C26690001_-_Bid_Package.pdf
PDF 7 MB Posted
- Solicitation number
- 0000039623
- Issued by
- Sacramento County, California
About this file
Bid Package Summary
This is an Invitation for Bids (IFB) package issued by the California Department of Parks and Recreation (DPR), Gold Fields District, for refuse and recycling collection services at Prairie City State Vehicular Recreation Area located in Rancho Cordova, Sacramento County. The contractor shall provide all labor, tools, equipment, materials, and supplies necessary to lawfully collect, transport, and dispose of refuse and recycling materials from various locations within the park. The scope includes regular refuse collection services (2-yard and 30-yard containers) and recycling services (cardboard, metal, wood, and concrete). Service is required for a base contract period of three years, from September 1, 2026, through August 31, 2029, with an option for one additional year (through August 31, 2030). Pickup frequencies vary by location and service type, ranging from weekly to "will call" basis. Electronic bid submissions in PDF format must be received at ContractBidReceipt.GoldFields@parks.ca.gov by 10:00 a.m. on July 9, 2026. Bids will be opened publicly via conference call at 1-877-399-7339, Participant Code 61796097.
The award will be made to the lowest qualified bidder submitting the lowest base bid amount. Bidders must complete the comprehensive bid package including certifications for Disabled Veteran Business Enterprise (DVBE), Small Business (SB) and Micro Business (MB) preferences, Target Area Contract Preference Act (TACPA) declarations, Darfur Contracting Act certifications, California Civil Rights Laws certification, Drug-Free Workplace certifications, and Artificial Intelligence disclosures. The estimated requirements are itemized by location and service period with bidders required to complete pricing on forms DPR 326B (Refuse Disposal Service Bid Form). Current business licensing, Sacramento County Solid Waste Collection Hauler Agreements, and payee data records (STD 204, STD 205, and DPR 88) must be submitted. The state reserves the right to increase, decrease, or eliminate any items as deemed necessary, with such changes not affecting unit pricing.
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| File | Type | Posted |
|---|---|---|
| C26690001_-_Sample_Documents.pdf | ||
| C26690001_-_IFB.pdf |
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Text version
INVITATION FOR BIDS
REFUSE & RECYCLING SERVICES
Prairie City State Vehicular Recreation Area
Bid Package
STATE OF CALIFORNIA
THE RESOURCES AGENCY
DEPARTMENT OF PARKS AND RECREATION
GOLD FIELDS DISTRICT
7806 FOLSOM-AUBURN ROAD
FOLSOM, CALIFORNIA 95630-1797
INVITATION FOR BIDS
REFUSE & RECYCLING SERVICES
Prairie City State Vehicular Recreation Area
Table of Contents
BID PACKAGE: NUMBER OF PAGES:
Bidder’s Declaration (GSPD-05-105)……………………………………………………………2 Current Department of General Services’ (DGS) SB/MB Certification+* DVBE Declarations (DGS PD 843)* Current DGS DVBE Certification+*…………………………………………………………...1 Target Area Contract Preference Area (TACPA) Preference Request for Goods &
Services Solicitations (STD 830) Manufacturer’s Summary of Contract Activities & Labor Hours (DGS PD 525) Bidder’s Summary of Contract Activities & Labor Hours (DGS PD 526) Commercially Useful Function - Bidder Certification (DPR87)* Refuse Disposal Service Bid Form, Exhibit B, Attachment 1 (DPR 326B) Darfur Contracting Act Certifications (DPR074) Artificial Intelligence (AI) Disclosure Form (DPR 97B) California Civil Rights Laws Certification (DGS OLS 4) Contractor Certification Clauses (CCC 04/2017) Payee Data Record (STD204) Payee Date Record Supplement (STD205)…………………………………………………….2 Payee Data Record Supplement (DPR 088) Current Business License for County or City of Business’ Location+ Current Sacramento County Solid Waste Collection Hauler Agreement+……… ……1
+ AS SUPPLIED BY CONTRACTOR
*IF CLAIMING PREFERENCE
C26690001
Contractor/Bidder Firm Name Representative's Signature Date
REPLACE THIS PAPER
WITH VALID
DEPARTMENT OF
GENERAL SERVICES
CLAIMING
STATE OF CALIFORNIA – DEPARTMENT OF GENERAL SERVICES PROCUREMENT DIVISION
DISABLED VETERAN BUSINESS ENTERPRISE DECLARATIONS
(Rev. /20 )
Instructions: The disabled veteran (DV) owner(s) and DV manager(s) of the Disabled Veteran Business Enterprise (DVBE) must complete this declaration when a DVBE contractor or subcontractor will provide materials, supplies, services or equipment [Military and Veterans Code Section 999.2]. Violations are misdemeanors and punishable by imprisonment or fine and violators are liable for civil penalties. All signatures are made under penalty of perjury.
SECTION 1
Name of certified DVBE: DVBE Ref. Number:
Description (materials/supplies/services/equipment proposed):
Solicitation/Contract Number: SCPRS Ref. Number:__________________________
(FOR STATE USE ONLY)
SECTION 2
APPLIES TO ALL DVBEs. Check only one box in Section 2 and provide original signatures.
I (we) declare that the DVBE is not a broker or agent, as defined in Military and Veterans Code Section 999.2 (b), of materials, supplies, services or equipment listed above. Also, complete Section 3 below if renting equipment.
Pursuant to Military and Veterans Code Section 999.2 (f), I (we) declare that the DVBE is a broker or agent for the principal(s) listed below or on an attached sheet(s). (Pursuant to Military and Veterans Code 999.2 (e), State funds expended for equipment rented from equipment brokers pursuant to contracts awarded under this section shall not be credited toward the 3-percent DVBE participation goal.)
All DV owners and managers of the DVBE (attach additional pages with sufficient signature blocks for each person to sign):
(Printed Name of DV Owner/Manager) (Signature of DV Owner/ Manager) (Date Signed)
(Printed Name of DV Owner/Manager) (Signature of DV Owner/Manager) (Date Signed)
Firm/Principal for whom the DVBE is acting as a broker or age nt:
(If more than one firm, list on extra sheets.) (Print or Type Name)
Firm/Principal Phone: Address:
SECTION 3
APPLIES TO ALL DVBEs THAT RENT EQUIPMENT AND DECLARE THE DVBE IS NOT A BROKER.
Pursuant to Military and Veterans Code Section 999.2 (c), (d) and (g), I am (we are) the DV(s) with at least 51% ownership of the DVBE, or a DV manager(s) of the DVBE. The DVBE maintains certification requirements in accordance with Military and Veterans Code Section 999 et. seq.
The undersigned owner(s) own(s) at least 51% of the quantity and value of each piece of equipment that will be rented for use in the contract identified above. I (we), the DV owners of the equipment, have submitted to the administering agency my (our) personal federal tax return(s) at time of certification and annually thereafter as defined in Military and Veterans Code 999.2, subsections (c) and (g). Failure by the disabled veteran equipment owner(s) to submit their personal federal tax return(s) to the administering agency as defined in Military and Veterans Code 999.2, subsections
(c) and (g), will result in the DVBE being deemed an equipment broker.
Disabled Veteran Owner(s) of the DVBE (attach additional pages with signature blocks for each person to sign):
(Printed Name) (Signature) (Date Signed)
(Address of Owner) (Telephone) (Tax Identification Number of Owner)
Disabled Veteran Manager(s) of the DVBE (attach additional pages with sufficient signature blocks for each person to sign):
(Printed Name of DV Manager) (Signature of DV Manager) (Date Signed)
Page of
PRINT CLEAR
STATE OF CALIFORNIA
DGS/PD 525 (Rev. 0 / ) MANUFACTURER’S SUMMARY Section I
SOLICITATION NUMBER
Of Contract Activities and Labor Hours To be eligible for bidding preferences, the following data/information must be provided AND signed, as indicated, by both the Manufacturer and the Bidder. Any person furnishing false certifications, willfully providing false information, omitting information, or failing to comply with the preference requirements is subject to sanctions as set forth in the statutes.
Section II Manufacturer’s Information: Must be completed by the Manufacturer
Report the projected production capacity of the facility for each product type/solicitation line item. This form must accompany any bid preference request form(s) (STD 830) submittal to the designated contracting official at the awarding department. Enter the number of all employee labor hours in an 8-hour shift at this site required and necessary to perform the contract. Employee labor hours may cover such activities as manufacturing, packaging, handling, warehousing and/or shipping the product (see reverse for additional information). Do not include labor-free time (automation or machine hours /storage/etc). If additional lines are needed, copies of this form may be used.
Contract Total Employee Contract Number Of Employees Used In 8-Hr Shift
Product Type Or Line Item Quantity Production Capacity Labor Hours Per (Of The Product Production Cycle)
(Manufactured At This Site) (Include (Units Per 8-Hr Shift) Product Type Or Line Item Product Units) Manufacturing Packaging Handling Warehousing Shipping Other *
1.
2.
3.
4.
5.
6.
7.
GRAND TOTAL
(Employee labor hours) *EXPLAIN “OTHER” ACTIVITIES OF THE MANUFACTURING CYCLE MUST BE DEFINED HERE, IF USED: (Use additional sheets, if necessary)
Section III Manufacturer’s Information and certification: Must be completed and signed by the Manufacturer
Separate “Manufacturer’s Summaries” are required for each site that is identified as a manufacturer of the contract goods.
MANUFACTURER’S NAME AND ADDRESS NAME AND TITLE OF PERSON SIGNING AS MANUFACTURER PHONE NUMBER
DATE
MANUFACTURER’S SIGNATURE FAX NUMBER
Section IV Bidder’s Certification: Must be completed and signed by the Bidder to be eligible for bidding preferences
I hereby certify under penalty of perjury that the manufacturer provided the above information to me. The proposed employee labor hours indicated above correlate with the hours reported on the preference request form(s) [STD 830] that accompany this bid.
BIDDER'S NAME AND TITLE BIDDER’S SIGNATURE PHONE NUMBER
DATE
FAX NUMBER
AGENCY/DEPT
MANUFACTURER’S SUMMARY
References and Instructions
The California Legislature has declared that it serves a public purpose and is a benefit to the State to encourage business investment, promote job development, and to facilitate job maintenance in economically distressed areas of the state. It is the intent of the Legislature to further these goals by providing appropriate preferences to California based companies submitting bids or proposals for state contracts to be performed at worksites in economically distressed areas when the contract is for goods or services in excess of $100,000. To obtain preferences, the bidder must demonstrate that a minimum 50% (for goods contracts) or 90% (for services contracts) of the projected employee labor hours necessary for the contract will be performed within the economically distressed area. This includes manufacturer’s employee labor hours.
Section I To be completed by the Bidder
Solicitation Number: Enter the solicitation number identified on the front page of the Invitation For Bid for which this form is being submitted.
Agency/Dept: Enter the name of the buying Agency and/or Department (e.g., State and Consumer Services Agency, Department of General Services)
Section II To be completed by the Manufacturer
This section identifies the projected production capacity of the manufacturer’s facility; number of employees used for each type of the bid product and total of the projected employee contract labor hours used to manufacturer the bid product for the entire contract period.
Target Area Contract Preferences Act, GC § 4530 et seq.
2 The State considers the manufacturer to be the company or companies that add value to the product by converting or transforming it from the raw or bulk product into the final bid product.
Product Type or Line Item: List the product type or line item as specified on the solicitation. Identify each product type or match the line items on the solicitation.
Contract Quantity: List the number of product unit(s) (i.e. # cases, pounds, etc.). Use the same quantity and unit of measure used in the state’s solicitation.
Production Capacity: Indicate the manufacturing capacity for each product type/line item in an 8-hour period.
Employees Used In 8-Hr Period: Indicate the number of employees used for the various production segments during an 8-hour period (example: .5, 1.5, 2). List only the production processes pertaining to the production of the bid product/line item.
Production tasks may include: manufacturing, packaging, handling, shipping, and/or other.
Production hours listed under “other” must be defined.
Total Hours: For each product type/line Item, identify the total number of employee contract labor hours projected to be used for the entire contract period.
Section III To be completed by the Manufacturer
Firm & address:
Authorized Representative:
Contact phone number:
Date:
Signature:
Section IV To be completed by the Bidder
Section IV must be completed and signed by the bidder to be eligible for the bidding preference.
Enter the manufacturer’s name & address.
Type or print the name and title of the person signing the form.
Enter the telephone number and fax number for the manufacturer.
Enter the date the form is completed and signed by the manufacturer
Sign y the manufacturer
1.
2.
3.
4.
5.
6.
7.
8.
9.
Report the projected contract labor hours for each contract activity for administration, receiving, order processing, order shipping preparation. and transportation to state delivery point (see reverse for additional information). Report all employee labor hours necessary to perform this contract. Do not include labor-free hours (automated processing/storage time, etc.).
Contract Quantity (Total Product
Units) ReceivingAdministration
Number Of Bidder Contract Labor Hours To Be Used For This Contract
Other*
Total Number Of Contract Labor Hours Per PS Type Or Line
Item
Product Type Or Line Item Transportation
Order Shipping
Preparation
Order Processing (pick/pull)
Section II
Section I
SOLICITATION NUMBER AGENCY/DEPT
To be eligible for the bidding preferences, the following data/information must be provided AND signed by the BIDDER. Any person furnishing false certifications, willfully providing false information, omitting information, or failing to comply with the preference requirements is subject to sanctions as set forth in statutes
BIDDER'S SUMMARY
Of Contract Activities and Labor Hours
DATE
I hereby certify under penalty of perjury that the information and labor hours reported on this form are accurate and complete. I understand that any person falsely certifying, willfully providing false information, omitting information, or failing to comply with the preference statutes may be subject to sanctions as set forth in the statutes.
(Employee Labor Hours) Grand Total
BIDDER'S NAME AND TITLE BIDDER'S SIGNATURE
FAX NUMBER
PHONE NUMBER
The "Bidder's Summary" of the contract activity and employee labor hours must be completed and signed by the Bidder. This form must accompany any bid preference request form STD 830 submittal to the designated contracting official at the awarding department.
STATE OF CALIFORNIA
DGS/PD 526
Rev. 0 /20
* EXPLAIN "OTHER" ACTIVITIES OF CONTRACT USED MUST BE DEFINED HERE: (Use additional sheets, if necessary)
Empty
Empty
Empty Section III To be eligible the following certification statement must be read and signed by the Bidder.
Empty Empty
Product/Service Type or Line Item:
List the product/service type line item/s as specified on the solicitation. Separate each product/service type to match the line items on the solicitation.
Contract Quantity: List the product/service unit (i.e. # cases, lbs., hours, etc.). Use the same quantity and unit measure as specified in the solicitation.
Hours For This Contract:
Empty Empty
Solicitation Number: Enter the solicitation number identified on the front page of the Invitation For Bid for which this form is being submitted.
Grand Total: List the cumulative employee labor hours for the entire contract period.
Agency/Department:
Empty
Empty
Target Area Contract Preferences Act, GC § 4530 et seq.
Section III must be completed and signed by the bidder.
Empty
BIDDER'S SUMMARY
References and Instruction
Section II
The purpose of this section is to capture the bidder’s projected employee/s labor hours to perform this contract. Hours projected should only be those that the bidder itself will use and does not include manufacturing, or any other subcontracted hours.
The California Legislature has declared that it serves a public purpose and is a benefit to the state, to encourage business investment, promote job development, and to facilitate job maintenance in economically distressed areas of the state. It is the intent of the Legislature to further these goals by providing appropriate preferences to California based companies submitting bids or proposals for state contracts to be performed at worksites in economically distressed areas by persons with a high risk of unemployment, when the contract is for goods or services in excess of $100,000. To qualify for TACPA preference, the bidder must show that a minimum 50% (for Goods) or 90% (for Services) contracts of the projected employee/s labor hours necessary for the contract will be performed within the economically distressed area.
Section IIIEnter the name of the buying Agency and/or Department (e.g., State and Consumer Services Agency, Department of General Services)
If the bidder requests TACPA contract preference, GC § 4530 et seq., the Bidder’s Summary form must be completed and signed by the bidder for requested preference. The purpose of this form is to give the state contracting official, a tool to evaluate the total bidder employee labor hours required to complete this contract both inside and outside the preference areas.
Section I
Provide the projected number of employee labor hours to be used by the bidder in the performance of this contract. Hours may include, for example, Administrative, Logistics, Receiving, Warehousing, Shipping, Handling, and/or Other. Do not include labor hours for time the product is stationary.
Empt
State of California � Natural Resources Agency
DEPARTMENT OF PARKS AND RECREATION
COMMERCIALLY USEFUL FUNCTION � BIDDER CERTIFICATION
All California Certified Small Business (SB), Micro Business (MB), and Disabled Veteran Business Enterprise (DVBE) suppliers contracting and subcontracting must complete this certification form.
LEGAL BUSINESS NAME (including �Doing Business As� DBA name) DPR REFERENCE/AGREEMENT NUMBER
CERTIFICATIONS (mark all that apply)
Small Business Micro Business DVBE
DGS CERTIFICATION NUMBER
(OSDS)
EXPIRATION DATE
For this agreement, this business is the: Prime Contractor Subcontractor
All Certified Small Business, Micro Business, and/or DVBE prime contractors, subcontractors or suppliers must meet the commercially useful function requirements under Government Code Section 14837(d)(4)(A) for Small and Micro Businesses, and Military and Veterans Code Section 999(b)(5)(B)(i) for DVBEs.
A. Is the GSPD-05-105, Bidder Declaration attached? Yes No
B. Is the DGS PD 843, Disabled Veteran Business Enterprise Declarations form attached if applicable?
Yes No N/A
Please answer the following 5 questions as they apply to your company for the goods and/or services being acquired in this solicitation:
Will your business be responsible for the execution of a distinct element of the resulting work?
Yes No
Will your business carry out the obligation of the contract by actually performing, managing or supervising the work involved?
Yes No
3 Will you perform work that is normal for your business, service and functions? Yes No
Will your business be responsible for products, inventories, materials, suppliers required for the contract, negotiating price, determining quality and quantity, ordering, installing (if applicable) and making payment?
(Note: This only applies to GOODS. If this is a service, mark N/A and skip to #5.)
Goods Services
Yes No N/A
If subcontracting a portion of the work, is it a normal portion as expected by current industry practices? (Also answer Yes if not subcontracting any portion.)
Yes No
A response of �No� may result in your quote being deemed non-responsive and disqualified.
BIDDER�S CERTIFICATION
The signatory of this document must be the certified business owner (or authorized representative in the case of a corporation) and as such, hereby certifies under penalty of perjury under the laws of the State of California that all information provided herein is truthful and accurate.
PRINTED NAME AND TITLE OF AUTHORIZED SIGNER SIGNATURE DATE
DEPARTMENT OF PARKS AND RECREATION USE
APPROVED DENIED
DPR BUYER/EVALUATOR PRINTED NAME SIGNATURE DATE
DPR 87 (Rev. 5/2025)(Word to PDF 5/28/2025)
FOR DEPARTMENT USE ONLY
C26690001 4
State of California, Department of Parks & Recreation
Gold Fields District
7806 Folsom-Auburn Road
BID OPENING
Folsom, CA 95630
DATE
DISTRICT NAME AND ADDRESS
REFUSE DISPOSAL SERVICE BID FORM
State of California - The Resources Agency
DEPARTMENT OF PARKS AND RECREATION
NAME OF BUSINESS
BUSINESS ADDRESS CITY/STATE/ZIP CODE
Partnership. Full names of partners:
Corporation. State in which incorporated:
Individual
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 qualified bidder who submits the lowest Base Bid amount. The State's intent is to utilize all services, but that there are items that are contingent that may not be utilized.
I hereby propose to provide all labor, materials, tools, and equipment necessary to perform all work required to haul refuse complete and ready for use as specified on the back of this form, in accordance with the bid documents and such addenda thereto as may be issued prior to bid opening
BIDDER'S SIGNATURE DATE PRINTED NAME TITLE
TIME
Exhibit B, Attachment 1
STATUS OF BUSINESS (Check appropriate box.)
CONTRACTOR NAME
AGREEMENT NO. PAGE
of
SMALL BUSINESS PREFERENCE
Not eligible for SB preference
A five percent preference will be granted to bidders properly approved as a Certified Small Business (SB) or a Certified Microbusiness (MB), or to a non-small business subcontracting 25% or more of the total monetary amount of the bid in supplies and/or labor costs with Certified Small Business subcontractors in accordance with Title 2, California Code of Regulations, Section 1896, et seq. To qualify as a Certified Small Business, the business must have an approved certification on file with the Office of Small Business and DVBE Services (OSDS), 707 Third Street, First Floor - Room 400, West Sacramento, CA 95605, by 5:00 p.m. on bid opening day.
Claiming preference as a Certified Small Business (Attach a copy of the SB certification printout from OSDS' website)
Claiming 25% SB subcontractor participation (Attach form DPR 85, Small Business Subcontractor Participation Worksheet)
PHONE NO.
FAX NO.
EMAIL ADDRESS
2 4
Weekly
Every
Other
Week
1 9/1/2026 8/31/2029 Contractor X 79 1 79
2 9/1/2026 8/31/2029 Contractor 12 1 12
3 9/1/2026 8/31/2029 Contractor 12 1 12
4 9/1/2026 8/31/2029 Contractor 12 1 12
TOTAL COST FOR REGULAR PICKUPS
ADDITIONAL CONTAINERS - If requested, the contractor shall furnish the following extra containers:
TOTAL COST FOR ADDITIONAL CONTAINERS [(F)x(G)]
ADDITIONAL PICKUPS - If requested, the contractor shall provide the following additional pickups.
TOTAL COST FOR ADDITIONAL PICKUPS [(H)x(I)x(J)]
DPR 326B Page 2
TOTAL PAGE TWO
FOR DEPARTMENT USE ONLY
C26690001
Gold Fields District Prairie City State Vehicular Recreation Area Maintenance Shop (RECYCLE)
4 YARD CARDBOARD
RECYCLE
Will Call
10 YARD METAL
RECYCLE
10 YARD WOOD
RECYCLE
Will Call
Will Call
10 YARD CONCRETE
RECYCLE
DISTRICT LOCATION WITHIN PARK UNIT
REFUSE DISPOSAL SERVICE BID FORM (REVISED) - Exhibit B, Attachment 1 Bidder completes (D), (E), (G), (J), TOTAL COSTS, and TOTAL BID PRICE.
ESTIMATED REQUIREMENTS FOR REFUSE DISPOSAL SERVICE ARE AS FOLLOWS:
PERIOD OF SERVICE
I
T
E
M
From To
TYPE OF
DUMPSTER
PROVIDED
BY
PICKUP
FREQUENCY
(A)
NO. OF
PICKUP
DAYS FOR
PERIOD
(B)
NO. OF
CONTAINERS
EACH
SERVICE
(D)
COST PER
CONTAINER
PER
SERVICE
(E)
COST FOR
SERVICE
PERIOD
[(C)X(D)]
TYPE OF CONTAINERS (F) NO. OF EXTRA CONTAINERS (G) COST PER CONTAINER
TYPE OF CONTAINERS (H) NO. OF CONTAINERS PER PICKUP
(J) COST PER CONTAINER
— Bidder understands that the quantities below are estimates only, for purposes of comparing bids, and that the State reserves the right to increase or decrease the amount of any item or eliminate any item or items as may be deemed necessary or advisable by the State. Such changes shall not affect the unit price of that item or any other items.
— In case of discrepancy between the unit price and the total set forth for the item, the unit price shall prevail. In case of discrepancy between the stipulated totals and the actual sum of the totals, the actual sum of all items shall prevail.
u n
S o n
M u e
T e d
W h u
T r i
F a t
S
PARK UNIT
(C)
NO. OF
CONTAINERS
PICKED UP IN
SERVICE PERIOD
[(A)X(B)]
(I) NO. OF ADDITIONAL PICKUPS
CONTRACTOR NAME
AGREEMENT NO. PAGE
of u n
S o n
M u e
T e d
W h u
T r i
F a t
S u n
S o n
M u e
T e d
W h u
T r i
F a t
S u n
S o n
M u e
T e d
W h u
T r i
F a t
S u n
S o n
M u e
T e d
W h u
T r i
F a t
S u n
S o n
M u e
T e d
W h u
T r i
F a t
S u n
S o n
M u e
T e d
W h u
T r i
F a t
S
PICKUP DAYS
a t
S
3 4
1 9/1/2026 6/30/2027 Contractor X 43 1 43
2 7/1/2027 6/30/2028 Contractor X 52 1 52
3 7/1/2028 6/30/2029 Contractor X 52 1 52
4 7/1/2029 8/31/2029 Contractor X 9 1 9
TOTAL COST FOR REGULAR PICKUPS
ADDITIONAL CONTAINERS - If requested, the contractor shall furnish the following extra containers:
TOTAL COST FOR ADDITIONAL CONTAINERS [(F)x(G)]
ADDITIONAL PICKUPS - If requested, the contractor shall provide the following additional pickups.
TOTAL COST FOR ADDITIONAL PICKUPS [(H)x(I)x(J)]
DPR 326B Page 3
TOTAL PAGE THREE
FOR DEPARTMENT USE ONLY
Gold Fields District
C26690001
Maintenance Shop (REFUSE)
30 YARD
REFUSE
30 YARD
REFUSE
30 YARD
REFUSE
30 YARD
REFUSE
Prairie City State Vehicular Recreation Area
DISTRICT LOCATION WITHIN PARK UNIT
REFUSE DISPOSAL SERVICE BID FORM (REVISED) - Exhibit B, Attachment 1 Bidder completes (D), (E), (G), (J), TOTAL COSTS, and TOTAL BID PRICE.
ESTIMATED REQUIREMENTS FOR REFUSE DISPOSAL SERVICE ARE AS FOLLOWS:
PERIOD OF SERVICE
I
T
E
M
From To
TYPE OF
DUMPSTER
PROVIDED
BY
PICKUP DAYS
PICKUP
FREQUENCY
Weekly Every Other Week
(A)
NO. OF
PICKUP
DAYS FOR
PERIOD
(B)
NO. OF
CONTAINERS
EACH
SERVICE
(D)
COST PER
CONTAINER
PER
SERVICE
(E)
COST FOR
SERVICE
PERIOD
[(C)X(D)]
TYPE OF CONTAINERS (F) NO. OF EXTRA CONTAINERS (G) COST PER CONTAINER
TYPE OF CONTAINERS (H) NO. OF CONTAINERS PER PICKUP
(J) COST PER CONTAINER
— Bidder understands that the quantities below are estimates only, for purposes of comparing bids, and that the State reserves the right to increase or decrease the amount of any item or eliminate any item or items as may be deemed necessary or advisable by the State. Such changes shall not affect the unit price of that item or any other items.
— In case of discrepancy between the unit price and the total set forth for the item, the unit price shall prevail. In case of discrepancy between the stipulated totals and the actual sum of the totals, the actual sum of all items shall prevail.
u n
S o n
M u e
T e d
W h u
T r i
F a t
S
PARK UNIT
(C)
NO. OF
CONTAINERS
PICKED UP IN
SERVICE PERIOD
[(A)X(B)]
(I) NO. OF ADDITIONAL PICKUPS
CONTRACTOR NAME
AGREEMENT NO. PAGE
of u n
S o n
M u e
T e d
W h u
T r i
F a t
S u n
S o n
M u e
T e d
W h u
T r i
F a t
S u n
S o n
M u e
T e d
W h u
T r i
F a t
S u n
S o n
M u e
T e d
W h u
T r i
F a t
S u n
S o n
M u e
T e d
W h u
T r i
F a t
S u n
S o n
M u e
T e d
W h u
T r i
F a t
S u n
S o n
M u e
T e d
W h u
T r i
F a t
S u n
S o n
M u e
T e d
W h u
T r i
F a t
S u n
S o n
M u e
T e d
W h u
T r i
F a
4 4
1 9/1/2026 6/30/2027 Contractor X 43 1 43
2 7/1/2027 6/30/2028 Contractor X 52 1 52
3 7/1/2028 6/30/2029 Contractor X 52 1 52
4 7/1/2029 8/31/2029 Contractor X 9 1 9
TOTAL COST FOR REGULAR PICKUPS
ADDITIONAL CONTAINERS - If requested, the contractor shall furnish the following extra containers:
TOTAL COST FOR ADDITIONAL CONTAINERS [(F)x(G)]
ADDITIONAL PICKUPS - If requested, the contractor shall provide the following additional pickups.
TOTAL COST FOR ADDITIONAL PICKUPS [(H)x(I)x(J)]
TOTAL BID PRICE
DPR 326B Page 4
FOR DEPARTMENT USE ONLY
C26690001
Gold Fields District Prairie City State Vehicular Recreation Area State Residence C (REFUSE)
2 YARD
REFUSE
2 YARD
REFUSE
2 YARD
REFUSE
2 YARD
REFUSE
DISTRICT LOCATION WITHIN PARK UNIT
REFUSE DISPOSAL SERVICE BID FORM (REVISED) - Exhibit B, Attachment 1 Bidder completes (D), (E), (G), (J), TOTAL COSTS, and TOTAL BID PRICE.
ESTIMATED REQUIREMENTS FOR REFUSE DISPOSAL SERVICE ARE AS FOLLOWS:
PERIOD OF SERVICE
I
T
E
M
From To
TYPE OF
DUMPSTER
PROVIDED
BY
PICKUP DAYS
PICKUP
FREQUENCY
Weekly Every Other Week
(A)
NO. OF
PICKUP
DAYS FOR
PERIOD
(B)
NO. OF
CONTAINERS
EACH
SERVICE
(D)
COST PER
CONTAINER
PER
SERVICE
(E)
COST FOR
SERVICE
PERIOD
[(C)X(D)]
TYPE OF CONTAINERS (F) NO. OF EXTRA CONTAINERS (G) COST PER CONTAINER
TYPE OF CONTAINERS (H) NO. OF CONTAINERS PER PICKUP
(J) COST PER CONTAINER
— Bidder understands that the quantities below are estimates only, for purposes of comparing bids, and that the State reserves the right to increase or decrease the amount of any item or eliminate any item or items as may be deemed necessary or advisable by the State. Such changes shall not affect the unit price of that item or any other items.
— In case of discrepancy between the unit price and the total set forth for the item, the unit price shall prevail. In case of discrepancy between the stipulated totals and the actual sum of the totals, the actual sum of all items shall prevail.
u n
S o n
M u e
T e d
W h u
T r i
F a t
S
PARK UNIT
(C)
NO. OF
CONTAINERS
PICKED UP IN
SERVICE PERIOD
[(A)X(B)]
(I) NO. OF ADDITIONAL PICKUPS
CONTRACTOR NAME
AGREEMENT NO. PAGE
of u n
S o n
M u e
T e d
W h u
T r i
F a t
S u n
S o n
M u e
T e d
W h u
T r i
F a t
S u n
S o n
M u e
T e d
W h u
T r i
F a t
S u n
S o n
M u e
T e d
W h u
T r i
F a t
S u n
S o n
M u e
T e d
W h u
T r i
F a t
S u n
S o n
M u e
T e d
W h u
T r i
F a t
S u n
S o n
M u e
T e d
W h u
T r i
F a t
S u n
S o n
M u e
T e d
W h u
T r i
F a t
S u n
S o n
M u e
T e d
W h u
T r i
F a
DPR 74 (Rev. 5/2013)(Excel 5/16/2013)
DO NOT COMPLETE THIS FORM UNLESS YOUR COMPANY MEETS THE CRITERIA OF OPTION #1 OR OPTION #2.
FOR DEPARTMENT USE ONLY
C26690001
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.
DO NOT COMPLETE OR RETURN THIS FORM IF: Within the previous three years, your company HAS NOT had any business activities or other operations outside of the United States.
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
All other companies, complete Option #1 or Option #2 and return:
State of California � Natural Resources Agency
DEPARTMENT OF PARKS AND RECREATION
ARTIFICIAL INTELLIGENCE (AI) FORM
Instructions for this form are on Page 3.
I. BIDDER CONTACT INFORMATION
BUSINESS NAME SOLICITATION NUMBER
REPRESENTATIVE NAME BUSINESS TELEPHONE NUMBER
BUSINESS ADDRESS CITY STATE ZIP CODE
Description of Services:
Describe in detail the services being provided. Include names of products and large language model.
II. DISCLOSURE
Will you and/or your subcontractor(s) be using or offering AI technology, model, service, or system (collectively, �product�) for this product in question?
Yes. (Answer 1-5 below) No. (Skip to Section III)
1. What type of AI is included?
Traditional AI Generative AI
2. Is the AI required for this product?
No Yes Other:
DPR 97B ( /2025)(Word to PDF /2025)(Page 1 of 3)
C26690001
Contractor to provide all labor, tools, equipment, materials and supplies necessary to lawfully collect, transport and dispose of refuse and/or recycling materials generated at the various locations within Prairie City State Vehicular Recreation Area. All work shall be complete and ready for use in accordance with the service specifications and contract documentation for stipulated sums which shall include all applicable expenses
ARTIFICIAL INTELLIGENCE (AI) FORM (Continued)
3. What is the model and version of this product?
4. What is the license tier of the AI product, if applicable (free, enterprise, platinum, etc.)?
5. How is the AI solution delivered: IaaS, PaaS, SaaS, or will it be deployed on-premises? (Indicate if this is a thin client, thick client, web extension, plugin, etc.)
Provide the best contact for information related to questions related to the AI included in the product (if different than the representative listed in Section I.)
NAME E-MAIL PHONE NUMBER
III. SIGNATURE
By signing this document, I have identified and reported any AI use in the performance of this product in question.
Signature Date
DPR 97B ( /2025)(Page 2 of 3)
ARTIFICIAL INTELLIGENCE (AI) FORM (Instructions)
Instructions:
The Department of Parks and Recreation (DPR) is required to track and complete risk assessments for any Generative Artificial Intelligence (GenAI) purchases. This document is intended to help DPR identify GenAI and assess the risk related to any GenAI purchases.
Section I:
Bidders shall fill in their contact information.
The DPR staff shall fill out the Description of Services in detail and/or reference the applicable Statement of Work or attachment(s). Include the services to be provided related to AI and include the names of products and large language model. It is important to include as much detail as possible related to any AI aspect of the potential purchase.
Section II:
Bidders shall disclose any aspect of AI related to the purchase.
If �no� is selected, no further information is required in this section.
If �yes� is selected, the Bidder shall fill out answers to questions 1-5. Bidders should provide as much detail as possible related to the AI technology, model, service or system as it relates to what the DPR is soliciting for.
If GenAI is selected and the DPR staff intends to pursue the product, the DPR staff must complete the SIMM 5305-F GenAI Intelligence Risk Assessment, Data Classification section and the Risk Assessment Questionnaire questions a-j; and submit it to ISPO@parks.ca.gov
Contact ISPO@parks.ca.gov for assistance with completing this assessment.
Upon review, ISPO will contact the DPR staff for more information, if needed, prior to submitting the finalized document to the California Department of Technology.
Procurement efforts will be placed on temporary hold pending CDT approval.
Definitions:
IaaS � Infrastructure as a Service is a cloud computing model that provides on-demand access to virtualized computing resources like servers, storage, and networking.
PaaS � Platform as a Service is a cloud computing model that provides a complete platform for developing, running, and managing applications.
SaaS � Software as a Service a cloud-based software delivery model where users access and use applications over the internet via a subscription rather than purchasing and installing software locally.
Section III:
Bidder signatures are required to certify all provided information on this document is true and accurate to the best of their knowledge.
DPR 97B ( /2025)(Page 3 of 3)
CALIFORNIA CIVIL RIGHTS LAWS CERTIFICATION
Pursuant to Public Contract Code section 2010, if a bidder or proposer executes or renews a contract over $100,000 on or after January 1, 2017, the bidder or proposer hereby certifies compliance with the following:
1. CALIFORNIA CIVIL RIGHTS LAWS: For contracts over $100,000 executed or renewed after January 1, 2017, the contractor certifies compliance with the Unruh Civil Rights Act (Section 51 of the Civil Code) and the Fair Employment and Housing Act (Section 12960 of the Government Code); and
2. EMPLOYER DISCRIMINATORY POLICIES: For contracts over $100,000 executed or renewed after January 1, 2017, if a Contractor has an internal policy against a sovereign nation or peoples recognized by the United States government, the Contractor certifies that such policies are not used in violation of the Unruh Civil Rights Act (Section 51 of the Civil Code) or the Fair Employment and Housing Act (Section 12960 of the Government Code).
CERTIFICATION
I, the official named below, certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Proposer/Bidder Firm Name (Printed)
Federal ID Number
By (Authorized Signature)
Printed Name and Title of Person Signing
Date Executed Executed in the County and State of
CCC 04/2017
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 below. This certification is made under the laws of the State of California.
Contractor/Bidder Firm Name (Printed)
Federal ID Number
By (Authorized Signature)
Printed Name and Title of Person Signing
Date Executed
Executed in the County and State of
CONTRACTOR CERTIFICATION CLAUSES
1. STATEMENT OF COMPLIANCE: Contractor has, unless exempted, complied with the nondiscrimination program requirements. (Gov. Code §12990 (a-f) and CCR, Title 2, Section 11102) (Not applicable to public entities.)
2. DRUG-FREE WORKPLACE REQUIREMENTS: Contractor will comply with the requirements of the Drug-Free Workplace Act of 1990 and will provide a drug-free workplace by taking the following actions:
a. Publish a statement notifying employees that unlawful manufacture, distribution, dispensation, possession or use of a controlled substance is prohibited and specifying actions to be taken against employees for violations.
b. Establish a Drug-Free Awareness Program to inform employees about:
1) the dangers of drug abuse in the workplace;
2) the person's or organization's policy of maintaining a drug-free workplace;
3) any available counseling, rehabilitation and employee assistance programs; and,
4) penalties that may be imposed upon employees for drug abuse violations.
c. Every employee who works on the proposed Agreement will:
1) receive a copy of the company's drug-free workplace policy statement; and,
2) agree to abide by the terms of the company's statement as a condition of employment on the Agreement.
Failure to comply with these requirements may result in suspension of payments under the Agreement or termination of the Agreement or both and Contractor may be ineligible for award of any future State agreements if the department determines that any of the following has occurred: the Contractor has made false certification, or violated the certification by failing to carry out the requirements as noted above. (Gov. Code §8350 et seq.)
3. NATIONAL LABOR RELATIONS BOARD CERTIFICATION: Contractor certifies that no more than one (1) final unappealable finding of contempt of court by a Federal court has been issued against Contractor within the immediately preceding two-year period because of Contractor's failure to comply with an order of a Federal court, which orders Contractor to comply with an order of the National Labor Relations Board. (Pub.
Contract Code §10296) (Not applicable to public entities.)
4. CONTRACTS FOR LEGAL SERVICES $50,000 OR MORE- PRO BONO
REQUIREMENT: Contractor hereby certifies that Contractor will comply with the requirements of Section 6072 of the Business and Professions Code, effective January 1, 2003.
Contractor agrees to make a good faith effort to provide a minimum number of hours of pro bono legal services during each year of the contract equal to the lessor of 30 multiplied by the number of full time attorneys in the firm’s offices in the State, with the number of hours prorated on an actual day basis for any contract period of less than a full year or 10% of its contract with the State.
Failure to make a good faith effort may be cause for non-renewal of a state contract for legal services, and may be taken into account when determining the award of future contracts with the State for legal services.
5. EXPATRIATE CORPORATIONS: Contractor hereby declares that it is not an expatriate corporation or subsidiary of an expatriate corporation within the meaning of
Public Contract Code Section 10286 and 10286.1, and is eligible to contract with the
State of California.
6. SWEATFREE CODE OF CONDUCT:
a. All Contractors contracting for the procurement or laundering of apparel, garments or corresponding accessories, or the procurement of equipment, materials, or supplies, other than procurement related to a public works contract, declare under penalty of perjury that no apparel, garments or corresponding accessories, equipment, materials, or supplies furnished to the state pursuant to the contract have been laundered or produced in whole or in part by sweatshop labor, forced labor, convict labor, indentured labor under penal sanction, abusive forms of child labor or exploitation of children in sweatshop labor, or with the benefit of sweatshop labor, forced labor, convict labor, indentured labor under penal sanction, abusive forms of child labor or exploitation of children in sweatshop labor. The contractor further declares under penalty of perjury that they adhere to the
Sweatfree Code of Conduct as set forth on the California Department of Industrial
Relations website located at www.dir.ca.gov, and Public Contract Code Section 6108.
b. The contractor agrees to cooperate fully in providing reasonable access to the contractor’s records, documents, agents or employees, or premises if reasonably required by authorized officials of the contracting agency, the Department of Industrial Relations, http://www.dir.ca.gov/ or the Department of Justice to determine the contractor’s compliance with the requirements under paragraph (a).
7. DOMESTIC PARTNERS: For contracts of $100,000 or more, Contractor certifies that Contractor is in compliance with Public Contract Code section 10295.3.
8. GENDER IDENTITY: For contracts of $100,000 or more, Contractor certifies that
Contractor is in compliance with Public Contract Code section 10295.35.
DOING BUSINESS WITH THE STATE OF CALIFORNIA
The following laws apply to persons or entities doing business with the State of
California.
1. CONFLICT OF INTEREST: Contractor needs to be aware of the following provisions regarding current or former state employees. If Contractor has any questions on the status of any person rendering services or involved with the Agreement, the awarding agency must be contacted immediately for clarification.
Current State Employees (Pub. Contract Code §10410):
1). No officer or employee shall engage in any employment, activity or enterprise from which the officer or employee receives compensation or has a financial interest and which is sponsored or funded by any state agency, unless the employment, activity or enterprise is required as a condition of regular state employment.
2). No officer or employee shall contract on his or her own behalf as an independent contractor with any state agency to provide goods or services.
Former State Employees (Pub. Contract Code §10411):
1). For the two-year period from the date he or she left state employment, no former state officer or employee may enter into a contract in which he or she engaged in any of the negotiations, transactions, planning, arrangements or any part of the decision-making process relevant to the contract while employed in any capacity by any state agency.
2). For the twelve-month period from the date he or she left state employment, no former state officer or employee may enter into a contract with any state agency if he or she was employed by that state agency in a policy-making position in the same general subject area as the proposed contract within the 12-month period prior to his or her leaving state service.
If Contractor violates any provisions of above paragraphs, such action by Contractor shall render this Agreement void. (Pub. Contract Code §10420)
Members of boards and commissions are exempt from this section if they do not receive payment other than payment of each meeting of the board or commission, payment for preparatory time and payment for per diem. (Pub. Contract Code §10430 (e))
2. LABOR CODE/WORKERS' COMPENSATION: Contractor needs to be aware of the provisions which require every employer to be insured against liability for Worker's
Compensation or to undertake self-insurance in accordance with the provisions, and
Contractor affirms to comply with such provisions before commencing the performance of the work of this Agreement. (Labor Code Section 3700)
3. AMERICANS WITH DISABILITIES ACT: Contractor assures the State that it complies with the Americans with Disabilities Act (ADA) of 1990, which prohibits discrimination on the basis of disability, as well as all applicable regulations and guidelines issued pursuant to the ADA. (42 U.S.C. 12101 et seq.)
4. CONTRACTOR NAME CHANGE: An amendment is required to change the
Contractor's name as listed on this Agreement. Upon receipt of legal documentation of the name change the State will process the amendment. Payment of invoices presented with a new name cannot be paid prior to approval of said amendment.
5. CORPORATE QUALIFICATIONS TO DO BUSINESS IN CALIFORNIA:
a. When agreements are to be performed in the state by corporations, the contracting agencies will be verifying that the contractor is currently qualified to do business in
California in order to ensure that all obligations due to the state are fulfilled.
b. "Doing business" is defined in R&TC Section 23101 as actively engaging in any transaction for the purpose of financial or pecuniary gain or profit. Although there are some statutory exceptions to taxation, rarely will a corporate contractor performing within the state not be subject to the franchise tax.
c. Both domestic and foreign corporations (those incorporated outside of California) must be in good standing in order to be qualified to do business in California. Agencies will determine whether a corporation is in good standing by calling the Office of the Secretary of State.
6. RESOLUTION: A county, city, district, or other local public body must provide the
State with a copy of a resolution, order, motion, or ordinance of the local governing body which by law has authority to enter into an agreement, authorizing execution of the agreement.
7. AIR OR WATER POLLUTION VIOLATION: Under the State laws, the Contractor shall not be: (1) in violation of any order or resolution not subject to review promulgated by the State Air Resources Board or an air pollution control district; (2) subject to cease and desist order not subject to review issued pursuant to Section 13301 of the Water
Code for violation of waste discharge requirements or discharge prohibitions; or (3) finally determined to be in violation of provisions of federal law relating to air or water pollution.
8. PAYEE DATA RECORD FORM STD. 204: This form must be completed by all contractors that are not another state agency or other governmental entity.
STATE OF CALIFORNIA – DEPARTMENT OF FINANCE
PAYEE DATA RECORD
(Required when receiving payment from the State of California in lieu of IRS W-9 or W-7) STD 204 (Rev. 03/2021)
Section 1 – Payee Information NAME (This is required. Do not leave this line blank. Must match the payee’s federal tax return)
BUSINESS NAME, DBA NAME or DISREGARDED SINGLE MEMBER LLC NAME (If different from above)
MAILING ADDRESS (number, street, apt. or suite no.) (See instructions on Page 2)
CITY, STATE, ZIP CODE E-MAIL ADDRESS
Section 2 – Entity Type Check one (1) box only that matches the entity type of the Payee listed in Section 1 above. (See instructions on page 2)
CORPORATION (see instructions on page 2)SOLE PROPRIETOR / INDIVIDUAL MEDICAL (e.g., dentistry, chiropractic, etc.)SINGLE MEMBER LLC Disregarded Entity owned by an individual
PARTNERSHIP
ESTATE OR TRUST
LEGAL (e.g., attorney services)
EXEMPT (e.g., nonprofit)
ALL OTHERS
Section 3 – Tax Identification Number Enter your Tax Identification Number (TIN) in the appropriate box. The TIN must match the name given in Section 1 of this form. Do not provide more than one (1) TIN.
The TIN is a 9-digit number. Note: Payment will not be processed without a TIN.
For Individuals, enter SSN.
If you are a Resident Alien, and you do not have and are not eligible to get an SSN, enter your ITIN.
Grantor Trusts (such as a Revocable Living Trust while the grantors are alive) may not have a separate FEIN. Those trusts must enter the individual grantor’s SSN.
For Sole Proprietor or Single Member LLC (disregarded entity), in which the sole member is an individual, enter SSN (ITIN if applicable) or FEIN (FTB prefers SSN).
For Single Member LLC (disregarded entity), in which the sole member is a business entity, enter the owner entity’s FEIN. Do not use the disregarded entity’s FEIN.
For all other entities including LLC that is taxed as a corporation or partnership, estates/trusts (with FEINs), enter the entity’s FEIN.
Social Security Number (SSN) or Individual Tax Identification Number (ITIN)
OR
Federal Employer Identification Number
(FEIN)
Section 4 – Payee Residency Status (See instructions)
CALIFORNIA RESIDENT – Qualified to do business in California or maintains a permanent place of business in California.
CALIFORNIA NONRESIDENT – Payments to nonresidents for services may be subject to state income tax withholding.
No services performed in California
Copy of Franchise Tax Board waiver of state withholding is attached.
Section 5 – Certification I hereby certify under penalty of perjury that the information provided on this document is true and correct.
Should my residency status change, I will promptly notify the state agency below.
NAME OF AUTHORIZED PAYEE REPRESENTATIVE TITLE E-MAIL ADDRESS
SIGNATURE DATE TELEPHONE (include area code)
Section 6 – Paying State Agency Please return completed form to:
STATE AGENCY/DEPARTMENT OFFICE UNIT/SECTION
MAILING ADDRESS FAX TELEPHONE (include area code)
CITY STATE ZIP CODE E-MAIL ADDRESS
Department of Parks & Recreation Gold Fields District
7806 Folsom-Auburn Road (916) 988-9062 (916) 988-0205
Folsom CA 95630 goldfields.billing@parks.ca.gov
Print Form Reset Form
STATE OF CALIFORNIA – DEPARTMENT OF FINANCE
PAYEE DATA RECORD
(Required when receiving payment from the State of California in lieu of IRS W-9 or W-7) STD 204 (Rev. 03/2021)
GENERAL INSTRUCTIONS
Type or print the information on the Payee Data Record, STD 204 form. Sign, date, and return to the state agency/department office address shown in Section 6.
Prompt return of this fully completed form will prevent delays when processing payments.
Information provided in this form will be used by California state agencies/departments to prepare Information Returns (Form1099).
NOTE: Completion of this form is optional for Government…
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