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ATTACHMENT C <br /> MBE/WBE PROCUREMENT REPORTING FORM <br /> Grantee's Name : -- - --- --- --- - <br /> 1 . EPA Financial Assistance Agreement Number: <br /> 2 . Reporting ( Performance) Period : <br /> 3 . Business 4 . $ Value of 5 . Date of 6 . Type of 7 . Name]Address/Phone Number of MBE/WBE <br /> Enterprise Procurement Award Product or Contractor. or Vendor <br /> MM/DD/YY Services <br /> Minority Women (Enter Code) <br /> (MBE) (WBE) <br /> , <br /> , <br /> , <br /> I <br /> I <br /> , <br /> I <br /> , <br /> , <br /> , <br /> , <br /> , <br /> , <br /> , <br /> ; <br /> Type of product or service codes: <br /> 1 = Construction 2 = Supplies 3 = Services 4 = Equipment <br /> DEP Agreement No. G0353 , Attachment C, Page 1 of 3 <br />