HomeMy WebLinkAbout10734ORDINANCE NO. 10734
AN ORDINANCE APPROVING AN INTERGOVERNMENTAL
AGREEMENT BETWEEN THE CITY OF PUEBLO, A
COLORADO MUNICIPAL CORPORATION, AND THE STATE OF
COLORADO BY AND THROUGH THE COLORADO
DEPARTMENT OF TRANSPORTATION, RELATING TO THE
OPERATION AND MAINTENANCE OF CERTAIN STATE-
OWNED DRAINAGE, IRRIGATION, AND LANDSCAPING
IMPROVEMENTS LOCATED ON THE EAST SIDE OF I-25
GENERALLY BETWEEN E. 22ND STREET AND E. 26TH
STREET, AND APPROVING THE MAYOR TO EXECUTE THE
INTERGOVERNMENTAL AGREEMENT ON BEHALF OF THE
CITY
BE IT ORDAINED BY THE CITY COUNCIL OF PUEBLO, that:
SECTION 1.
Colorado Municipal Corporation, and the State of Colorado, by and through the Colorado
Department of Transportation, relating to the operation and maintenance of certain drainage,
landscaping, irrigation, and associated improvements, a copy of which is attached hereto,
having been approved as to form by the City Attorney, is hereby approved.
SECTION 2.
The Mayor is authorized to execute and deliver the Agreement in the name of the City of
Pueblo and the City Clerk is directed to affix the seal of the City thereto and attest same.
SECTION 3.
The officers of the City of Pueblo are authorized to perform any and all acts consistent
with this Ordinance and the Agreement to implement the policies and procedures described
herein.
SECTION 4.
This Ordinance shall become effective on the date of final action by the Mayor and City
Council.
Action by City Council:
Introduced and initial adoption of Ordinance by City Council on June 24, 2024.
Final adoption of Ordinance by City Council on July 8, 2024.
____________________________
President of City Council
Action by the Mayor:
Approved on _______________.
Disapproved on ______________ based on the following objections:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________
Mayor
Action by City Council After Disapproval by the Mayor:
Council did not act to override the Mayor's veto.
Ordinance re-adopted on a vote of ____________, on _____________
____________________________
President of City Council
ATTEST
________________________________
City Clerk
City Clerk's Office Item # R2
Background Paper for Proposed
Ordinance
COUNCIL MEETING DATE: July 8, 2024
TO: President Mark Aliff and Members of City Council
CC: Mayor Heather Graham
VIA: Marisa Stoller, City Clerk
FROM: Andrew Hayes, Public Works Director
SUBJECT: AN ORDINANCE APPROVING AN INTERGOVERNMENTAL
AGREEMENT BETWEEN THE CITY OF PUEBLO, A COLORADO
MUNICIPAL CORPORATION, AND THE STATE OF COLORADO BY
AND THROUGH THE COLORADO DEPARTMENT OF
TRANSPORTATION, RELATING TO THE OPERATION AND
MAINTENANCE OF CERTAIN STATE-OWNED DRAINAGE,
IRRIGATION, AND LANDSCAPING IMPROVEMENTS LOCATED ON
THE EAST SIDE OF I-25 GENERALLY BETWEEN E. 22ND STREET
AND E. 26TH STREET, AND APPROVING THE MAYOR TO EXECUTE
THE INTERGOVERNMENTAL AGREEMENT ON BEHALF OF THE
CITY
SUMMARY:
This Ordinance approves an Intergovernmental Agreement between the City of Pueblo,
a Colorado Municipal Corporation, and the State of Colorado by and through the
Colorado Department of Transportation, relating to the operation and maintenance of
certain state-owned drainage, irrigation, and landscaping improvements located on the
east side of I-25 generally between E. 22nd Street and E. 26th Street, and approving
the Mayor to execute the Intergovernmental Agreement on behalf of the City.
PREVIOUS COUNCIL ACTION:
None.
BACKGROUND:
As part of its upcoming project to reconstruct the interchange at I-25 and US-50B,
CDOT will be installing new landscaping, irrigation, and drainage improvements in
several areas that serve as drainage ponds to retain stormwater runoff from I-25. At
the City's request, CDOT has agreed to install turf grass and irrigation systems within
those areas that have historically been used as green space by community members
that live near the ponds. The ponds will be separated from I-25 by a sound wall and,
under the terms of the proposed Intergovernmental Agreement, the City will be
responsible for maintaining all of the turf areas, the riprap, drainage channels, City-
owned utilities, and other improvements in the drainage pond areas.
The City's Parks and Recreation Department has maintained the turf grass and
irrigation systems in these areas in the past. This agreement will formalize that
arrangement incident to CDOT's upcoming construction project.
FINANCIAL IMPLICATIONS:
Minimal additional costs are anticipated above those which the City has historically
incurred for maintenance of the turf grass and irrigation systems in the area.
BOARD/COMMISSION RECOMMENDATION:
None.
STAKEHOLDER PROCESS:
Not applicable to this ordinance.
ALTERNATIVES:
Failure to approve this Ordinance will preclude the City from entering into the
Intergovernmental Agreement with CDOT and community members in the vicinity of
these drainage ponds will lose the use of the green space amenity that they have
historically enjoyed.
RECOMMENDATION:
Approve the Ordinance.
ATTACHMENTS:
1. Complete Draft MTCE Pueblo (23535) 331003316 May 02 2024 (City edits
240610)
Routing #: 24-HA2-XC-00034
OLA #: 331003316
STATE OF COLORADO INTERGOVERNMENTAL AGREEMENT
Signature and Cover Page
State Agency Agreement Routing Number
Department of Transportation24-HA2-XC-00034
Local Agency Agreement Effective Date
City of PuebloThe later of the effective date or March 4, 2024
Agreement Description Agreement End Date
I-25 at US50B ReconstructionUseful Life of the Improvements
Project # Region # Contract Writer Agreement Maximum Amount
BR 025A- 2 CM $0.00
049 (23535)
THE PARTIES HERETO HAVE EXECUTED THIS AGREEMENT
Each person signing this Agreement represents and warrants that he or she is duly authorized to
execute this Agreement and to bind the Party authorizing his or her signature.
STATE OF COLORADO
Jared S. Polis, Governor
Department of Transportation
Shoshana M. Lew, Executive Director
______________________________________
Keith Stefanik, P.E., Chief Engineer
Date: _________________________
LEGAL REVIEW
Philip J. Weiser, Attorney General
______________________________________
Assistant Attorney General
______________________________________
By: (Print Name and Title)
Date: _________________________
LA.MT.PWQ_4.11.23 Page 1 of 9
Routing #: 24-HA2-XC-00034
OLA #: 331003316
AGREEMENT
This Agreement, is entered into by and between the State of Colorado for
the use and “State” or “CDOT”), and the CITY OF PUEBLO (the “Local Agency”); CDOT
the Local Agency individually shall be referred to as a “Party”, and together shall
referred to as the “Parties.” This Agreement shall not be valid or enforceable until
the Effective Date as shown on the Signature and Cover Page of this Agreement.
RECITALS
CDOT has designed and improvements for I-25 at US50B
Reconstruction Project located in
, Colorado, ("Project”) and;
The Parties recognize the importance and benefit to their respective systemsby the
LocalAgencies’operation and maintenance of a portion of the Projectand;
ThePartiesdesiretoagreeuponthedivisionofresponsibilityfortheir
respective maintenance and operation obligations (the “Work”) on the Project as
shown in Exhibit A and;
The Local Agency is adequately staffed and suitably equipped to undertake
and satisfactorily carry out its operations and maintenance responsibilities
under this Agreement; and
Required approval, clearance and coordination has been accomplished from and
with appropriate agencies; and
This Agreement is executed by the State under authority of §§43-1-106, 43-1-110,
43-1-201, et seq., 43-2-102, and 43-2-144, C.R.S., as amended; and
The Local Agency agrees by its execution hereof that it is duly authorized to enter
into this Agreement. Authorization may be evidenced by an appropriate ordinance/
resolutionorauthorityletter.Acopyofanysuchordinance/resolutionorauthority
letter may be attached as Exhibit B. The provision by the Local Agency to
CDOT of such ordinance/resolution or authority letter is at the Local Agency’s
discretion; and
These recitals are hereby incorporated into the terms of this Agreement.
NOW, THEREFORE, it is hereby agreed that:
The Work under this Agreement shall consist of the inspection,
operations, maintenance, and repair responsibilities of the Project as set forth
and depicted in Exhibit A.
LA.MT.PWQ_4.11.23 Page 2 of 9
Routing #: 24-HA2-XC-00034
OLA #: 331003316
Exhibits
The Exhibits attached to this Agreement are:
Exhibit A- Scope of Work of the Project
E
xhibit B- Local Agency Resolution
Exhibit C-PII Certification
Order of Precedence
In the event of conflicts or inconsistencies between this Agreement and its exhibits,
such conflictsor inconsistencies shall be resolved by reference to the documents
in the following order of priority:
Special Provisions contained in Section IX of this Agreement
This Agreement
Exhibit A- Scope of Work of the Project
Exhibit B- Local
Agency Resolution
Exhibit C- PII Certification
Term
This Agreement shall begin the date approved by all Parties and shall extend for
the useful life of the improvements, unless earlier modified or terminated by written
agreement of the Parties.
CDOT Commitments
CDOT shall accept inspection, operation, maintenance, and repair
responsibilities for the portions of the Work identified as CDOT’s area of
responsibility shown in Exhibit A.
CDOT shall, at its own cost and expense, inspect, operate, maintain, repair,
and make ample provision each year for said activities for those portions of the
Work identified as CDOT’s area of responsibility in Exhibit A .
CDOT grants the Local Agency access to enter CDOT Right of Way (“ROW”)
to perform inspection and maintenance duties. Though a separate access
permit will not be required, notification to CDOT of a Local Agency approved
and CDOT accepted Method of Handling Traffic shall be required for any work
impacting traffic.
CDOT (and FHWA, if applicable) may make periodic inspections of the Project
to verify that they are being adequately operated, maintained, and
repaired. IfCDOT inspections indicate the Project are not
functioning as designed, CDOTmay issue a written notice to the Local Agency
to cure deficiencies. In the eventthe deficiencies are not remedied within the
Project timeline after written noticefrom CDOT to the Local Agency, CDOT
may take whatever steps CDOT deemsnecessary to maintain the Project. The
Local Agency shall reimburse CDOT itsactual and documented costs for such
maintenance and repair work includinglabor, equipment, supplies, and
materials. If CDOT repairs any deficiencies, itis under no obligation to
maintain or repair in the future.
Local Agency Commitments
Page 3 of 9
LA.MT.PWQ_4.11.23
Routing #: 24-HA2-XC-00034
OLA #: 331003316
A.The Local Agency shall accept inspection, operation, maintenance, and repair
responsibilities for the portions of the Work identified as the Local Agency’s
area of responsibility for the Work shown in Exhibit A.
B.The Local Agency shall, at its own cost and expense, inspect, operate,
maintain, repair, and make ample provision each year for those portions of the
Work identified as the Local Agency’s area of responsibility, as shown in
Exhibit A.
Work by the Local Agency must be performed bya person experienced in
C.All
the inspection, operation, and maintenance of the Project. This is to ensure that
the Project are operating as designed. Any inspection form may be used if it is
acceptable by agreement of the Parties.
D.The Local Agency grants CDOT access to enter Local Agency ROW to perform
CDOT’s inspection, operation, maintenance, and repair dutiesof the Work.
E.If after inspection of the Project, CDOT may issue a written notice to cure
deficiencies if the Local Agency fails to inspect, report, or properly maintain the
Project identified in Exhibit A. In the event the deficiencies are not remedied
within the Project timeline after written notice from CDOT to the Local Agency,
CDOT may take whatever steps CDOT deems necessary to maintain the
Project. The Local Agency shall reimburse CDOT its actual and documented
costs for such maintenance and repair work including labor, equipment,
supplies, and materials. If CDOT repairs any deficiencies, it is under no
obligation to maintain or repair in the future.
Joint Commitments
CDOT and the Local Agency will provide liaison through the representatives
listed below. If the representatives or contact information changes the Party is
to give written notice regarding the substitution of representatives or contact
information to the other Party’s Liaisons.
CDOT Project Liaison
CDOT Region 2
5615 Wills Blvd.
Pueblo, CO 81008
Phone:719-2
Email: @state.co.us
LA.MT.PWQ_4.11.23 Page 4 of 9
Routing #: 24-HA2-XC-00034
OLA #: 331003316
Local Agency Project Liaison
Andrew Hayes, Public Works Director
City of Pueblo
211 E. D Street
Pueblo, CO 81003
Phone: 719-553-2267
Email: ahayes@pueblo.us
B.If safety concerns are identified relating to the Project, the Parties willpartner
with each other and any other affected local jurisdictions to identify the
appropriate response to maintain safe and functional Project.
C.Prior to commencing any activities, the Parties shall coordinate with each other
to minimize impacts to landscaping and/or enhancements that were installed
by the Local Agency. CDOT will not be responsible for replacing any enhanced
landscaping or irrigation installed by the Local Agency.
D.In the event the Project fails due to surpassing their useful life cycle, the Parties
will be responsible for improvements that are not covered by maintenance
responsibilities of the Local Agency pursuant to Exhibit A.
E.Any fines levied against CDOT, or the Local Agency shall be the responsibility
of the Party whose action or inaction is the cause of the fine, regardless of
which Party the fine is levied against.
F.The Parties shall make, keep, maintain, and allow inspection and monitoring
by CDOT, of a complete file of all records, documents, communications, notes,
and other written materials, electronic media files, and communications
pertaining in any manner to the Work. The Parties shall maintain such records
for the useful life of the Project, following federal, State, and Local Agency
record retention policies in either paper or electronic form.
VIII.General Provisions
A.Assignment
Local Agency’s rights and obligations under this Agreement are personal and
may not be transferred or assigned without the prior, written consent of the
State. Any attempt at assignment or transfer without such consent shall be void.
Any assignment or transfer of Local Agency’s rights and obligations approved
by the State shall be subject to the provisions of this Agreement.
B.Captions and References
The captions and headings in this Agreement are for convenience of reference
only, and shall not be used to interpret, define, or limit its provisions. All
references in this Agreement to sections (whether spelled out or using the §
symbol), subsections, exhibits or other attachments, are references to sections,
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Routing #: 24-HA2-XC-00034
OLA #: 331003316
subsections, exhibits, or other attachments contained herein or incorporated as
a part hereof, unless otherwise noted.
C.Entire Understanding
This Agreement represents the complete integration of all understandings
between the Parties related to the Work, and all prior representations and
understandings related to the Work, oral or written, are merged into this
Agreement.
D.Modification
The State may modify the terms and conditions of this Agreement by issuance
of an updated Agreement, which shall be effective if Local Agency accepts
Agreement Funds following receipt of the updated letter. The Parties may also
agree to modification of the terms and conditions of the Agreement in a formal
amendment to this Agreement, properly executed and approved in accordance
with applicable Colorado State law and State Fiscal Rules.
E.Statutes, Regulations, Fiscal Rules, and Other Authority
Any reference in this Agreement to a statute, regulation, State Fiscal Rule,
fiscal policy, or other authority shall be interpreted to refer to such authority
then current, as may have been changed or amended since the Agreement
Issuance Date. Local Agencyshall strictly comply with all applicable Federal
and State laws, rules, and regulations in effect or hereafter established,
including, without limitation, laws applicable to discrimination and unfair
employment practices.
F.Digital Signatures
If any signatory signs this Agreement using a digital signature in accordance
with the Colorado State Controller Contract, Agreement and Purchase Order
Policies regarding the use of digital signatures issued under the State Fiscal
Rules, then any agreement or consent to use digital signatures within the
electronic system through which that signatory signed shall be incorporated
into this Agreement by reference.
G.Severability
The invalidity or unenforceability of any provision of this Agreement shall not
affect the validity or enforceability of any other provision of this Agreement,
which shall remain in full force and effect, provided that the Parties can continue
to perform their obligations under the Agreement in accordance with the intent
of the Agreement.
H.Survival of Certain Agreement Terms
Any provision of this Agreement that imposes an obligation on a Party after
termination or expiration of the Agreement shall survive the termination or
expiration of the Agreement and shall be enforceable by the other Party.
I.Third Party Beneficiaries
Except for the Parties’ respective successors and assigns described above,
this Agreement does not and is not intended to confer any rights or remedies
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Routing #: 24-HA2-XC-00034
OLA #: 331003316
upon any person or entity other than the Parties. Any services or benefits which
third parties receive as a result of this Agreement are incidental to the
Agreement, and do not create any rights for such third parties.
J.Waiver
A Party’s failure or delay in exercising any right, power, or privilege under this
Agreement, whether explicit or by lack of enforcement, shall not operate as a
waiver, nor shall any single or partial exercise of any right, power, or privilege
preclude any other or further exercise of such right, power, or privilege.
K.Accessibility
i.Local Agency shall comply with and the work provided under this
Agreement shall be in compliance with all applicable provisions of
§§24-85-101, et seq., C.R.S., and the Accessibility Standards for
Individuals with a Disability, as established by OIT pursuant to
Section §24-85-103 (2.5), C.R.S. Local Agency shall also comply
with all State of Colorado technology standards related to technology
accessibility and with Level AA of the most current version of the
Web Content Accessibility Guidelines (WCAG), incorporated in the
State of Colorado technology standards.
ii.The State may require Local Agency’s compliance to the State’s
Accessibility Standards to be determined by a third party selected by
the State to attest to Local Agency’s work and software is in
compliance with §§24-85-101, et seq., C.R.S., and the Accessibility
Standards for Individuals with a Disability as established by OIT
pursuant to Section §24-85-103 (2.5), C.R.S.
IX.COLORADO SPECIAL PROVISIONS (COLORADO FISCAL RULE 3-3)
These Special Provisions apply to all contracts (agreements). Contractor refers to
Local Agency and Contract refers to Agreement.
A.Statutory Approval §24-30-202(1), C.R.S.
This Contract shall not be valid until it has been approved by the Colorado State
Controller or designee. If this Contract is for a Major Information Technology
Project, as defined in §24-37.5-102(19), then this Contract shall not be valid
until it has been approved by the State’s Chief Information Officer or designee.
B.Fund Availability §24-30-202(5.5), C.R.S., applicable Local Agency law, rule or
regulation
Financial obligations of the Partiespayable after the current State Fiscal Year
are contingent upon funds for that purpose being appropriated, budgeted, and
otherwise made available.
C.Governmental Immunity
Liability for claims for injuries to persons or property arising from the negligence
of the Parties, its departments, boards, commissions committees, bureaus,
offices, employees and officials shall be controlled and limited by the provisions
of the Colorado Governmental Immunity Act, §24-10-101, et seq., C.R.S.; the
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Routing #: 24-HA2-XC-00034
OLA #: 331003316
Federal Tort Claims Act, 28 U.S.C. Pt. VI, Ch. 171 and 28 U.S.C. 1346(b), and
the State’s risk management statutes, §§24-30-1501, et seq. C.R.S. No term
or condition of this Contract shall be construed or interpreted as a waiver,
express or implied, of any of the immunities, rights, benefits, protections, or
other provisions, contained in these statutes.
D.Independent Contractor
Contractor shall perform its duties hereunder as an independent contractor and
not as an employee. Neither Contractor nor any agent or employee of
Contractor shall be deemed to be an agent or employee of the State. Contractor
shall not have authorization, express or implied, to bind the State to any
agreement, liability or understanding, except as expressly set forth herein.
Contractor and its employees and agents are not entitled to
unemployment insurance or workers compensation benefits through the
State and the State shall not pay for or otherwise provide such coverage
for Contractor or any of its agents or employees. Contractor shall pay
when due all applicable employment taxes and income taxes and local
head taxes incurred pursuant to this Contract. Contractor shall (i) provide
and keep in force workers' compensation and unemployment
compensation insurance in the amounts required by law, (ii) provide
proof thereof when requested by the State, and (iii) be solely responsible
for its acts and those of its employees and agents.
E.Compliance with Law
Contractor shall comply with all applicable federal and State laws, rules, and
regulations in effect or hereafter established, including, without limitation, laws
applicable to discrimination and unfair employment practices.
F.Choice of Law, Jurisdiction, and Venue
Colorado law, and rules and regulations issued pursuant thereto, shall be
applied in the interpretation, execution, and enforcement of this Contract. Any
provision included or incorporated herein by reference which conflicts with said
laws, rules, and regulations shall be null and void. All suits or actions related to
this Contract shall be filed and proceedings held in the State of Colorado and
exclusive venue shall be in the City and County of Denver.
G.Prohibited Terms
Any term included in this Contract that requires the State to indemnify or hold
Contractor harmless; requires the State to agree to binding arbitration; limits
Contractor’s liability for damages resulting from death, bodily injury, or damage
to tangible property; or that conflicts with this provision in any way shall be void
ab initio. Nothing in this Contract shall be construed as a waiver of any
provision of §24-106-109 C.R.S. Any term included in this Contract that limits
Contractor’s liability that is not void under this section shall apply only in excess
of any insurance to be maintained under this Contract, and no insurance policy
shall be interpreted as being subject to any limitations of liability of this
Contract.
H.Software Piracy Prohibition
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Routing #: 24-HA2-XC-00034
OLA #: 331003316
State or other public funds payable under this Contract shall not be used for
the acquisition, operation, or maintenance of computer software in violation of
federal copyright laws or applicable licensing restrictions. Contractor hereby
certifies and warrants that, during the term of this Contract and any extensions,
Contractor has and shall maintain in place appropriate systems and controls to
prevent such improper use of public funds. If the State determines that
Contractor is in violation of this provision, the State may exercise any remedy
available at law or in equity or under this Contract, including, without limitation,
immediate termination of this Contract and any remedy consistent with federal
copyright laws or applicable licensing restrictions.
I.Employee Financial Interest/Conflict of Interest §§24-18-201 and 24-50-507,
C.R.S.
The signatories aver that to their knowledge, no employee of the State has any
personal or beneficial interest whatsoever in the service or property described
in this Contract. Contractor has no interest and shall not acquire any interest,
direct or indirect, that would conflict in any manner or degree with the
performance of Contractor’s services and Contractor shall not employ any
person having such known interests.
THE REMAINDER OF THIS PAGE IS INTENTIONALLY LEFT BLANK
LA.MT.PWQ_4.11.23 Page 9 of 9
Exhibit A-Scope of Work
th
I-25 @ US50B Areas West of Noise Wall 28 to
Maintenance IGA
The “Work” under this contract shall consist of maintenance responsibilities between CDOT and the City of Pueblo
thrd
(City), for areas west of the proposed I25 noise wall from 28 St to 23 St that is a part of the I-25 @ US50B
Project in the City of Pueblo as further described below and as shown in following map exhibits. This is only
related to the triangular areas and doesn’t apply to anything on US50B.
All physical features constructed with the I25 @ US50B project, and the maintenance of those features, are covered
by the Division of Authority statute and existing or future overall City-wide IGAs.
LANDSCAPING
CDOT RESPONSIBILITIES:
Locating of any CDOT Utilities that are underground in the triangular landscaped areas.
CITY of Pueblo RESPONSIBILITIES:
All concrete trickle channels in the triangular landscaping areas and other drainage
features (ie pipes,inlets, etc)connecting the areas.
Using the noise wall as a physical dividing line – City maintains from the noise wall west to the city streets.
Irrigation system(s) including water and electric services.
Maintain all trees and any other planting materials (irrigated or non-irrigated).
Sidewalk and accessible ramps on the west side of the triangular landscaping areas adjacent to the city streets.
Locating of irrigation system water and electric facilities.
Locating of any City of Pueblo Utilities that are underground in the triangular landscaping areas.
Trash collection from the noise wall west to the city streets.
Attachment – Two (2) plan view sheets with shaded area of the triangular landscaped areas.
Exhibit B:
Exhibit B: Page 1 of 1
EXHIBIT
PII Certification
STATE OF COLORADO
LOCAL AGENCY CERTIFICATION FOR ACCESS TO PII THROUGH A
DATABASE OR AUTOMATED NETWORK
Pursuant to § 24-74-105, C.R.S., I, _________________, on behalf of
__________________________ (legal name of Local Agency) (the “Local Agency”),
hereby certify under the penalty of perjury that the Local Agency has not and will not
use or disclose any Personal Identifying Information, as defined by § 24-74-102(1),
C.R.S., for the purpose of investigating for, participating in, cooperating with, or
assisting Federal Immigration Enforcement, including the enforcement of civil
immigration laws, and the Illegal Immigration and Immigrant Responsibility Act,
which is codified at 8 U.S.C. §§ 1325 and 1326, unless required to do so to comply
with Federal or State law, or to comply with a court-issued subpoena, warrant or
order.
I hereby represent and certify that I have full legal authority to execute this
certification on behalf of the Local Agency.
Signature: __________________________
Printed Name: __________________________
Title: __________________________
Date: ___________
Exhibit Page 1 of 1