Cities Index.
Attach 2 - Scope and Amendment 2 Executed

Hercules City Council
September 13, 2022

Document
Attach 2 - Scope and Amendment 2 Executed
Meeting
September 13, 2022
Body
Hercules City Council
Pages
4
Original file
1.4 MB
Text extracted from the city's file for reading and search. Open the original on hercules.legistar1.com. That file is the official record.

Original Agreement No.19-002
Original Agreement No. 19-002 Amendment 2
City Council Resolution No.___________
Sycamore Ave Truck Sewer Replacement Project
AMENDMENT NO. 2

APPROVING A REVISED ATTACHMENT A “SCOPE OF SERVICES” AND ATTACHMENT B “PAYMENT”

1. Parties. The parties to this Contract Amendment are the City of Hercules , a public body corporate and the following named Contractor:

Carollo Engineers, Inc.
2795 Mitchell Drive, Walnut Creek, CA 94598
Attn: Anne Prudhel / [email protected]

The parties to this Contract Amendment do mutually agree and promise as follows:

2. Purpose. This Amendment No. 2 is being entered into to amend an existing contract between the City and Contractor which was approved by the City Council of the City of Hercules on January 8, 2019 by Resolution No. 19-002. Said contract shall hereinafter be referred to as the "Original Contract" and is incorporated herein by reference.

3. Original Contract Provisions. The parties hereto agree to continue to abide by those terms and conditions of the Original Contract, and any amendments ther eto, which are unaffected by this Contract Amendment Agreement.

4. Amendment. This Amen dment No. 2 is intended to amend the Original Contract and previously approved amendments (collectively, the "Amended Contract") thereto to provide for additional compensation in an amount not to exceed $58,913, total contract amount $1,010,297.

5. Amendment Approval: This Amendment No. 2 is hereby approved by the City Council of the City of Hercules on this _______ day of _____________, 2022.

6. Signatures. These signatures attest the parties' agreement hereto:

City of Hercules

s/_______________________________
Dante Hall, City Manager

Date: ___________________________

Approved as to form:

By ______________________________
Patrick Tang, City Attorney
Carollo Engineers, Inc.

s/_________________________ s/______________________

__________________________ _______________________ Name/Title Name/Title

Date: _________________ Date: __________________

Attachments: Attachment A: Scope of Service, Attachment B: Payment DocuSign Envelope ID: F2D43688-4A0E-44B0-AFEF-DA78CA58C3E4 Vice President
9/5/2022
Anne E Prudhel
DocuSign Envelope ID: 60CFEFEF-F1F9-4BD7-BB27-F1A4FB9D6FD7 9/6/2022
Sr.VPKen Wilkins

2795 Mitchell Drive, Walnut Creek, California 94598
P. 925.932.1710 F. 925.930.0208

A. | Amendment  Request.docx
September , 

Mr. Mike Roberts, Public Works Director/City Engineer
City of Hercules
 Civic Drive
Hercules, CA *+,
Subject: Sycamore Avenue Trunk Sewer Replacement Pr oject – Amendment No.  Request Dear Mr. Roberts:

Carollo addressed the constructability comments in October  and prepared a set of construction documents for bidding. At the time, some key permits including the Corps of Engineers and Union Pacific Railroad (UPRR) were still outstanding. The decision was made to hold off on bidding the project due to the uncertainty of when permits would be received. Since then, we have been working diligently on obtaining the remaining permits and easements required for the final alignment.

The Army Corps permit has since been acquired and the UPRR license agreement will be executed upon approval of City Council. At this time, we are still working with UPRR to confirm the cost of the license agreement and have included an optional task to have Associated Right of Way Services help with UPRR negotiations.

Ten months have passed since completing the documents and there have been changes in market conditions that will impact the project including pipeline availability and lead times and material costs. The contract documents and engineer’s estimate need to be reviewed and updated prior to bidding the project.

Additionally, the sewer alignment was revised during design to avoid construction within a resident’s driveway and near the foundation of their house. This change requires acquisition of two easements. The original scope and budget assumed acquisition of just one easement.

Below is a more detailed description of the additional work to performed and the associated level of effort by task.

Task 4 – Right-of-Way Services
Appraise, negotiate, and prepare acquisition documents for an easement on a second property at the top of Camden Lane. Documents will include offer letter, appraisal summary statement and summary of the basis for just compensation, summary statement pertaining to the acquisition of real property or an interest therein, purchase agreement, deed, and public acquisition brochure. All acquisition documents will be provided to the City for written approval of use prior to being used in the field.

Optional Task: Support the City in negotiating the UPRR license agreement cost.

Task 7 – Final Design
Bid Set Completion. Review the contract documents from October  and revise as necessary to reflect recently received permit conditions, work performed by EBMUD and PG&E, changes required based on current industry and market conditions, and revised bid date information.

DocuSign Envelope ID: F2D43688-4A0E-44B0-AFEF-DA78CA58C3E4 DocuSign Envelope ID: 60CFEFEF-F1F9-4BD7-BB27-F1A4FB9D6FD7 Mr. Mike Roberts
City of Hercules
September , 

Page 

carollo.com
Revise the engineer’s estimate of probable construction cost to reflect current market conditions.

Provide draft bid set to Construction Manager (CM) for review. Address any final comments from CM and prepare final bid set.

Fee for Additional Work
The fee associated with the work identified above is >?,. An optional task to be authorized at the City’s discretion is also provided for an additional >,+. Table  presents the breakdown of the fee by task.

Attachment  provides a detailed breakdown of hours.

Table  –Amendment  Requested fee by Task
Task Carollo
Hours Carollo Labor Cost Sub Consultant Cost Amendment Request Task . – Right of Way Services  >+ >,,?+ >?,A Task ,. – Final Design  >,+? > >,+
TOTAL  , , ,
Optional Task (UPRR License Agreement Support) , 

If you have any questions or would like to discuss further, please contact me at (*+) *,,‐* or [email protected] .

Sincerely,

CAROLLO ENGINEERS, INC.

Anne E. Prudhel, P.E.

Vice President/Project Manager

AP:ap

cc: File

DocuSign Envelope ID: F2D43688-4A0E-44B0-AFEF-DA78CA58C3E4 DocuSign Envelope ID: 60CFEFEF-F1F9-4BD7-BB27-F1A4FB9D6FD7

PIC/PM PE Drafter Engineer DP Total Labor PECE ODC Total Task Task Description $323 $242 $194 $165 $111 Hours Cost $13.50 Trips Amount Total Cost

4.0 Right of Way Services

4.2 Negotiations, Development of Easement Docs 0 2 0 0 0 2 $483 $17,850 $27 $0 0 $0 $17,877 $18,360 Task 4.0 Totals = 0 2 0 0 0 2 $483 $17,850 Task 4.0 Totals = $18,360

7.0 Final Design
Bid Set Completion 8 48 48 12 24 140 $28,163 $1,890 $0 0 $0 $1,890 $30,053 Task 7.0 Totals = 8 48 48 12 24 140 $28,163 $0 Task 7.0 Totals = $30,053 TOTAL 8 50 48 12 24 142 $28,646 $17,850 $1,917 $0 0 $0 $19,767 $ 48,413 Optional Task (UPRR License Agreement Support) $10,500
ATTACHMENT 1
Subconsultants
Mileage

LABOR AND BUDGET ESTIMATE
City of Hercules
Sycamore Ave Sewer Trunk Replacement
Amendment No. 2 Request for Design and Bidding Services Other Direct Costs (ODC)
Carollo Labor
Includes 5%
Markup
Pass
Through
Fee
Hercules Trunk Sewer_Budget_Amendment 2.xlsx 9/1/2022
DocuSign Envelope ID: F2D43688-4A0E-44B0-AFEF-DA78CA58C3E4 DocuSign Envelope ID: 60CFEFEF-F1F9-4BD7-BB27-F1A4FB9D6FD7

2300 Contra Costa Blvd.

Suite 525
Pleasant Hill, CA 94523
925.691.8500 phone
925.691.6505 fax
www.arws.com

MEMORANDUM

DATE: September 1, 2022
TO: Anne Prudhel – Carollo
FROM: Matthew Schock – Associated Right of Way Services, Inc.

PROJECT: City of Hercules – Sycamore Avenue Trunk Sewer Replacement Project SUBJECT: Change in Scope of Services and Budget Amendment

Type of Change:

 Level of Effort  Scope of Services  Other
The original scope of work was for appraisal and acquisition services from 1 parcel. T he current (revised) scope is to perform the same services, but for 2 parcels.

Budgetary Change:

No Change at this Time Additional Funds Needed Reduction of Budget We previously were approved for services for right of way services (including appraisal, acquisition and project management) for one parcel at a budget of $20,000. However, services will be required for 2 parcels (APN 404 -460-008 and 404- 460-041). Our estimate is that an additional $17,000 will be required to provide the right of way services for the additional parcel , for a total of $37,000.

Please contact me with any questions. I can be reached at (925) 400-8501.

Additional Funds Authorized

By: Date:

Title:

DocuSign Envelope ID: F2D43688-4A0E-44B0-AFEF-DA78CA58C3E4 DocuSign Envelope ID: 60CFEFEF-F1F9-4BD7-BB27-F1A4FB9D6FD7 Ms. Anne Prudhel
September 1, 2022

Page 2 of 4 ends

ADDITIONAL SCOPE OF WORK
Associated Right of Way Services, Inc. (AR/WS) will provide right of way services to Carollo Engineers, Inc. (Client) for the City of Hercules (City) Sycamore Avenue Trunk Sewer Replacement Project.

AR/WS was previously scoped to provide project management, appraisal and acquisition services for one parcel. The scope detailed below is identical to the scope originally required for one parcel, and has been revised to include these services for 2 subject properties, as follows:

APN OWNER ADDRESS
404-460-008 MCCLURE, JANAIAH LUNDBLADE 136 CAMDEN LN
404-460-041 COLLINS MANAGEMENT CAMDEN LN
ASSUMPTIONS :
→ No major improvements are within the acquisition areas. Only includes minor site improvements.
→ Assumes no damages result to the remainder parcels as a result of the acquisitions or project.

PROJECT MANAGEMENT – GENERAL CONSULTATION
• Establish work process with Client and schedule, manage and coordinate all real estate functions.
• On-going consultation, meetings and recurring project management duties. • Coordinate with Client, City, appraiser, property acquisition agent and legal counsel. • Assistance with analyzing various courses of action. Work with Client and City to resolve problems and recommend solutions.
• Contract management, budget monitoring and control, and project reporting. • Implementation and compliance with applicable state and federal laws and regulations. • Maintaining accurate records. Monitor work plan and work flow.

APPRAISAL
• Appraisals to be delivered to Client and City staff as directed. • Appraisals to be prepared in accordance with California Eminent Domain Law, California Government Code Section 7260 et seq., and the Uniform Standards of Professional Appraisal Practice requirements, except as jurisdictionally exempt. • The owner or a designated representative will be invited by the appraiser to accompany him/her during the inspection of the property.
• Appraisals to be prepared in an Appraisal Report format in accordance with Uniform Standards of Professional Appraisal Practice, Standard Rule 2-2. • Appraisal is for the “Fair Market Value” of the property as per California Code of Civil Procedure, Section 1263.320.

DocuSign Envelope ID: F2D43688-4A0E-44B0-AFEF-DA78CA58C3E4 DocuSign Envelope ID: 60CFEFEF-F1F9-4BD7-BB27-F1A4FB9D6FD7 Ms. Anne Prudhel
September 1, 2022

Page 3 of 4 ends

• The appraiser will issue the necessary public acquisition informational brochure to all owners.
• In accordance with the California Code of Civil Procedure Section 1263.330, the market value of the property acquired will not include consideration of any increase or decrease in the value of the property that is attributable to any of the following:
→ The project for which the property is taken;
→ The eminent domain proceeding in which the property is taken; → Any preliminary actions of the acquiring authority relating to the taking of the property. • If revi sions are made to the property or assignment requirements during the appraisal process or upon completion of the report, appraisal time to address these revisions will be billed on an hourly basis in accordance with the AR/WS Fee Schedule. (Optional Service) D

ELIVERABLES
 Draft Notice of Decision to Appraise for approval.
 Appraisal Report.

CLIENT /C ITY OBLIGATIONS
• Design information and construction plans.
• Current title reports for each ownership.
• Environmental reports, if available.

NEGOTIATIONS / ACQUISITIONS
• AR/WS to prepare acquisition documents. Said documents include, but are not limited to:
offer letter, appraisal summary statement and summary of the basis for just compensation, summary statement pertaining to the acquisition of real property or an interest therein, purchase agreement, deed, and public acquisition brochure. AR/WS will initiate and maintain individual acquisition files. All acquisition documents to receive City’s written approval as to form prior to use in the field.
• AR/WS will negotiate to acquire permanent easement s identified by the Client. We are assuming there will be negotiations with up to 2 property owners and no lessees. • All discussions for the acquisition of property or an interest therein will be directed to result in the payment of just compensation.
• If settlement with owners is reached pursuant to the City approved appraisal or City approved administrative settlement, AR/WS will prepare a Memorandum of Settlement for transmittal to City, reviewing the issues. This mem orandum will require City written approval before implementation of any settlement agreement. • AR/WS will make every reasonable effort to acquire property on behalf of the City expeditiously through agreement with its owner and to avoid litigation. This may necessitate greater levels of effort in the negotiations phase and, where appropriate, should continue after eminent domain has been initiated. City will provide ongoing feedback to AR/WS as to authorization for settlements.

DocuSign Envelope ID: F2D43688-4A0E-44B0-AFEF-DA78CA58C3E4 DocuSign Envelope ID: 60CFEFEF-F1F9-4BD7-BB27-F1A4FB9D6FD7 Ms. Anne Prudhel
September 1, 2022

Page 4 of 4 ends

• AR/WS will establish a proces s of coordinating escrow closings and reviewing escrow instructions. Where there are escrow closings, preparation of escrow instructions will be completed by title company. Approval of conditions of title and escrow instructions, including but not limited to, “subject to” title exceptions, will be done by City. • If agreement with all owners cannot be reached, AR/WS will advise City that negotiations have reached an impasse. The City will consider scheduling of an action in eminent domain including the required public necessity hearing. AR/WS will provide condemnation support as needed and requested, budget allowing.

D

ELIVERABLES
 Draft Acquisition Documents for approval.
 Memorandum of Settlement and Signed Agreement (upon settlement).  Notice that negotiations have reached an impasse (if needed).

CLIENT /C ITY OBLIGATIONS
• Written approval of all acquisition documents in a timely manner. • Direction as to administrative settlements, negotiating authority and condition of title acceptance.
• Providing any formats to be used by AR/WS on City’s behalf. • Selection of title company.
• Review and approval of title company prepared escrow instructions.

DocuSign Envelope ID: F2D43688-4A0E-44B0-AFEF-DA78CA58C3E4 DocuSign Envelope ID: 60CFEFEF-F1F9-4BD7-BB27-F1A4FB9D6FD7 ORDINANCE NO. 534

AN ORDINANCE OF THE CITY COUNCIL OF THE CITY OF HERCULES AMENDING HERCULES MUNICIPAL CODE TITLE 2, BY ADDING A NEW ARTICLE 5 (CHAPTER 2-3.5) ENTITLED, “CITY CONTRACTOR EQUAL PAY ACT COMPLIANCE ”, TO PROVIDE A

LOCAL MEANS OF DETERMINING WHETHER ENTITIES CONTRACTING WITH

THE CITY OF HERCULES ARE IN COMPLIANCE WITH THE REQUIREMENTS OF

THE CALIFORNIA EQUAL PAY ACT
WHEREAS, the California Equal Pay Act was originally enacted to prohibit an employer from paying its employees less than employees of the opposite sex for equal work; and WHEREAS, in 2015, Governor Jerry Brown signed the California Fair Pay Act, which strengthened the California Equal Pay Act and signaled California’s commitment to achieving real gender pay equity; and
WHEREAS, since 2015 there have been additional amendments to the California Equal Pay Act; effective January 1, 2017, Governor Brown signed a bill that added race and ethnicity as protected categories so that the Act now prohibits paying employees less than employees of the opposite sex, or of another race, or of another ethnicity for substantially similar work; and WHEREAS, the protections, procedures, and remedies relating to race- or ethnicity-based claims are now identical to the ones relating to gender; and
WHEREAS, in addition, employers are prohibited from using prior salary to justify any sex -, race-, or ethnicity-based pay difference; and
WHEREAS, while the State of California has amended the Equal Pay Act to eliminate loopholes and expand its protections, there is no mechanism for a local agenc y to determine whether contractors or firms who seek to contract with the local agency are in compliance with the requirements of the Equal Pay Act; and
WHEREAS, recent salary studies have shown that women continue to be paid less than men for the same line of employment; and
WHEREAS, recent salary studies have verified that similarly qualified Black, Asian, and Latinx women continue to earn less on average than their white counterparts; and WHEREAS, anecdotal evidence suggests that the COVID -19 pandemic has disproportionately impacted women, especially women of color.

DocuSign Envelope ID: 6377961B-C5E9-4CBB-B346-030C1DD7589C DocuSign Envelope ID: F2D43688-4A0E-44B0-AFEF-DA78CA58C3E4 DocuSign Envelope ID: 60CFEFEF-F1F9-4BD7-BB27-F1A4FB9D6FD7

NOW, THEREFORE, THE CITY COUNCIL OF THE CITY OF HERCULES DOES HEREBY ORDAIN AS FOLLOWS:

SECTION 1. Recitals. The City Council hereby incorporates the above recitals into this Ordinance by this reference.

SECTION 2. Amendment. That the City Council of the City of Hercules does hereby AMEND the Hercules Municipal Code to ADD Title 2, Chapter 3, Article 5, to read as follows:
“Article 5. City Contractor EQUAL PAY ACT Compliance
Sec. 2-3.501 Purpose.

In adopting this Article, it is the intent of the City Council to provide a local means of determining whether entities contracting with the City are in compliance with the California Equal Pay Act.

The regulations established by this Article shall apply to all individuals or firms who provide services to the City as independent contractors or paid consultants.

Sec. 2-3.502 Definitions.
“City” as used herein shall mean the City of Hercules, California. “City Officials,” for the purposes of this Article, means City elected officials, City appointed officials, and City employees, including all individuals who are employed by the City Manager, City Attorney, and City Clerk, as well as all employees of City agencies and departments.
“Contractor” means any individual or firm providing or proposing to provide material, equipment, or services to the City as an independent contractor or consultant.

Sec. 2-3.503 Requiring Equal Pay Act Compliance in Public Contracting. (a) Statement of Policy. It is the policy of the City of Hercules to avoid awarding contracts for supplies, construction, maintenance, and professional or other services to contractors that are not in compliance with the requirements of the California Equal Pay Act. The awarding of a contract or the approval of payments or expenses under a contract DocuSign Envelope ID: 6377961B-C5E9-4CBB-B346-030C1DD7589C DocuSign Envelope ID: F2D43688-4A0E-44B0-AFEF-DA78CA58C3E4 DocuSign Envelope ID: 60CFEFEF-F1F9-4BD7-BB27-F1A4FB9D6FD7 by a City Official, to a person or entity that has not complied with the reporting requirements of this Article, is regarded as a violation of this Section.

It is therefore the City’s policy to prohibit awarding City contracts, according to the guidelines below:
(1) A contractor shall not be awarded a contract with the City when the contractor has been determined to have violated the Equal Pay Act at any time within the preceding five (5) years.
(2) A firm shall not be awarded a contract with the City when an owner, manager, senior member, principal, officer, or partner of the firm has been determined to have violated the Equal Pay Act at any time within the preceding five (5) years. (3) A City Official The City Manager is prohibited from approving the awarding of a contract to a contractor who refuses to comply with the requirement to provide an acknowledgment of Equal Pay Act compliance pursuant to Section 2-3.506.

The intent of this Section is to ensure that no discrimination against individuals or groups protected under the California Equal Pay Act enters into the contracting practices of the City.
(b) Responsibility to Report a Violation of Contractor Equal Pay Act compliance requirements. It is the responsibility of City Officials to report a violation of this Section.

A City employee must notify his or her supervisor, and an elected or appointed official must notify the City Manager, when he or she is aware of any of the following situations:
(1) When a contractor has been found to be in violation of the Equal Pay Act and is being considered for the award of a contract to provide services to the City; and/or (2) When a City Official becomes aware of a contractor with an existing contract to provide material, equipment or services to the City is found to be in violation of the Equal Pay Act.
(c) Penalty for Failure to Report. A City Official who knows or should know that a contractor is being considered for or has been awarded a contract with the City in violation of this Article, and fails to report the violation, is subject to discipline, including, but not limited to, suspension or termination.

DocuSign Envelope ID: 6377961B-C5E9-4CBB-B346-030C1DD7589C DocuSign Envelope ID: F2D43688-4A0E-44B0-AFEF-DA78CA58C3E4 DocuSign Envelope ID: 60CFEFEF-F1F9-4BD7-BB27-F1A4FB9D6FD7 (d) A contractor with a contract with the City or who seeks a contract with the City and fails to report a violation of the Equal Pay Act or is otherwise not in compliance with requirements of this Article may have his or her contract terminated and may be precluded from being awarded any future contracts with the City.

Sec. 2-3.505 Penalties Not Exclusive.

The penalties provided under this Article are not exclusive, and do not preclude punishment under any other applicable provision of law.

Sec. 2-3.506 Notice and Acknowledgment.
(a) The requirements of this Article shall be acknowledged by all contractors, on a form developed by the City Attorney and provided to contractors by the City Clerk. No contract shall be entered into without submission of the required acknowledgment form. (b) All contractors, and all prospective contractors, shall be notified in writing of the requirements of this Article at the time the City issues a request for proposals or qualifications, and prior to entering into an agreement.” SECTION 3. SEVERABILITY. If any section, subsection, sentence, clause, or phrase of this Ordinance is for any reason held to be invalid, such decisions shall not affect the validity of the remaining portions of this Ordinance. The Council hereby declares that it would have adopted the Ordinance, and each section, subsection, sentence, clause, or phr ase thereof, irrespective of the fact that any one or more sections, subsections, sentences, clauses or phrases be deleted.

SECTION 4. Effective Date and Publication. The City Clerk shall certify to the adoption of this Ordinance and shall publish or post the Ordinance as required by law. This Ordinance shall be effective thirty (30) days from date of final adoption.

THE FOREGOING ORDINANCE was first read at a regular meeting of the Hercules City Council on the 13 th day of July, 2021, and was passed and adopted at a regular meeting of the Hercules City Council on the 27th day of July, 2021, by the following vote:

DocuSign Envelope ID: 6377961B-C5E9-4CBB-B346-030C1DD7589C DocuSign Envelope ID: F2D43688-4A0E-44B0-AFEF-DA78CA58C3E4 DocuSign Envelope ID: 60CFEFEF-F1F9-4BD7-BB27-F1A4FB9D6FD7 AYES:

NOES:

ABSENT:

ABSTAIN:

Chris Kelley, Mayor
__________________________________________
Lori Martin, MMC
Administrative Services Director / City Clerk
COUNCIL MEMBERS: T. Grimsley, D. Romero, A.Walker-Griffin, Vice Mayor D. Bailey, Mayor C. Kelley.

None.

None.

None.

DocuSign Envelope ID: 6377961B-C5E9-4CBB-B346-030C1DD7589C DocuSign Envelope ID: F2D43688-4A0E-44B0-AFEF-DA78CA58C3E4 DocuSign Envelope ID: 60CFEFEF-F1F9-4BD7-BB27-F1A4FB9D6FD7

CONTRACTOR ACKNOWLEDGMENT OF COMPLIANCE WITH CALIFORNIA EQUAL PAY ACT SECTION A:

To be completed by City Representative Prior to Distribution to Contractor:

City Representative Phone Project Spec No.

Department Contract/Proposal Name __
SECTION B:

This is an Original Revised form (check one). If Original, complete all that applies. If revised, complete Contractor Name and include any changed data.

Contractor/Consultant Name____________________ Phone
Street Address City State Zip
Type of Submission (Check One) Bid Proposal Qualification Contract/Agreement/Amendment SECTION C:

The undersigned Contractor’s Representative acknowledges by his or her signature the following:

It is the policy of the City of Hercules to avoid awarding contracts for supplies, construction, maintenance, professional or other services to contractors who are not in compliance with the equal pay requirements of the California Equal Pay Act.. The awarding of a contract or the approval of payments or expenses under a contract by a City Official, to a person or contractor not in compliance with the California Equal Pay Act, is regarded as a violation of this Section.

I have read Hercules Ordinance Number 534 and certify that I/we have not in the past 5 years been found to be in violation of the California Equal pay Act, and I/we have not knowingly, nor will I/we in the future, enter into a contract with the City of Hercules or accept payment from the City of Hercules when to do so is in violation of Ordinance Number 534 .

If circumstances require changing the information on this form while I/we have a bid, proposal, or qualifications under review, or while we are under contract with the City, we will amend this form within five business days.

Signature Date
Print Name of Signer Position
SECTION D:

To Be Completed by Administrative Services Department with the City of Hercules after Submission of the Compl eted Form by Contractor
Date Received by City By XXXXXXXX
via DocuSign

XXXXXXXXX
via DocuSign
DocuSign Envelope ID: F2D43688-4A0E-44B0-AFEF-DA78CA58C3E4 925-932-1710
X
CA 94598
Vice President
2795 Mitchell Drive

9/5/2022
Carollo Engineers
Anne E Prudhel
Walnut Creek
DocuSign Envelope ID: 60CFEFEF-F1F9-4BD7-BB27-F1A4FB9D6FD7

← All documents from this meeting