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• <br />• <br />Exhibit 15 -G2 Local Agency Bidder DBE Information (Construction Contracts) <br />(Inclusive of all DBEs including the UDBEs listed at bid proposal) <br />NOTE: PLEASE REFER TO INSTRUCTIONS ON THE REVERSE SIDE OF THIS <br />AGENCY: (f t'-t q 6J 5Q,nJ.J � LOCATION: (;j/) S+IC44 <br />PROJECT DESCRIPTION: PROJECT NO. 11 -6733: LYON STREET REHABILITATION FROM EDINGER AVE. TO <br />PROJECT NO. ESPL 5063(138 ) <br />CHESTNUTjj, F�� <br />"1EffD,��ERAL <br />TOTAL CONTRACT AMOUNT: S 2 3 ;—1 , DD <br />UI <br />ID DATE: Iq UC1 tl . % g e)I I) <br />BIDDER'S NAME:, <br />ONTRACT <br />ITEM OF WORK AND DESCRIPTION <br />DBE Cert. No. <br />NAME OF DBEs <br />DOLLAR AMOUNT <br />ITEM NO. <br />OR SERVICES TO BE <br />AND EXPIRATION <br />Must be certified on the date bids <br />DBE <br />SUBCONTRACTED OR MATERIALS <br />DATE <br />are opened - include DBE address <br />TO BE PROVIDED <br />rid hone number) <br />a � <br />0 <br />Ar L D <br />- 0 2 -L"2 <br />C, <br />(? ° to — <br />6PX leg b <br />3,00 - k - toll <br />U6 <br />For Local Agency to Complete: <br />Local Agency Contract Number: <br />Total Claimed <br />Participation <br />Federal Aid Project Number: <br />Federal Share: <br />, } <br />10. . U % <br />Contract Award Date: <br />Local Agency certifies that the DBE certification(s) has been verified and all information <br />is complete and accurate. <br />a r+ raLilec/,V ic�,,�re�id�t <br />Signature of Bidder <br />Print Name Signature Date <br />Local Agency Representative <br />g�y iv Lq 51 7310-7 Cow <br />Date (Area Code) Tel. No. <br />Area Code) Telephone Number: <br />For Caltrans Review: <br />Print Name Signature Date <br />Caltrans District Local Assistance Engineer <br />Local Agency Bidder DBE Information (Rev 3/09) <br />15 wuuvu. k, wpy — rax or scan a copy to me Caltrans District Local Assistance Engineer (DLAE) within 15 days of contract execution. Failure to <br />• send a copy to the DLAE within 15 days of contract execution may result in de- obligation of funds for this project. <br />(2) Copy — Include in award package to Caltrans District Local Assistance <br />(3) Original — Local agency files <br />TO BE INCLUDED IN BID PACKAGE <br />BP 21 of 29 <br />