Vendor_Information_Request_Form_.pdf

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Attached to
Supply and Delivery of Three (3) Electric Vehicle Chargers
Solicitation number
IFQ-TH-0122
Issued by
Los Angeles County, California

About this file

Written by GovTribe AI ·

This is a Vendor Information Request Form for West Basin Municipal Water District, a public agency serving 17 cities and nearly one million residents in coastal Los Angeles, California. The form is used to collect comprehensive vendor information for the supply and delivery of three (3) electric vehicle chargers to be installed at the Edward C. Little Water Recycling Facility in El Segundo, California. The procurement requires bidders to supply ChargePoint model CT4021-GW1 Level 2 commercial charging stations with dual-port capability, bollard concrete mounting kits, and activation fees. Quotations are due electronically through the OpenGov procurement portal by April 23, 2026 at 2:00 pm, with a deadline for submitting questions and comments set for April 16, 2026 at 4:00 pm. All quotations must remain valid for at least 90 days from the closing date. The award will be made to the lowest responsive quotation, subject to West Basin's Board of Directors approval.

Pricing is subject to 9.5% sales tax, with payment terms established at net 30 days from receipt of correctly completed invoices. All goods must be shipped prepaid F.O.B. destination. West Basin encourages participation from Small Business Enterprises (SBEs) and Local Business Enterprises (LBEs), offering evaluation scoring adjustments of 3% for SBEs or LBEs serving as prime contractors, 6% for bidders qualifying as both SBE and LBE, and 1% for prime contractors utilizing SBE or LBE subcontractors receiving at least 30% of total contract compensation. Qualified bidders must submit vendor information including business registration, certifications, proof of signature authority, and compliance with Build America, Buy America Act requirements mandating 65% domestically sourced components. Vendors must maintain comprehensive insurance coverage including $2,000,000 general liability and $1,000,000 pollution liability for hazardous materials transporters, and provide full indemnification of the District.

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VENDOR INFORMATION REQUEST - West Basin Municipal Water District

Yes No

Yes No

Yes No

Entered By: Date: Yes No W-9 Received: Yes No

Email:

Title:

Address 2 (suite, unit, etc.):

Vendor Number:

Verified

SBE & LBE:

FOR PURCHASING ONLY

Email:

List the representative(s) from your organization that would like to receive a copy of the executed agreement:

Title: Print Name:

Print Name:

Email:

COMPANY INFORMATION

Complete Legal Name:

Address 1: Contact Phone:

Which Public Agency are you Certified With?

Certification Number:

Are you a Certified Small Business Enterprise (SBE)? If yes, Small Business certification must be submitted.

ACCOUNTS RECEIVABLE (remittance name and address)

City/State/Zip:

Contact Fax:

Remittance name: Contact Name:

Are you a Local Business Enterprise (LBE)?

If yes, please provide a copy of your business license.

Business License Number:

Address - Same as above

Address 1: Contact Phone:

ADDITIONAL INFORMATION

CONTRACTS/AGREEMENTS INFORMATION

Payment Discounts:

(West Basin terms: Net 30) Contact Email:

List the representative(s) from your organization that will be signing the agreement and attach proof of signature authority. Documentation should state that the representative has the authority to execute contracts—examples of proof: Articles of Incorporation, corporate resolution, written consent, etc.

Title: Print Name:

Title: Print Name:

Email:

Print Name:

Length of time at this address? Contact Email:

By signing, you authorize West Basin to verify the information stated on this form. Signature:

If applicable, do your company's products comply with the Build America, Buy America (BABA) Act?

(Product components are 65% domestically sourced.)

Address 2: Contact Fax:

City/State/Zip:

Title:

1-22-2026

Complete Legal Name:
Length of time at this address:
Business License Number:
Remittance name:
Entered By:
Title:
Certification Number:
Which Public Agency are you Certified With:
Address 1:
Address 2:
Contact Fax:
Contact Phone:
City/State/Zip:
Contact Email:
Contact Name:
Print Name:
Email:
Vendor Number:
Payment Discounts: [NET 30 Days]
Contact Fax 2:
Address 3:
Address 4:
Contact Phone 2:
Contact Email 2:
City/State/Zip Code:
Title 1:
Title 2:
Title 3:
Title 4:
Print Name 2:
Print Name 3:
Print Name 4:
Email 2:
Email 3:
Email 4:
Print Name 1:
Date1_af_date:
Group5: Off
Check Box8: Off

File details come from the government source that posted it. Updated .