Vendor_Information_Request_Form_.pdf

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Attached to
Groundwater Modeling and Reporting Services for the West Coast Basin Barrier Project
Solicitation number
RFP-DS-0151
Issued by
Los Angeles County, California

About this file

Written by GovTribe AI ·

This is a Vendor Information Request Form from West Basin Municipal Water District related to a groundwater modeling and reporting services contract for the West Coast Basin Barrier Project in California. The form is designed to collect comprehensive vendor information from organizations seeking to work with West Basin, including company legal name, contact information, remittance address details, and authorized signatories for contract execution. The district requests documentation of signature authority such as articles of incorporation, corporate resolutions, or written consent, along with verification of W-9 forms and business licenses. Vendors must indicate their certification status as Small Business Enterprises (SBE) or Local Business Enterprises (LBE) with the appropriate supporting documentation, and identify the representatives authorized to receive copies of executed agreements.

The form specifies standard payment terms of Net 30 days and requests disclosure of any payment discounts available. Vendors are required to verify compliance with the Build America, Buy America (BABA) Act if applicable, ensuring product components are at least 65 percent domestically sourced. The form authorizes West Basin to verify all stated information and requires vendor signature as consent for this verification process. The groundwater modeling work supports the West Coast Basin Barrier Project, which uses hydraulic barriers to prevent seawater intrusion into groundwater aquifers and operates under Los Angeles Regional Water Quality Control Board Permit R4-2006-0069, Title 22 Recycled Water Regulations, and the Recycled Water Policy, with annual groundwater modeling required as a permit condition and component of the Five-Year Engineering Report submitted to regulators.

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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:
Check Box8: Off
Check Box4: Off
Check Box5: Off
Check Box6: Off
Check Box7: Off
Check Box9: Off
Check Box10: Off
Check Box11: Off
Check Box12: Off
Check Box13: Off
Check Box14: Off

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