(corn

Email

.Brad Purvear March 7, 2016Date

Execution by LLC

.Doug Haugh

LLC Name *Member/Manager Printed Name and Signature

Date Telephone and Email

Execution by Partnership/Joint Venture

Partnership/Joint Venture Name "Partner/Joint Venturer Printed Name and Signature

Date Telephone snd Email

Execution by Sole Proprietorship

Printed Name and Signature Date

Telephone Email

Subscribed and sworn to before me this7th day of March, 2016. ttlilNiya>

=-" ~i",. ax~'.:Juiie Tittle Notary Seal T +

If the operating agreement, partnership agreement or governing documents requirlljgfgx 'on~ bere,managers, partners, or joint venturers, please complete snd execute additional Conffgrrtf ~ ages.

EDS-16 x ~ftfTY, 6 ass~ 6/2o16<IIIIN4l>~