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Local Assistance Procedures Manual <br />EXHIBIT 10 -02 <br />Consultant Contract DBE Information <br />EXHIBIT 10 -02 CONSULTANT CONTRACT DBE INFORMATION <br />(Inclusive of all DE Es listed at contract award. Refer to instructions on the reverse side of this form) <br />Consultant to Complcte'this Section <br />t. Local Agency Name: <br />2. Project Location: <br />3. Project Description: <br />4. Total Contract Award Amount: $ <br />5. Consultant Name: <br />6. Contract DBB Goal %: <br />7. Total Dollar Amount For all Subconsultants: $ <br />S. Total Number of all Subconsultants: <br />Award DBE /DBE Information <br />9. Description of Services to be Provided <br />10. DBE/DBB Finn <br />11. DBE Cen. <br />12. DBE Dollar <br />Contact Information <br />Number <br />Amount <br />Ldcal Agoncy to Ct uaplet0 this'secGan <br />is <br />1 I <br />Do <br />20. Local Agency Contract Number: <br />21. Pedeml -aid Project Number: <br />22. Contract execution Date; <br />Clauned <br />Local Agency certifies that all DBE certifications are valid and the <br />information on this form is complete and accurate: <br />a Y c <t iYl Std t, <br />' � 3 <br />I 3! NS 15 '1 1�i f fF, <br />a rr } <br />23. Local Agency Representative Name (Print) <br />24. Local Agency Representative Siguature 25. Date <br />26. Local Agency Representative Title 27. (Area Code) Tel. No, <br />15. preparer's Signahue <br />16. Preparer's Name (Print) <br />Gtllfrans ko Con¢ `lets this Seetlon <br />C¢Itrans District Local Assistance Engineer (DLAE) certifies that this form <br />17. Preparer's Title <br />has been reviewed for completeness: <br />78. Date 19. (Area Code) Tat. No <br />28. DLAE Name (Print) 29. DLAE Signature 30. Date <br />Distribution: (1) Copy — Email a copy to the Caltrans District Local Assistance Engineer (DLAE) within 30 days of contractawar'd, Failure to send a <br />copy to the DLAE within 30 days of contact award may result in delay of payment. <br />(2) Copy — Include in award package sent to Caltmns DLAE <br />(3) Original — Local agency files <br />LPP 1301 <br />251 -44 <br />Page I of 2 <br />May S, 2013 <br />