C1547026_Bidders_Checklist_W.Bid_Submittal_Docs..pdf

State of California Natural Resources Agency Edmund G. Brown Jr., Governor

DEPARTMENT OF PARKS AND RECREATION Lisa Ann L. Mangat, Director

Bidder’s Checklist

Items below must be submitted with your Bids. Bids missing this information will be regarded as non-responsive and therefore rejected.

____ Public Works Contract Bid Form (Exhibit B, Attachment I) (DPR 482B)

____ Non Collusion Affidavit (DPR837)

____ Bidder’s Bond (DPR495)

____ Small business Preference (DPR 85)

____ Bidder’s DVBE Participation (DPR 486)

____ Disabled Veteran Business Enterprises Declarations (STD843) ____ California Public Contract Code Section 10162 Questionnaire 10162 (DPR20) ____ Darfur Contracting Act Certification (DPR 74) - Public Contract Code sec 10478

YOUR RETURN ADDRESS

(REQUIRED)

INVITATION FOR BID (IFB) –

CONFIDENTIAL

Park Name:

Border Field State Park Contract Number and Project Name:

C1547026 – Goat Canyon Sediment Clean Out and Removal of Deposition Material SB/DVBE Option Bid/Quote Day:

Monday, April 18, 2016 at 2:00 PM

Department of Parks and Recreation San Diego Coast District 4477 Pacific Highway San Diego, CA 92110

14:00 4/18/2016

Nondiscrimination Compliance Statement: The prospective contractor's signature affixed hereon and dated shall constitute a certification under penalty of perjury under the laws of the State of California that the bidder has, unless exempted, complied with the nondiscrimination program requirements of Government Code Section 12990 and Title 2, California Code of Regulations, Section 8103.

Verification: By signing this Bid Form, the bidder assures the state that it has not been convicted of violating a state or federal law regarding the employment of undocumented aliens, in the preceding five years.

The prospective contractor's signature affixed hereon and dated shall constitute a certification that the representations made by the prospective contract in the bid are made under penalty of perjury under the laws of the State of California.

Important: Pursuant to Title 2, California Code of Regulations, Section 8103 and Business and Professions Code Section 7028.15, no bid will be considered unless it contains the certifications and license information requested on this form. The State reserves the right to waive any irregularity in any bid or to reject any or all bids.

LICENSE NO.

DPR 482B (Rev. 10/2003)(Excel 10/15/2003)

KIND OF WORK NAME AND ADDRESS

1500 Monument Road, San Diego, CA 92173

Goat Canyon Sediment Basin Clean Out and Deposition

Material Removal

State of California - The Resources Agency

DEPARTMENT OF PARKS AND RECREATION

PUBLIC WORKS BID FORM

PROJECT LOCATION

PROJECT NAME

STATUS OF BUSINESS (Check appropriate box.)

Individual.

Corporation. State in which incorporated:

Partnership. Full names of partners:

Listed hereinafter are the names, addresses and contractor's license numbers of all subcontractors who will perform work or labor or render services in an amount in excess of one-half of one percent of the general contractor's total bid if this bid is accepted and the portion of the work that each will perform. Material vendors are not included.

FAX NO.

BY (Authorized Signature)

CITY/STATE/ZIP CODE

PRINTED NAME AND TITLE OF PERSON SIGNING

CONTRACTOR/BIDDER FIRM NAME (Printed)

ADDRESS

LICENSE CLASSIFICATION

DATE

BID DATE BID TIME

CERTIFICATION

I, the official named below, CERTIFY UNDER PENALTY OF PERJURY that I am duly authorized to legally bind the prospective Contractor to the clause(s) listed above. This certification is made under the laws of the State of California. I understan d that failure to submit the Public Works Bid Form without the appropriate bidder signature will result in rejection of the bid.

LICENSE EXPIRATION DATE LICENSE NO.

Exhibit B, Attachment 1

PHONE NO.

Exhibit B, Attachment I (Bid Form) Goat Canyon Sediment Basin Clean Out and Deposition Material Removal.

C1547026

The Goat Canyon Sediment Basin complex (GCSB), managed by California State Parks (CSP, the State), is a sediment capture/retention facility located within Border Field State Park (BFSP), 1500 Monument Road, San

Diego, CA 92154 (Figure 1); it captures cross-border run-off from Mexico. The GCSB includes the Sediment

Basins which consist of a concrete bottom in-canyon diversion structure that transitions into a flow-through sedimentation basin system of two earth bottom sedimentation retention basins in series. Additional infrastructure associated with the GCSB includes the Processing Pad- a roughly 9-acre staging and work area designed to stage and process Deposition Material captured by and removed from the Sediment Basins, and

Trash Booms. Additional infrastructure also associated with the GCSB includes a system of access roads and routes, general staging areas, a water source, and other features.

The Contractor shall un-hook the two Trash Booms and pull them to the basin edge prior to removal of the depositional material from the Sediment Basins. Upon completion of sediment removal, the

Contractor shall re-attach the two Trash Booms. The Contractor shall remove Solid Waste consolidated in discrete surface accumulations behind the two Trash Booms. Haul off-site, out of the Park, appropriate volume of Deposition Material.

All According to the Scope of Work, marked Exhibit A, Attachment I, hereby attached and made a part of this bid booklet.

The State desires to complete the maximum amount of work that can be accomplished within available funds.

The award of contract, if made, will be to the lowest responsible bidder who submits the lowest Total Base

Bid for Option A (preferred).

Should the lowest qualified bid for the Total Base Bid for Option A be greater than the available funds, the

State will then review the bids for the Total Base Bid for Option B. The award of contract, if made, will be to the lowest responsible bidder for the Total Base Bid for Option B.

Should the lowest qualified bid for the Total Base Bid for Option B be greater than the available funds, the

State will then review the bids for the Total Base Bid for Option C. The award of contract, if made, will be to the lowest responsible bidder for the Total Base Bid for Option C.

Should the lowest qualified bid for the Total Base Bid for Option C be greater than the available funds, the

State will then review the bids for the Total Base Bid for Option D. The award of contract, if made, will be to the lowest responsible bidder for the Total Base Bid for Option D.

Should the lowest qualified bid for the Total Base Bid for Option D be greater than the available funds, the

State will then review the bids for the Total Base Bid for Option E. The award of contract, if made, will be to the lowest responsible bidder for the Total Base Bid for Option E.

Should the lowest qualified bid for the Total Base Bid for Option E be greater than the available funds, the

State will then review the bids for the Total Base Bid for Option F. The award of contract, if made, will be to the lowest responsible bidder for the Total Base Bid for Option F.

All of the following Quote/Bid Options A, B, C, D, E, and F must be completed with a dollar amount.

Bid Option A:

Contractor shall remove 20,000 cubic yards (cy) of Deposition Material from the Sediment Basins. Contractor shall haul 25,000 cy of Deposition Material off-site, out of the park. Additionally, the Contractor shall haul off all products of any Deposition Material sorting or processing. During the authorized work period, the

Contractor shall own all Deposition Material with option to process and separate at their discretion. The State shall make the Processing Pad available to the Contractor. To the extent possible, Contractor shall seek to haul additional Deposition Material off-site for beneficial re-use, at no additional cost to the State.

The intent of Option A is to clean the Sediment Basins of 20,000 cy of Deposition Material and require the off-site removal of 25,000 cy of Deposition Material, and to encourage the off-site removal (out of the park) of additional Deposition Material by allowing the Contractor to explore beneficial re-use of all the Deposition

Material.

Totals

Remove Deposition Materials from Sediment Basins $_______/cy 20,000cy $_______

Haul off-site $_______/cy 25,000cy $_______

Est… Labor: $__________________________

Materials & Related Expenses: $___________

Total Base Bid Option A: $_______________

Total Base Bid A. Dollar Amount Written Out -_____________________________________

Bid Option B:

Contractor shall remove 20,000 cy of Deposition Material from the Sediment Basins. Contractor shall haul

20,000 cy of Deposition Material off-site, out of the park. Additionally, the Contractor shall haul off all products of any Deposition Material sorting or processing. During the authorized work period, the Contractor shall own all Deposition Material with option to process and separate at their discretion. The State shall make the Processing Pad available to the Contractor. To the extent possible, Contractor shall seek to haul additional

Deposition Material off-site for beneficial re-use, at no additional cost to the State.

The intent of Option B is to clean the Sediment Basins of 20,000 cy of Deposition Material and require the off-site removal of 20,000 cy of Deposition Material, and to encourage the off-site removal (out of the park) of additional Deposition Material by allowing the Contractor to explore beneficial re-use of all the Deposition

Material.

Totals

Remove Deposition Materials from Sediment Basins $_______/cy 20,000cy $_______

Haul off-site $_______/cy 20,000cy $_______

Est… Labor: $__________________________

Materials & Related Expenses: $___________

Total Base Bid Option B: $________________

Total Base Bid B. Dollar Amount Written Out -_____________________________________

Bid Option C:

Contractor shall remove 20,000 cy of Deposition Material from the Sediment Basins. Contractor shall haul 15,000 cy of Deposition Material off-site, out of the park. Additionally, the Contractor shall haul off all products of any Deposition Material sorting or processing. During the authorized work period, the Contractor shall own all Deposition Material with option to process and separate at their discretion. The State shall make the Processing Pad available to the Contractor. To the extent possible, Contractor shall seek to haul additional

Deposition Material off-site for beneficial re-use, at no additional cost to the State.

The intent of Option C is to clean the Sediment Basins of 20,000 cy of Deposition Material and require the off-site removal of 15,000 cy of Deposition Material, and to encourage the off-site removal (out of the park) of additional Deposition Material by allowing the Contractor to explore beneficial re-use of all the Deposition

Haul off-site $_______/cy 15,000cy $_______

Est… Labor: $__________________________

Materials & Related Expenses: $___________

Total Base Bid Option C: $________________

Total Base Bid C. Dollar Amount Written Out -_____________________________________

Bid Option D:

Contractor shall remove 20,000 cy of Deposition Material from the Sediment Basins. Contractor shall haul

12,000 cy of Deposition Material off-site, out of the park. Additionally, the Contractor shall haul off all products of any Deposition Material sorting or processing. During the authorized work period, the Contractor shall own all Deposition Material with option to process and separate at their discretion. The State shall make the Processing Pad available to the Contractor. To the extent possible, Contractor shall seek to haul Deposition

Material off-site for beneficial re-use, at no additional cost to the State.

The intent of Option D is to clean the Sediment Basins of 20,000 cy of Deposition Material and require the off-site removal of 12,000 cy of Deposition Material, and to encourage the off-site removal (out of the park) of additional Deposition Material by allowing the Contractor to explore beneficial re-use of all the Deposition

Haul off-site $_______/cy 12,000cy $_______

Est… Labor: $__________________________

Materials & Related Expenses: $___________

Total Base Bid Option D: $________________

Total Base Bid D. Dollar Amount Written Out -_____________________________________

Bid Option E:

Contractor shall remove 20,000 cy of Deposition Material from the Sediment Basins. Contractor shall haul

10,000 cy of Deposition Material off-site, out of the park. Additionally, the Contractor shall haul off all products of any Deposition Material sorting or processing. During the authorized work period, the Contractor shall own all Deposition Material with option to process and separate at their discretion. The State shall make the Processing Pad available to the Contractor. To the extent possible, Contractor shall seek to haul Deposition

The intent of Option E is to clean the Sediment Basins of 20,000 cy of Deposition Material and require the off-site removal of 10,000 cy of Deposition Material, and to encourage the off-site removal (out of the park) of additional Deposition Material by allowing the Contractor to explore beneficial re-use of all the Deposition

Haul off-site $_______/cy 10,000cy $_______

Est… Labor: $__________________________

Materials & Related Expenses: $___________

Total Base Bid Option E: $________________

Total Base Bid E. Dollar Amount Written Out -_____________________________________

Bid Option F:

Contractor shall remove 20,000 cy of Deposition Material from the Sediment Basins. Contractor shall haul

7,000 cy of Deposition Material off-site, out of the park. Additionally, the Contractor shall haul off all products of any Deposition Material sorting or processing. During the authorized work period, the Contractor shall own all Deposition Material with option to process and separate at their discretion. The State shall make the Processing Pad available to the Contractor. To the extent possible, Contractor shall seek to haul Deposition

The intent of Option F is to clean the Sediment Basins of 20,000 cy of Deposition Material and require the off-site removal of 7,000 cy of Deposition Material, and to encourage the off-site removal (out of the park) of additional Deposition Material by allowing the Contractor to explore beneficial re-use of all the Deposition

Haul off-site $_______/cy 7,000cy $_______ Est… Labor: $__________________________

Materials & Related Expenses: $___________

Total Base Bid Option F: $________________

Total Base Bid F. Dollar Amount Written Out -_____________________________________

ADDENDUM ACKNOWLEDGEMENT (Please initial for Addendums received)

ADDENDUM #1 ___________ADDENDUM #2____________ADDENDUM #3___________

State of California - Natural Resources Agency

DEPARTMENT OF PARKS AND RECREATION

NON-COLLUSION AFFIDAVIT TO BE EXECUTED BY

BIDDER AND SUBMITTED WITH BID FOR PUBLIC WORKS

STATE OF CALIFORNIA

COUNTY OF

SS

(Name)

DATED: By

(Position title)

(The bidder)

(Person signing for bidder)

Subscribed and sworn to (or affirmed) before me on this___________ day of ___________________, 20_____ , by the

THIS FORM MUST REMAIN WITH THE BID

(Notary Public) (Notarial Seal)

DPR 837 (Rev. 6/2011)(Excel 6/22/2011) the party making the foregoing bid that the bid is not made in the interest of, or on behalf of, any undisclosed person, partnership, company, association, organization, or corporation, that the bid is genuine and not collusive or sham; that the bidder has not directly or indirectly induced or solicited any other bidder to put in a false sham bid, and has not directly or indirectly colluded, conspired, connived, or agreed with any bidder or anyone else to put in a sham bid, or that anyone shall refrain from bidding; that the bidder has not in any manner, directly or indirectly, sought by agreement, communication, or conference with anyone to fix the bid price of the bidder or any other bidder, or to fix any overhead, profit, or cost element of the bid price, or of that of any other bidder, or to secure any advantage against the public body awarding the contract of anyone interested in the proposed contract; that all statements contained in the bid are true;

and, further, that the bidder has not, directly or indirectly, submitted his or her bid price or any breakdown thereof, or the contents thereof, or divulged information or data relative thereto, or paid, and will not pay, any fee to any corporation, partnership, company, association, organization, bid depository, or to any member or agent thereof to effectuate a collusive or sham bid.

, being first duly sworn, deposes and says that he or she is person named above, proved to me on the basis of satisfactory evidence to be the person(s) who appeared before me.

That we, , as Principal, and as Surety, are held and firmly bound unto the State of California, hereinafter called the State, in the penal sum of ten percent (10%) of the total amount of the bid of the Principal above named, submitted by said Principal to the State of California, Department of Parks and Recreation for the work described below, for the payment of which sum in lawful money of the United States, well and truly to be made, we bind ourselves, our heirs, executors, administrators and successors, jointly and severally, firmly by these presents.

WHEREAS, the Principal has submitted the above-mentioned bid to the State of California, Department of Parks and Recreation, for certain construction specifically described as follows, for which bids are to be opened at for

NOW, THEREFORE, If the aforesaid Principal is awarded the contract and, within the time and manner required under the specifications, after the prescribed forms are presented to him or her for signature, enters into a written contract, in the prescribed form, in accordance with the bid, and files the two bonds with the Department, one to guarantee faithful performance and the other to guarantee payment for labor and materials, as required by law, then this obligation shall be null and void; otherwise, it shall be and remain in full force and virtue.

In the event suit is brought upon this bond by the Obligee and judgment is recovered, the Surety shall pay all costs incurred by the Obligee in such suit, including a reasonable attorney's fee to be fixed by the court.

IN WITNESS WHEREOF, We have hereunto set our hands and seals on this day of , 20

(SEAL)

(SEAL)

(SEAL)

(SEAL)

(SEAL)

(SEAL)

NOTE: Signatures of those executing for the Surety must be properly acknowledged.

County of ss

On this day of before me, a notary public in and for the county and state aforesaid, personally appeared, known to me to be the person whose name is subscribed to the within instrument and known to me to be the attorney-in-fact of and acknowledged to me that he subscribed the name of the said company thereto as surety, and his own name as attorney-in-fact.

DPR 495 (Rev. 11/2002)(Excel 11/8/2002)

KNOW ALL PEOPLE BY THESE PRESENTS:

CERTIFICATE OF ACKNOWLEDGEMENT

BIDDER'S BOND

State of California - The Resources Agency

DEPARTMENT OF PARKS AND RECREATION

THE CONDITION of this obligation is such that:

Surety

Principal

State of California

(SEAL

Notary Public

(Insert date of bid opening)

(Insert place where bids will be opened)

(Copy here the exact description of work, including location, as it appears on the proposal) in the year of 20 on

COMPANY NAME CONTRACTING WITH NATURE OF WORK TIER

DOLLAR

VALUE

OF

Total Small Business Subcontractor Dollar Value

Total Amount of Bid

TOTAL % OF BID FOR ALL SMALL BUSINESS SUBCONTRACTORS

DPR 85 (Rev. 6/2011)(Excel 6/6/2011)

COMPLETION INSTRUCTIONS

SMALL BUSINESS PREFERENCE

State of California - Natural Resources Agency

DEPARTMENT OF PARKS AND RECREATION

Certified Small Businesses (SBs) may receive a 5% preference. Non Certified Small Business (SB) contractors may receive a 5% preference by subcontracting a minimum of 25% of the total monetary amount of their bid to Certified Small Businesses.

See the DPR 478, Small Business Notice for more information about the SB Preference.

COMPANY NAME: List the names of the subcontractors and suppliers proposed for the 25% Small Business (SB) subcontractor participation.

CONTRACTING WITH: Enter the name of the company with which the company listed is contracting.

NATURE OF WORK: Identify the proposed work (or materials or equipment) to be provided.

TIER: The Bidder may count toward its 25% Small Business participation goal the dollar value of work and supplies to be obtained by its primary subcontractors and suppliers from SB subcontractor firms as second and third level tier subcontractors/suppliers. Using the following codes, indicate the contracting tier for each SB company listed for participation:

0 = Prime or Joint Contractor 1 = Primary Subcontractor or Supplier 2 = Subcontractor/Supplier of Level 1 Subcontractor/Supplier 3 = Subcontractor/Supplier of Level 2 Subcontractor/Supplier

DOLLAR VALUE: Enter the dollar amount of the bid to be performed by the listed company’s own forces.

PERCENTAGE OF BID: Enter the percentage of the total bid amount the dollar value represents.

PRINTOUT: In order to claim the 25% Small Business participation credit, a printout from the Office of Small Business and DVBE Services eProcurement website for each SB listed.

PRINT-

OUT

DATE CONTRACTOR NAME

PART I

IS CONTRACTOR A CALIFORNIA CERTIFIED SMALL BUSINESS?

YES NO

If Yes, attach Contractor's certification printout from the eProcurement website to this form and stop here.

If No, you still may qualify for the Small Business Preference, complete Part II below.

PART II

SB CERT NO.

SB CERT NUMBER:

SB CERT NUMBER:

SB CERT NUMBER:

SB CERT NUMBER:

DPR 486 (New 1/2010)(Excel 1/26/2010)

C1547026

COMPANY INFORMATION

COMPANY INFORMATION: List the information (Company Name, Contact information) of subcontractor(s) and supplier(s) proposed for DVBE. If prime contractor is a DVBE, the name must be listed for participation.

COMPLETION INSTRUCTIONS

PART 1 — SUMMARY OF DISABLED VETERAN BUSINESS ENTERPRISE (DVBE) PARTICIPATION

State of California - Natural Resources Agency

DEPARTMENT OF PARKS AND RECREATION

COMPANY NAME

CONTACT

COMPANY NAME

CONTACT

I hereby certifiy that I have made a diligent effort to ascertain the facts with regard to the representations made herein. In making this certification, I am aware of Section 12650 et seq. of the Government Code providing for the imposition of treble damages for making false claims against the State and Section 10115.10 of the Public Contract Code making it a crime for intentionally making an untrue statement in this certificate.

PART 2 — BIDDER'S CERTIFICATION

BIDDING COMPANY'S NAME

SIGNATURE

DATE

TITLE (e.g. BUSINESS OWNER/CHIEF EXECUTIVE OFFICER, ETC.)

CONTRACTING WITH: Show the name of the department or company with which the company listed is contracting.

PRINT OUT: In order to claim DVBE participation credit, a printout from the eProcurement system showing their supplier ID and the status of their certification must be furnished with the bidder's bid or upon the signing of contract documents. Check mark if a copy of the printout is included.

NATURE OF WORK: Identify the proposed work (or materials or equipment) to be provided.

TIER: Bidder may count toward its participation goal the dollar value of work and supplies to be obtained by its primary subcontractors and suppliers from DVBE firms as second and third level tier subcontractors/suppliers. Contracting tier should be indicated with the following designations:

DVBE company listed for participation.

0 = Prime or Joint Contractor 1 = Primary Subcontractor or Supplier 2 = Subcontractor/Supplier of Level 1 Subcontractor/Supplier 3 = Subcontractor/Supplier of Level 2 Subcontractor/Supplier

DOLLAR VALUE: The dollar amount of the bid to be performed by the listed company’s own forces.

PERCENTAGE OF BID: The percentage of the total bid amount the dollar value represents.

CONTRACTING WITH

PERCENT OF BID

PRINT-

OUT

TIER

NATURE OF WORK

CONTACT PHONE

DOLLAR VALUE

COMPANY NAME

CONTACT

CONTRACTING WITH

PERCENT OF BID

PRINT-

OUT

TIER

NATURE OF WORK

CONTACT PHONE

DOLLAR VALUE

CONTRACTING WITH

PERCENT OF BID

PRINT-

TIER

NATURE OF WORK

CONTACT PHONE

DOLLAR VALUE

COMPANY NAME

CONTACT

CONTRACTING WITH

PERCENT OF BID

PRINT-

TIER

NATURE OF WORK

CONTACT PHONE

DOLLAR VALUE

BIDDER'S DVBE PARTICIPATION

PRINTED NAME

OUT

OUT

SOLICITATION NUMBER

DVBE CERTIFICATION NO.

DVBE CERTIFICATION NO.

DVBE CERTIFICATION NO.

DVBE CERTIFICATION NO.

DVBE CERTIFICATION NO.: Provide the DVBE Certification Number assigned to company.

http://www.documents.dgs.ca.gov/pd/poliproc/STD-843FillPrintFields.pdf http://www.documents.dgs.ca.gov/pd/poliproc/STD-843FillPrintFields.pdf

Bidders are cautioned that making false certification may subject the certifier to criminal prosecution.

The Department of Parks and Recreation (DPR) reserves the right under California Public Contract Code Section 10162 to reject any bidder, any officer of such bidder, or any employee of such bidder who has a proprietary interest in such bidder who has been disqualified, removed or otherwise prevented from bidding on, or completing a federal, state or local govern-ment project because of a violation of law or violation of safety regulations.

Failure to return this form with the bid shall not be cause for rejection; however, bidders must furnish the completed form within the time frame prescribed by the DPR. Failure to submit this form within the time frame prescribed by the DPR may be deemed refusal of an award which shall be cause for forfeiture of bidder's security.

By my signature, I certify under penalty of perjury under the laws of the State of California that the foregoing questionnaire and statements pursuant to California Public Contract Code Section 10162 are true and correct.

DPR 20 (New 10/2003)(Excel 10/24/2008)

CERTIFICATION

Goat Canyon Sediment Basin Clean and Deposition Material Removal

NOTICE TO BIDDERS

State of California - The Resources Agency

DEPARTMENT OF PARKS AND RECREATION

CALIFORNIA PUBLIC CONTRACT CODE SECTION 10162

PARK UNIT NAME

In accordance with Section 10162 of the California Public Contract Code, bidders shall complete, HAVE YOU, ANY OFFICER OF YOUR BUSINESS, OR ANY EMPLOYEE OF YOUR BUSINESS WHO HAS PROPRIETARY INTEREST IN YOUR BUSINESS EVER BEEN DISQUALIFIED, REMOVED, OR OTHERWISE PREVENTED FROM BIDDING ON, OR COMPLETING A FEDERAL, STATE, OR LOCAL GOVERNMENT PROJECT BECAUSE OF A VIOLATION OF LAW OR

VIOLATION OF SAFETY REGULATIONS?

Yes (Explain circumstances below. Attach additional pages if needed.) No

BIDDER SIGNATURE PRINTED NAME DATE

under penalty of perjury, the question below. Please answer the following:

— Questionnaire —

PROJECT NAME

NAME OF BUSINESS

DPR 74 (Rev. 9/2010)(Excel 9/2/2010)

FOR DEPARTMENT USE ONLY

C1547026

State of California - Natural Resources Agency

DEPARTMENT OF PARKS AND RECREATION

DARFUR CONTRACTING ACT CERTIFICATION

Public Contract Code Sections 10475 -10481 applies to any company that currently or within the previous three years has had business activities or other operations outside of the United States. For such a company to bid on or submit a proposal for a State of California contract, the company must certify that it is either a) not a scrutinized company; or b) a scrutinized company that has been granted permission by the Department of General Services to submit a proposal.

If your company has not, within the previous three years, had any business activities or other operations outside of the United States, you do not need to complete this form.

AGREEMENT/PAPO NO.

OPTION #1 - CERTIFICATION

If your company, within the previous three years, has had business activities or other operations outside of the United States, in order to be eligible to submit a bid or proposal, please insert your company name and Federal ID Number and complete the certification below.

I, the official named below, CERTIFY UNDER PENALTY OF PERJURY that a) the prospective proposer/bidder named below is not a scrutinized company per Public Contract Code 10476; and b) I am duly authorized to legally bind the prospective proposer/bidder named below. This certification is made under the laws of the State of California.

COMPANY/VENDOR NAME (Printed)

BY (Authorized Signature)

PRINTED NAME AND TITLE OF PERSON SIGNING

DATE EXECUTED EXECUTED IN THE COUNTY AND STATE OF

FEDERAL ID NUMBER

OPTION #2 - WRITTEN PERMISSION FROM DGS

Pursuant to Public Contract Code section 10477(b), the Director of the Department of General Services may permit a scrutinized company, on a case-by-case basis, to bid on or submit a proposal for a contract with a state agency for goods or services, if it is in the best interests of the state. If you are a scrutinized company that has obtained written permission from the DGS to submit a bid or proposal, complete the information below.

We are a scrutinized company as defined in Public Contract Code section 10476, but we have received written permission from the Department of General Services to submit a bid or proposal pursuant to Public Contract Code section 10477(b). A copy of the written permission from DGS is included with our bid or proposal.

COMPANY/VENDOR NAME (Printed)

INITIALS OF SUBMITTER

PRINTED NAME AND TITLE OF PERSON INITIALING

FEDERAL ID NUMBER