Loading...
HomeMy WebLinkAboutMINUTES - 05181999 - C80-C84 17 U TO: BOARD GP SUPERVISORS FROM, William Waller, M.D. , Health Services Director •,r t ������ By: Ginger Marieiro, Contracts Administrator �' Costa DATE: Aprii 28, 1999 County suBsEOT: Approval of Contract #24- 950-21 with Rhiannon Shires, MFCC SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION RECOMMENDED ACTION Approve and authorize the Health Services Director, or his designee (Donna Wigand) , to execute on behalf of the County, Contract 424-950-21 with Rhiannon Shires, MFCC, for the period from March 1, 1999 through June 30, 2000, to provide Medi-Cal mental health ;specialty services, to be paid in accordance with the rates set forth in the attached fee schedule . FISCAL IMPACT: This Contract is funded by State and. Federal FFP Medi-Cal Funds . BACKGF.OUNDZREA.SON(,S) FOR RECOMMENDATIONS : Cn January 14 , 19.97, the Board of Supervisors adopted. Resolution #97/17, authorizing the Health Services Director or his designee (Donna Wigand, LCSW) to contact with the ,State Department of Mental Health to assume responsibility for Medi-Cal specialty mental health services as of july 1, 1997 . Responsibility for outpatient specialty mental health services involves contracts with individual, group and organizational providers to deliver these services . Approval of Contract #24-9.50-21 will allow the Contractor to provide mental health specialty services through June 30, 2000 . ATTACHMENT: YES a SIGNATURE` gat RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE APPROVE —OTHER 1 ACTION OF BOARD ON_ 2L�'� APPROVED AS RECOMMENDED - ,�"� ©TREK VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE UNANIMOUS {ABSENT° ) AND CORRECT COPY OF AN ACTION TAKEN AYES: NOES: m AND ENTERED ON THE MINUTES OF THE BOARD ABSENT: ABSTAIN: OF SUPERVISORS ON THE DATE SHOWN. ATTESTED r > ,CLERK PHIL BATCH LOROI=THE80ARD FOF SUPERVISORS AND COUNTY ADMINISTRATOR Contact Person: Donna Wigand {313 .6411} CC: Health Services(Contracts) Risk Management Auditor Controller BY i, t ✓�,4 DEPUTY Contractor Board Order Pane 2 MFCC REIMBURSEMENT TABU i LEVEL CPT CODE PROCEDURE TIME RATE LEVEL E CODES 99205 ; Outpatient Assessment Visit- New Patient ? 60 min. $30 i 90844 individual Psychotherapy 60 rain. $30 X9508 Family Therapy 60 rain. $30 90853 AGroup Therapy- per person/per visit 90 rein. $12. X9544 Case Conference 30 min $15 zX9546 Case Conference 60 min. $ 0 TO: BOARD OF SUPERVISORS FROM. William Waller, M.D. , Health Services Director r 1� Contra Ginger Marieiro, Contracts Administrator Costa DATE: April 30, 1399 County SUBJECT: Approval of Contract #24-950-1 with Trinity Counseling Center SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION RECOMMENDED ACTION: Approve and authorize the Health Services Director, or his designee (Donna Wigand) , to execute on behalf of the County, Contract 424-950-1 with Trinity Counseling Center, for the period from January 1, 1.999 through June 30, 1999, to provide Medi-Cal mental health specialty services, to be paid in accordance with the rates set forth in the attached fee schedule. FISCAL IMPACT: This Contract is funded by State and Federal FFP Medi-Cal Funds . BACKGROUND/REASON(S) FOR RECOMMENDATIONS: On January 14, 1997, the Board of Supervisors adapted Resolution 497/17, authorizing the Health Services Director or his designee (Donna Wigand, LCSW) to contract with the State Department of Mental Health to assume responsibility for Medi-Cal specialty mental health services as of July 1, 1997 . Responsibility for outpatient specialty mental health services involves contracts with individual, group and organizational providers to deliver these services . Approval. of Contract #24- 950-1 will allow the Contractor to provide mental health specialty services through June 30, 1999 . ATTR FIM NT Y gS SIGNATURE t° °- •. RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE APPROVE OTHER -- ACTION OF BOARD ON '! APPROVED AS RECOMMENDED . _ OTHER VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE _ UNANIMOUS (ABSENTS ��` ) AND CORRECT COPY OF AN ACTON TAKEN AYES: NOEE S: AND ENTER€D ON THE MINUTES OF THE BOARD ABSENT: ABSTAIN; OF SUPERVISORS ON THE DATE SHOWN. ATTESTED,Z&OW, /Q t j'L�7� PHIL BATCfiELOR,CLERK OF THE BOARD OF Contact Person: Donna Wigand (313-6411) SUPERVISORS AND COUNTY ADMINISTRATOR CC: Health Services(Contracts) Risk Management �� q Auditor Controller BY Contractor DEPUTY Board order Page 2 PHYSICIAN REIMBURSEMENT TABLE LEVET. CPT CODE PROCEDURE TIME RATE LEVEL I CODES 99204 InIIial qutpatient Psychiatrlo Assessment 60 min. $90�l 901362 Medic.lien Mena gemen#y'_ 20 min. $45 99242 s Child Consultation 30 min. $60 99244 Child Consultation 60 min. $90 EMERGENCY DEPARTMENT 99284 �Emergency Department Mental Health Services 45 min. $45 HOSPITAL INPATIENT 99222 ;Hospital Care-Initial 60 min. $60 SERVICES :__.._..______... i99232 Hosplta3 Gara-Subsequanl 30 min. $30 --99233 1-Hospital Gare-Subsequent 60 min. $60 NURSING FACILITY 1 99301 1 Evaluation and Management 30 min. $30 ASSESSMENT 99303 Evaluation and Management 60 min. 550 `99311 Subsequent Nursing Facility Care 15 min. $15 99313 i Subsequent Nursing Facility Care 30 min. $30 IRESTHOME 99323 Evaivation of New Patient 60 min. $60 —__.- .. _. .___ __. -- - - — -- ---- 99333 Evaluation of Established Patient 30 min. $30 HOME SERVICES 99341 Evaluallon of New Patient 80 titin. $60�� 99353 Evaluation of Established Patient -� � 30 min. I PhD REIMBURSEMENT TABLE LEVEL_ CPT CODE PROCEDURE TIME MATE LEVEL I CODES X9514 Test Administration(max 6 hours) 60 min. $30 X9532 Test Scoring(max-2-hours) 60 min. $30 X9538 i Tesl Report Writing(max 2 hours) 80 min. $30 i I X9502 Individual Psychotherapy-inpatient Selling i 60 titin. $30 99205 Outpatient Assessment Visit-New Patient 60 min. $30 90644 individual Psychotherapy 60 min. $30 X9508 ,Family Therapy _.— 60 min. $30y� 90953 ; her Group TI -per personfper visit I 90 min $12 l _ X9544 Case Conference 30 min. $15 l X9546 Case Conference __ _ 60 min. �$30 EMERGENCY DEPARTMENT , 99284 ;Emergency Department Mental health Services 45 min. $22.50 l INPATIENT CONSULTS 99251 Inpaifen.t Consultation New Patient 30 min. l $154 99253 inpatlanl Consultation New Patient 60 min. 4 �$30 i MFCC REIMBURSEMENT TABLE LEVEL CPT CODE PROCEDURE TIME RATE i LEVEL I CODES ' 99205 G Oulpiitient Assessment Visit-New Patient 60 min. $30 l 90344 `Individual Psychotherapy 60 min. $30 X9506 Family Therapy 60 min. i $30 90853_ Group Therapy-per persontper visit�Tu s 90 min. �$12.�__ X9544 Case Conference 30 ruin $15 i X9546 Case Conference 60 min. $30 LCSW REIMBURSEMENT TABLE LEVEL CPT CODE PROCEDURE TIME RATE i 1 LEVEL I CODES 99205 �Outpatient Assessment Visit-New Patient 60 min. i $30 90644 Individual Psychotherapy 60 min. $30 X950$ Family-Therapy W 60 min _$30 90853 Group Therapy per personfper visit i 90 min. $12 X9544 i Case Conference 30 min $15 X9546 Case Conference 60 min. $30 25614 EPSDT Supplemental Services delivered by an LCSW 530 1 iMERGENCY DEPARTMENT� 93284 Emergency Department Mental Heath Services 48 min. i $22.50 i TO: BOARD OF SUPERVISORS FROM: William. Walker, M.D. , Health Services Director Contra By: Ginger Marieiro, Contracts Administrator ` Costa [SATE: koril 28, 1999 County SUBJECT: Approval of Contract #24-950-27 with Sharon Wigg-Owens, MFCC SPECIFIC REQUEST(S)OR RECOMMENDATIONS;&BACKGROUND AND JUSTIFICATION - RECOMMENDED ACTION: Approve and authorize the Health Services Director, or his designee (Donna Wigand`, , to execute on behalf of the County, Contract ##24-950-27 with Sharon Pigg-Owens, MFCC, for the period from April 1, 1999 through June 30, 2000, to provide Medi-Cal mental health specialty services, to be paid in accordance with the rates set forth in the attached fee schedule . FISCAL IMPACT: This Contract is funded by State and Federal FF? Medi-Cal Funds . BACKGROMPZREASON(S) FOR RECOMMENDATIONS : On January 14, 1997, the Board of Supervisors adopted ResolutioT? #97/17, authorizing the Health Services Director or his designee (Donna Wigand, LCSW1j to contract with the State Department of Mental Health to assume responsibility for Medi-Cal specialty mental health services as of July 1, 1997 . Responsibility for outpatient specialty mental health services involves contracts with individual, group and organizational providers to deliver these services . Under Contract #24-950-27 the Contractor will provide mental health specialty services through June 30, 2000 . - 4NU4G N-ATTACHMENT: y YES SIGNATU RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOAR(`COMMITTEE ✓` APPROVE OTHER ACTION OF BOARD ON APPROVED AS RECOMMENDED OTHER VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE UNANIMOUS (ABSENT/-/-/; ) AND CORRECT COPY OF AN ACTION TAKEN AYES: NOES: AND ENTERED ON THE MINUTES OF THE,BOARD ABSENT: ABSTAIN: � OF SUPERVISORS ON THE DATE SHOWN. ATTESTED PHIL BATCHE C7f2,CLERK OF THE BOARD OF SUPERVISORS AND COUNTY ADMINISTRATOR Contact Verson: Donna Wigan (3136411) CC: Health SeMces(Contracts) Risk Management Auditor Controller BY � : fi/ DEPUTY Contractor Beard Carder Paae 2 MFCC REIMBURSEMENT TABLE i LEVEL CPT CODE PROCEDURE TIME RATE LEVEL l CIC-)DES 99205 Outpatient Assessment Visit-New Patient 60 min. $30 844 j individual Psychotherapy�u 60 min. $30 X9508 Family Therapy_ 60 rain. $30 90853 _ Group Therapy-per person/per visit 00 rain. $12, I X9544 Case Conference , 30 miry $16 ( X9546 Case Conference 60 min. T0: BOARD OF SUPERVISORSContra GUS S. KRAMER, ��....,,.... FROM: Qty FRO �. 4� County DATE: May 18, 1999 SUBJECT: APPRAISAL CONSULTATION SPECIFIC REOUEST(S)OR RECOMMENDATION(S)3 BACKGROUND AND JUSTIFICATION RECOMMENDATION: Approve and authorize the Chair of the Beard of Supervisors to execute a contract with Larry Black in the amount of$54,971.55 for drafting services from the period May 3, 1999 through June 30, 2000. FISCAL IMPACT This contract will be paid out of AB719 Property Tax Administration funds.. BACKGROUND: The Assessor's Office is in the process of converting its parcel maps to electronic format and this will require an experienced drafter to assist in verifying the accuracy of the converted maps. Mr. Black will also be performing additional manual and CA® drafting functions. sac% ATTACHMENT: YES SIGNATURE: - RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF SOARD C, ITTEE APPROVE OTHER SIGNATURES ACTION OF BOARD ON_ ,`-��.' 412APPROVED AS RECOMMENDED OTHER VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE UNANIMOUS{ABSENT 22 ° ) AND CORRECT COPY OF AN ACTION TAKEN AYES: NOES:_ _ _. .. -_-- AND ENTERED ON THE MINUTES OF THE BOARD ABSENT: ABSTAIN: OF SUPERVISORS ON THE DATE SHOWN; CC: M f7 C ATTESTED cYr PHIL BATCHELOR,CLERK OF THE BOARD OF SS-es S 6;x SUPERVISORS AND COUNTY ADMINISTRATOR M382 (10/88) BY ,!� ,DEPUTY Contra Costa County Number S a-,.i,d rd Form I/87 SEORT FORM SERVICE CONTRACT Fund1(3r-4 .- Account # 1. Contract Identification. .. Other # Department: Assessor Subject: Consultation and assistance with drafting functions. 2. Parties. The County of Contra Costa, California (County) , for its Department named above, and the following named Contractor mutually agree and promise as follows: Contractor: Larry Black Capacity: Manual and CAD Drafter Taxpayer TD# 565-52-4626 Address: 24 Sunnyvale Place Walnut Creek, CR 94596 3. Term. The effective date of this Contract is KV 3, 1999 and it terminates June 30, 2000 unless sooner terminated as provided herein. 4. 'germination. This Contract may be terminated by the County, at its sole discretion, upon five-day advance written: notice thereof to the Contractor, or cancelled immediately by written mutual consent . 5. Payment Limit. County's total payments to Contractor under this Contract shall not exceed�_ $ 54,g7I 6. County's Obligations . In consideration of Contractor' s provision of services as described below, and subject to the payment limit expressed herein, County shall pay Contractor, upon submission of a properly documented demand for payment in the manner and form prescribed by County (Demand Form. D-15) and upon approval of such demand by the head of the Cotnnty Department for which this Contract is made or his designee, as follows: [Check one alternative only] (X) hour, or [vlf a. FEE RATE: S 22.65 per service unit: ( ; session, as defined below or ( ) calendar (insert day, week or month) NOT TO EXCEED a total. of 2427 service unit(s) . b. Payment in full after approval by the Department . ( c. As set .forth in the attached Payment Provisions . 7. Contractor's f3bliga,tions. Contractor .small provide the following described services: To provide consulting services and assist in manual and CAD drafting functions. E. CcsMUance with Law. Contractor shall be subject to and comply with all Federal., State and local laws and regulations applicable with respect to its performance under this Contract, including but not limited to, licensing, employment and purchasing practices; and wages , hours and conditions of employment, including nondiscrimination. 9. Nondiscriminatory Services. Contractor agrees that all goods and services under this Contract shall be available to all qualified persons regardless of age, sex, race, rel i- gion, color, national origin., or ethnic background, or handicap, and that none shall be used, in, whole or in part , for religious worship or instruction. -I- SHORT FORM SERVICE CON�AC1 Number 10. �;ndiinendent Contractor Status . This Contract is by and between two independent contract-ors and is not intended to and shall not be construed to create the relationship between the parties of agent , servant, employer, partnership, joint venture, or association. 11. Disputes. Disagreements between the County and Contractor concerning the meaning, requirements, or performance of this Contract shall be subject to final determination in writing by the head of the County Department for which this Contract is trade or his designee or in accordance with the applicable procedures (if any) required by the State or Federal Government . 12. Access to Books and Records of Contractor, Subcontractor. Pursuant to Section 1861_ v)(1) of the Social. Security Act, and any regulations promulgated thereunder, Contractor shall-, upon written request and until the expiration of four years after the furnishing of services pursuant to this Contract, make available to the Secretary of Health and Human Services, the Comptroller General, the County, or any of their duly authorized representatives, this Contract and books, documents, and records of Contractor that are necessary to certify the nature and extent of all costs and charges hereunder. Further, if Contractor carries out any of the duties of this Contract through a sub- contract with a value or cast of $10,000 or more over a. twelve-month period, suck: sub- contract sha?l, contain a clause to the effect that upon written request and until the expiration of four years after the furnishing of services pursuant to such subcontract, the subcontractor shall, maks: available, to the Secretary, the Comptroller General, the County, or any of their duly authorized representatives, the subcontract and books, docu- ments, and records of the subcontractor that are necessary to verify the nature and extent of all costs and charges hereunder . This special condition is in addition to any and all other terms regarding the maintenance or retention, of records under this Contract and is binding on the heirs, successors, assigns and representatives of Contractor. 13. Reporting Rmuiremerts. Pursuant to Government Code §7550, Contractor shall include in all doc :ar:ts or written reports completed and submitted to County in accordance with this Contract, a separate section listing the numbers and dollar amounts of all contracts and subcontracts relating to the preparation of each such doc,=ent or written report. This section shall apply only if the payment limit under this Contract exceeds $5,000. 14. lndemrLif3.cation. 'ahe Contractor shall defend, indemnify, save, and hold harmless the County and its officers and employees from any and all claims, costs and liability for any damages, sickness , death., or injury to person(s) or property, including without Limitation all, consequential damages , from any cause whatsoever arising directly or indirectly from or connected with the operations or services of the Contractor or its agents, servents, employees or subcontractors hereunder, save and except claims or litigation arising through the sore negligence or sole willful misconduct of the County or its officers or employees . Contractor will make good to and reimburse the County for any expenditures, including reasonable attorneys fees , the County may make by reason of such matters and, if requested by the County will defend any such suits at the sole cost and exaense of the Contractor. 15= Le a... Authority. Thos Contract is entered into under and subject to the following legal authorities : California Government Code Sections 26227 and 31-000. 16. Signatures. These signatures attest the parties" agreement hereto: CC {y F 0034 . 0 CALIFORNIA CON" .C.r , By By 4 Designee Z e� '01 .tou n Administrator � � (Designate official_ capacity) Y, .; Y -- Designee Recommended bDepartment " �' 'Form approved, by County Counsel] UF-STIONNAIR FOR j2F-I'Ettivil IN t!G IND ENDENT A=cbment#l. CON7RACTOR PAYMENT MMiQ All new or renewal independent cont-ctor agreements that do not meet IRS criteria for independent contract stags must be paid through the payroll system so that withholding taxes and Social Security can be deduced (nom: this does not apply in the case of contracts with corporations, temporary help agencies, and partnerships). For complebon by Department Head or Authorized Designee 3- Do €, as the employer, have the right to control not only the result of the work, bine also the way in which it is done? b. Am I setting the Independent contractor's hours; C. Is the independent contractor restricted from taking jobs from other businesses at the same time they are working for me? d. Do I or outer departments have employee(s) wth similar duties as the independent contractor? (X) C? e< Does the County supply assistants to the contractor'? ( ) ) f Is the duration of employment for a specific period of time rather than a specific job? g. Does the County furnish training, tools, or equipment to the contractor? A *yes" answer to any of the above questions will require paying the contractor through the payroll system. CONTRACTOR CER-1 IFICAT'ION PREPARED BY: I Certify that the answers to Robin Perez the above questions accurately X reflect t. e amicipated workilig relataon�hi REVIEWED ANAPPROVED BY: ffy�j{p/` IS hr De ?rent Head or Authonzed Des:nf:ee Contra Costa County Attachment #% Standard Form Revised 1195 } _ NUT 1 ' ' Tl€Tii SIN g It'd` M A 1. Withholding and FICA Deductions. Notwithstanding Paragraph 14 of the General Conditions (paragraph 10 of the Short 'Form Contract), for purposes of the withholding state and federal takes and Social Security mlv from payments due, the Auditor- Controller will matte deductions for these purposes. Contractor is = a County employee. Contractor further understands that the County has no obligation to provide, and Contractor will not be provided fringe benefits, including but not limited to, vacation, sick leave, retirement, and health plan coverage. The County will provide workers' compensation coverage and unemployment insurance if County has ri lit to control way in which work is done. Initial: # (Contractor) (County) 000-9903/A.1.1 TO: BOARD OF SUPERVISORS FROM: BARTON J. GILBERT, DIRECTOR OF GENERAL SERVICES Contra Costa DATE: May 18, 1999 County SUBJECT: APPROVING THE FIRST AMENDMENT TO THE CONSULTING SERVICES AGREEMENT FOR COURT SECURITY IMPROVEMENTS AT VARIOUS COUNTY SITES (W-H416B & WH3632) SPECIFIC REQUESTS OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION I. RECOMMENDATION A. APPROVE a First Amendment authorizing extra work under the Consulting Services Agreement dated January 13, 1999, with Daniel Rainey, Architect for architectural services for Court Security Improvements at Various County Sites. The First Amendment increases the scope of services and increases the payment limit from $35,470.00 to $47,760.00, an increase of$11,290.00. B. AUTHORIZE the Director of General Services to execute the First Amendment to the consulting services agreement and to issue written authorization for extra work, in addition to the authorization for this First Amendment, provided that the cumulative total extra cost for such additional authorizations shall not exceed$5,000.00. II. FINANCIAL, IMPACT Sufficient funds are available in the plant acquisition account to cover this increase in the Consultant's payment limit. III. REASONS FOR RECOMMENDATIONS/BACKGROUND On February 2, 1999 the Board of Supervisors approved and authorized the Director of General Services to execute the original consulting services agreement with the Consultant. The First Amendment increases the scope of services to provide additional architectural services and ADA modifications for Sally Port at 45 Civic Avenue, Pittsburg and the review and coordination of mechanical and electrical drawings for the Court Security Improvements at Various County Sites. CONTINUED ON ATTACHMENT:___7,Yf59' SIGNATURE: RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE APPROVE OTHER SIGNATURES ACTION OF BOARD ON May 184 1.999 APPROVED AS RECOMMENDED X OTHER VOTE OF SUPERVISORS UNANIMOUS(ABSENT 1VYone ) AYES: NOES: ABSENTS: ABSTAIN: MEDIA CONTACT: BARTON J.GILBERT(313-7100) CC: General Services Department 1 HEREBY CERTIFY THAT THIS IS A TRUE Architectural Division AND CORRECT COPY OF AN ACTION TAKEN AND ENTERED ON THE MINUTES OF THE BOARD Accounting OF SUPERVISORS ON THE DATE SHOWN. File: 000-9903/A.5 County Administrator's Office ATTESTED MAA 18'.. 1999 Auditor-Controller PHIL BATCHELOR,CLERK OF THE BOARD OF County Counsel SUPERVISORS AND COUNTY ADMINISTRATOR Superior Court(Via A/D) Consultant(Via A/D .` a ) DEPUTY H:\1999\0009903\9A00333b.doa Is Page 1 of 1 M382(10188) File:000-9903/A.1.1 FIRST AMENDMENT TO CONSULTING SERVICES AGREEMENT FOR COURT SECURITY IMPROVEMENTS AT VARIOUS COUNTY SITES (WH416B&WH363Q) 1. Effective Date and Parties: Effective May 18, 1999, Daniel Rainey, Architect(herein called "Consultant"), a California Corporation, and the County of Contra Costa(herein called"County") a political subdivision of the State of California,mutually agree as follows: 2. Pur rase: Or.January 13, 1999,the parties entered into a contract entitled"Consulting Services Agreement,"referred to as the"Agreement.."which covers architectural services for Court Security Improvements at Various County Sites. The parties desire to amend the Agreement to expand the scope of service and to increase the payment limit accordingly. 3. Amendments to Agreement: A. In tae Agreement,Section I(e),change the Payment Limit from$35,470.00 to$46,760.00,an increase of 511,290.00.This change shall apply to charges from and after March 9, 1999. B. In accordance with Section 14 of the Agreement,provide the following extra services: Provide additional architectural services and ADA modifications for Sally Port at 45 Civic Avenue,Pittsburg. 2. Review and coordination of mechanical and electrical drawings. 4. Effect: Subject to the revisions made by this and any prior amendments,the Agreement shall remain in full force and effect. 5, Signature: These signatures attest the parties'agreement hereto: PUBLIC AGENCY CONSULTANT By: Date: Type of business: Director of General Services/Purchasing Agent (Designate type—corporation,sole proprietorship,partnership, partnership,government agency,limited liability company,eta) If corporation,state of incorporation: By: Title: (Designate official capacity in the business) By: Title: (Designate official capacity in the business) 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,resident 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 On the date written below,before me,the undersigned Notary Public,personally appeared the person(s)signing above for Consultant,personally:mown to me (or proved to me on fie basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capaeity(ies),and that by his/her/their signature(s)on the instrument the person(s),or the entity"upon behalf of which the person(s)acted,executed the instrument. WITNESS my hand and official seal. Dated: [Notary`s Seal] Notary Public RECOMMENDED FOR APPROVAL: By: APPROVED AS TO FORM: Deputy County Administrator VICTOR J.WESTMAN County Counsel By: Deputy GB:LS:js TI:\1999\0009903\9A00334a.dcc Page 1 of I