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HomeMy WebLinkAbout25A - ENVIRONMENTAL SERVICES URSREQUEST FOR COUNCIL ACTION CITY COUNCIL MEETING DATE: DECEMBER 6, 2010 TITLE: AGREEMENT FOR ENVIRONMENTAL SERVICES WITH URS CORPORATION TO PREPARE AN EIR FOR A 24-UNIT SINGLE FAMILY RESIDENTIAL DEVELOPMENT AT 1584 E. SANTA CLARA CITY MANAGER RECOMMENDED ACTION CLERK OF COUNCIL USE ONLY: APPROVED ? As Recommended ? As Amended ? Ordinance on 1St Reading ? Ordinance on 2nd Reading ? Implementing Resolution ? Set Public Hearing For_ CONTINUED TO FILE NUMBER Authorize the City Manager and the Clerk of the Council to execute the attached agreement with URS Corporation for environmental services in an amount not to exceed $48,335 for a new 24-unit single-family residential development at 1584 East Santa Clara Avenue, subject to non-substantive changes approved by the City Manager and City Attorney. DISCUSSION In April 2010, Tava Development contacted the City with hopes to re-commence development of the former Empire Homes 24-unit single family residential development at 1584 East Santa Clara Avenue. The Tava Development proposal will be similar in scope, layout and quality to the project previously proposed by Empire Homes. An environmental impact report is required for this project pursuant to the California Environmental Quality Act. A Request for Proposal was circulated to three qualified environmental firms in 2007 as a part of the Empire Homes proposal. URS Corporation was selected as the environmental consultant and it thereafter began work on the EIR. URS had nearly completed the draft EIR when, in 2009, Empire Homes decided to cancel the project due to economic circumstances. Work on the EIR was discontinued at that time. It is recommended that URS Corporation be awarded this contract to complete the EIR because of its track record in preparing high quality environmental studies, its familiarity with the City and its detailed background and knowledge about this project. URS proposes to update the prior nearly- complete EIR in all material respects. The fee proposal to complete this effort is $48,335. Funding for the prior work on the EIR was provided entirely by Empire Homes; funding to complete the EIR would be provided by Tava Development. 25A-1 Agreement with URS Corporation December 6, 2010 Page 2 FISCAL IMPACT This agreement will not impact any City/Agency funds. Funds in the amount of $48,335 will be deposited by Tava Development into the Planning and Building Agency account for, contractual services (No. 09801001-24035) prior to the consultant commencing any work. APPROVED AS TO FUNDS AND ACCOUNTS: Ja M Trevino Francisco Gutierrez Ex utive Director Executive Director Planning and Building Agency Finance & Management Services Agency VF:rb Vflreports\URS Corporation E I R contract.cc120610 Exhibit: 1. Agreement 25A-2 PROFESSIONAL SERVICES AGREEMENT THIS AGREEMENT, made and entered into this day of , 2010 by and between URS CORPORATION, a Nevada corporation ("Consultant'), doing business as URS Corporation Americas, and the City of Santa Ana, a charter city and municipal corporation of the State of California ("City"). RECITALS A. The City desires to retain a consultant having special skill and knowledge in the field of professional environmental reports and services. B. Consultant represents that Consultant is able and willing to provide such services to the City. C. In undertaking the performance of this Agreement, Consultant represents that it is knowledgeable in its field and that any services performed by Consultant under this Agreement will be performed in compliance with such standards as may reasonably be expected from a professional consulting firm in the field. NOW THEREFORE, in consideration of the mutual and respective promises, and subject to the terms and conditions hereinafter set forth, the parties agree as follows: 1. SCOPE OF SERVICES Consultant shall provide professional environmental services, including the preparation of a Focused Environmental Impact Report regarding the TAVA Development project. The scope of services (including estimated fees and costs) is attached hereto as Exhibit A and is incorporated by this reference to this Agreement. 2. DELIVERY OF WORK PRODUCT Consultant shall deliver to City all work product which results from the services provided. Said work product shall be submitted in hard copy and produced in a form compatible with the City's computer system, as agreed between the Project Manager and Consultant. In regard to all copyrightable material produced as a deliverable under this Agreement, including but not limited to books, reports, plans, photographs, drawings, films, recordings, videotapes, and computer programs, Consultant agrees, for itself and for its affected officers, employees, agents, contractors, and volunteer workers, that (a) other such material may not be copyrighted without prior review from the City, and (b) the authors of all such material, whether copyrighted or not, award to the City, and to its officers, agents and employees acting within the scope of their official duties, as a condition of payment to the Consultant, a royalty-free, nonexclusive, irrevocable license throughout the world for governmental purposes to disclose, publish, translate, reproduce, and use such materials. 25A-3 3. COMPENSATION City agrees to pay, and Consultant agrees to accept as total payment for its services, the cumulative rates and charges identified in Exhibit A. The total sum to be expended under this Agreement shall not exceed $48,335.0.0 during the term of this Agreement. Payment by City shall be made within thirty (30) days following receipt of proper invoice evidencing work performed, subject to City accounting procedures. Payment need not be made for work which fails to meet the standards of performance set forth in the Recitals which may reasonably be expected by City. 4. TERM This Agreement shall commence on the date first written above and terminate upon the completion of the Scope of Services or depletion of the maximum contract amount as stated in Section 3 above, unless terminated earlier in accordance with provisions, below. The term of this Agreement may be extended upon a writing executed by the City Manager and the City Attorney. 5. INDEPENDENT CONTRACTOR Consultant shall, during the entire term of this Agreement, be construed to be an independent contractor and not an employee of the City. This Agreement is not intended nor shall it be construed to create an employer-employee relationship, a joint venture relationship, or to allow the City to exercise discretion or control over the professional manner in which Consultant performs the services which are the subject matter of this Agreement; however, the services to be provided by Consultant shall be provided in a manner consistent with all applicable standards and regulations governing such services. Consultant shall pay all salaries and wages, employer's social security taxes, unemployment insurance and similar taxes relating to employees and shall be responsible for all applicable withholding taxes. 6. INSURANCE Prior to undertaking performance of work under this Agreement, Consultant shall maintain and shall require its subcontractors, if any, to obtain and maintain insurance as described below: a. Commercial General Liability Insurance. Consultant shall maintain commercial general liability insurance naming the City, its officers, employees, agents, volunteers and representatives as additional insureds) and shall include, but not be limited to protection against claims arising from bodily and personal injury, including death resulting therefrom and damage to property, resulting from any act or occurrence arising out of Consultant's operations in the performance of this Agreement, including, without limitation, acts involving vehicles. The amounts of insurance shall be not less than the following: single limit coverage applying to bodily and personal injury, including death resulting therefrom, and property damage, in the total amount of $1,000,000 per occurrence. Consultant shall supply City with a fully executed 2 25A-4 additional insured endorsement in substantially the form attached hereto as Exhibit B upon execution of this Agreement and shall be approved in form by the City Attorney. b. Business automobile liability insurance, or equivalent form, with a combined single limit of not less than $1,000,000 per occurrence. Such insurance shall include coverage for owned, hired and non-owned automobiles. c. Worker's Compensation Insurance. In accordance with the provisions of Section 3300 of the Labor Code, Consultant, if Consultant has any employees, is required to be insured against liability for worker's compensation or to undertake self-insurance. Prior to commencing the performance of the work under this Agreement, Consultant agrees to obtain and maintain any employer's liability insurance with limits not less than $1,000,900 per accident. d. Professional liability (errors and omissions) insurance, with a combined single limit of not less than $1,000,000 per claim. e. The following requirements apply to the insurance to be provided by Consultant pursuant to this section: (i) Consultant shall maintain all insurance required above in filll force and effect for the entire period covered by this Agreement. (ii) Certificates of insurance shall be furnished to the City upon execution of this Agreement and shall be approved in form by the City Attorney. (iii) Certificates and policies shall state that the policies shall not be canceled or reduced in coverage or changed in any other material aspect without thirty (30) days prior written notice to the City. £ If Consultant fails or refuses to produce or maintain the insurance required by this section or fails or refuses to furnish the City with required proof that insurance has been procured and is in force and paid for, the City shall have the right, at the City's election, to forthwith terminate this Agreement. Such termination shall not affect Consultant's right to be paid for its time and materials expended prior to notification of termination. Consultant waives the right to receive compensation and agrees to indemnify the City for any work performed prior to approval of insurance by the City. 7. INDEMNIFICATION Consultant agrees to and shall indemnify and hold harmless the City, its officers, agents, employees, consultants, special counsel, and representatives from liability: (1) for personal injury, damages, just compensation, restitution, judicial or equitable relief arising out of claims for. personal injury, including health, and claims for property damage, which may arise due to negligent acts, omissions or willful misconduct, from the direct or indirect'operations of the Consultant or its contractors, subcontractors, agents, employees, or other persons acting on their behalf which relates to the services described in section 1 of this Agreement; and (2) from any 3 25A-5 claim that personal injury, damages, just compensation, restitution, judicial or equitable relief is due by reason of the terms of or effects arising from, and to the extent of Consultant's, negligent acts, omissions or willful misconduct in the performance of this Agreement. 8. CONFIDENTIALITY If Consultant receives from the City information which due to the nature of such information is reasonably understood to be confidential and/or proprietary, Consultant agrees that it shall not use or disclose such information except in the performance of this Agreement, and further agrees to exercise the same degree of care it uses to protect its own information of like importance, but in no event less than reasonable care. "Confidential Information" shall include all nonpublic information. Confidential information includes not only written information, but also information transferred orally, visually, electronically, or by other means. Confidential information disclosed to either party by any subsidiary and/or agent of the other party is covered by this Agreement. The foregoing obligations of non-use and nondisclosure shall not apply to any information that (a) has been disclosed in publicly available sources; (b) is, through no fault of the Consultant disclosed in a publicly available source; (c) is in rightful possession of the Consultant without an obligation of confidentiality; (d) is required to be disclosed by operation of law; or (e) is independently developed by the Consultant without reference to information disclosed by the City. 9. CONFLICT OF INTEREST CLAUSE Consultant covenants that it presently has no interests and shall not have interests, direct or indirect, which would conflict in any manner with performance of services specified under this Agreement. 10. NOTICE Any notice, tender, demand, delivery, or other communication pursuant to this Agreement shall be in writing and shall be deemed to be properly given if delivered in person or mailed by first class or certified mail, postage prepaid, or sent by telefacsimile or other telegraphic communication in the manner provided in this Section, to the following persons: To City: City of Santa Ana C/o Clerk of the Council 20 Civic Center Plaza P.O. Box 1988 Santa Ana, CA 92702-1988 telefacsimile (714) 647-6956 With copy to: Executive Director of PBA City of Santa Ana 20 Civic Center Plaza P.O. Box 1988 Santa Ana, California 92702 4 25A-6 telefacsimile (714) 973-1461 and City Attorney City of Santa Ana 20 Civic Center Plaza (M-29) P.O. Box 1988 Santa Ana, California 92702 telefacsimile (714) 647-6515 To Consultant:URS Corporation Harley S. Martin Vice President Division Manager Environmental Planning 2020 East First Street, Suite 400 Santa Ana, CA 92705 telephone (714) 648-2899 cell (714) 227-8597 telefacsimile (714) 433-7701 harley_jnai-tin@urscoi-p.com A party may change its address by giving notice in writing to the other party. Thereafter, any communication shall be addressed and transmitted to the new address. If sent by mail, communication shall be effective or deemed to have been given three (3) days after it has been deposited in the United States mail, duly registered or certified, with postage prepaid, and addressed as set forth above. If sent by telefacsimile, communication shall be effective or deemed to have been given twenty-four (24) hours after the time set forth on the transmission report issued by the transmitting facsimile machine, addressed as set forth above. For purposes of calculating these time frames, weekends, federal, state, County or City holidays shall be excluded. 11. EXCLUSIVITY AND AMENDMENT This Agreement represents the complete and exclusive statement between the City and Consultant, and supersedes any and all other agreements, oral or written, between the parties. In the event of a conflict between the terms of this Agreement and any attachments hereto, the terms of this Agreement shall prevail. This Agreement may not be modified except by written instrument signed by the City and by an authorized representative of Consultant. The parties agree that any terms or conditions of any proposal or other instrument that are inconsistent with, or in addition to, the terms and conditions hereof, shall not bind or obligate Consultant nor the City. Each party to this Agreement acknowledges that no representations, inducements, promises or agreements, orally or otherwise, have been made by any party, or anyone acting on behalf of any party, which are not embodied herein. 25A-7 12. ASSIGNMENT Inasmuch as this Agreement is intended to secure the specialized services of Consultant, Consultant may not assign, transfer, delegate, or subcontract any interest herein without the prior written consent of the City and any such assignment, transfer, delegation or subcontract without the City's prior written consent shall be considered null and void. Nothing in this Agreement shall be construed to limit the City's ability to have any of the services which are the subject to this Agreement performed by City personnel or by other consultants retained by City. 13. TERMINATION This Agreement may be terminated by the City upon thirty (30) days written notice of 'termination. In such event, Consultant shall be entitled to receive and the City shall pay Consultant compensation for all services performed by Consultant prior to receipt of such notice of termination, subject to the following conditions: a. As a condition of such payment, the Executive Director may require Consultant to deliver to the City all work product completed as of such date, and in such case such work product shall be the property of the City unless prohibited by law, and Consultant consents to the City's use thereof for such purposes as the City deems appropriate. b. Payment need not be made for work which fails to meet the standard of performance specified in the Recitals of this Agreement. 14. NON-DISCRIMINATION Consultant shall not discriminate because of race, color, creed, religion, sex, marital status, sexual orientation, age, national origin, ancestry, or disability, as defined and prohibited by applicable law, in the recruitment, selection, training, utilization, promotion, termination or other employment related activities. Consultant affirms that it is an equal opportunity employer and shall comply with all applicable federal, state and local laws and regulations. 15. JURISDICTION -VENUE This Agreement has been executed and delivered in the State of California and the validity, interpretation, performance, and enforcement of any of the clauses of thisAgreement shall be determined and governed by the laws of the State of California. Both parties further agree that Orange County, California, shall be the venue for any action or proceeding that may be brought or arise out of, in connection with or by reason of this Agreement. 16. PROFESSIONAL LICENSES Consultant shall, throughout the term of this Agreement, maintain all necessary licenses, permits, approvals, waivers, and exemptions necessary for the provision of the services hereunder and required by the laws and regulations of the United States, the State of California, 6 25A-8 the City of Santa Ana and all other governmental agencies. Consultant shall notify the City immediately and in writing of its inability to obtain or maintain such permits, licenses, approvals, waivers, and exemptions. Said inability shall be cause for termination of this Agreement. 17. MISCELLANEOUS PROVISIONS a. Each undersigned represents and warrants that its signature hereinbelow has the power, authority and right to bind their respective parties to each of the terms of this Agreement, and shall indemnify City fully, including reasonable costs and attorney's fees, for any injuries or damages to City in the event that such authority or power is not, in fact, held by the signatory or is withdrawn. b. All Exhibits referenced herein and attached hereto shall be incorporated as if fully set forth in the body of this Agreement. IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year fist above written. ATTEST: MARIA D. HUIZAR Clerk of the Council APPROVED AS TO FORM: JOSEPH W. FLETCHER City Attorney By: Ryan O. Hodge Assistant City Attorney RECOMMENDED FOR APPROVAL: JAY TREVINO' Executive Director - PBA CITY OF SANTA ANA DAVID N. REAM City Manager URS CORPORATION HARLEY S. MARTIN Vice President 7 25A-9 EHIBIT A SCOPE OF SERVICES (Attached) 25A-10 0 October 12, 2010 Mr. Vincent C. Fregoso, AICP City of Santa Ana. Planning and Building Agency 20 Civic Center Plaza P.O. Box 1988 Santa Ana, CA 92702 RE: TAVA Development - Proposal to Reinitiate Preparation of Focused Environmental Impact Report Dear Mr. Fregoso: URS is pleased to present herein our proposal to reinitiate preparation of the Focused Environmental Impact Report (EIR) regarding the TAVA Development project (formerly known as the Empire Homes EIR project). As you are aware, URS coordinated with the City of Santa Ana (City) to prepare the Focused EIR up until December 2008; subsequently, the proposed project was put on hold indefinitely. Therefore, this proposal includes efforts associated with reinitiating preparation and obtaining approval of the Focused EIR, The below scope of work details the efforts, as discussed and confirmed with the City, to prepare and obtain approval of the Focused EIR or this project. Task I.- Project Management It is assumed that the project schedule would not exceed 8 months in duration from date of notice to proceed received from the City. This task includes day-to-day management of the project, issuing status reports and billings once per month, and setting up and re-opening the project within URS' accounting system for reporting and invoicing. This particular task also assumes attendance by the URS' Project Manager at one kick-off meeting. Task 2 - Updat it alit Stu The current version of the air quality study previously prepared by URS will be updated to account for current regulations pertaining to greenhouse gas (GHG) emissions regulations and South Coast Air Quality Management District's Interim GHG Thresholds. It is assumed that the air quality study will be reviewed by the City only, and require no more than one revision based on the City's review. Task - Update Traffic Im t Study KOA Corporation, URS' traffic subconsultant for this project, will update the previously prepared and City-approved Traffic Impact Study as agreed to by and with the City, UAS Corporation 2020 East First Streel, Suite 400 Santa Ana, CA 92705 Tel: 714.835.6886 Fax: 714.667.7147 www.urscorp.com 25A-11 2010 - Existing Condition Analysis KOA will not conduct additional traffic counts. The 2010 existing conditions will be represented by the old counts based on the understanding that the 2010 counts are less than the old counts due to the economic meltdown. The old counts should represent more conservative conditions. Sample comparison table and explanation with why we are not recounting and recalculating all intersections will be included in the updated report. The City will provide traffic counts conducted in October 2009 for KOA to conduct the comparison analysis. 2012 - Project Built Out Condition Analysis KOA will contact the City to obtain the updated the cumulative project lists and update the analysis accordingly, 2035 - General Plan Build Out Condition Analysis KOA will use OCTAM 3.3 model to generate 2035 volumes. Post processing will be performed in order to obtain a set of 2035 volume data for operational analysis. KOA has recently completed another study in City of Santa Ana, however, the study area is not within the close proximity of this project. Revise Cut-Through Traffic The revision will be based on the analysis scenarios indicated in Task I through Task 3. It is assumed that the Traffic Impact Study will be reviewed by the City only, and require no more than one revision based on City input. Task 4 - Hazardous Materials Records Search The EIR, as prepared by URS to date, incorporates the results of a Phase I Environmental Site Assessment (ESA) prepared in 2007 (as contracted directly from Empire Homes to LandAnierica Assessment Corporation). Given the date of the above-reference Phase I ESA, URS will conduct an updated regulatory database search (e.g., Environmental Data Resources, Inc.) to identify any potential hazardous waste and materials concerns that were not otherwise identified in that 2007 Phase I ESA. The EIR will be updated to state that a subsequent regulatory database search was performed to supplement the initial Phase I ESA. This proposal does not include preparation of an updated Phase I ESA, or level of reporting or investigation not otherwise described herein. Task 5 -Update Draft EIR for Public Circul This task involves updating the pertinent sections of the Draft EIR to account for the updated technical studies as described herein (i.e., traffic, hazardous waste, and air quality). It is assumed that the updated EIR will be reviewed by the City no more than once prior to public circulation. Task 6 - Prepare Notice of Completion and Circulate Draft EIR URS will prepare the Notice of Completion for the City's transmittal to the State Clearinghouse and County Clerk's Office. It is assumed that the City will update the Draft EIR distribution mailing list that was previously compiled (by the City) as part of URS' original contract. It too is assumed that the project proponent and/or City.will mail copies of the Draft EIR to those individuals and agencies to whom it 25A-12 needs to be mailed to. The cost estimate provided for this particular task assumes that URS will reproduce the necessary number of copies of the Draft EIR for the City's/proponent's public distribution (assumed to be no more than 30 copies). It is also assumed that the City will create and post the public notice providing availability of the Draft EIR and notice of the public meeting in one newspaper of general circulation. Task 7 - Public Meetine on Draft EIR Based on previous discussions with the City, it is assumed that one public meeting (open-house format) will be held on the Draft EIR during the 45-day public review period. It will be the responsibility of the City to secure the meeting venue. It is assumed that two URS staff, including the Project. Manager, and one staff member from each KOA Corporation and Discovery Works, Inc. will attend the public meeting. URS will assist the City to compile comments received at the public meeting for presentation in a memo prepared by URS for inclusion with the Final EIR. URS will prepare a maximum of four (4) boards for presentation at the public meeting. URS will prepare a black and white, 8.5" x 11" comment card that will be made available at the public meeting and can be used by the public to record and mail comments to the City for inclusion in the Final EIR. Those submitting comments (commentors) using this card would be responsible for postage. It is assumed that no formal presentation will be required of URS staff at the public meeting. It is also assumed that URS will not be responsible for retaining an entity to record public comments (e.g., court reporter). Task 8 -- Prepare Responses to Comments on Draft ElR and Prepare Final E1R URS, including its traffic and cultural resources subconsultants, will coordinate with the City to prepare responses to comments received on the Draft EiR during its 45-day public review circulation period. It is assumed that no more than 20 comments (a maximum of 5 of which will be cultural resources related; a maximum of 5 of which will be traffic analysis related) will be received on the Draft EIR, and none of the comments received will require additional analysis not already addressed in the technical studies that support the EIR. KOA Corporation will prepare responses to the traffic-related comments, and Discovery Work, Inc. will prepare responses to the cultural resources related comments on the Draft HM. URS will prepare responses to the remaining comments (i.e., 10) received on the Draft EIR. Task 9 - Attend Planning Commission and City Council Meetings In addition to attendance at the public meeting on the Draft EIR as described above in Task 7, the URS Project Manager will attend one Planning Commission Meeting and one City Council Meeting, at which time the project will be considered for approval. Task 10 - Prepare Notice of Determination URS will prepare the Notice of Determination (NOD) for the City's transmittal to the State Clearinghouse. URS is not responsible for any associated filing fees (e.g., CA Dept. of Fish and Game) associated with the NOD submittal. 25A-13 Additional Assumptions: • The project description and details remain as reflected in the Draft EIR that has been prepared by URS, If the project description changes, URS reserves the right to assess those changes and adjust its scope of work and fee proposal accordingly for reconsideration by the City. • Except as noted otherwise herein, none of the technical studies and analyses already approved by the City [e.g., Cultural Study Report (Discovery Works, Inc. September 2008), etc,] for this project will need to be updated for inclusion in the EIR. • This proposal assumes, as stated in Task 7, that one staff member (e.g., Beth Padon) from Discovery Works, Inc. will attend the public meeting on the Draft EIR; this would not include an architectural historian (e.g., Foothill Resources Ltd,, subconsultant to Discovery Works, Inc.). • The proposal does not include efforts associated with obtaining any permits. This proposal does not include any project-required filing fees. Project Schedule With regards to project schedule, and for the purposes of this proposal as noted above, it is assumed that the project duration will be 8 months. Once notice to proceed is received from the City, USR will coordinate with the City to develop a detailed schedule identifying key milestone dates. Cost Estimate The time-and-materials cost estimate to perform the work described herein is $48,335.00. Attachment A includes the detailed fee estimate. Should you have any questions regarding this proposal, please call me at (714) 835-6886. Sincerely, URS CORPORATION P 'ec anags Attachment A - Fee Proposal Vice President 25A-14 ATTACHMENT A Fee Proposal 25A-15 K a O F F ??i ? ?? ?i m M oo L f h y N b ? V N r b b 1f? 44 M b a a b Q ?h"j H tthh O O Q f- !?Y t ?1 Y Y N M1_ S o ? N V b 00 00 b N H - - - - - - O N - - - - - - - - - V 25A-16 EXHIBIT B ADDITIONAL INSURED ENDORSEMENT FOR COMMERCIAL GENERAL LIABILITY POLICY Insurance Company This endorsement modifies such insurance as is afforded by the provisions of Policy # relating to the following: 1. The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701; its officers, employees, agents, volunteers and representatives are named as additional insureds ("additional insureds") with regard to liability and defense of suits arising from the operations and uses performed by or on behalf of the named insured. 2. With respect to claims arising out of the operations and uses performed by or on behalf of the named insured, such insurance as is afforded by this policy is primary and is not additional to or contributing with any other insurance carried by or for the benefit of the additional insureds. 3. This insurance applies separately to each insured against whom claim is made or suit is brought except with respect to the company's limits of liability. The inclusion of any person or organization as an insured shall not affect any right which such person or organization would have as a claimant if not so included. 4. With respect to the additional insureds, this insurance shall not be cancelled, or materially reduced in coverage or limits except after thirty (30) days written notice has been given to the City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701. (Completion of the following, including countersignature, is required to make this endorsement effective.) Effective Policy # _ Issued to this endorsement form as a part of Named Insured Countersigned by Authorized Representative 9 25A-17 25A-18