Loading...
HomeMy WebLinkAbout2002-100 1 RESOLUTION NO. 2002-100 2 3 RESOLUTION OF THE MAYOR AND COMMON COUNCIL OF THE CITY OF SAN BERNARDINO AUTHORIZING THE SUBMITTAL OF A CONTRACT PROPOSAL FOR THE DEVELOPMENT AND IMPLEMENTATION OF A METROPOLITAN MEDICAL RESPONSE SYSTEM (MMRS) AND ACCEPT FUNDING ALLOCATION IN THE AMOUNT OF $400,000. BE IT RESOLVED BY THE MAYOR AND COMMON COUNCIL OF THE CITY OF SAN BERNARDINO AS FOLLOWS: 4 5 6 7 SECTION 1. The City Adrninistrator or designee is authorized to sign and subrnit a 8 9 contract proposal to the Department of Health and Hurnan Services for the developrnent of a 10 Metropolitan Medical Response Systern in the arnount of $400,000. A copy of the contract 11 proposal is attached as Attachrnent "A", and incorporated herein by reference. 12 1111 13 1111 14 1111 15 1111 1111 16 17 1111 18 1111 19 1111 20 1/11 21 1//1 22 1111 23 1111 24 1111 25 1111 1111 26 27 1111 28 1111 1 1 2002-100 RESOLUTION OF THE MAYOR AND COMMON COUNCIL OF THE CITY OF SAN BERNARDINO AUTHORIZING THE SUBMITTAL OF A CONTRACT PROPOSAL FOR THE DEVELOPMENT AND IMPLEMENTATION OF A METROPOLITAN MEDICAL RESPONSE SYSTEM (MMRS) AND ACCEPT FUNDING ALLOCATION IN THE AMOUNT OF $400,000. 2 3 4 5 I HEREBY CERTIFY that the foregoing resolution was duly adopted by the Mayor and Cornrnon 6 Council of the City of San Bernardino at a joint regular rneeting thereof, held on the 7 8 1st day of April , 2002, by the following vote, to wit: 9 COUNCILMEMBERS AYES NAYS ABSTAIN ABSENT ESTRADA x LIEN x MCGINNIS J( DERRY x SUAREZ x ANDERSON X MCCAMMACK X 10 11 12 13 14 15 16 17 ~~juL h c ttl--J~~ Racli Clark, CIty Clerk 18 19 Th, forego'" re,ol,",o', h,reby "pprr"'d ili'~2 Susan Lien, Mayor Pro Tern I City of San Bernardino 20 21 22 23 24 Approved as to Form and legal content: 25 26 JAMES F. PENMAN, City Attorney 27 2 28 Attachment "A" Metropolitan Medical Response System Proposal City of San Bernardino Fire Department 200 East Third Street San Bernardino, California 92410 RFP #233-02-0042 March 2002 City of San Bernardino PROPOSAL FOR THE DEVELOPMENT OF A METROPOLITAN MEDICAL RESPONSE SYSTEM TABLE OF CONTENTS Section I: Technical Proposal . Introduction . Situation and Threat Background . Objective and Scope . Timetable for Deliverables Section II: Business Proposal . Proposed Budget . Payment Information Form Section III: Representations and Certifications . Solicitation, Offer and Award (Standard Form 33) . Section K -- Representations, Certificates, and Other Statements of Offerors . Disclosure of Lobbying Activities City of San Bernardino PROPOSAL FOR THE DEVELOPMENT OF A METROPOLITAN MEDICAL RESPONSE SYSTEM INTRODUCTION The City of San Bernardino, with a population of over 186,000, is the largest city in the largest county in the United States, The County of San Bernardino is geographically the largest county in the contiguous United States, covering 20,000 square rniles of diverse clirnate and terrain. The City and County share a very large jurisdiction with resources that are critical to the State of California and the econorny ofthe United States, The presence of potential terrorist targets within our rnilitary and civilian hazardous materials handling facilities, transportation corridors, and critical resources is undeniable, SITUATION AND THREAT BACKGROUND Terrorisrn is of increasing concern because of its potential for mass injury, destruction and death in venues previously deerned to be safe havens, Chernical and Biological warfare tactics are being used rnore frequently by terrorist-type groups and pose an increasingly serious threat to public safety organizations and the public, The rapid technological growth in the San Bernardino region during the past few decades has resulted in an infrastructure that is tightly interconnected by vast systerns of cornrnunications, transportation, industry, government and econornic integration, Threat Assessment -- Chemical Facilities Approxirnately 8000 facilities in the San Bernardino area handle, process, and dispose of hazardous materials in quantities requiring disclosure under the State's Ernergency Planning and Cornrnunity Right to Know law. Of these facilities, 412 house chernicals above the designated threshold planning quantities lirnits that the EP A has classified as Extrernely Hazardous Substances. These facilities include high volurne (bulk tank or railcar) users of chernicals including but not lirnited to chlorine, arnrnonia, nitric acid, sulfuric acid, and hydrofluoric acid, Highly toxic gases such as arsine, hydrogen fluoride, hydrogen chloride, and various industrial gases are used in quantities exceeding reporting thresholds, Due to the type and nature of this chernical handling, sorne of these facilities could be targeted for theft, sabotage, or intentional release of chernicals, Vulnerable zones for the releases of sorne of these large volurne toxic gases (e.g, railcars of chlorine) have been calculated to exceed 25 rniles. Approxirnately 43 facilities were required to prepare Risk Managernent Programs under EP A Accidental Release Prevention Program requirernents, An intentional act ofterrorisrn at any ofthese facilities could result in a large-scale disaster. Threat Assessment -- Radioactive Waste A radioactive waste disposal site is being proposed for a desert area in San Bernardino County known as Ward Valley, adjacent to Interstate 40, This location has already been the site of nurnerous events of civil disobedience and could be targeted for a terrorist act. In addition to this proposed facility, low-level radioactive waste generated frorn federal cleanup activities is transported through the County on its way to the controversial Nevada Test Site, Proposal for Developrnent ofMMRS Plan Technical Proposal Page 2 of7 TRANSPORTATION INFRASTRUCTURE The San Bernardino region occupies a strategic location with regard to transportation corridors, It straddles rnost of the surface routes connecting the Southern California Metropolitan Area (including the Ports of Long Beach and Los Angeles) with the rest of the contiguous United States, Consequently, rail, pipeline, and highway transportation is a significant factor in both the potential for a large scale release frorn one ofthese rnodes of bulk transportation due to an intentional act, and in the resulting devastating disruption in national commerce and civil rest. The Cajon Pass is a critical geographic feature of the San Bernardino area that co-locates one Interstate, two railroads, two hazardous liquid pipelines, two high-pressure natural gas transrnission lines, water lines, and two high-power electric transrnission corridors. The lifelines of fuel, power, water, and commerce to Southern California corne through the Cajon Pass. Traffic loads through the Pass can be as high as 250,000 vehicle trips per day, The California Public Utilities Cornrnission has identified the Cajon Pass as one of the highest risk sections of rail in the State due to steep terrain and serpentine track patterns, The Cajon Pass Derailrnent of 1996 clearly illustrated the strategic location and national significance of an extended closure of the Cajon Pass, By the third day of the incident trains were backed up as far to the East as New Mexico, and the econornic irnpacts were felt all the way to the East Coast. Hil!hwavs The San Bernardino region has three rnajor Interstate Highways -- Interstate 10, Interstate 15 and Interstate 40. Interstate 10 is the rnajor connecting route between the Los Angeles area and the East Coast. Interstate 15 is the only rnajor route that connects frorn the U,S,- Mexican border at San Diego to Las Vegas and beyond, Interstate 40 connects Northern California to the East Coast and is part ofthe designated route for escorted DoD and NASA shiprnents ofdinitrogen tetroxide frorn Aerojet and Vandenberg, Major connecting freeways include the 60 and 215 Freeways which are State Highways, A significant portion of State Highway 395 connects Southern California to the Tahoe Basin, The Highway 58IUnion Pacific Corridor frorn Barstow to the Kern County line is the only southern rail link for the San Francisco Bay Area and Central California, The significance of its strategic location was dernonstrated in February 1997 when a train collided with a tractor-trailer and was closed for 30 hours, In that tirne, rail and truck traffic backed up into Central California. It is also the only designated route for rocket fuel for both Edwards Air Force Base and Vandenberg Air Force Base. Proposal for Developrnent ofMMRS Plan Technical Proposal Page 3 of? Railroads Four major railroads traverse the San Bernardino region including Union Pacific (UP) Railroad, Burlington Northern Santa Fe Railroad (BNSF) and passenger lines Amtrak and Metropolitan Transportation Authority (MTA), Both UP and BNSF have two rnajor classification yards in the County, As the two remaining transcontinental rail service providers, all commodities traveling frorn the Pacific Rirn Countries to the Eastern Sea Board rnust pass through these terminals, A Transportation Hazards Analysis done for the Local Ernergency Planning Committee (LEPC) indicated that San Bernardino County rail shiprnents exceeded all other counties in the LEPC Region in terms of shiprnents as well as the variety of hazardous cargo transported, Pipelines Several large diarneter high-pressure hazardous liquid pipelines traverse the San Bernardino area connecting points along the pacific coast with points east. A large, high pressure fuel line known as the CALNEV Pipeline runs frorn the Los Angeles Basin to Las Vegas, Nevada, carrying petroleurn products, including but not Iirnited to jet fuel for Nellis Air Force Base, The pipeline travels parallel to both rail lines and rnajor roadways at various points along its course and is considered a potential target for terrorists, All- American pipeline transports petroleurn through rnore than 100 rniles of pipeline within the County, on its path from Santa Barbara to Texas, Two pipelines transporting hydrogen and oxygen connect suppliers with their rnajor custorners, The hydrogen line runs parallel to the railroad and crosses the rail line and Interstate 10. Airports There are three international airports within San Bernardino County including Ontario International Airport (orA), Southern California International Airport (SCIA) and San Bernardino International Airport (SBDIA), All three are considered potential targets of a terrorist act. Government Facilities Situated within San Bernardino County are various State and Federal facilities that could becorne targets, These include five rnajor rnilitary bases: the Marine Corps Logistics Base at Yermo, the Fort Irwin National Training Center north of Barstow, 29 Palrns Marine Corp Air Ground Cornbat Center in 29 Palrns, the Naval Weapons Center at China Lake and a portion of Edwards Air Force Base that houses the X-33 Space Shuttle rocket launching and testing facility, Over 83,000 pounds ofliquid hydrogen propellant are stored and used at the rocket-launching site. The prirnary rnission of the rnilitary facilities is to act as national training centers for all branches of the rnilitary, including preparation for desert warfare activities, Also included within govemment facilities are offices for the: Immigration and Naturalization Service (INS); USFS Departrnent of Agriculture; Military recruiting offices; Army ReservelNational Guard Armories; U,S, Bankruptcy Court; California Franchise Tax Board; the Central U.S. Postal Distribution Facility; and a Mexican Proposal for Development ofMMRS Plan Technical Proposal Page 4 of? Consulate Office. State Corrections has three institutions with rnaxirnurn-security inmates in the Chino area -- California Institute for Men, California Institute for Wornen, and California Youth Authority, Civilian Venues San Bernardino County has several large civilian facilities that could be a potential terrorist target as well. The California Speedway in Fontana attracts crowds over 100,000 four to five tirnes per year, There are large convention centers near Ontario International Airport and another in San Bernardino. Blockbuster Pavilion, located at the Glen Helen Regional Park attracts thousands of people during live concert activities, The annual San Bernardino Route 66 rendezvous attracts in excess of 500,000 people over a three-day period, Sources of Safe Drinkinl! Water The California Aqueduct traverses the county bringing drinking water frorn Northern California to the Southland, draining into Lake Silverwood Reservoir in the San Bernardino Mountains, This water eventually is destined for the rnajor rnetropolitan area of Los Angeles. This is a popular tourist site as are rnany of the rnountain resorts, particularly during the winter rnonths and could becorne a potential terrorist target. The Colorado River borders the eastern boundary of the County and is a source of recreation, drinking water, and agricultural irrigation for cornmunities in several states. Medical Facilities There are no less than ten major hospitals within San Bernardino County, Included arnong these is the County Arrowhead Regional Medical Center, Jerry L. Pettis Mernorial Veterans Medical Center, and Lorna Linda University Medical Center and Research Facility, both of which are located in Lorna Linda approxirnately one half mile apart. OBJECTIVE AND SCOPE The City of San Bernardino, through a collaborative effort with the County of San Bernardino and other local jurisdictions and/or agencies within San Bernardino County, is proposing to enhance the current local resources in response to health and rnedical consequences of a nuclear, biological or chernical (NBC) terrorist incident. The San Bernardino City Fire Departrnent will rnanage the development and irnplernentation of the MMRS Project. The San Bernardino MMRS Project will be integrated with the existing regional San BernardinolRiverside Terrorisrn Early Warning Group (TEWG), The goal will be to involve all key agencies represented on the TEWG including: the County Public Health Departrnent, local hospitals, local Emergency Medical Providers, Fire Departrnents (including EMS and Hazardous Materials Tearns), Law Enforcernent Agencies (including Bornb Squads and SWAT Tearns), Mental Health, local laboratories, veterinarians, Medical Exarniner, Local and State Ernergency Proposal for Developrnent ofMMRS Plan Technical Proposal Page 5 of7 Managernent, State EMS Authority and Health Departrnent, National Guard, FBI, Public Utility Agencies, American Red Cross, and other local federal agency representatives, The MMRS Plan will include the following cornponents: 1, Method for identifying concepts of operation including plans for: a, Notification and alert procedures of EMS, fire, law enforcement, hospitals and public health. This rnust include procedures for notification of hospitals, clinics and HMOs; b. System for command and control; c, Centralized cornrnunications with the ability to contact both local and national resources, There is a need, not only for a common cornrnunications systern among ernergency responders, but also between ernergency responders and local county agencies, The MMRS Plan will address this issue with solutions for a fluid cornrnunications systern; d. A rneans for rnanagernent of public affairs; e, Identification of agent; f, Containment of agent; g. Managernent of victirns including decontarnination, triage, pre-hospital treatrnent, and transportation to appropriate facilities (to local facilities or other areas within the region or nation as appropriate); h, Many victirns will present at hospitals and clinics on their own and by- pass pre-hospital interventions, The MMRS Plan will include provisions addressing Weapons of Mass Destruction (WMD) recognition and treatrnent, lock-down procedures, outside triage, outside decontamination, proper Personal Protective Equipment (PPE) for healthcare workers, and adequate security for these sites, I. Definitive treatrnent at hospitals; J. Examination and disposal of deceased; k. Appropriate response by rnental health workers. 2, A rnission staternent, organization, rnernbership and operational guidelines for the Metropolitan Medical Strike Team (MMST), if a strike tearn is determined the best option for the San Bernardino area, 3, Management of health consequences of a biological WMD, This will include the integration of the plan with existing local and state health surveillance plans for bioterrorisrn and influenza pandernic planning. This portion of the plan will address five issues: a, Early Recognition -- including early indicators and who will make decisions to irnplernent response plans; Proposal for Developrnent ofMMRS Plan Technical Proposal Page 6 of? b. Mass Immunizations -- develop plans for rnanaging and irnplementing rnass immunizations/prophylaxis; c, Mass Patient Care -- providing care for a significant portion of the community; d, Mass Fatality Management -- develop plans for providing care and disposition for large nurnbers of fatalities including decontarnination/isolation procedures e. Environmental Surety -- identifying environmental risks, decontamination or vector intervention and re-entry into the suspect area with the help of local, state and federal environmental agencies, 4, Identification of training requirernents for MMRS personnel including ernergency first responders, EMTs, Paramedics, hospital and other personnel who may be involved in an incident. a. As a current recipient ofthe V,S, Departrnent of Justice's Terrorisrn Domestic Preparedness Program, the City, County and other local ernergency support agencies have been participating in all available terrorisrn preparedness courses, The train-the-trainer courses will allow participating agencies to develop additional training opportunities for their respective agencies, This training will continue until all appropriate personnel have been trained. b, Continuing education/refresher training will also be conducted along with systern-wide exercise drills. c. This training will include the assessrnent and implernentation of additional specialized training for San Bernardino Hazardous Materials Team rnernbers in the area of Hazardous Materials and WMD, d, There is a need for hospital staff to conduct ongoing Hospital Ernergency Incident Command Systern (HEICS) training. HEICS Training will be provided to San Bernardino hospital personnel. There is also a need for training of other healthcare workers (e,g" clinics, HMOs, etc.), These groups will be identified and training needs assessed. 5, A pharmaceutical plan will be developed to identify and procure approved pharmaceuticals to rneet the needs of ernergency responders and the community in the event of an NBC terrorist incident. The plan will include a way of "rotating" pharmaceuticals and a rneans ofrnaintaining an appropriate supply beyond the term of this project. 6, An equiprnent list will be developed to rneet the needs of the San Bernardino area in the event of an NBC terrorist incident. This list rnay include personal protective equiprnent, detection equiprnent, decontarnination equipment, and cornrnunications equiprnent. Any equipment purchased will be coordinated with equiprnent received by other county agencies frorn California Office of Ernergency Services, State Departrnent of Health Services, State EMS Authority, Proposal for Developrnent ofMMRS Plan Technical Proposal Page 70f7 DoD, DOJ, DHHS, and FEMA. The San Bernardino City Fire Department will work with public health, local hospitals, laboratories, law enforcement and other fire departments to assess the needs, A "property officer" will be identified to be responsible for all property received under this contract. TIMETABLE FOR DELIVERABLES I. Meet with Project Officer Within I rnonth of contract award 2, MMRS Development Plan 3. Basic MMRS Plan 4. MMRS Plan cornponent to rnanage the health consequences in the event of a biological WMD agent release, 5, MMRS Plan cornponent for responding to and rnanaging the health consequences of an incident resulting frorn use of a chemical, radiological, nuclear, and/or explosive WMD. 6, MMRS Plan cornponent for a Metropolitan Medical Strike Team (MMST) capability, if applicable, 7. MMRS Plan component for addressing the Forward Movernent of Patients to other areas of the region or the nation. 8, MMRS Plan cornponent for the local Hospital and healthcare systern that will ensure a surge capacity to accommodate 500 critically ill patients in hospitals or alternative care facilities. 9, MMRS Training Plan la, MMRS Equiprnent Plan II, Progress ReportslFinal Report Within 45 days of contract award Within 7 rnonths of contract award Within 8 months of contract award Within 9 rnonths of contract award Within 12 rnonths of contract award Within 18 rnonths of contract award Within 18 months of contract award Within 18 rnonths of contract award Within 18 rnonths of contract award Monthly Progress ReportslFinal Report due at end of 18 rnonth contract period City of San Bernardino PROPOSAL FOR DEVELOPMENT OF A METROPOLITAN MEDICAL RESPONSE SYSTEM Business Proposal Budget For 18 Month Project Planninl!: Personnel* Consultant ($301hr x 400 hrs) $ 12,000 Long Distance Travel $ 5,000 Planning Total $ 17,000 Pharmaceuticals $150,000 Equipment/Training $200,000 Office SupplieslEquipment $ 5,000 Total Direct Costs $372,000 Miscellaneous (Indirect 7.5%) $ 27,900 TOTAL COSTS $399,900 * Project Managernent (planning and development) will be provided primarily through in-kind services from the San Bernardino City Fire Department's Disaster Management Coordinator and EMS Coordinator positions. The use of consultant services may be necessary during the project planning phase. Mar 12 02 Oc;47r ~an bernardinc cit~ Pire 909 384-52B1 Department of Health'and Human services program Support center Payment Information Form The information requested on this form concerns your financial instlt~tlon your account at that institution, and personal informatl~n WhlCh needs to . verified and completed. p.2 Privacr ~t Statement The following information is provlded to comply with the Privacy Act of 1914 IP.~. 93-~19). All info~tion collected on this form is required under the provisions of 31 USC 3322 and 31 CFR 210. This information will be used by the TreaSUry Department to transmit payment data, by electronic means to your financial institution. Failure to provide the requested information may delay or prevent the receipt of payments througli the Automated Clearing House Payment system. Check one of the following: Federal Employee: Contractor: Vendor: Name: Business Address: Remi t TO Address: (If same as above, ~eave blank. Must match address on invoice for internal control' purposes.) Taxpayer Identification I (TIN): 95 6 0 0 0 7 7 2 (If you are an individual. this maybe your socra1l>ecuri"fY"niiiiiDeYJ" 1. Payee's Telephone Number: (_____, The following information must be completed by your financial institution representati ve: 2. Name of FinanCial Institution: I,ELLS FARGO BANK 3. Address of Financial Institution: Government Banking 707 \,ilshire Blvd" 16th Floor 4. Financial Institution's 9-digit ABA Routing Number for Transfer of Funds: L L -L ~ JL., ...lL ..L. ..it.... -1L 5. Depositor Account Title: City of San Bernardino 6. Depositor Account Number: 4159283308 7. Type of Account: ~ Checking _____ Savings e. Signature and Title of Authorized official (Financial Institutionl:, / 'r' " ) _,--~ J Ii. i --'-.' <,'; r ' MAcliE2818--16A, Los Angeles, CA 90017 ~\ Ic..,,,,-.jl) Telephone Number: l~' 384-"~?1 Date: 3/12/02 ,. ............ The following must be signed by the payee..........~..* I have verified the i~formation .. ,.~,( Ii {i 'j,/ . (t> .// \ slgnature "/ . , on this form. f/ '/. /~.....' Uat.e . souaT AlION, OFFER AND AW ARD II THIS CO\IT RACT IS A RATED mOER ~ I"AIING I PA~ I ~~GES- UNOER OPAS (IS CfR 700) 2. CQ\JT RAG NO. 3 soUaT ATIQ\l NO. 4. TYPE Cf salOT ATlCN 5 OAT E ISSUED 6. REQJISITICN,iPUROlASE D SEALED BID OFB) NO. 233-02-0042 rx NEGOr IAr ED (RFP) 02/26/02 000089 7.ISSUED BY =EI 8. ADDRESS CfFER TO (If oth€l' tha1/tan 7) DHHSlProgram Support Center AOS/Division of Acquisition Management Parklawn Building, Room 5-101 5600 Fishers Lane. Rockville, MD 20857 NOTE: In sede:lbdsOlidtclicns "offer" Old " offeror" rTEO"'lS "tier rnd"bct:isr" SOlIOT AT ION 9, 5edecl otfers in crignd end 3 hCnCt:aried in the OOp:6itory 1000ro in CAUTION. LATE Sutrrissicn. Mcdflextioos, mdWithctONds: ccndtims CO"ltdned in this sdidtdioo 10. Frn A NAME INFa?MATlCN II1II.... CALL, ,... cx::pes fa furnishing the sl.q:Hes Cf saviCE5 in the SchedJle will be ra:eivEd d the Jja:e s,::e:::ified in item 6, a if See Block 7 until 5:00n.m. Icx::d time 04111102 (Hcu) (Dde) SeeSEdim L. Pravisicn No. 52.214-7 or 52.215-1. All offers aesut::led todl term end Michele Troller B. TELEPHalE NO=IEcr CAllS ArEOCcx:B INLITt:Er IEXT 301 1443-1658 I 11. TABLE OF CONTENTS C E.MAIL AOORESS mtrotter@psc,gov (X) SEC I OESmlPTlal IPAGe(S) (X) I SEC I DEsmlPT lal IPAGE(S) PART I - THE SOlEDUlE PART 11 - CCNT RAcr QAUSES X A SWOT AT lallCQolT RAcr FrnM I xl I I <INTRACT QAUSES I 26-33 X B SUPPLIES rn SERVICES ANO PRICES {(Xl;T S 2-3 PART 111 . UST Cf DCXJJMENTS, EXHIBITS AND OTHER ATT AQ-i. X C OESmIPTlalISPECS.M'rnK ST ATEMENT 4-16 xl J I LIST Cf ATT AO<MENT 5 I 34-59 X D PACKAGING AND MARKING 17 PART IV - REPRESENT ATlO\lS AND INSTRUCTIO\IS X E INSPEa 10\1 AND ACCEPT ANCE 18 REPRESENT AT1~S. CERT1F1CATIO\IS AND X K 1-15 X F DEUVERIES rn PERFrnMANa 19-20 o.THER sr AT EMENTS Cf CfFERrnS X G c:c:NT RAG ADMINIST RAT ICN DAT A 21.24 X L INSrRS. <INOS.. AND NCJ!ICES To.CfFERms 1-3 X H SPEOAL <INTRACT REQJIREMENTS 25 X M EVAlUATIQ'.J FAOCRS Frn AWARD I OFFER (Musf te fully a:rrpelro Ot offerer) NorE: 'It an 12 cbes not CWy if thesolidtction indl.JCi:s the p'CNision ci 52.214-16. Minirrum Bid Aa::::eJ;:trnce Pa"ioci 12. In corn:;lirncewith the ct:xNe the lJfld::rsiglEld cgees, if this offer is o::x:ep-Ed within cdenc::b d:::>,'s (60 criUlCb cq,s unless odffa-f3'1f pa-iod is ins9"tro by the offfra) frem the d::te for receiJ:i of offers specified c:tDIe to furnish my or dJ itan; UpYl whim pice; ae offered d the pice set ~ite eo::h item d91ivered ci the cE5igded fX)int(s). within the tirre sj::€dfiEd in the sctle:::Ue. T3. DISCOJNT Fen PRCMPT PAYMENT ~ 10 CALENDAR DAVS 120 CALENDAR OAYS 30 CALENDAR DAYS 140 CALENDAR DAVS (SeeSectim/, OQJseNo. 52-232-8) 14. AO<NONLEDGMENT a: AMENDMENT S AMENDMENT NO. DATE AMENDMENT NO. DATE (The of/fireX' a:knowled;}es fa::ap of 0TI€rld- fT1EJ1ts to 'he S alOT A T IOV fa offfrcxS ad faded d::xumer1ts nlJfTt:a"ed end d:Ja:t) =EI I FAOllTY I 16. NAME ANO TITLE Cf PERSal AUT HrnlZED TO. SIGN CfFER 15A. NAME (rypea ;::rint) ANO of AOORESS City San Bernardino Fred Wilson Cf 300 North "D" Street City Administrator CfFERrn San Bernardino, CA 92418 15B TELEPHalE NUMBER 15C a-tEO< IF REMITT ANCE ADDRESS IS 17. SlGf\lATURE rbt, 12~ 16. CfFER DATE AraJ uxe Iturrt:Er IEXT 0 DIFFERENT FROv1 ABOVE ENTER SUQ-! it ,0( II 1/.51 909 384-5122 AOORESS IN SO<EDULE 1".,' 'lj 'jil (F"'; AWARD (To tea:rrpelrotJ( Governmer1t) J / 19 ACCEPTED AS TO IT EMS NUMBERED 120. AMaJNT 21. ACCCUNT ING AND APPRCPRIAT 1Q\J 22, AUTHrnlTY Fm USING OTHER THAN FULL AND (yEN CQv1PETIT 10\!: 23, SUBMIT INVOCES TO AOORESS SHONN IN ITEM 010 U.S.C 2304 (e)( ) 041 U.S.C 253 (e) ( ) (4 ropes unless othet'wise spocW€d) ~ 24. ADMINIS T ERED BY (If Ofhfx then Hem 7) =ET 25. PAYMENT Will BE MADE BY =E 26_ NAME a: CCNTRAGINGcrFlaR (rypea p'int) 27 UNITED ST ATES a AMERIO\ 2B AWARD OArE (Sirnrture of CcnrrcctlrYl Ofi03") IMPORT ANT - Awad will te m:de en this Farn a on S tmcl::rd. Fam 26. a bi othEr OJthaizEd offidd writtEn notice. AUTHrnlZED Frn LOCAL REPROOJCTIOO ST ANDARD FORM 33 (REV Q.Q7) PfENiCUS edtlQ"l is l.JlUscble Pr€501trob; GSA. FAR (48 GR) 53 214 (c) cmiltdo/ ~MetI..,A",.ar..rlll:l)1] <W3-"J,.\5J IEF SECTION K - REPRESENTATIONS. CERTIFICATES. AND OTHER STATEMENTS OF OFFERORS 10. 1. 2 . Certificate of Independent Price Determination Certification and Disclosure Regarding Payments to Influence Certain Federal Transactions Taxpayer Identification Certification Regarding Debarment, Suspension, Proposed Debarment and Other Responsibility Matters place of Performance Small Business Concern Representation Previous Contracts and Compliance Reports Affirmative Action Compliance Certification of Toxic Chemical Release Reporting The Pro-Children Act of 1994 FAR 52.203-2 FAR 52.203-11 3 . 4 . FAR 52.204-3 FAR 52.209-5 5. 6. 7. 8 . 9 . FAR 52.215-6 FAR 52.219-1 FAR 52.222-22 FAR 52.222-25 FAR 52.223-13 P.L. 103-227 To Be Completed by the Offeror: (The Representations and Certifications must be executed by an individual authorized to bind the offe~or.) The offeror makes the following Representations and Certifications as part of its proposal (check or complete all appropriate boxes or blanks on the following pages) . City of San Bernardino (Name of Offeror) 233-02-0042 (RFP No.) Ii- II {(2- (Date) ed Individual) Fred Wilson, City Administrator (Typed Name of Authorized Individual) Note: The penalty for making false statements in offers is prescribed in 18 U.S,C. 1001. SECTION K 233-02-0042 Page 2 of 15 1. 52.203-2 Certificate of Independent Price Determination. (APR 1985) (a) The offeror certifies that - (1) The prices in this offer have been arrived at independently, without, for the purpose of restricting competition, any consultation, communication, or agreement with any other offeror or competitor relating to - (i) Those prices; (ii) The intention to submit an offer;, or (iii) The methods or factors used to calculate the prices offered. (2) The prices in this offer have not been and will not be knowingly disclosed by the offeror, directly or indirectly, to any other offeror or competitor before bid opening (in the case of a sealed bid solicitation) or contract award (in the case of a negotiated solicitation) unless otherwise required by law; and (3) No attempt has been made or will be made by the offeror to induce any other concern to submit or not to submit an offer for the purpose of restricting competition. (b) Each signature on the offer is considered to be a certification by the signatory that the signatory - (1) Is the person in the offeror's organization responsible for determining the prices being offered in this bid or proposal, and that the signatory has not participated and will not participate in any action contrary to subparagraphs (a) (1) through (a) (3) of this provision; or (2) (i) Has been authorized, in writing, to act as agent for the following principals in certifying that those principals have not participated, and will not participate in any action contrary to subparagraphs (a) (1) through (a) (3) of this provision [insert full name of person(s) in the offeror's organization responsible for determining the prices offered in this SECTION K 233-02-0042 Page 3 of 15 bid or proposal, and the title of his or her position in the offeror's organization]; (ii) As an authorized agent, does certify that the principals named in subdivision (b) (2) (i) of this provision have not participated, and will not participate, in any action contrary to subparagraphs (a) (1) through (a) (3) of this provision; and (iii) As an agent, has not personally participated, and will not participate, in any action contrary to subparagraphs (a) (1) through (a) (3) of this provision. (c) If the offeror deletes or modifies subparagraph (a) (2) of this provision, the offeror must furnish with its offer a signed statement setting forth in detail the circumstances of the disclosure. 2. 52.203-11 Certification and Disclosure Regarding Payments to Influence Certain Federal Transactions. (APR 1991) (a) The definitions and prohibitions contained in the clause, at FAR 52.203-12, Limitation on Payments to Influence Certain Federal Transactions, included in this solicitation, are hereby incorporated by reference in paragraph (b) of this certification. (b) The offeror, by signing its offer, hereby certifies to the best of his or her knowledge and belief that on or after December 23, 1989 - (1) No Federal appropriated funds have been paid or will be paid to any person 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 on his or her behalf in connection 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; (2) If any funds other than Federal appropriated funds (including profit or fee received under a covered SECTION K 233-02-0042 Page 4 of 15 Federal transaction) have been paid, or will be paid, to any person 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 on his or her behalf in connection with this solicitation, the offeror shall complete and submit, with its offer, OMB standard form LLL, Disclosure of Lobbying Activities, to the Contracting Officer; and (3) He or she will include the language of this certification in all subcontract awards at any tier and require that all recipients of subcontract awards in excess of $100,000 shall certify and disclose accordingly. (c) Submission of this certification and disclosure is a prerequisite for making or entering into this contract imposed by section 1352, title 31, United States Code. Any person who makes an expenditure prohibited under this provision or who fails to file or amend the disclosure form to be filed or amended by this provision, shall be subject to a civil penalty of not less than $10,000, and not more than $100,000, for each such failure. 3. 52.204-3 Taxpayer Identification. (OCT 1998) (a) Definitions. Common parent, as used in this provision, means that corporate entity that owns or controls an affiliated group of corporations that files its Federal income tax returns on a consolidated basis, and of which the offeror is a member. Taxpayer Identification Number (TIN), as used in this provision, means the number required by the Internal Revenue Service (IRS) to be used by the offeror in reporting income tax and other returns. The TIN may be either a Social Security Number or an Employer Identification Number. (b) All offerors must submit the information required in paragraphs (d) through (f) of this provision to comply with debt collection requirements of 31 U.S.C. 770l(c) and 3325(d), reporting requirements of 26 U.S.C. 6041, 6041A, and 6050M, and implementing regulations issued by the IRS, If the resulting contract is subject to the payment reporting requirements described in Federal Acquisition SECTION K 233-02-0042 Page 5 of 15 Regulation (FAR) 4.904, the failure or refusal by the offeror to furnish the information may result in a 31 percent reduction of payments otherwise due under the contract. (c) The TIN may be used by the Government to collect and report on any delinquent amounts arising out of the offeror's relationship with the Government (31 U.S.C. 770l(c) (3)). If the resulting contract is subject to the payment reporting requirements described in FAR 4.904, the TIN provided hereunder may be matched with IRS records to verify the accuracy of the offeror's TIN. (d) Taxpayer Identification Number (TIN). [X] TIN: 95-6000772 TIN has been applied for. TIN is not required because: [ ] Offeror is a nonresident alien, foreign corporation, or foreign partnership that does not have income effectively connected with the conduct of a trade or business in the United States and does not have an office or place of business or a fiscal paying agent in the United States; [ ] Offeror is an agency or instrumentality of a foreign government; [ ] Offeror is an agency or instrumentality of the Federal Government. (e) Type of organization. [ Sole proprietorship; Partnership; Corporate entity (not tax-exempt); Corporate entity (tax-exempt); [X] Government entity (Federal, State, or local); [ ] Foreign government; SECTION K 233-02-0042 Page 6 of 15 International organization per 26 CFR 1.6049-4; Other (f) Common parent. N/A [ l Offeror is not owned or controlled by a common parent as defined in paragraph (a) of this provision. [ l Name and TIN of common parent: Name TIN 4. 52.209-5 Certification Regarding Debarment, Suspension, Proposed Debarment, and Other Responsibility Matters. (APR 2001) (a) (1) The Offeror certifies, to the best of its knowledge and belief, that - (i) The Offeror and/or any of its Principals - (A) Are [ l are not [Xl presently debarred, suspended, proposed for debarment, or declared ineligible for the award of contracts by any Federal agency; (B) Have [ l have not [xl, within the three-year period preceding this offer, 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) contract or subcontract; violation of Federal or state antitrust statutes relating to the submission of offers; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, or receiving stolen property; (C) Are [ 1 are not [xl presently indicted for, or otherwise criminally or civilly charged by a governmental entity with, commission of any of the offenses enumerated in paragraph (a) (1) (i) (Bl of this provision; and SECTION K 233-02-0042 Page 7 of 1.5 (D) Have [ 1 have not [X l, within a three-year period preceding this offer, 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) contract or subcontract; violation of Federal or state antitrust statutes relating to the submission of offers; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, or receiving stolen property; and (E) Are [ 1 are not [Xl presently indicted for, or otherwise criminally or civilly charged by a governmental entity with, commission of any of the offenses enumerated in subdivision (a) (1) (i) (D) of this provision. (ii) (A) The offeror, aside from the offenses enumerated in paragraphs (a) (1) (i) (A), (B), and (C) of this provision, has [ 1 has not [Xl within the past three years, relative to tax, labor and employment, environmental, antitrust, or consumer protection laws - (1) Been convicted of a Federal or State felony (or has any Federal or State felony indictments currently pending against them); or (2) Had a Federal court judgment in a civil case brought by the United States rendered against them; or (3) Had an adverse decision by a Federal administrative law judge, board, or commission indicating a willful violation of law. (B) If the offeror has responded affirmatively, the offeror shall provide additional information if requested by the Contracting Officer; and (iii) The Offeror has [ 1 has not [xl, within a three-year period preceding this offer, had one or more contracts terminated for default by any Federal agency, (2) Principals, for the purposes of this certification, means officers; directors; owners; partners; and, persons having primary management or supervisory responsibilities within a business entity (e.g., SECTION K 233-02-0042 Page 8 of 15 general manager; plant manager; head of a subsidiary, division, or business segment, and similar positions) . This Certification Concerns a Matter Within the Jurisdiction of an Agency of the United States and the Making of a False, Fictitious, or Fraudulent Certification May Render the Maker Subject to Prosecution Under Section 1001, Title 18, United States Code. (b) The Offeror shall provide immediate written notice to the Contracting Officer if, at any time prior to contract award, the Offeror learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances. (c) A certification that any of the items in paragraph (a) of this provision exists will not necessarily result in withholding of an award under this solicitation. However, the certification will be considered in connection with a determination of the Offeror's responsibility. Failure of the Offeror to furnish a certification or provide such additional information as requested by the Contracting Officer may render the Offeror nonresponsib1e. (d) Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render, in good faith, the certification required by paragraph (a) of this provision. The knowledge and information of an Offeror is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. (e) The certification in paragraph (a) of this provision is a material representation of fact upon which reliance was placed when making award. If it is later determined that the Offeror knowingly rendered an erroneous certification, in addition to other remedies available to the Government, the Contracting Officer may terminate the contract resulting from this solicitation for default. 5. 52.215-6 Place of Performance. (OCT 1997) (a) The offeror or respondent, in the performance of any contract resulting from this solicitation, [ ] intends, [X] does not intend [check applicable block] to use one or more plants or facilities located at a different address from the address of the offeror or respondent as indicated in this SECTION K 233-02-0042 Page 9 of 15 proposal or response to request for information. (b) If the offeror or respondent checks intends in paragraph (a) of this provision, it shall insert in the following spaces the required information: Place of Performance (Street Address, City, State, County, Zip Code) Name and Address of Owner and Operator of the Plant or Facility if Other than Offeror or Respondent 6. 52.219-1 Small Business Program Representations. (MAY 2001) Alternate I (OCT 2000) (a) (1) The North American Industry Classification System (NAICS) code for this acquisition is (NA). (2) The small business size standard is (NA). (3) The small business size standard for a concern which submits an offer in its own name, other than on a construction or service contract, but which proposes to furnish a product which it did not itself manufacture, is (NA). (b) Representations. (1) The offeror represents as part of its offer that it [ ] is, [x] is not a small business concern. (2) [Complete only if the offeror represented itself as a small business concern in paragraph (b) (1) of this provision.] The offeror represents, for general statistical purposes, that it [ ] is, [ ] is not, a small disadvantaged business concern as defined in 13 CFR 124.1002. (3) [Complete only if the offeror represented itself as a small business concern in paragraph (b) (1) of this provision.] The offeror represents as part of its offer that it [ ] is, [ ] is not a women-owned small business concern. SECTION K 233-02-0042 Page 10 of 15 (4) [Complete only if the offeror represented itself as a small business concern in paragraph (b) (1) of this provision.] The offeror represents as part of its offer that it [ ] is, [ ] is not a veteran-owned small business concern. (5) [Complete only if the offeror represented itself as a veteran-owned small business concern in paragraph (b) (4) of this provision.] The offeror represents as part of its offer that it [ ] is, [ ] is not a service-disabled veteran-owned small business concern. (6) [Complete only if offeror represented itself as a small business concern in paragraph (b) (1) of this provision.] The offeror represents, as part of its offer, that - (i) It [ ] is, [ ] is not a HUBZone small business concern listed, on the date of this representation, on the List of Qualified HUBZone Small Business Concerns maintained by the Small Business Administration, and no material change in ownership and control, principal office of ownership, or HUBZone employee percentage has occurred since it was certified by the Small Business Administration in accordance with 13 CFR Part 126; and (ii) It [ ] is, [ ] is not a joint venture that complies with the requirements of 13 CFR Part 126, and the representation in paragraph (b) (6) (i) of this provision is accurate for the HUB Zone small business concern or concerns that are participating in the joint venture. [The offeror shall enter the name or names of the HUBZone small business concern or concerns that are participating in the joint venture: .] Each HUBZone small business concern participating in the joint venture shall submit a separate signed copy of the HUBZone representation. (c) Definitions. As used in this provision - Service-disabled veteran-owned small business concern - (1) Means a small business concern - SECTION K 233-02-0042 Page 11 of 15 (i) Not less than 51 percent of which is owned by one or more service-disabled veterans or, in the case of any publicly owned business, not less than 51 percent of the stock of which is owned by one or more service-disabled veterans; and (ii) The management and daily business operations of which are controlled by one or more service-disabled veterans or, in the case of a veteran with permanent and severe disability, the spouse or permanent caregiver of such veteran. (2) Service-disabled veteran means a veteran, as defined in 38 U.S.C. 101(2), with a disability that is service-connected, as defined in 38 U.S.C. 101(16). Small business concern means a concern, including its affiliates, that is independently owned and operated, not dominant in the field of operation in which it is bidding on Government contracts, and qualified as a small business under the criteria in 13 CFR part 121 and the size standard in paragraph (a) of this provision. Veteran-owned small business concern means a small business concern - (1) Not less than 51 percent of which is owned by one or more veterans (as defined at 38 U.S.C. 101(2)) or, in the case of any publicly owned business, not less than 51 percent of the stock of which is owned by one or more veterans; and (2) The management and daily business operations of which are controlled by one or more veterans. Women-owned small business concern means a small business concern - (1) That is at least 51 percent owned by one or more women; or in the case of any publicly owned business, at least 51 percent of the stock of which is owned by one or more women; and (2) Whose management and daily business operations are controlled by one or more women. (d) Notice. (1) If this solicitation is for supplies and has SECTION K 233-02-0042 Page 12 of 15 been set aside, in whole or in part, for small business concerns, then the clause in this solicitation providing notice of the set-aside contains restrictions on the source of the end items to be furnished. (2) Under 15 U.S.C. 645(d), any person who misrepresents a firm's status as a small, HUBZone small, small disadvantaged, or women-owned small business concern in order to obtain a contract to be awarded under the preference programs established pursuant to section B(a), B(d), 9, or 15 of the Small Business Act or any other provision of Federal law that specifically references section B(d) for a definition of program eligibility, shall - (i) Be punished by imposition of fine, imprisonment, or both; (ii) Be subject to administrative remedies, including suspension and debarment; and (iii) Be ineligible for participation in programs conducted under the authority of the Act. 7. 52.222-22 Previous Contracts and Compliance Reports. (FEB 1999) The offeror represents that - (a) It [ l has, [Xl has not participated in a previous contract or subcontract subject the Equal Opportunity clause of this solicitation; (b) It [ l has, [ l has not filed all required compliance reports; and (c) Representations indicating submission of required compliance reports, signed by proposed subcontractors, will be obtained before subcontract awards. 8. 52.222-25 Affirmative Action Compliance. (APR 1984) The offeror represents that - (a) It [Xl has developed and has on file, [ l has not developed and does not have on file, at each establishment, affirmative action programs required by the rules and SECTION K 233-02-0042 Page 13 of 15 regulations of the Secretary of Labor (41 CFR 60-1 and 60-2); or (b) It [ ] has not previously had contracts subject to the written affirmative action programs requirement of the rules and regulations of the Secretary of Labor. 9. 52.223-13 Certification of Toxic Chemical Release Reporting. (OCT 2000) (a) Submission of this certification is a prerequisite for making or entering into this contract imposed by Executive Order 12969, August 8, 1995. (b) By signing this offer, the offeror certifies that - (1) As the owner or operator of facilities that will be used in the performance of this contract that are subject to the filing and reporting requirements described in section 313 of the Emergency Planning and Community Right-to-Know Act of 1986 (EPCRA) (42 U.S.C. 11023) and section 6607 of the Pollution Prevention Act of 1990 (PPA) (42 U.S.C. 13106), the offeror will file and continue to file for such facilities for the life of the contract the Toxic Chemical Release Inventory Form (Form R) as described in sections 3l3(a) and (g) of EPCRA and section 6607 of PPA; or (2) None of its owned or operated facilities to be used in the performance of this contract is subject to the Form R filing and reporting requirements because each such facility is exempt for at least one of the following reasons: [Check each block that is applicable,] (i) The facility does not manufacture, process, or otherwise use any toxic chemicals listed under section 3l3(c) of EPCRA, 42 U,S.C. 11023(c); (ii) The facility does not have 10 or more full-time employees as specified in section 3l3(b) (1) (A) of EPCRA, 42 U.S.C. 11023(b) (1) (A); (iii) The facility does not meet the reporting thresholds of toxic chemicals established under section 3l3(f) of EPCRA, 42 U.S.C. 11023(f) (including the alternate thresholds at 40 CFR SECTION K 233-02-0042 Page 14 of 15 372.27, provided an appropriate certification form has been filed with EPA); (iv) The facility does not fall within Standard Industrial Classification Code (SIC) major groups 20 through 39 or their corresponding North American Industry Classification System (NAICS) sectors 31 through 33; or (v) The facility is not located within any State of the United States, the District of Columbia, the Commonwealth of Puerto Rico, Guam, American Samoa, the United States Virgin Islands, the Northern Mariana Islands, or any other territory or possession over which the United States has jurisdiction. 10. P.L. 103-227 The Pro-Children Act of 1994 CERTIFICATION REGARDING ENVIRONMENTAL TOBACCO SMOKE Public Law 103-227, also known as the Pro-Children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, day care, early childhood development services, education or library services to children under the age of 18, if the services are funded by Federal programs either directly or through State or local governments, by Federal grant, contract, loan, or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for impatient drug or alcohol treatment; service providers whose sole source of applicable Federal funds is Medicare or Medicaid; or facilities where WIC coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. By signing this certification, the offeror/Contractor (for acquisitions) or applicant/grantee (for grants) certifies that the submitting organization will comply with the requirements of the Act and will not allow smoking within SECTXON K 233-02-0042 Page 15 of 15 any portion of any indoor facility used for the provisions of services for children as defined by the Act. The submitting organization agrees that it will require that the language of this certification be included in any subawards which contain provisions for children's services and that all subrecipients shall certify accordingly. NOT APPLICABLE DISCLOSURE OF lOBBYING ACTIVITIES APPfCh-.:f by , Q)"e-.oo.., 1, Type 01 Fcdenl Ac1ion: 2. SI.J.lul of Fede'~ Action: 3. Report Type: 0 a. conlr~ct 0 ., bidloffer/lpplic.Jlion 0 I. Inillll filing b. Brant b. loitill .award b. molteri.1 Cholnge c. coopeuli...e agreement posl-award fo, M.terlal Ch.nse Only. d,lo.n c. e. lOIn gu.af.Jntee ,eu qUI"er d.te of IUI "port - f, lOin insurance 4. N.me .nd Add.... 01 Reportlns Enlity: S. II Reportins Enlily in No.4 is Sub.watdee, Enler N.me a Prime a Subawardee and Add,ess 01 P,ime: lier _' if known: Cons'euion.J' Oil.rice. if known: Conlression.11 District. if known: 6- Federal Dep.J.rtmenUAlency: 7. Feder.) Prosnm Nl.melDescriplion: CFDA Number. jf applicable: 8, Feder.J.1 Action Number. if known: 9, Awud Amount. if known: S 10, .. N.me .nd Add.... o/lobbyinS Enl~ b. Indiyidual, Performin, Servkes lincludinl addreu It (if individuJ/, liSt name, lint nlm., 0: different /rom No. rOJ tlut nlmr. first name. MIJ: (.rr.ch Conr;nuadCM Sh"".' tf-W.'" il n.c.U.llY1 11. Amounl 01 P.ymenl lcheck a/l fhal apply): 11 Type 01 P.ymentlcheck a/l rh.r apply): S a .clu.1 a pl.nned a a. retainer a b, one. lime lee 12. fo,m of Paymenl (check a/l fhar apply): a c, commission a ., cuh a d, conllnsenl fee a b. in-kind; specify: naCure a e, deferred a I, olher; specify: yalue t4. 8,iel Oescripllon 0' Se",lce. Perlo,med 0' to be Perfo,med and Ool<lsl 01 Service. includln, ollleerisl, employe<isl. 0' Memberisl conlocted. 10' Paymenllndluled in llem 11: 'illicit COIII;null;on ShHU.J Sf.UL.A j' "<<.'IIIYI 15. Conllnuolion Sh~d(sl Sf.Ul.A Ollached: aVes a No ". ....-.. ....-1... "-'.... Ilhit ton. " .,rt..rt.... .., ... 11 U.J.e. ,-<Uon un. !)ok dhc"--- cI ~ ............... . _..... ~.Ibt SisnaCure: III bel .... ..t.cft ""'-. .. ,a.c.... b, lit. .... Mo.. _h." Ih., Print Nuu: ,,-*'" _.-... -...din... "'"'.~ ill......... ~ I. SI u.s.c. 'In .,.... 1.11.. MI,.. ... ... NflIW'M .. ..., ~ ___ Til~ ..-.....,......... bot ..IM.......,....c ~ ""' ,...-....w... ....... ..........chc'-- thIII_........chi ,..,."-,,.... '"' "'-' Telephone No.: Date-: I M.OOllI ..... not __ dwt 1lOIII._ Iw.... -=II ,....... .. ,l Feckr.l Use o..Jy:"?~~,~g]~l1.ilI~d~il;'~~;j<';;'$~""~i!l.,"j'MJ.iOi.~f~~~ ....hori.... I., ...... .........- ,;~./...,.~ ";;';- ~.;:r.':..;.,.~i-j,..,;+,_ :,:,~-:;,:~::'G:~+; ;:'r.'::~~::r;..r~';.~.,-$:'_~_r.::~';-'--_'! ;,;.:~~:t,:;I';:~~~_':'.:~;:~~'!~';':';:~.~:~f(-~.:t~+,..: s--.......,_. w. Complele this lorm 10 dlsclo.e lobbying aCliville. pursuanllo 31 U,S.c. 1352 (See revene lor public burden di,dosu,e.)