HomeMy WebLinkAboutMINUTES - 10172006 - C.17 sE
TO: BOARD OF SUPERVISORS, AS GOVERNING BOARD Contra
OF THE CANYON LAKES GEOLOGICAL HAZARD ,l
CostaABATEMENT DISTRICT
z
FROM: MAURICE M. SHIU, PUBLIC WORKS DIRECTOR
oSTgtOUt= �~ county
DATE: October 17, 2006 Q t-�_
SUBJECT: RATIFY the decision of the Canyon Lakes Geologic Hazard Abatement District(GHAD) General
Manager to execute a Consulting Services Agreement with Farallon Geographies, Inc. in an amount
not to exceed $26,400 to provide asset management information and consulting services to the
Canyon Lakes GHAD for the period August 1, 2006 through June 30, 2007, San Ramon area. (Canyon
Lakes GHAD Funds) (District III) Project No. 7761-6X5148
SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION
RECOMMENDED ACTION:
RATIFY the decision of the Canyon Lakes Geologic Hazard Abatement District (GHAD) General Manager to
execute a Consulting Services Agreement with Farallon Geographies, Inc. in an amount not to exceed $26,400 to
provide asset management information and consulting services to the Canyon Lakes GHAD for the period August 1,
2006 through June 30, 2007.
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❑ SIGNATURE:
CONTINUED ON ATTACHMENT; S
✓,. RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
—7 APPROVE OTHER
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SIGNATURE(S): L '
ACTION OF BOODO d2 �`y �T %J�I��11� APPROVED AS RECOMMENDED OTHER
VOTEOF UPERVISORS: I HEREBY CERTIFY THAT THIS IS A TRUE AND CORRECT
COPY OF AN ACTION TAKEN AND ENTERED ON
UNANIMOUS(ABSENT �n(� ) MINUTES OF THE BOARD OF SUPERVISORS ON THE
AYES: NOES: DATE SHOWN.
ABSENT: ABSTAIN:
Contact: Eric Whan 313-2242
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G:\SpDist\Board Orders\2006-Board Ordersl10-17-06 BO Farallon Canyon ATTESTED
Lakes.doc JOHN CULLEN, CLERK OF THE BOARD OF
SUPERVISORS AND COUNTY ADMINISTRATOR
cc: County Administrator
County Counsel
Assessor
Auditor-Controller BY: DEPUTY
E.Doten,Special Districts
Kleinfelder,Inc.
SUBJECT: RATIFY the decision of the Canyon Lakes Geologic Hazard Abatement District (GRAD)
General Manager to execute a Consulting Services Agreement with Farallon Geographics, Inc. in
an amount not to exceed $26,400 to provide asset management information and consulting
services to the Canyon Lakes GHAD for the period August 1, 2006 through June 30, 2007, San
Ramon area. (Canyon Lakes GHAD Funds) (District III) Project No. 7761-6X5148
DATE: October 17, 2006
PAGE: 2 of 2
FISCAL IMPACT:
There is no impact to the County General Fund. The Canyon Lakes GHAD is funded through revenues generated by
special assessments on properties within the boundaries of the Canyon Lakes GHAD.
REASONS FOR RECOMMENDATIONS AND BACKGROUND:
Farallon Geographics, Inc. has provided ongoing consulting services in the area of GIS (Geographic Information
Systems) and GPS (Geographic Position Systems), which allows the District to manage data collected through a
variety of means including incident response reports, repair site maps and location and condition data of other
District maintained facilities.
Farallon Geographics will continue to provide monthly web hosting services, update the database with regard to
property ownership and property geometries.
In addition, the general manager requested Farallon Geographics, Inc. to provide public access to portions of the
website to further develop the District's public communications plan; import additional mapping layers to the GIS
system to allow a more comprehensive spatial analysis of collected data, and to assist the District in implementing
and managing its GPS systems program.
CONSEQUENCES OF NEGATIVE ACTION:
Negative action would deprive the District of access to time-sensitive and critical data to use in its operations. It
would further inhibit the District's ability to manage new data and information during its routine operations.
CONSULTING SERVICES AGREEMENT
1.Soecial Conditions. These Special Conditions are incorporated below by reference.
(a) Public Agency: Canyon Lakes Geologic Hazard Abatement District
(b) Consultant's Name&Address: Farallon Geographlcs. Ino_
600 Mission Street 2" Floor
San Francisco CA 94105 Phone:(415)227-1140 Fax:(415)227-1148
(c) Project Name,Number&Location: Geographic Information Service
(d) Effective Date: August 1,2006 (e) Payment Limit(s): $26,400
(f) Completion Date(s): June 30,2007
(g) Federal Taxpayer's I.D.: 94-3278601
2. Signatures. These signatures attest the parties'agreement hereto:
PUBLIC AGENCY CONS T NT
By:Richard D.Short,Kleinfelder, Inc. Cr GY
General Manager 8
(Designate official capacity in the business)
By
By: � ...K^ � V (Designate official capacity in the business)
Type of Business:Sole Proprietorship,Government Agency,
Partnership or Corporation(circle one)
If Corporation,State of Incorporation: r-"T�t
Note to Consultant: For corporations,the contract must be signed by two officers. The first signature must be that of the chairman of the board,president or
vice-president;the second signature must be that of the secretary,assistant secretary,chief financial officer or assistant treasurer.(Civ.Code,Sec.1190 and
Corps.Code.Sec.313.) The acknowledgment below must be signed by a Notary Public.
CERTIFICATE OF ACKNOWLEDGMENT
State of California )
ss.
County of I�v.
On the date write below, efore me, OY personally appeared(insert name and title of the offi er
personally known to me(or proved to me on the sis of satisfactory evidence)to b he person
whom se na v— is' re ubscribed to the within instrument and acknowledged to me that he/she�e executed the same in hi her eir uthorize
capacity, and that by his/her/ signature6 on the instrument the persor16,or the entity upon behalf of which the persold acted,executed the
instrume`it
WITNESS my hand and official seat.
Dated: f2�0k 6--) -Z8oc�
(Notary's Seal
45- ERICA GARCIA BOLANOS
Commission# 1676000
Notary Public.California
San Francisco County
Expifes Jun 18.2010
3. Parties. Effective on the above S nsultant mutually agree and promise as follows:
4. Employment Public Agency hereby employs Consultant,and Consultant accepts such employment,to perform the professional services described
herein,upon the terms and in consideration of the payments stated herein.
5. Scope of Service. This is an"on call"contract. Scope of service shall be described in Appendix A,attached hereto and made a part hereof bythis
reference.
6. Reoort Disclosure Section. Any document or written report prepared hereunder by Consultant,or a subcontractor,for Public Agency shall contain,
in a separate section,the numbers and dollar amounts of this contract and all subcontracts relating to the preparation of such document or written
report, provided that the payment limit specified in Sec. 1(e)exceeds$5,000. When multiple documents or written reports are the subject or
products of this agreement,the disclosure section may also contain a statement indicating that the total contract amount represents compensation
for multiple documents or written reports.
7. Insurance. Consultant shall, at no cost to Public Agency,obtain and maintain during the term hereof: (a)Workers'Compensation Insurance
pursuant to state law; (b) Professional Liability Insurance with minimum coverage of 51,000,000 a maximum deductible of$50,000;and (c)
Comprehensive General Liability Insurance,including blanket contractual(or contractual liability)coverage,broad form oropertydamage coverage,
and coverage for owned and non-owned vehicles,with a minimum combined single limit coverage of$2,000,000 for all damages due to bodily
injury, sickness or disease,or death to any person,and damage to property,including the loss of use thereof,arising out of each accident or
occurrence,and naming Contra Costa County,Sands Construction Company,Inc.,Canyon Lakes GRAD,Richard D.Short,Kleinfelder,Inc. and
their boards,officers and employees as additional insureds. Consultant shall promptly furnish t0 Public Agency certificates of insurance evidencing
such coverage and requiring 30 days'written notice to Public Agency of policy lapse,cancellation or material change in coverage.
8. Payment. Public Agency shall pay Consultant for professional services performed at the rates shown in Appendix B attached hereto,which include
all overhead and incidental expenses,for which no additional compensation shall be allowed. Notwithstanding the foregoing,those incidental
expenses specifically itemized in Appendix B shall be reimbursable by Public Agency to Consultant,provided that Consultant submits copies of
receipts and,if applicable,a detailed mileage log to Public Agency. In no event shall the total amount paid to Consultant exceed the payment
limit(s)specified in Sec. 1(e)without prior written approval of the Public Agency. Consultant's billing statements shall be submitted at convenient
intervals approved by Public Agency and shall list,for each item of services,the employee categories,hours and rates.Public Agency will pay
consultant in accordance with the requirements of Civil Code Section 3320 as applicable.
9. Status. The Consultant is an independent contractor,and shall not be considered an employee of Public Agency.
10. Time for Completion. Unless the time is extended in writing by Public Agency,Consultant shall complete all services covered by this Agreement no
later than the Completion Date(s)listed above.
11. Record Retention and Auditina. Except for materials and records delivered to Public Agency,Consultant shall retain all materials and records
prepared or obtained in the performance of this Agreement,including financial records,fora period of at least five years after Consultant's receipt of
the final payment under this Agreement. Upon request by Public Agency,at no additional charge,Consultant shall promptly make such records
available to Public Agency,or to authorized representatives of the state and federal governments,at a convenient location within Contra Costa
County designated by Public Agency,and without restriction or limitation on their use.
12. Documentation. Consultant shall prepare and deliver to Public Agency at no additional charge,the items described in Appendix A to document the
performance of this Agreement and shall furnish to Public Agency such information as is necessary to enable Public Agency to monitor the
performance of this Agreement.
13. Ownership of Documents. All materials and records of a finished nature, such as final pians,specifications, reports,and maps, prepared or
obtained in the performance of this Agreement,shall be delivered to and become the property of Public Agency. All materials of a preliminary
nature, such as survey notes, sketches, preliminary plans, computations and other data, prepared or obtained in the performance of this
Agreement,shall be made available,upon request,to Public Agency at no additional charge and without restriction or limitation on their use.
14. Extra Work. Any work or services in addition to the work or services described in Appendix A shall be performed by Consultant according to the
rates or charges listed in Appendix B. In the event that no rate or charge is listed for a particular type of extra work,Consultant shall be paid for the
extra work at a rate to be mutually agreed on prior to commencement of the extra work. In no event shall Consultant be entitled to compensation for
extra work unless a written authorization or change orderdescribing the work and payment terms has been executed by Public Agency prior to the
commencement of the work.
15. Payment Retention. Public Agency shall retain ten percent(10%)of the monies due the Consultant as security for the fulfillment of this Agreement.
After the Consultant has completed all work under this Agreement,submitted final billing,and the Public Agency has found the work to be accurate,
the Public Agency will pay all withheld funds. Public Agency will pay withheld funds in accordance with the requirements of Civil Code Section 3320
as applicable. Retention will not be withheld for any"on-call"work.
16. Termination by Public Aaency. At its option, Public Agency shall have the right to terminate this Agreement at any time by written notice to
Consultant,whether or not Consultant is then in default, Upon such termination,Consultant shall,without delay,deliver to Public Agency all
materials and records prepared or obtained in the performance of this Agreement,and shall be paid,without duplication,all amounts due for the
services rendered up to the date of termination.
17. Abandonment by Consultant. In the event the Consultant ceases performing services under this Agreement or otherwise abandons the project prior
to completing all of the services described in this Agreement,Consultant shall,without delay,deliver to Public Agency all materials and records
prepared or obtained in the performance of this Agreement,and shall be paid for the reasonable value of the services performed up to the time of
cessation or abandonment,less a deduction for any damages or additional expenses which Public Agency incurs as a result of such cessation or
abandonment.
18. Breach. In the event that Consultant fails to perform any of the services described in this Agreement or otherwise breaches this Agreement,Public
Agency shall have the right to pursue all remedies provided by law or equity. Any disputes relating to the performance of this Agreement shall not
be subject to non-judicial arbitration. Any litigation involving this Agreement or relating to the work shall be brought in Contra Costa County,and
Consultant hereby waives the removal provisions of Code of Civil Procedure Section 394.
19. Compliance with Laws. In performing this Agreement,Consultant shall comply with all applicable laws,statutes,ordinances,rules and regulations,
whether federal,state or local in origin.This includes compliance with prevailing wage rates and their payment in accordance with California Labor
Code,Section 1775.
20. Assignment. This Agreement shall not be assignable or transferable in whole or in part by Consultant,whether voluntarify,by operation of law or
otherwise;provided,however,that Consultant shall have the right to sub-contract that portion of the services for which Consultant does not have the
facilities to perform so long as Consultant notifies Public Agency of such subcontracting prior to execution of this Agreement.Any other purported
assignment,transfer or sub-contracting shall be void.
21. Subcontracting. All subcontracts exceeding$25,000 in cost shall contain all of the required provisions of this contract. Consultant will pay each
subconsultant in accordance with the requirements of Civil Code Section 3321 as applicable.
22. Endorsement on Plans. Consultant shall endorse all plans,specifications,estimates, reports and other items described in Appendix A prior to
delivering them to Public Agency,and where appropriate,indicate his/her registration number.
23. Patents and Copyrights. The issuance of a patent or copyright to Consultant or any other person shall not affect Public Agency's rights to the
materials and records prepared or obtained in the performance of this Agreement. Public Agency reserves a license to use such materials and
records without restriction or limitation,and Public Agency shall not be required to pay any additional fee or royalty for such materials or records.
The license reserved by Public Agency shall continue for a period of fifty years from the date of execution of this Agreement,unless extended by
operation of law or otherwise.
24. Indemnification. Consultant shall defend,indemnify,save and hold harmless Public Agency,Contra Costa County,Richard D.Short,Kleinfelder,
Inc.,Canyon Lakes GHAD,Sands Construction Company,Inc.and their boards,officers and employees from any and all claims,costs and liability
for any damages,injury or death arising directly or indirectly from,or connected with,the services provided hereunder and due to,or claimed or
alleged to be due to, negligence or willful misconduct of Consultant, its officers, employees, agents, subconsultants,or any person under its
direction or control,save and except claims or litigation arising through the sole negligence or sole willful misconduct of Public Agency,and will
make good to and reimburse the indemnitees for any expenditures,including reasonable attorney's fees,the indemnitees may make by reason of
such matters and, if requested by any of the indemnitees, will defend any such suits at the cost and expense of Consultant. Consultant's
obligations under this section shall exist regardless of concurrent negligence or willful misconduct on the part of the Public Agency or any other
person;provided,however,that Consultant's obligation to indemnify shall be limited to the proportion of negligence orwillful misconduct attributable
to Consultant,its subconsultants,or any person under Consultant's direction or control.
25. Heirs Successors and Assigns. Except as provided otherwise in Section 20 above,this Agreement shall inure to the benefit of and bind the heirs,
successors,executors,personal representatives and assigns of the parties.
26. Public Endorsements. Contractor shall not in its capacity as a contractor with Public Agency publicly endorse or oppose the use of any particular
brand name or commercial product without the prior approval of the Public Agency's governing board. In its Public Agency Contractor capacity,
Contractor shall not publicly attribute qualities or lack of qualities to a particular brand name or commercial product in the absence of a well-
established and widely-accepted scientific basis for such claims or without the prior approval of the Public Agency's governing board. In its Public
Agency contractor capacity, Contractor shall not participate or appear in any commercially-produced advertisements designed to promote a
particular brand name or commercial product,even if Contractor is not publicly endorsing a product,as long as the Contractor's presence in the
advertisement can reasonably be interpreted as an endorsement of the product by or on behalf of Public Agency. Notwithstanding the foregoing,
Contractor may express its views on products to other contractors, the Public Agency's governing board, its officers,or others who may be
authorized by the Public Agency's governing board or by law to receive such views.
27. Project Personnel. In performing the services under this Agreement,Consultant shall use the personnel listed in Appendix C,attached hereto and
made a part hereof by this reference. Changes in project personnel may only be made with Public Agency's written consent,and Consultant shall
notify Public Agency in writing at least thirty(30)days in advance of any proposed change. Any person proposed as a replacement shall possess
training,experience and credentials comparable to those of the person being replaced.
28. Payment Review. Public Agency's payment for the services performed by Consultant under this Agreement shall be subject to review,
determination of satisfaction,and approval of the Contra Costa County Public Works Department,pursuant to Section 1 of the Joint Exercise of
Powers Agreement dared June 24, 1986 between Public Agency and the County of Contra Costa.
Attachments:Appendix A,Appendix B,Appendix C
Form approved by County Counsel(5,198)
Canyon Lakes Geologic Hazard Abatement District (GRAD)
Farallon Geographies, Inc.
Professional Services Contract
Appendix A
Scope of Work
Task A: GIS Web Application Hosting Service
Description: Farallon Geographic will provide monthly hosting services for the Canyon Lakes GRAD GIS applications.
This service includes management and maintenance of the web server hardware/software and GIS map server software
as well as access by Kleinfelder and the Canyon Lakes GHAD to the Canyon Lakes GRAD GIS applications. Under this
task, Farallon will maintain all aspects of the Canyon Lakes GHAD GIS web applications, database, and related web
server hardware and software.
Task B: Semi-annual Update of GHAD GIS Database
Description: This task will include semi-annual updates of the property owner records and the parcel geometries in
the Canyon Lakes GHAD GIS. Farallon will update the Canyon Lakes GHAD GIS property owner records and
parcel geometry to reflect new subdivisions,parcel splits, and parcel merges based on the County's parcel basemap.
I.n past years,parcel geometries in the Canyon Lakes GHAD GIS were only updated annually. This task assumes a
total of two(2) semi-annual updates (including parcel geometry updates) to the Canyon Lakes GHAD GIS.
Task C: GIS Technical Support Services
Description: The Canyon Lakes GHAD has requested Farallon develop a budget to provide GIS Technical Support
Services for fiscal year 2006/2007. Tasks that fall under this scope have not yet been defined in detail. Once defined,
Farallon will provide a detailed proposal and cost estimate. We have identified several tasks that could be supported
under this task:
o Strategic consulting services
o Development of Issue Tracker for the GHAD
o Semi-annual updates of asset data
o Further development of Asset Management application
a Additional web application development or site enhancements
o Development of new GIS layers
• GPS support
® General support and training
All work under this task will be performed using GHAD Task Orders and scoped using Farallon's 2006 Pate Sheet
(see attachment).
General Manger may add other tasks to scope of services on an as-needed basis.
Canyon bakes Geologic Hazard Abatement District (CHAD)
Farallon Geographies, Inc.
Professional Services Contract
Appendix B
Fee Schedule
2006 RATE SHEET
PERSONNEL:
Personnel charges are for technical work performed including the preparation of reports and correspondence and for the time associated with
production of such documents.Direct charges are not made for secretarial service,office management,and accounung;these items are included
in overhead.The rates for each Personnel Category are listed below:
Personnel Category Hourly Rate
Senior Managers $200-$250
Project Managers $140-$185
Senior GIS Application Developers S160-$200
GIS Application Developers S125 -$150
Senior Database Engineers S 185 -$225
Database Engineers $165 -$185
Senior GIS Analysts $150-S175
CIS Analysts $125 -$140
Associates $90-$105
Technical Training $165 -$225
Time spent in travel in the interest of the client will be charged at hourly rates,except that no more than 8 hours of travel time will be charged in
any day.When it is necessary for an employee to be away from the office overnight,actual costs,or a negotiated rate,will be charged for living
expenses.Rates are subject to change on January 1'"'2007.
OUTSIDE SERVICES:
Outside services will be charged at cost plus 15%.Common outside items include:equipment rental,printing and photographic work,special
insurance,and outside consultants.
REIMBURSABLE EXPENSES:
These out-of-pocket expenses include travel expenses,large format color map production,in-house document production,postage or delivery
services, long-distance communications and specialized computer software expenses.These expenses will be invoiced at cost plus 15%.
INVOICES:
A late charge of 1.5%per month or the maximum charge allowed by law,whichever is less,will be payable on accounts not received within 30
days from invoice date.
Farallon will invoice the GRAD monthly for the work described in this Proposal for GIS Services. Any monthly invoices will be based on the
percentage completion of the project.
Changes in this scope of work initiated by the GHAD may require modifications of the project budget. If you find the proposed scope of work,
cost, and project schedule acceptable,please develop a CHAD Task Order outlining our scope and costs for each task.
Canyon bakes Geologic Hazard Abatement District (GHAD)
Farallon Geographies, Inc.
Professional Services Contract
Appendix C
Personnel
Consultant agrees to assign the following personnel:
Dennis Wuthrich
Jeff Saunders
David Lapp
Alexie Peters
Stephanie Stanfield
Other personnel may be assigned from time to time; Consultant understands that any such
appointments may be subject to approval of the General Manager
Contra Costa County
Self Certification Form
Small Business Enterprise and Outreach Programs
All of the non-statistical information provided in SECTION 1 will be included in the County's SBE and
Outreach Directory, which may be shared with County Departments, contractors, consultants, and others
in both electronic (internet, intranet, e-mail, facsimile) and paper formats, unless you indicate otherwise in
SECTION 5.
ECT[ON 1
Name of Firm(Print)
Street Address(City,State) (Zip Code)
f1141 S_'/a ,,) 1_ rc,SGv C/9
Mailing Address(City,State) (Zip Code)
(Area Cade)Phone No. 4rea Code)Fax No. E-mail
Is your main office located in Contra Costa County`? Yes all No jq. o _
Business Entity Status
Check all appropriate boxes: MBE ❑ WBE ❑ DBE Z SBE LBE ❑ DVBE ❑ OBE ❑
See Page 3 For Definitions)
For Statistical Purposes Only
Ethnicity of Owner(s): White Black ❑ Hispanic ❑ Asian ❑ American Indian/Alaskan Native ❑
SECTION 2 Complete this section to certify as a Small Business Enterprise. (See Page 3 for Definitions)
State Certified SBE: Yes No
Certification No.: kv
Have your gross receipts for the past three years averaged$10 million or less Do you employ more than 100 employees to ether
per year? Yes No with affiliates? Yes No
Is your principal office located in California? Yes No ❑
The officers reside in California? Yes No ❑
SECTION 3 Complete this section to certify as a Minority Business Enterprise (MBE)and/or Woman Business
61/61
Enterprise(WBE) and/or Disabled Veteran Business Enterprise(DVBE) (See Page 3 for Definitions)
Check appropriate box:
Contractor❑ Special Trade Contractor❑ Tracker ❑ Manufacturer❑ Construction Supplier❑ Vendor❑
Consultant/Service Provider ❑
Are you certified with any other agencies: Yes No
If"Yes"please list: Q Q
If you are a Contractor,are your annual gross receipts fourteen million dollars(514,000,000)or less? Yes No Qi
If you area Special Trade Contractor,are your annual gross receipts seven million dollars($7,000,000)or less? Yes No
If you are a Trucker/Manufacturer/Supplier/Vendor,do you meet the SBA size standard? Yes ❑ No (�(
(For the specific SBA size standard contact the Affirmative Action Office,(925)335-1045
Is your firm 51%owned and managed by one or more minority owners? Yes Ul No
Is your firm 51%owned and managed by one or more women owners? Yes ❑ No ❑
Is your firm 51%owned and managed by one or more disabled veteran owners? Yes ❑ No ❑
Are the owners citizens or lawful permanent residents of the U.S.? Yes U No
If you are a DVBE,is your principal office located in the United States? Yes ❑ No ❑
As a DVBE,do you reside in California? Yes ❑ No ❑
Revised 09/10/04
a:SBEOutreachSelfCertification See Other Side Page l of 3
Contra Costa County
Small Business Enterprise and Outreach Programs
Self Certification Form
ECTION Work Conducted By Firm(Describe what your firm does.)
Construction
Vendor/Supplies
Consultant �"
Service Provider (,jGCI / tf'Q y �f, „1 f n�G r•-.-sTIG�
SECTION Acknowledgement of Publication
The undersigned acknowledges and agrees that the non-statistical information provided in SECTION I may be published in the County's
SBE and Outreach Directory which may be shared with County Departments,contractors,consultants,and others in both electronic
(internet, intranet,e-mail; facsimile)and paper formats,unless exceptions are noted below.
A 1 agree to publication of all SECTION I information.
❑ 1 do not agree to publication of the following(check all that apply):
❑ Street Address ❑ Phone Number ❑ E-mail Address
❑ Mailing Address ❑ Fax Number ❑ Business Entity Status
SECTION Certification of Ownership
The undersigned is authorized to execute this Self Certification form on behalf of
(DC� Mt $ SILn .1 -T ! �o )Ah 7/anCISCD C. J VS1COfFirm'
��h1SyYtlt,G
Street Address(City,State,Zip Code) Name(s)of Owner(s)
And swears under penalty of perjury that our firm meets the definition of MBE,WBE,DBE,SBE,LBE,DVBE,and/or OBE set forth on
page 3 of this form and that all information contained in this form is true and correct.Any material misrepresentation will be grounds
for terminating any purchase orders or contracts which may be or have been awarded.
Signed in _(� " -TiAnC + fC0 CA-
a 1 _ 6 ,200 �(City,County,State)
on �° ,n -CY'/-VBy q�fi. cam, �. !� ✓ "Y'/-V
t=— f �y -Name) J e, c _• Title �
f
(Signature) Area CodePhone No.
Return this Self-Certification Form to the department who sent you this form or:
Contra Costa County
Affirmative Action Oft-ice
651 Pine Street—10i'Floor
Martinez,CA 94553
De artment Use
ECT10N Departmental Concurrence
The undersigned department concurs in the above Self-Certification form and is satisfied that the applicant meets the requirements for self
certification as an MBE,WBE,DBE,SBE,LBE,DVBE,and/or OBE.
By
(Print Name) (Department)
(Signature of Department Head or Deputy) (Area Code) Phone No.
Date
Revised 09/10/04
a:SBEOutreachSelfCertification See Other Side Page 2 of 3