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Exhibit 1 5-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 APPENDIX F <br />GHNCY: _4'ity oC Sa mta Ana I.OCA"PION: Jerome Park '? ?' °W9_ <br />'{ • '"ff <br />Q? J Nye ?C <br />r <br />PROJECT UL-SC'I21 P'1'ION: 1'KOJ EC''I' NO. 12-7528 J • o ' P' k Parl:?ne I t I pro c t ?'(s ?1?+ --- <br />Cd <br />t <br />?? <br />?? <br />. <br />-y? <br />`? <br />07 AL I?LDLRAL CONTRACT AMOUNT: $ ? ?l gJ I-7 3 - ?? 1?L'? G+?'f "?CO,C? ??'???F <br />i <br />? <br />BtD DArr <br />: (o?Olol/Z ?w'j <br />?'?=?ri? <br />_ <br />? <br />,p,? <br />, .??y?}' <br />r <br />!? <br />BIDDER'S NAME_ ?X? ??}•V?I? ?Q]'Y/PAyNC? <br />ONl"12ACT ITEM OF WORK AND DISC'KI P'IION 'ert. No. of DBE NAME OP DBL-s DOLLAR AMOUNT <br />Il'EM NO_ li SERVICES T'O BG ND EXPIRATION Must he certified on the date bids DBE <br /> U BCONTRACTED OR MATIiR IA LS DATE re opened -include DBE address <br /> 'O BE PROVIDED nd hone number <br /> <br /> t ? <br /> <br /> CA <br /> <br /> - to - <br />g - ?i - Ti GT ? SFr7 °jO <br /> 4t SsZ t45 }a-A,(? <br /> <br /> ,4- <br /> -7 1 - 9 - 'f I <br />For Local Agency to Complete: <br /> Total Claimed O6 <br />$ 3`i`(sZ3 <br />Local A enc Contract Number: <br />g Y P <br />i <br />i <br />i _ <br /> art <br />c <br />pat <br />on <br />Federal Aid Project Number. <br /> ?? <br />Federal Share: % <br />ontract Award Date: <br />Local Agency certifies that all information is complete and accurate. ? J F; B ? p?,,jl ; <br /> ? ??cc?r-?cs;-•. <br /> <br />Print Name Signature Date Signature of Bidder <br />Local Agency Representative tt,,?? r? <br />.??IV - B ?0?2 <br />(Area Code "Pete hone Number_ ?JFJ ELI :79?-08-x.9 <br /> <br />For Caltrans Review: <br /> llatc (Area Code) Tel. No. <br />Print Name Signature ? Dale <br />Caltrans District Local ASSISta nee 1-:ngincer Local Agency bidder- DBI Information (Rev 3/09) <br />D?sin UUt?on_ (1) Copy- Fax or scan a copy Co The Caltrans llisirict Local Assistance Engineer (DLAE) within 75 days of award. Failure to <br />send a copy to the DLAE within 15 days of award may result in dc-obligation oC funds for Chis project. <br />(2) Copy -- In cluck in award packo gc to Caltrans llistri ct Local Assistance <br />(3) Original-Local agency tiles <br />TO BE INCLUDED IN BID PACKAGE <br />BP 25 of 37