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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 O <br />N <br />APPENDIX F <br />AGENCY: e <br />? <br />LOCATION: PROJECT NO 10-6703 TRAFFIC SIGNAL INSTALLATION ON <br />17r?? ST Fc KING ST <br />PROJECT DESCRIPTION: PROJECT NO. <br />OTAL CONTR <br />A <br />T AMOUNT: $ <br />C <br />[ <br />? <br />2 <br />` <br />BID DATE: ? \V/I???I:s? ? ?.?i ? :wwwl C wwiwp <br />BIDDER'S NAME: ?r <br />CONTRACT ITEM OF WORK AND DESCRIPTION ert_ No. of DBE AME OF DBEs DOLLAR AMOUNT <br />ITEM NO. R SERVICES TO BE AND EXPIRATION Must be certified on the date bids BE <br /> SUBCONTRACTED OR MATERIALS ATE re opened -include DBE address <br /> O BE PROVIDED nd hone number <br /> <br /> <br /> <br /> <br /> G <br />l U <br /> <br /> <br /> <br />For Local Agency to Complete: ? ??--77 <br /> Total Claimed $ <br />`??? <br />Local A <br />enc <br />Contract Number: P <br />iu <br />i ? <br />g <br />y art <br />pat <br />on <br />Federal Aid Project Number: <br />Federal Share: $18.040 <br /> <br />ontrnct Award Dale: __ <br />Local Agency ce rtifles that all information is complete and acc urate. <br />Print Name Signature Date Signature of Bidder <br />Local Agency Representative <br />A <br />C <br />d <br />T <br />l <br />h <br />N <br />b ^ 1 r? ?11'\ <br />?\ L??` 2 ??- `-' "y- ??? <br />rea <br />o <br />e <br />e <br />e <br />one <br />um <br />er: <br />For Caltrans Review: <br />Dale (Area Code) Tel_ No_ <br />Print Name Signature Date <br />Caltrans District Local Assistance Engineer Local Agency Bidder -DBE Inform e[ion (Rev 3/09) <br />Distribution: (1) Copy -Fax or scan a copy to the Caltrans District Local Assistance Engineer (DLAE) within l 5 days of award. Failure to <br />send a copy to the DLAE within 15 days oFaward 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 £les <br /> <br />TO BE INCLUDED IN BID PACKAGE <br />BP 24 of 32