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HomeMy WebLinkAboutResolution - 2019-R0138 - Liberty Oilfield Repair - 04_23_2019Resolution No. 2019-RO138 Item No. 7.12 April 23, 2019 RESOLUTION BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK: THAT the Mayor of the City of Lubbock is hereby authorized and directed to execute for and on behalf of the City of Lubbock, Service Contract No. 14675 for Fabrication and Repairs on Heavy Duty Vehicles and Equipment as per ITB 19-14534-RR, by and between the City of Lubbock and Liberty Oilfield Repair and Service Inc. DBA Liberty Welding, of Lubbock, Texas, and related documents. Said Contract is attached hereto and incorporated in this resolution as if fully set forth herein and shall be included in the minutes of the City Council. Passed by the City Council on April 23, 2019 DANIEL M. POPE, MAYOR ATTEST: J2" J" . I. Reb ca Garza, City Secret ty APPROVED AS TO CONTENT: Markearwo , Assista t City Manager APPROVED AS TO FORM: I wtc, lli Leisure, Assistant City Attorney ccdocs/RES.Contract 14675 Fabrication and Repairs on Heavy Duty Vehicles and Equipment April 5,2019 Resolution No. 2019-RO138 Contract 14675 City of Lubbock, TX Contract for Fabrication and Repairs on Heavy Duty Vehicles and Equipment THIS CONTRACT made and entered into this day of Aura 2019, by and between the City of Lubbock ("City"), and Liberty Oilfield Repair and Service Inc. DSA Liberty Welding, Contractor"). WITNESSETH: WHEREAS, the City of Lubbock duly advertised for bids for Fabrication and Repairs on Heavy Duty Vehicles and Equipment, and bids were received and duly opened as required by law; and WHEREAS, after careful consideration of the bid submitted by Contractor, the City authorized the execution, in the name of the City of Lubbock a contract with said Contractor covering the purchase and delivery of the said Fabrication and Repairs on Heavy Duty Vehicles and Equipment. NOW,THEREFORE, in consideration of the mutual agreement contained herein, as well as the financial consideration hereinafter referred to,the parties hereby covenant and agree as follows: 1. In accordance with City's specifications and Contractor's bid,copies of which are attached hereto and made part hereof,Contractor will deliver to the City,Fabrication and Repairs on Heavy Duty Vehicles and Equipment and more specifically referred to as Items one through eight on the bid submitted by the Contractor or in the specifications attached hereto. 2. The City promises and agrees to employ, and does employ, the Contractor to cause to be done the work provided for in this Contract and to complete and finish the same according to the attached specifications, offer, and terms and conditions contained herein. 3. The contract shall be for a tenn of one year, with the option of two, one year extensions, said date of term beginning upon formal approval. All stated annual quantities are approximations of usage during the time period to be covered by pricing established by this bid. Actual usage may be more or less. Order quantities will be determined by actual need. The City of Lubbock does not guarantee any specific amount of compensation,volume,minimum, or maximum amount of services under this bid and resulting contract. The Contractor must maintain the insurance coverage required during the tern of this contract including any extensions.It is the responsibility of the Contractor to ensure that valid insurance is on file with the Purchasing and Contract Management Department as required by contract or contract may be terminated for non- compliance. 4. This contract shall remain in effect until the first of the following occurs: (1)the expiration date, 2) performance of services ordered, or(3) termination of by either party with a 30 day written notice. The City of Lubbock reserves the right to award the canceled contract to the next lowest and best bidder as it deems to be in the best interest of the city. 5. Contractor shall at all times be an independent contractor and not an agent or representative of City with regard to performance of the Services. Contractor shall not represent that it is, or hold itself out as, an agent or representative of City. In no event shall Contractor be authorized to enter into any agreement or undertaking for or on behalf of City. 6. Insurance Requirements SECTION A. Prior to the approval of this contract by the City, the Contractor shall furnish a completed Insurance Certificate to the City, which shall be completed by an agent authorized to bind the named underwriter(s) to the coverages, limits, and termination provisions shown thereon, and which shall furnish and contain all required information referenced or indicated thereon. THE CITY SHALL HAVE NO DUTY TO PAY OR PERFORM UNDER THIS CONTRACT UNTIL SUCH CERTIFICATE SHALL HAVE BEEN DELIVERED TO THE CITY. SECTION B. The City reserves the right to review the insurance requirements of this section during the effective period of the contract and to require adjustment of insurance coverages and their limits when deemed necessary and prudent by the City based upon changes in statutory law, court decisions,or the claims history of the industry as well as the Contractor. SECTION C. Subject to the Contractor's right to maintain reasonable deductibles in such amounts as are approved by the City, the Contractor shall obtain and maintain in full force and effect for the duration of this contract, and any extension hereof,at Contractor's sole expense,insurance coverage written by companies approved by the State of Texas and acceptable to the CL ,in the following type(s)and amount(s): TYPE OF INSURANCE COMBINED SINGLE LIMIT GENERAL LIABILITY Commercial General Liability General Aggregate 1,000.000 Claims Made Occurrence Products-Comp/Op AGG X W/Heavy Equipment Personal&Adv.Injury X To Include Products of Complete Operation Endorsements Contractual Liability X Fire Damage(Any one Fire) Med Exp(Any one Person) PROFESSIONAL LIABILITY General Aggregate AUTOMOTIVE LIABILITY Any Auto All Owned Autos Scheduled Autos Hired Autos Non-Owned Autos Per Occurrence 1.000,000 EXCESS LIABILITY Umbrella Form Each Occurrence Aggregate GARAGE LIABILITY Any Auto Auto Only-Each Accident $1,000.000 Other than Auto Only: Each Accident Aggregate BUILDER'S RISK 100%of the Total Contract Price INSTALLATION FLOATER 100%of the Total Material Costs CARGO WORKERS COMPENSATION—STATUTORY AMOUNTS OR OCCUPATIONAL MEDICAL AND DISABILITY 00.000 EMPLOYERS' LIABILITY 1,000,000 OTHER:COPIES OF ENDOSEMENTS ARE REQUIRED City of Lubbock named as additional insured on Auto/General Liability on a primary and non-contributory bases. To include products of completed operations endorsement. Waiver oj'subrogation in favor of the City of Lubbock on all coverages, except IMPORTANT: POLICY ENDORSEMENTS The Contractor will provide copies of the policies without expense,to the City and all endorsements thereto and may make any reasonable request for deletion, revision, or modification of particular policy terms, conditions, limitations,or exclusions(except where policy provisions are established by law or regulation binding upon either of the parties hereto or the underwriter of any of such policies). Upon such request by the City,the Contractor shall exercise reasonable efforts to accomplish such changes in policy coverages, and shall pay the cost thereof.Any costs will be paid by the Contractor. REQUIRED PROVISIONS The Contractor agrees that with respect to the above required insurance, all insurance contracts and certificate(s) of insurance will contain and state, in writing, on the certificate or its attachment, the following required provisions_ a. Name the City of Lubbock and its officers,employees,and elected representatives as additional insureds, as the interest of each insured may appear)as to all applicable coverage; b. Provide for 30 days'notice to the City for cancellation,nonrenewal,or material change; c. Provide for notice to the City at the address shown below by registered mail; d. The Contractor agrees to waive subrogation against the City of Lubbock, its officers, employees, and elected representatives for injuries,including death,property damage,or any other loss to the extent same may be covered by the proceeds of insurance; e. Provide that all provisions of this contract concerning liability, duty, and standard of care together with the indemnification provision,shall be underwritten by contractual liability coverage sufficient to include such obligations within applicable policies. NOTICES The Contractor shall notify the City in the event of any change in coverage and shall give such notices not less than 30 days prior the change, which notice must be accompanied by a replacement CERTIFICATE OF INSURANCE. All notices shall be given to the City at the fol lowing address: Marta Alvarez, Director of Purchasing&Contract Management City of Lubbock 162513 h Street, Room 204 Lubbock, Texas 79401 SECTION D. Approval, disapproval, or failure to act by the City regarding any insurance supplied by the Contractor shall not relieve the Contractor of frill responsibility or liability for damages and accidents as set forth in the contract documents. Neither shall the bankruptcy, insolvency, or denial of liability by the insurance company exonerate the Contractor from liability. 7. Neither the City nor the Contractor shall assign, transfer or encumber any rights, duties or interests accruing from this Contract without the written consent of the other. 8. The City reserves the right to exercise any right or remedy available to it bylaw,contract,equity, or otherwise, including without limitation,the right to seek any and all forms of relief in a court of competent jurisdiction. Further, the City shall not be subject to any arbitration process prior to exercising its unrestricted right to seek judicial remedy. The remedies set forth herein are cumulative and not exclusive, and may be exercised concurrently. To the extent of any conflict between this provision and another provision in,or related to, this document,this provision shall control. 9. At any time during the term of the contract, or thereafter, the City, or a duly authorized audit representative of the City or the State of Texas, at its expense and at reasonable times, reserves the right to audit Contractor's records and books relevant to all services provided to the City under this Contract. In the event such an audit by the City reveals any errors or overpayments by the City, Contractor shall refund the City the full amount of such overpayments within 30 days of such audit findings, or the City, at its option, reserves the right to deduct such amounts owing the City from any payments due Contractor. 10. All funds for payment by the City under this contract are subject to the availability of an annual appropriation for this purpose by the City. In the event of non-appropriation of funds by the City Council of the City of Lubbock for the goods or services provided under the contract, the City will terminate the contract, without termination charge or other liability, on the last day of the then-current fiscal year or when the appropriation made for the then-current year for the goods or services covered by this contract is spent, whichever event occurs first. If at any time funds are not appropriated for the continuance of this contract, cancellation shall be accepted by the Seller on 30 days prior written notice, but failure to give such notice shall be of no effect and the City shall not be obligated under this contract beyond the date of termination. 11. The Contractor shall not assign or sublet the contract, or any portion of the contract, without written consent from the Director of Purchasing and Contract Management. Should consent be given, the Contractor shalt insure the Subcontractor or shall provide proof on insurance from the Subcontractor that complies with all contract Insurance requirements. 12. Contractor acknowledges by supplying any Goods or Services that the Contractor has read, fully understands, and will be in full compliance with all terms and conditions and the descriptive material contained herein and any additional associated documents and Amendments. The City disclaims any terms and conditions provided by the Contractor unless agreed upon in writing by the parties. In the event of conflict between these terms and conditions and any terms and conditions provided by the Contractor, the terms and conditions provided herein shall prevail. The terms and conditions provided herein are the final terms agreed upon by the parties, and any prior conflicting terns shall be of no force or effect. 13. SB 252 prohibits the City from entering into a contract with a vendor that is identified by The Comptroller as a company known to have contracts with or provide supplies or service with Iran, Sudan or a foreign terrorist organization. 14. The Contractor warrants that it complies with Chapter 2270, Subtitle F, Title 10 of the Texas Government Code by verifying that: 1) The Contractor does not boycott Israel; and 2) The Contractor will not boycott Israel during the term of the Agreement. 15. This Contract consists of the following documents set forth herein; Invitation to Bid No. 19- 14534-RR, Specifications, and the Bid Form. INTENTIONALLY LEFT BLANK----- IN WITNESS WHEREOF, the parties hereto have caused this Contract to be executed the day and year first above written. Executed in triplicate_ CITY OF LUBBOCK CONTRACTOR BY: JtJ u Daniel M. Pope, Mayr Authorized Representative ATTEST:t3pJk'-\A /lf hl RAY LgRcIL Print Name ot Reb ca Garza, City Secre r i 2o-e; hy. A-.4,--T Address APPROVED AS TO CONTENT: L,,Wd, L ,—F,)( 74q lSwo—WAO City, State, Zip Code Billy Taylor, Fleet Operations Director APP.MA.S T FORM Kelli Leisure, Assistant City Attorney General Specifications for Fabrication, Maintenance& Repair on City Heavy Vehicles and Equipment Scope The City of Lubbock is seeking a contract for fabrication, maintenance and repairs of heavy vehicles and equipment including hydraulics, welding and fabricating. The successful bidder ("the Company") will provide fabrication and repairs to heavy vehicles and equipment not covered under any manufacturer's warranty,unless the Company is the authorized warranty dealer,to maintain fleet availability for the City of Lubbock.Maintenance and repairs include,but are not limited to,the following: Fabrication of metal components Repairs to Solid Waste Refuse Truck bodies Welding Hydraulic repairs including cylinders,pumps,etc. Power Take-Off(PTO) Equipment&Truck Categories The following is a current list of Descriptions of City of Lubbock vehicles and equipment by Category which are included in this maintenance and repair contract. Category Description I)Trucks Class 6-7-8-9 Refuse Trucks,Roll offs and Dump Trucks Work Authorization Vehicle shop repairs will be estimated on a per job basis with a fixed labor rate per hour as stated on the Bid Form. Prior to the start of any vehicle repair, the Company must provide a written repair estimate by a trained service advisor or technician. Estimates must include parts at the quoted cost rate. All estimates shall be at no charge to the City. The Company must obtain a work order number and authorization to perform the work from the City of Lubbock authorized Fleet Services designee before making any repairs.The Company must also obtain City approval for the type of repairs and the cost of repairs before proceeding with the work. The Company must submit a copy of the Work Order along with the Company's invoice itemizing the labor hours, hourly labor rate,supplies,cost of supplies, parts list, and price for each part. The Work Order must contain the V number assigned by the City, the VIN number,the current license plate number, and the current vehicle mileage or hours. If any of the information is missing or incorrect, the Company will not be reimbursed for any services,repairs,maintenance,parts,or supplies. Approval Procedures Approval for maintenance and repairs on all vehicles shall be as follows: Repairs up to$1,000 shall be verbally approved by an authorized Fleet Services designee.Repairs from$1,000 to$2,500 must have written approval from an authorized Fleet Services designee. Repairs over$2,500 must have written approval from an authorized Fleet Services designee and Director of Fleet Services. If any repairs are completed without proper authorization,the Company will not be reimbursed for any services,repairs, maintenance,parts,or supplies. Repair Time Notifications The Company must make a determination of the repairs, costs and times and notify the City within 24-hours after receiving the vehicle or equipment. Repeat Repairs The vendor will be responsible for correcting all previous repairs performed by the vendor that were incorrectly repaired or the repair failed to correct the reported deficiency. The vendor will be responsible for the total cost of the repair including any replacement parts. In the event of a Repeat Repair, the vendor shall open a new vendor work order. The new vendor work order must indicate on the work order "repeat" or "return" work. Copies of the original City and vendor work orders and any applicable invoices shall be attached to the new work order. Pick-Up and Delivery The bidder's bid may include a separate price for pick-up and delivery of heavy vehicles or equipment. The bidder must indicate on the Bid Form the additional charge, if any, for this pick-up and delivery service. The City reserves the right to use this service as needed. Vehicles must be picked up by City personnel or delivered to a City location within 24-hours after the vehicle has been repaired. Parts, Supplies and Services The Company must use their own parts and/or supplies in completing all repairs. No City parts or supplies will be issued by the City Garage to the Company. The Company's invoice must include charges for all parts, supplies, and services used in making repairs. The Company must return all parts that were removed and replaced during the repair of the vehicle or equipment upon completion of the repair(s) and the parts must accompany the vehicle or equipment.The Company is responsible for all core returns and credits. Bid subnusslons Bids will be awarded by category of vehicles and equipment. Bidders are responsible for submitting all relevant, factual and correct information with their bid. If additional sheets are attached to the bid submittal package, the bidder shall clearly cross-reference the appropriate location in the bid solicitation (i.e. page number, paragraph, subject, etc.) Invoices Invoices will show only the cost rates indicated on the Bid Form. Any additional charges or fees not listed will be disallowed from any invoice. Vehicle shop repairs will be billed per the approved estimate. An individual Work Order shall be issued for vehicle shop repairs. No delivery or repair shall be performed without proper authorization. Invoices for parts purchased by the Company for all repairs to City vehicles and equipment will be made available for inspection by a City representative upon request. Invoices must display the company name imprinted on the face, the parts purchased and the date of the purchase. Repair invoices should match the parts invoice when there were replacement parts required for the repair. If a request is submitted by the City to review a particular invoice, that request will be met within 24 hours from the time of the request. Vehicle Pickup The Company is responsible for any damage to the vehicle or equipment while in the Company's control. The City shall be responsible for damages after the vehicle or equipment has been delivered to a City representative and said representative has inspected the vehicle or equipment and has verified that no damage occurred during the repair process. In the event that a vehicle is scheduled to be picked up from the City for repairs, the vehicle will be: 1. Picked up by tow vehicle/wrecker, or 2. Driven to the repair destination by a licensed and insured individual representing the Company. Special Requirements: 1. Company to provide secure shelter{locked fence} for City vehicles. 2. Estimate mist be submitted to Fleet Services within 24-hour period of request. 3. All furnished parts must be OEM or OEM re-cycled parts unless approved by Fleet Services. 4. All repairs shall be warranted for a period of 12 months or 12,000 miles BID FORM City of Lubbock,TX Purchasing and Contract Management Fabrication and Repairs on Heavy J)pty Vehicles&Equipment ITB No. 19-44534-RR In compliance with the Invitation to Bid 19-1.4534-RR,the undersigned Bidder having examined the Invitation to Bid and Specifications,and being familiar with the conditions to be met,hereby submits the following Bid for furnishing the material,equipment,labor and everything necessary for providing the items listed below and agrees to deliver said items at the locations and for the prices set forth on this form. A bid will be subject to being considered irregular and may be rejected if it shows omissions, alterations of form, conditional alternate bids, additions or alternates in lieu of the items specified, if the unit prices are obviously unbalanced(either in excess of or below reasonably expected values),or irregularities of any kind. The Invitation to Bid 19-14534-RR is by reference incorporated in this contract.The Bid Form must be completed in blue or black ink or by typewriter. Category: Class 6,7,8,9 Refuse Trucks,Roll-Offs and Dump Trucks ITEM DESCRIPTION I Labor Rate(Billed in increments of full, o0 half and %<hours) t o o per hour 2 % Mark up above/below parts"jobber" 2blist Do you provide pickup and delivery of Yes r No 3 vehicles? If yes, what is the charge one way? Yes No 4 Do you offer towing services? If yes,what is the charge per tow? 5 Could you respond to a pickup 24 hours a Yes Noday? Miles from your location to City Fleet 6. Services Garage(206 Municipal Dr., Miles Lubbock TT 79403) Do you provide service calls? If yes.what is your service call fee? G 7• e J per hour Yes No Do you charge mileage for service calls? If yes.what is your service charge per 8 mile? per miles Yes No Unless otherwise specified herein, the City may award the bid either item-by—item or on an all-or-none basis for any item or group of items shown on the bid. The City of Lubbock is seeking a contract for Fabrication and Repairs on Heavy Duty Vehicles & Equipment with one or more contractors.In order to assure adequate coverage,the City may make multiple awards, selecting multiple vendors to provide the products desired, if multiple awards are in the best interest of the City.A decision to make a multiple award of this Bid,however,is an option reserved by the City,based on the needs of the City. PAYMENT TERMS AND DISCOUNTS-Bidder offers a prompt payment discount of net_calendar days. Discounts will not be considered in determining low bid. Unless otherwise indicated on the Bid Form,payment terms will be NET THIRTY DAYS.The City will pay the successful bidder within thirty days after the receipt of a correct invoice or after the date of acceptance, whichever event occurs later. Discpunts for prompt payment requiring payment by the City within a stipulated number of days will be interpreted as applying within the stipulated number of calendar days after the date of receipt by the City of a correct invoice or after the date of acceptance that meets contract requirements,whichever event occurs later. Discounts for payment in less than ten days will not be considered. MOST FAVORED PRICING:The Bidder certifies that the price quoted is not in excess of the lowest price charged anyone else,including its most favored customer,for like quality and quantity of the products/services;does not include an element of profit on the sale in excess of that normally obtained by the Bidder on the sale of products/services of like quality and quantity; and does not include any provision for discounts to selling agents. If at any time during the contract period,the supplier should sell or offer for sale to any other customer, an equal or less quantity of similar contract products of like or better quality,at a lower net price(s)than provided herein,supplier agrees to notify the City and sell same product(s)at the lower price(s)on all deliveries made during the period in which such lower price(s)is effective. INTERLOCAL PURCHASING(optional): The City desires to make available to other local governmental entities of the State of Texas,by mutual agreement with the successful bidder,and properly authorized interlocal purchasing agreements as provided for by the Interlocal Cooperation Act(Chapter 791,Government Code),the right to purchase the same services,at the prices quoted,for the period of this contract. Each bidder shall indicate on the Bid Form in the space provided below if he/she will honor Political Subdivision orders in addition to orders from the City of Lubbock. Should these other governmental entities decide to participate in this contract, would you (the bidder) agree that all terms, conditions, specifications,and pricing would apply? Other governmental entities that might have interests in this contract are Frenship Independent School District, Lubbock Housing Authority, Lubbock County, Lubbock County Hospital District, Lubbock Independent School District,South Plains Association of Governments,City of Texarkana,Texas Tech University,West Texas Municipal Power Agency,Lynn County,and City of Wolfforth. YES NO X If you(the bidder)checked YES,the following will apply: Governmental entities utilizing Interlocal Agreements for Cooperative Purchasing with the City of Lubbock will be eligible,but not obligated,to purchase materials/services under the contract(s)awarded as a result of this solicitation. All purchases by governmental entities other than the City of Lubbock will be billed directly to that governmental entity and paid by that governmental entity. City of Lubbock will not be responsible for another governmental entity's debts.Each governmental entity will order their own materials/service as needed. THIS BID IS SUBMITTED BYz.jp&a zgiAd 0 ' 4f a corporation organized under the laws of the State of Tn=yt A 5 or a partnership consisting of or individual trading as of the City of L u 6iopc.1_ Firm: Z.l 6 r 001rel d o!,r c,,d rvice Inc DBA L Io5 We A Address: I Z05 N1. &/j"T City: Lu66ock State: TX Zip--79 Lf 15 Bidder acknowledges receipt of the following addenda: Addenda No. Addenda No. Addenda No. Addppda No. Date Date Date Date M/WBE Firm: Woman Black AmericanNative American lEs anic American Asian Pacific Americ Other(Specify) By Date: Z -- Z O -- f Authorized Rep esentativ -must sign by hand Officer Name and Title: RAY Lairc c-A 51 0 tam Please Print Business Telephone Number-60(a FAX: 6% "7 j 89 T E-mail Address:_"_e*-Wed dfnarra.;I. Corn FOR CITY USE ONLY Bid Form Item Number(s)Awarded to Above Named Firm/Individual: Date of Award by City Council (forbids over$50,000): Date P.O./Contract Issued: RETURN COMPLETED&SIGNED BID FORM ALONG WITH CITY OF LUBBOCK SPECIFICATIONS. LABEL THE OUTSIDE OF YOUR SEALED BID WITH THE ITB NUMBER,THE CLOSING DATE AND TIME,AND YOUR COMPANY NAME AND ADDRESS. CERTIFICATE OF INTERESTED PARTIES FORM 1295 1of1 Complete Nos. 1- 4 and 6 if there are interested parties. OFFICE USE ONLY Complete Nos.1, 2, 3, 5, and 6 if there are no interested parties. CERTIFICATION OF FILING Certificate Number: 1 Name of business entity filing form, and the city, state and country of the business entity's place of business. 2019-487951 Liberty Oilfield Repair and Service, Inc. Lubbock, TX United States Date Filed: 05/08/2019 2 Name of governmental entity or state agency that is a party to the contract for which the form is being filed. City of Lubbock Texas Date Acknowledged: 05/08/2019 3 Provide the identification number used by the governmental entity or state agency to track or identify the contract, and provide a description of the services, goods, or other property to be provided under the contract. 14675 Fabrication and repairs on heavy duty vehicles and equipment 4 Name of Interested Party City, State y Country (place of business) Nature of interest (check applicable) Controlling Intermediary Lorck, Benjamin Lubbock, TX United States X 5 Check only if there is NO Interested Party. 6 UNSWORN DECLARATION My name is and my date of birth is My address is , (street) (city) (state) (zip code) (country) I declare under penalty of perjury that the foregoing is true and correct. Executed in County, State of , on the day of , 20 (month) (year) Signature of authorized agent of contracting business entity (Declarant) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.391`8039c CERTIFICATE OF INTERESTED PARTIES FORIVI 1295 Iof1 Complete Nos. 2 - 4 and 6 if there are interested parties. Complete Nos.1, 2, 3, 5, and 6 if there are no interested parties. OFRCE USE ONLY CERTIFICATION OF FILING Certificate Number. 20I9-487951 1 Name of business entity filing form, and the ckt, sty and country of the business entity's place of business. Liberty Oilfield Repair and Service, Inc. Lubbock, TX United states Date Rled: 0510812019 2 Name of governmental entity or state agency that is a party to the contract for WWich the form is being filed. City of Lubbock Texas fate Acknowledged: 3 Provide the identification number used by the governmental entity or state agency to track or identify the contract, and .provide a description of the services, goads, or other property to be provided under the contract. 14675 Fabrication and repairs on heavy duty vehicles and equipment 4 Name of tnterested Party City, State, Country (place of business) Nature of interest (check applicable) Controlling intermediary Lorck, Benjamin Lubbock, TX United States X 5 Check only if there is NO Interested Party. LD 6 UNSWORN DECt.ARATioN My name is e in a.�..: w L_orG� , and my date of birth is My address is 20]5 ftL. gL , Lv_bbocj. , Tx l5 U3J� (street) (City) (state? (zipcode) (counhy) I declare under penaltyof perjurytha the foregoing is true and correct. Executed in Ll) 66 Oct County, State of —r;iX GL ,S, , on the o day of { ' 1 CL , 20 1 C _ (=nth) (year) Sig re of a Red agent of contra business enft (Dectarant) WVVW.Mnsc5.5tWe.uc.us Version V1.1.39MO39c