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Exhibit 15 -G2 Local Agency Bidder DBE Information (Construction Contracts) <br />(Inclusive of all DBEs at bid proposal) <br />NOTE: PLEASE REFER TO INSTRUCTIONS ON APPENDIX F <br />AGENCY: LOCATION: <br />PROJECT DESCRIPTION: PROJECTNO. )3 -6797 Meole IIike Tra'I SafetvE l - -n 1 0 'd• t lSheaC St And e •P14 leoe. <br />St. Gertrude Place CM- 5063(149) <br />TOTAL FEDERAL CONUA T@ AMOUNT: $ 26 <br />BID DATE: J�p q'Zp _ <br />t <br />BIDDER'S NAME: <br />ri Y'�: Fitt R <br />CONTRACT <br />ITEM OF WORK AND DESCRIPTION <br />CorLNo.ofDBE <br />NAME OF DBEs <br />DOLLAR AMOUNT <br />ITEM NO, <br />Olt 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 />O BE PROVIDED <br />mid hone number <br />—1 — <br />AJOI <br />64 6 <br />L T <br />t <br />i <br />_ <br />iRJn <br />1 213 / road <br />W ) 613 6 7011 - -- <br />_. <br />Mb IYUMALA <br />For Local Agency to Complete:l� <br />Total Claimed <br />1 i !_fifl = <br />Local Agency Contract Number: <br />Participation <br />1$ W� <br />Federal Aid Project Number: <br />Federal Share: <br />t'i <br />, 1+ % <br />Contract Award Date: <br />Local Agency certifies that all information is complete and accurate. <br />®ry p <br />C "P° WN' PFIES ENE <br />Print Name Signature Date <br />Signature of Bidder <br />Local Agency Representative <br />Area Code) Telephone Number: <br />— Date (Area Code) Tel. No, <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 />Distribution: (I) Copy — Fax or scan a copy to the Caltrans District Local Assistance Engineer (DLAE) within 15 days of award, Failure to <br />send a copy to the BLAB within 15 days of award 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 />Bla 18 of 26 <br />23BB -28 <br />