HomeMy WebLinkAboutExhibit C Grant Forms 2026 Pioneer BidI.To be submitted with the bid: z
a. Build America, Buy America Certification
b. American Iron and Steel Certification /
c. Certification Regarding Debarment, Suspension, Ineligibility and Voluntary
Exclusion
f. Certification Regarding Debarment, Suspension, Ineligibilit d Voluntary
Exclusion, Lower Tier Covered Transactions (USDA) 7"
e. Lobbying For (complete one as applicable)
1. Certification Regarding Lobbying, or
2. Disclosure of Lobbying Activities
f. Certification of Non -Segregated Facilitiq
g. Drug -Free Wora ificatio
h. Non- Discrimin7
ati 7..
5"
i. Bidder- List
j. Good Faith Efforts Verification and Backup Documentation
k. DBE Solicitation Log and Backup Documentation ��
BUILD AMERICA, BUY AMERICA CERTIFICATION
CONTRACTOR/APPLICANT: Vl*ncl N Ln,- C_010-C-rVCT7017
The Contractor acknowledges to and for the benefit of the District ("Owner") and the California
Drinking Water State Revolving Fund (DWSRF) Program (the "Funding Authority") that it
understands the goods and services under this Agreement are being funded with federal
monies and have statutory requirements commonly known as "Build America, Buy America;"
that requires all of the iron and steel, manufactured products, and construction materials used in
the project to be produced in the United States ("Build America, Buy America Requirements")
including iron and steel, manufactured products, and construction materials provided by the
Contactor pursuant to this Agreement.
1. The Contractor hereby represents and warrants to and for the benefit of the Owner and
Funding Authority:
a) The Contractor has reviewed and understands the Build America, Buy America
Requirements,
b) All of the iron and steel, manufactured products, and construction materials used in the
project will be and/or have been produced in the United States in a manner that
complies with the Build America, Buy America Requirements, unless a waiver of the
requirements is approved, and
c) The Contractor will provide any further verified information, certification or assurance
of compliance with this paragraph, or information necessary to support a waiver of the
Build America, Buy America Requirements, as may be requested by the Owner or the
Funding Authority.
7f=]VI—Marnam-ea OEM
or loan recipient to the above described certification. I am fully aware that this certification,
executed on the date and in the county below, is made under penalty of perjury under the laws
of the State of California.
OFFICIAL'S NAME: Au,57-m Vi',7c,,- Vev,�
.1
DATE EXECUTED: if"A& EXECUTED IN COUNTY OF:
CONTRACTOR/APPLICANT SIGNATURE:
TITLE:
CONTRACTOR/APPLICANT: \// r1c` vc�_,Ora� c�/T-10 ^7 , X�11C�.
q Mean
schedule and consistent with the deadlines prescribed in or required by the bid solicitation.
2.\AahficationofU3.Production: The Bidder certifies that all components contained inthe bid solicitation that are
American -made have been umidentified, and ifthis bid iuaccepted, the Bidder agrees that it will provide reaaonable,
sufficient, and timely verification to the Purchaser of the U.S, production of every component so identified,
3. Documentation Regarding Non -American -made Iron and Steel: The Bidder certifies that for any component or
components that are not American -made and are so identified in this bid, the Bidder has included in or attached to
the bid one or both of the following, as applicable:
a. Identification of and citation to a categorical waiver published bythe U.Environmental Protection Agency in the
Federal Register that isapplicable to such component orcomponents, and ananalysis that supports its
applicability to the component or components.
b. Verifiable documentation sufficient tothe Purchaser, as required in the bid solicitation motherwise, that the
Bidder has sought tusecure American made components but has determined that such components are not
available onthe schedule and consistent with the deadlines prescribed inthe bid solicitation, with assurance
adequate for the Bidder under the applicable conditions stated in the bid solicitation or otherwise.
4,Information and Detailed Justification RegardingNun- Iron and Steel: The Bidder certifies that for
any such component mcomponents that are not noavailable, the Bidder has also providedinorattached to this bid
information, including but not limited to the verifiable documentation and a full description of the bidder's effort to
secure any such American -made component or components, that the Bidder believes are sufficient to provide and as
far onpossible conetitutethe detailed justification required for awaiver under section 1GO5with respect 0osuch
component or components. The Bidder further agrees that, if this bid is accepted, it will assist the Purchaser in
amending, supplementing, orfurther supporting such information as required bythe Purchaser torequest and, am
applicable, implement the terms of a waiver with respect to any such component or components.
1, the official named below, hereby swear that I am duly authorized legally to bind the contractor
or loan recipient to the above described certification. I am fully aware that this certification,
executed on the date and in the county below, is made under penalty of perjury under the laws
of the State of California.
DFF|C�[SNAME� ��vi��i v^�� �*�����
a^
|� �
D/g[EEXECUTED: �� / �^� / »,^«� EXECUTED |NCOUNTY OF: ��_ or,pO�
C{}NTRACTOR]APPL|CANTS\GNATURE�=�~�' -/
TITLE:
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND
VOLUNTARY EXCLUSION
CONTRACTOR/APPLICANT: 1,4 C_ �) irerf-a°,_ / " q C
(1) The contractor certifies, by submission of this proposal, that it and its principals:
(a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or
voluntarily excluded by any Federal agencies;
(b) Have not within a three year period preceding this proposal been convicted of or had a civil
judgment rendered against them for commission of fraud or a criminal offense in connection
with obtaining, attempting to obtain, or performing a public (Federal, State or local) transaction
or contract under a public transaction; violation of Federal or State antitrust statutes or
commission of embezzlement, theft, forgery, bribery, falsification or destruction of records,
making false statements, or receiving stolen property;
(c) Are not presently indicted for or otherwise criminally or civilly charged by a governmental
entity (Federal, State or local) with commission of any of the offenses enumerated in paragraph
• of this certification; and
(d) Have not within a three year period preceding this application1proposal had one or more
public transactions (Federal, State or local) terminated for cause or default.
(2) Where the contractor is unable to certify to any of the statements in this certification, such
contractor shall attach an explanation to this proposal*.
*Exceptions will not necessarily result in denial of award, but will be considered in determining
bidder responsibility. For any exception noted, indicate to whom it applies, initiating agency,
dates of action, and the type of violation,
below, nere6y swear Trial I amr-7-tuly at Din It
tr loan recipient to the above described certification. I am fully aware that this certification,
executed on the date and in the county below, is made under penalty of perjury under the laws
xf tWe State • •
OFFICIAL'S NAME: AL/J-r/-1
'J
DATE EXECUTED: EXECUTED IN COUNTY OF: DOrVII-Jo
CONTRACTOR/APPLICANT SIGNATURE:
TITLE: Pr 4
AD-1048 OMB No0505-0027
Expiration Date: ,130:202,S
USDA 0-9Certification Regarding Debarruent. Suspension, Ineligibility and Voluntary Exclusion
Lower Tier Covered Transactions
The "O"orwng statement is made in @=rdarcc wth the PrcacyArta( 19,4 i5 U,S.C. § 552a. as amerided), Tt,is ,sieq,,,reJby1he regWarors
;mplenip -o Ming Execotive Order 12549, Det�armentard aqd2 CFR§,' 160,30. t80,335, T)�eregiular,,ow vrere
wntidecf and pjNmhed or, 4ugjot 3!, 2UJ5, ip 70 Fed Reg, 5166&-516K Cop!e5 & zhe reguc atfcw^s Ma>° we OVarnaa bv contacN,,g the of
A pwt;ti;re agemy offefitig the proposed cowered uano -a c,',,O,)
cco,drr�g to the PapetworA Rejucljon Av of 1995, an agency may notcond,,xi or sponser. and a permn ;z rot 1equired to rpspond to a ro!"&,-bon of
uniess it m5plays a ir-also' OMB corit(o I nurrf3er Thq I, a i.-,d O&IB cc n,ro? rvrn"er for t!w� wrlc !"n at, on Co ,'e:t;on is 0505-002T The Orre reourt Ito
comp"Ote, Thts n1forwel= cotievron "5 esb-Mated to 0,rrage t5 Min'AC-5 per rcoponse, h-,c1.,d,--,rg the time forrcwew.--ng irzibrutio�lr, searchmg eyfstirigdata
sourcer, gathenng and mantam!ng Me dam needed andcori?pletmg and iev,'C-*wrg the cohlection ofinforer-aton. ofwpeQrnkite carmnai or
ca'll ftaUd, pr,,�acy, and tithe," statutes mav ,)c- @ppJ,';cat;Je ha tke M11ormabon pi Lwa&d.
(Read in stmetiom on page two bi, ,fore coniplering certffleation.)
A. 1-lie prospective lower trer paiiiciparit certifies, by siibnnssion of t1iis proposal, that neither it nor its prilic ipals is
presently debarred. suspended, proposed for debimient, declared ureLigible, or voluntarily excluded frorn participation
iii this trairsaction by an-v Federal department oragelicy:
B. %Xqiere the prospective to-wer tier par-ricipant is iiiiable to certify to any of the Statements in this cenification, such
prospective participant sliall attach .an explanation to this proposal.
OF GACNIZATION NA-\E
P-R. AWARM N-UNIBER OR PROJECT NANTE
\/jA 11�', Vef-O'k— C04SCMU701 /-rnc. aOo-%6 Pt'oqeew
NAMErS, -,l TIT LEi,S) OF AUTHORIZED REPRESEN-1 AMT(S)
r1%
Av-�nq z- vinc., verrp— M61jen+
SIGNA=RE j I DAIT
to acwrrlancerwith Fodvae![ cv,:i rghMiawaid U.S. DE;'M-r--rAO1 AgflW!:Ire (USD,) cming'itc regUalaom, and, pdiciso, the USDA, its, Agansi,-sclises and eyrp�,ryees, and
msm,bons, pam`patra in ci prograrir, are pso�Ibrej frorn diaw.minating based an race, cckx, nat-,cna� cnmr,, ef)qion,sex, gerdffienttly {=Iu;;bpg gender
exprem--ny teusf onentaton, d sa litr age, rxlr*W status. fzm1i!y!p3remai status, incopne derr;ed from a pubitr am:-anca rrrrara, pottica; b,-befs, or -,epngal or ietaVabon kr plc,.
adrvvcr- ,n any grog-amcr 30v;ty cnnduc'ed programs)
OLrlcra"ae, A-rneeean Sign tangsgre, etc' chou.d contact
the,,espcPsVe Ager,,/ or USDA-, TARGET (voice and 77i} or mitact USCA thtwah LNe Feaerw Rela}Ssr;ize M-5339. Aldltfor3ii7, gFo,,Mrrl
,am at any U30-1 offce or Me a le*ft-r addswse* to USDA and pr-;:!vrde in sae Net all of the unf:,unation re cuested ri d-,e fom,,, 70 eqj,--t -, copy of the complamt fcmi, cat. (665�
s-52,9992 Sulrrnr y�ruT ocmdeted fcn-, cr leer totSDA i7y: (1) mad, U.G. C•epettnent ofAgnculture, Cffme rf the Ass-&ftant -Scereta-'(ft, Csd,'. Nghts, 1400 Independence Aaenu;,
VA%IN*wshqngton, D,C, 2025C-941,0; (2j fw: 69G-T442, 0, en-111.
UMA is an equal oppomrurj crc-vider, en-Voyer, and tender.
Instructions for Cer-tirication
i !-) By signing amid. submitiing thii, forar. the PrISPeCrlve lower tier pirlicipwir is providing tire certification set out on pa.ge 1 in
accordance xvith these urstructrons
f2) The certification iii this clause is itiaterial representation of fact upon %1,111ch rellance was Placed when this trarmictloll cans
a entered into. If it is later determined that the prospective lower tier participant knowin.ly tendered an erroneous certificuton, iii
addition to other teniedies available to the Federal Go-,-eriirneut, the Departnient or ;agency with which this trinsaction originated
Inav pursue avirlatiJe remedies, including suspension or debarment.
i3) The prospective lower tier parnelpairt must provide ininiediaTe written notice to the personks) to which this proposal is submitted
if at iar i. time the prospective lower tier participant learns that its certification was erroneons when submitted or his become
erroneous by reason of changed circlunstances-
(4) The tenons "covered transacdoir." '"debarred.'. "suspended." "Ineligible", "lowel tier covered transaction." "Participant", *'person,
primary covered transaction," "principal-" "proposal." -and "volunt3rils- excluded." :as used in this clause. hiva the ineqnui— wet
out in the Definations and Coverage sections of the rules implementing Executive Order 12-549. at -7 C'FRParts 1SO wnd4l7 You
may couractthe Deparuirent 013genC)- Towhich this proposal is being submitted for assist race mobtaiiiing a copy ofthose
regulations.
(5) The prospective lower tier participant agrees by subli-inting this form that. sliould the proposed covered transaction be entered
into, it may not knowingly enter into any lower tier covered tran-,action with a person as is debafie& suspended. eecilled
nieh,2ible. or voluntarily excluded from participation in this covered transaction, unlessandroirzed by the Department or agency
with -which this transaction ofu7nicled.
Tile prospeCtr,.-e jo.%-er Irej parucipairt further agrees by subniitturg this forril war it will include thlM clause titled "'Certification
Re2ardin,2 DebairlienT. Suspension, Itleligibilits.,1116 Voluntary Exclusion - Lower Tier Covered Tran,actions." without
modification, ni all lower tier covered transactions and in all solicitations for lower tier covered trausactions.
i7) A participant in i covered transaction may rely upon a certification of a prospective pinicipinT ina lower tier covered transaction
that is not debarred, suspended. ineligible- or voluntarily excluded froin the covered transaction. unless it knows that the
certification is erroneous. A participant mi), decide the method and frequency by which it deterinnies the eligib-dity of its
principals Each participant may, but is not required to. check the Gerieril Services Administration's System for -Award
MI
anagement Exclusions database,
iS) 'Nothing coamilled in the foregoing shall be construed to require establishniere of systern of records to lender in good flith the
certification required by, this clause. The knowledge and information of participant is not required io exceed thatshr-h is
nornially possessed by a prudent person in the ordinary course of busuless dealings.
'9) Except for trillsact,115 authofized under paragr ph (5' ofthese instsictions. ifa participant in i covered transacti.0 n knowingh 10 3
enters into lower tier covered transaction with aperson who is suspended. debarred. ineligible- or voluntarily excluded flonr
parficipation in this transaction. in addition to other remedies available to tire Federal Governinerit. the Departirient or agency
I '%-nth wl'ich this transaction or ig nated prat Plinne avillable renredies, includmg sitspeasion ind'of deb,-wrient.
ffw9 Rl w 9 � � ME rt"i I - KOH 2 Will 4 WA -.1 W-Al 12 1 I'm
CERTIFICATION REGARDING LOBBYING
CONTRACTOR/APPLICANT:
The undersigned certifies to the best of his or her knowledge and belief that:
(1) Ro federal appropriated funds have been paid or will be paid, by or on behalf of the
undersigned, to any person for influencing or attempting to influence an officer or employee of
an agency, a Member of Congress, an officer or employee of Congress, or an employee of a
Member of Congress in conjunction with the awarding of any Federal contract, the making of
any Federal grant, the making of any Federal loan, the entering into of any cooperative
agreement, and the extension, continuation, renewal, amendment, or modification of any
Federal contract, grant, loan, or cooperative agreement.
*1LSVJZ.0U# Wan -
7 -dtaTre�WVT' -
und signed shall complete and submit Standard Form LLL, Disclosure Form to Report
Lobbying, in accordance with its instructions.
1, the official named below, hereby swear that I am duly authorized legally to bind the contractor
or loan recipient to the above described certification. I am fully aware that this certification,
executed on the date and in the county below, is made under penalty of perjury under the laws
of the State of California.
OFFICIAL'S NAME: ALIS7711
DATE EXECUTED: qlpj EXECUTED IN COUNTY OF:
CONTRACTOR/APPLICANT SIGNATURE:
TITLE: rr e, 5 efe-1 r f
�' l � l � , #
DISCLOSURE OF LOBBYING ACTIVITIES
Complete this form to disclose lobbying activities pursuant to 31 U-S.C. 1352
(See reverse for public burden disclosure.)
Wdi—f AM n: 3. e 1. Type of Federal Action: 2. Statu—s —ot )- `ecfeff-a-f -AU-555fi: y pu'
a. contract a. bid/offer/application a. /initifiling
I
m
b. grant b. initial award b. m erial change
c. cooperative agreement c. post -award For M erial Change Only:
d. loan
e. loan guarantee
f. loan insurance
4. Name and Address of Reporting Entity:
Prime E] Subalwardee
Tier , if known:
FMITOMMI
waf=,",
(if individual, last name, first namia
11 Information requested through this form
'This
disclosure of lobbying activities
which reliance was placed by the tier
entered into. This disclosure is r q
information will be reported to the ont A/,
public inspection. Anypersonw fails Ia.
'—:1Y of nat less th-
failure.
Federal Use 0 /V:
Ivthorized by title 31 U.S.C. section 1352-
a.material representation of fact upon
rove when this transaction was made or
red pursuant to 31 U.S.C. 1352. This
)ss semi-annually and will be available for
file the required disclosure shall be subject
mdTietirme-t4w Sq@"88 far 3_a.
quarter
of last report
1374111• -t •11M
5. If Reporting Enti No. 4 is a Subawardee, Enter Name
a and Address of ime:
I
n
R
d
e A p d 0 d r r ti
es g s E 0 n f tity PI V
�0 0
C gressional District, if known:
i'l 7. ederal /Progriam Name/Description:
b. Individuals Performing Services (including address if
different from No. I Oa )
(last name, first name, Ml):
If
Signature:,,,,��
Print Name: A'JS rin C_
cie-T-F
Title: prc6i "
Authorized for Local Reproduction
Standard Form LLL (Rev. 7-97)
ACTIVITIES 11
This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the initiation or receipt of
a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C. section 1352. The filing of a form is required for
each payment or agreement to make payment to any lobbying entity for influencing or attempting to influence an officer or employee of any
agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with a covered
Federal action. Complete all items that apply for both the initial filing and material change report. Refer to the implementing guidance
published by the Office of Management and Budget for additional information.
1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered
Federal action.
Z Identify the status of the covered Federal action.
3. Identify the appropriate classification of this report. If this is a followup report caused by a material change to the information previously
reported, enter the year and quarter in which the change occurred. Enterthe date of the last previously submitted report by this reporting
entity for this covered Federal action.
4. Enter the full name, address, City, State and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate
classification of the reporting entity that designates if it is, or expects to be, a prime or subaward recipient. Identify the tier of the subawardee,
e.g., the first subawardee of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract
awards under grants.
5. If the organization filing the report in item 4 checks "subawardee," then enter the full name, address, city, State and zip code of the prime
Federal recipient. Include Congressional District, if known.
6. Enter the name of the Federal agency making the award or loan commitment. Include at least one organizational level below agency name, if
known. For example, Department of Transportation, United States Coast Guard.
7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic
Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments.
8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g., Request for Proposal
(RFP) number; Invitation for Bid (IFB) number; grant announcement number; the contract, grant, or loan award number; the
application/proposal control number assigned by the Federal agency). Include prefixes, e-g., "RFP-DE-90-001."
9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the
award/loan commitment for the prime entity identified in item 4 or 5.
10. (a) Enter the full name, address, city, State and zip code of the lobbying registrant under the Lobbying Disclosure Act of 1995 engaged by
the reporting entity identified in item 4 to influence the covered Federal action.
(b) Enter the full names of the individual(s) performing services, and include full address if different from 10 (a). Enter Last Name, First
Name, and Middle Initial (MI).
11, The certifying official shall sign and date the form, print his/her name, title, and telephone number.
According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays a valid OMB Control
Number. The valid OMB control number for this information collection is OMB No. 0348-0046. Public reporting burden for this collection of information is
estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0046), Washington,
DC 20503.
CERTIFICATION OF NON -SEGREGATED FACILITIES
CONTRACTOR/APPLICANT: VI'AC- j*VerYrA, C_0,7,5-CrVC,-n0-7
Environmental Protection Agency Region IX
75 Hawthorne Street
San Francisco, California 94105
OFFICIAL'S NAME: Aus v.-? V,',m C_ I it i
DATE EXECUTED: EXECUTED IN COUNTY OF: 6L- 90f;�-dO
CONTRACTOR/APPLICANT SIGNATURE: L
TITLE:
Note:The penalty for making false statements in offers is prescribed in 18 U.S.C. 1001.
DRUG -FREE WORKPLACE CERTIFICATION
CONTRACTOR/APPLICANT: V1, AC, S -etu cq7,D -I
The contractor or applicant named above hereby certifies compliance with Government Code Section
8355 in matters relating to providing a drug -free workplace. The above named contractor or applicant
will:
1 . Publish a statement notifying employees that unlawful manufacture, distribution, dispensation,
possession, or use of a controlled substance is prohibited and specifying actions to be taken against
employees for violations, as required by Government Code Section 8355(a).
2. Establish a Drug -Free Awareness Program as required by Government Code Section 8355(b), to
inform employees about all of the following:
(a) The dangers of drug abuse in the workplace,
(b) The person's or organization's policy of maintaining a drug -free workplace,
(c)Any available counseling, rehabilitation and employee assistance programs, and
(d) Penalties that may be imposed upon employees for drug abuse violations.
3. Provide as required by Government Code Section 8355(c), that every employee who works on
the proposed contract or loan:
(a) Will receive a copy of the company's drug -free policy statement, and
(b) Will agree to abide by the terms of the company's statement as a condition of employment on
the contract or loan.
OFFICIAL'S NAME: AL,1,5 T7 1) \/I-n CA"nove-17,P11
R3/2 6 ly
DATE EXECUTED, L11 o EXECUTED IN COUNTY OF:
CONTRACTOR/APPLICANT SIGNATURE:
TITLE: ty
NON-DISCRIM I NATION CLAUSE
CONTRACTOR/APPLICANT:
During the performance of this contract, contractor and its subcontractors shall not unlawfully
discriminate against any employee or applicant for employment because of sex, race, religion,
color, national origin, ancestry, physical disability (including HIV and AIDS), mental disability,
medical condition (cancer), marital status, age (over 40) or denial of family care leave.
Contractors and subcontractors shall insure that the evaluation and treatment of their employeet
and applicants for employment are free of such discrimination and harassment. Contractors and
subcontractors shall comply with the provisions of the Fair Employment and Housing Act
(Government Code Section 12900 (a-� et seq.) and the applicable regulations promulgated
thereunder (California Administrative Code, Title 2, Section 7285.0 et seq.). The applicable
regulations of the Fair Employment and Housing Commission implementing Government Code,
Section 12900 (a-�, set forth in Chapter 5 of Division 4 of Title 2 or the California Administrative
Code are incorporated into this contract by reference and made a part hereof as if set forth in
full. Contractor and its subcontractor shall give written notice of their obligations under this
clause to labor organizations with which they have a collective bargaining or other agreement.
2. The contractor shall include the nondiscrimination and compliance provisions of this clause in all
subcontracts to perform work under the contract.
OFFICIAL'S NAME: A V e-
DATE EXECUTED: 3 IA6 EXECUTED IN COUNTY OF: Dorvao
CONTRACTOR/APPLICANT SIGNATURE: 'e-11 ...............
TITLE: prrns'de'ni-