Conflict of Interest Disclosure-v2-10.18.24.docx
DOCX document 56 KB Posted
- Attached to
- 2026 Local Watershed Sanitary Survey
- Solicitation number
- 136966
- Issued by
- Santa Clara County, San Diego City, California
About this file
This is a Conflict of Interest Disclosure form required by Valley Water for the 2026 Local Watershed Sanitary Survey project in California. The form must be completed and submitted by all prime consultants and subconsultants as part of their proposal. The document consists of three parts: Part A requires firm information including name, address, contact details, and authorization signature; Part B requires confirmation of whether the proposer has previously performed services for Valley Water; and Part C requires detailed disclosure of any prior agreements with Valley Water, including agreement titles, numbers, contract values, performance periods, and descriptions of work performed. Proposers must certify that all disclosures are complete, accurate, and not misleading, and must ensure all subconsultants at all tiers complete the form.
The disclosure form specifically addresses organizational conflicts of interest and requires proposers to identify any real or apparent conflicts and propose mitigation measures. The form provides space for disclosure of up to three prior agreements with Valley Water. Minimum qualifications for the project require proposers or their assigned employees to have at least 10 years of experience conducting complex watershed sanitary surveys, possess knowledge of drinking water source protection and policies, and demonstrate extensive understanding of drinking water quality, treatment, and water supply operations. Submission of the completed conflict of interest disclosure is mandatory and represents a required submittal document for all proposals.
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Text version
CONFLICT OF INTEREST DISCLOSURE DOCUMENT
IMPORTANT INFORMATION
Prime Consultant or subconsultant must complete this form and submit as part of the proposal.
Proposers planning to utilize one or more subconsultants must ensure that its subconsultants complete this form including, Part A, Part B and Part C as instructed:
· Part A: Firm Information
· Part B: Service Confirmation
· Part C: Disclosure Detail (Only if Proposer has provided services and/or work for Valley Water.)
PART A: FIRM INFORMATION
CHECK ONE OF THE FOLLOWING:
☐ I am completing this form as the Proposer
| - or - | ||
| ☐ | I am completing this form as a subconsultant to the Proposer |
COMPLETE THIS INFORMATION:
Firm Name:
Street Address:
City, State, ZIP:
Phone #:
Email address:
Submittal of this form by the Proposer certifies that:
a) the Proposer's disclosures are complete, accurate, and not misleading; and
b) proposed subconsultants (all tiers) shall be required to complete this form.
AUTHORIZED REPRESENTATIVE:
I hereby certify that I am authorized to sign this COI Disclosure Form as a representative for the firm identified above:
Signature:
Name (print):
Title:
Date:
PART B: SERVICE CONFIRMATION
CHECK ONE OF THE FOLLOWING:
| ☐ | Proposer acknowledges that no services and/or work have ever been performed as a Prime Consultant or subconsultant for Valley Water. | ||
| - or – | |||
| ☐ | Proposer acknowledges that services and/or work have been performed as a Prime Consultant or subconsultant for Valley Water. (Please disclose services and/or work performed for Valley Water in the next part – PART C: DISCLOSURE DETAIL). |
PART C: DISCLOSURE DETAIL
Provide all required information for services and/or work performed as a prime consultant and/or subconsultant listed below.
1. Agreement Title:
Agreement No.:
CAS/VW No.:
Value of Agreement ($):
Work Performed as:
Period of Performance:
Description of services and or work provided:
If real or apparent organizational conflicts exist, please provide a description of proposed alternatives/ mitigation measures in the space below:
2. Agreement Title:
Agreement No.:
CAS/VW No.:
Value of Agreement ($):
Work Performed as:
Period of Performance:
Description of services and or work provided:
If real or apparent organizational conflicts exist, please provide a description of proposed alternatives/ mitigation measures in the space below:
3. Agreement Title:
Agreement No.:
CAS/VW No.:
Value of Agreement ($):
Work Performed as:
Period of Performance:
Description of services and or work provided:
If real or apparent organizational conflicts exist, please provide a description of proposed alternatives/ mitigation measures in the space below:
| Valley Water | Conflict of Interest Disclosure-v2-10.18.24 |
| Required Submittal Document | Page 1 |
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