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Home My WebLink About20190994.tiffRESOLUTION RE: APPROVE APPLICATION FOR SUPPLEMENTAL REIMBURSEMENT FOR PETROLEUM STORAGE TANK REMEDIATION AND AUTHORIZE CHAIR TO SIGN WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, the Board has been presented with an Application for Supplemental Reimbursement for Petroleum Storage Tank Remediation from the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Buildings and Grounds, to the Colorado Division of Oil and Public Safety (CDLE), commencing upon full execution of signatures, with further terms and conditions being as stated in said application, and WHEREAS, after review, the Board deems it advisable to approve said application, a copy of which is attached hereto and incorporated herein by reference. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, that the Application for Supplemental Reimbursement for Petroleum Storage Tank Remediation from the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Buildings and Grounds, to the Colorado Division of Oil and Public Safety (CDLE), be and hereby is, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said application. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 6th day of March, A.D., 2019. BOARD OF COUNTY COMMISSIONERS ATTEST: C�(�it C r _;e1 Weld County Clerk to the Board ounty Attorney Steve Moreno Date of signature: 2S- lei WELD COUNTY, COL RADO Aic .(AAL ` .ti_, arbara Kirkmeyer, hair Mike Freeman, Pro-Tem CL'. TT/5�), AC.'Tc&Jc0) 3 tZllq 2019-0994 BG0021 DEPARTMENT OF BUILDINGS AND GROUNDS PHONE: (970) 304-6531 FAX: (970) 304-6532 WEBSITE: www.co.weld.co.us 1105 H STREET P.O. BOX 758 GREELEY, COLORADO 80632 March 1, 2019 To: Board of County Commissioners From: Toby Taylor Subject: Colorado Petroleum Storage Tank Fund Reimbursement Weld County awarded a contract to Palmetto Environmental Group LLC to perform the Site Characterization Report and subsequent remediation activities based on the results of the discovery of a leaking underground storage tank at our Fleet Services Building. The cleanup has been completed. Through the Colorado Division of Oil and Public Safety (CDLE), Division of Oil & Public Safety (OPS) office, we are eligible to apply to the Colorado Petroleum Storage Tank Fund for additional reimbursement of these costs. Two applications have been made and approved so far. The current amounts expended for the ongoing remediation/sampling is $8,513.34. Therefore, Buildings and Grounds is recommending approval for of this supplemental application to the fund for reimbursement of the $8,513.34 used for this remediation activity. If you have any questions, please contact me at extension 2023. Sincerely, Toby Taylor Director 2019-0994 31(D �doa_I Colorado Petroleum Storage Tank Fund SUPPLEMENTAL REIMBURSEMENT APPLICATION Short Form S (2017) This form should be used, and can only be used, on Supplemental Reimbursement Applications when the Applicant has already established eligibility for reimbursement of remedlatlon costs relative to this occurrence. �y Y `' s `' " it .w....,:et µ - w �7P�r1 d7sr t s' :,. ) 1.31J � SYJ �fl},q:W The nature of this Supplemental Reimbursement Application is: [Select all that apply] Additional costs not previously reimbursed. X Other (Explain): List RAP # of last application previously filed for this remediation: 33144 Applicant's Full Legal Name: Weld County Government Social Security # or Federal Tax ID # 84-6000813 Contact Person: Toby Taylor Phone # 970.356.4000 ext 2023 Fax # 970.304.6532 Mailing Address: Street: 1150 0 Street Email: ttaylor@weldgov.com City: Greeley State CO Zip 80631 Reimbursement Mailing Address (if different) : Remit Entity: Street: City: State Zip Email Applicant is (select one): ' Government Site Name: Weld County Repair Garage Site Address: Street: 1399 N. 17th Avenue City: Greeley State CO Zip 80631 ., Comp(e0: chi's section only if you wanr-the�:representafiye to be tl�e primary contact and'copt<ed�on;:all:�; -;:: Correspondence:. , ... , .:... Applicant's Representative (if applicable) Name Palmetto Environmental Group Address 4995 York St. Email: mailiSpalmetto-environmental.com City Denver State CO Zip 80216 Phone # 303.825.8117 Fax # 303.534.5049 Total from Listing of Costs, last column: $8,513.34 Less reimbursement from any other source (see #5): NET REIMBURSEMENT REQUEST: $8,513.34 Dates of work covered by this application: From: 7/1/18 To: 1/20/19 } S J +.'k• , +•fi: .5:%.: Y( ' ..f1. iiJ" S�k:. Sly :<.-.. /r t' -'Mr •�'l.' <:9f:' •;- :-C': .W. ['{.:lV.Y•..; f :ii :•( i^r: --,f'"'Tr '.gw {Krn.i5rr :-G f r. ''r�'. e. is C; `.:Y �: c'lf' a Y �jt�y. ru.>. 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Y. ^.( f.•<≤r:-re r•f1! ,. 'aril', atl''.�i•r5,5lx.7' tK �tf -•osJlr -'` )•7,r, r+r :-�'0't:��i;Tn> 4t<I�`,is �. �' 'tiA ...1 �, ,F•'r i�"`�' r5. i�r . .E.�..";�.'isJ .. .S ... ,.., ,: ..r., ... �r. ::: :.�:..-r.:':., aa> .;;:• .r.< 'rd,>,.;f :..i. -.r:;:. :..... .., y, ..,rr .. .•r.. .....- 1.. .. .: :'J. •:" :Y...- } .. j.. '-:7✓ .R ��' ':1'<:.lh !, 1 ,f .! _ft,. .r3 J. J. �:'i.':•ta. .c}'..� Civx .,:w :.: +: ... ..., r . i'...:.•,Z•,:. .,.. •.,. ..:. ,. �>F;.. FS•= - � .. , 1r�.. . ,: ,, s. . .., ..1, .. : Y _, r. .:. .. ;'i,.': - > .rc''r - ... .. .. ... ... �. .. ..._ -. r•,rr .,,. ,.<. ..r i'. fn'rd'�4,:u vi' 4 ! t ay�•'�?:'°,�!Y .xy..,T � �:t;:L �( "`N 1, 5art'',4 f,{:Y^;%•�i .kR'fi�7�,,.% <�J'�'..,,of‘��•�('. . ::.[:'' %1.:'; '�t'T.-". P, k", i.l��- -Pt i-'tiG, D,aL''�, ,� ., '3il �-�,kj•...:.ik`f REV 8/4/17 *Prior versions of this application will not be accepted Page 10(4 REIMBURSEMENT INFORMATION 1 Will there be additional reimbursement applications for this release? Yes 2 Have any of the costs submitted for reimbursement already been submitted with another reimbursement application? if yes, identify these costs and explain why you are resubmitting these costs: ' No 3 Do any of the costs submitted for reimbursement cover a time period for which you have already received, or requested reimbursement? If yes, identify these costs and explain why you are resubmitting them: PD No 4 Except for any contractual relationship established In response to this remediation, is there any relationship - personal, financial, or otherwise - between Applicant and any company or person who performed work for which reimbursement is claimed? If yes, explain: No 5 Has Applicant received, or does Applicant expect to receive, compensation for corrective action costs from ANY source other than the Colorado Petroleum Storage Tank Fund, including lawsuits, settlements, Judgments, contributions from other parties? if yes, state amount of other reimbursement: $ . Identify source of reimbursement, including court case name and number, No if applicable: Note: ` If (*SW* been?asY _changes'to=insurance,from that:submitted with the -'Original. 1 pplicatoproviden, updated information with this Application (in the same tormat as the. Original Application) , ",. 6 Do any costs claimed for reimbursement represent work performed by the Applicant or Applicant's employees? If yes, submit the Affidavits Regarding Work Performed by Applicant No 7 8 Has the Legal Name, Remit Entity or Address, Mailing Address or Tax Payer Identification Number changed since the submittal of the Original or last Supplemental Reimbursement Application? If so, please submit a W- 9 (scanned signature is acceptable) - see Completing App Instructions tab. No W-9 - If you answered yes to question 7, attach a W-9 to this application and explain any changes here. REV 8/4/17 'Prior versions of this application will not be accepted Page 2 of 4 By submitting this application, the Applicant affirms and agrees that: 1. The Applicant certifies, under penalty of law, that Applicant is the appropriate person to request reimbursement, and that this document and all attachments were prepared under Applicant's direction or supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. 2. The Applicant is the owner/operator or duly authorized agent of the owner/operator responsible for this Slte. The Applicant is and shall be responsible for assuring compliance with all applicable State and federal regulations. 3. The information submitted by the Applicant, to the best of Applicant's knowledge and belief, is true, accurate and complete. Applicant understands that this application will be submitted by the Colorado Department of Labor and Employment (CDLE or State) for consideration by the Petroleum Storage Tank Committee (Committee). Upon demand by the Committee, Applicant agrees to return the entire award Applicant may receive or any other amount the Committee considers appropriate if (a) Applicant misrepresented or omitted any fact, either in writing or orally, relevant to the determinations made by the Committee or the CDLE; or (b) Applicant fails to complete, to the Committee's or the CDLE's satisfaction, the corrective action. 4. The Applicant shall not be entitled to obtain any other reimbursement from any source other than the State for the same costs or work reimbursed by the State. Any reimbursement the Applicant receives or is entitled to receive, including insurance proceeds, is and shall be the property of the State of Colorado to the extent of payment(s) made to the Applicant by the State from the Petroleum Storage Tank Fund. Upon receipt of any such reimbursement from a source other than the State, Applicant shall immediately report and pay such reimbursement to the State. 5. To the extent payment is made from the Petroleum Storage Tank Fund, the Applicant hereby assigns to the State of Colorado any rights the Applicant may have which may allow the Applicant to seek and obtain recovery from any other entity for the costs or work reimbursed by the State, including the right to recover from insurance companies. 6. The Applicant shall not submit any further claims for reimbursement from the State for the Site(s) and work identified in this application, other than an amendment to the application or protest of the Fund Payment Report, if any, for work not heretofore reimbursed. 7. Applicant shall indemnify, save, and hold harmless the State, its employees and agents, and the Committee against any and all claims, damages, liability and court awards including costs, expenses, and attorney fees and related costs, incurred as a result of any act, omission or misrepresentation by the Applicant, or its employees, agents, subcontractors, or assignees pursuant to the terms of this application. As to governmental entity Applicants, no term or condition of this application shall be construed or interpreted as a waiver, express or implied, of any of the immunities, rights, benefits, protection, or other provisions, of the Colorado Governmental Immunity Act, CRS 24-10-101 et seq., or the Federal Tort Claims Act, 28 USC 2671 et seq., as applicable, as now or hereafter amended. 8. In addition to any other legal rights the State of Colorado may have, the State shall have audit and on -site inspection rights fora years after navment. 9. The remediation services and supplies for which expenses are listed in this application were performed and/or purchased at the most reasonable rates available for compliance. 10. The Applicant shall provide all formal or informal environmental assessment information to any future owner upon request. 11. In the event the Applicant breaches any of the terms, conditions or requirements of this application , the State of Colorado, in addition to any other remedies, at law or equity, shall be entitled to immediate repayment on demand of all amounts paid to the Applicant; and in the event that the State is required to take legal action to enforce any of the provisions contained herein, the State shall be entitled, in addition to damages, to its costs and reasonable attorney fees and related expenses incurred in connection with such enforcement. 12. At all times during the performance of this remediation, the Applicant shall strictly adhere to all applicable federal and state laws, rules and regulations that have been or may hereafter be established, including without limitation 42 USC 6991 and CRS 8-20.5-101, et seq., and associated regulations. 13. The State may allocate more or less funds to the remediation described in this Application than the amount requested by the Applicant. Once the reimbursement request is approved, the State will issue a Fund Payment Report, substantially in the form of Exhibit B, documenting the amount that will be processed and paid. 14. The Committee has the authority and the right to designate funds be paid to Applicants on pro -rata basis when the Petroleum Storage Tank Fund balance prevents payment in full, pursuant to CRS 8-20.5-206(e)(2). 15. Each additional request by Applicant for reimbursement from the Petroleum Storage Tank Fund must be submitted on a new supplemental application. Any additional payment by the State shall be conditioned upon the issuance by the Committee of a new Fund Payment Report for navnipnt. 16. Pursuant to 7 CCR 1101-14, Article 8, the Applicant may file a protest of the Fund Payment Report if the Applicant disputes a decision by the Committee, as stated on the Fund Payment Report. The Applicant may petition the Committee to review its decision. A Protest must be submitted within 60 days of the date of the Fund Payment Report. See 7 CCR 1101-14, 8-6. The Applicant shall use the form of Protest of Fund Payment Report provided by the Division of Oil and Public Safety of the Colorado Department of Labor and Employment. 17. The maximum amount to be paid by the State, if any, in connection with this reimbursement request shall be authorized by the Committee in the Fund Payment Report. 18. The payment by the State and acceptance by the Applicant of any reimbursement amounts requested under this application shall be deemed to be good and sufficient consideration for the promises, certifications and affirmations made by Applicant in this Application. REV 8/4/17 `Prior versions of this application will not be accepted Page 3 of 4 Signatory Page Applicant: Weld County Government Legal Name of Applicant 84-6000813 SociPVSecurity Number or F id / t ature of Applicant or {uthorized Off cer Date MAR 002019 Barbara Kirkmeyer, Chair, Board of Weld County Commissioners Print Name & Title of Authorized Officer Complete if this is a replacement signatory page RAP# FACILITY ID# EMAIL TO: cdle PSTReimbursementApps®state.co.us If you have any questions please consult the OPS website and/or contact OPS at (303) 318-8510. OPS website: http://www.colorado.gov/ops 99 REV 8/4/17 *Prior versions of this application wilt not be accepted Page 4 of 4 Colorado Petroleum Storage Tank Fund Photocopy additional pages as necessary LISTING OF COSTS Primary Invoice #1 Contractor Name Dates of Work . xx/xx/7x xxlx x/x x Beginning Ending Proof of Payment Invoice Amount Amount Submitted for Reimbursements Canceled Check3 Other's Check # Check Amt 8552 Palmetto 7/1/18 1/20/19 AFF $8,429.05 $8,429.05 8552z Palmetto 7/1/18 1/20/19 AFF $84.29 $84.29 TOTAL SUBMITTED FOR REIMBURSEMENT CONSIDERATION: $8,513.34 1 List all PRIMARY invoices. If Invoice does not clearly Identify work performed, add that information to the Invoice copy submitted with the application. 2 List invoices In order by the date of work performed. 3 If proof of payment Is bycanceled check, back of canceled check is also.requlred if the dollar amount is not encoded by the bank on the front of the check. 4 If proof of payment Is by payee affidavit or CPA Certification, use following codes: AFF = Affidavit. CPA = CPA Certification of Payment. Use CDLE Forms. 5 List only ALLOWABLE costs, if amount requested differs from invoice amount, identify on the invoice any cost for which reimbursement Is NOT requested. PALMETTO V,/, ENVIRONMENTAL GROUP LLC -Affidavit: Proof of Payment (Revised 1/5/2016) This form should be used when an applicant submits anaffidavit as proof of payment for costs claimed for reimbursement. This form is not required if copies of canceled checks or other bankconfirmations of payment are provided. Please note the following requirements. • This formmust be reproduced on the company letterhead of the payee (not the applicant's letterhead). o Affidavits that are not on the payee's letterhead will not be accepted. • This form must be signed by the payee, not the applicant. • Use a separate affidavit for each contractor. • Do not use this form if there is any affiliation or relationship between the applicantand the payee. More information is available in Section 8-2 (b) (2) of the Petroleum Storage Tank Regulations. Applicant Information Applicant Name:. County of Weld Site Name: Weld County Repair Garage Site Address: 1399 N. 17th Avenue City: I Greeley I Stater I CO I ZIP: I' 80631 Payee Information and Certification Check the following, as appropriate. CO I, being first duly sworn upon oath and being of lawful age, state that the following invoices relative to the referenced application for reimbursement from the Colorado Petroleum Storage Tank. Fund have been paid in full by the applicant. ❑ I, being first duly sworn upon oath and being of lawful age, state that the following invoices relative to the referenced application for reimbursement from the Colorado Petroleum Storage Tank Fund will be paid in full by the applicant upon receipt of the reimbursement in accordance with a promissory agreement. o Provide a signed and notarized copy of the agreement.. Invoice # Invoice Date Amount Paid Invoice # Invoice Date Amount Paid 8552 1/22/19 $8,429.05 85522 1/22/19. $84.29 • I further state that there is no relationship or affiliation between myself and the applicant. • I hereby certify that the foregoing.information is correct to the best of my knowledge, information and belief. I understand there are severe civil and/or criminal penalties for any false statement or misrepresentation of a material fact, knowing it to be false, or failing to • close a material f ct with the intent to defraud. Signature: Date: D , c), , ) q Printed Name: I Joh D. Drafts I Title: I Principal I Phone #: .303.825.8117 Company (Payee) Name: I Palmetto Environmental Group Company (Payee) Mailing Address: 14995 York St CO: I Denver I State: I CO I ZIP: 180216 Notary Public Certification Subscribed and sworn to before me in the county of , State of this Z-2- day of ,- . • Notary Public Printed Name: %190/ G,, MICHAEL R. CRITCHLEY Signature: 7 NOTARY PUBLIC STATE OF COLORADO, My Commission Expires: �/_%->cl NOTARY ID 20114071422 (303) 825-8117 D fax (303) 534-5049 D 4995 York Street CI Denver, Colorado 80216 INVOICE ace Analytical www.pacelabs.com Sold To: John Drafts Palmetto Environmental 4995 York Street Denver, CO 80216 303-825-8117 x107 Pace Analytical Services, LLC 9608 Loiret Blvd. Lenexa, KS 68219 Phone: (913)599-5666 Invoice Number. 1860057278 Date: 09/07/2018 Total Amount Due: $1,050.00 Please Remit To: Pace Analytical Services, LLC P.O. Box 684056 Chicago, IL 60695-4056 ih 60-006268 / Palmetto r Heather Wilson EglkerfftIM Net 30 Days MAW Client Project 1399 N 17TH Pace Project No: 60279392 Report Sent To: John Drafts, Palmetto Environmental Comments: Client Name: Palmetto Sample Received: 9/1/2018 quantity Unit Description ANALYTICAL CHARGES Method Matrix Price Total 7 Ea 8280 VOCs Water $150.00 $1,050.00 Analytical Subtotal $1,050.00 Samples Received for analysis: Lab ID Client Sample ID 60279392001 MW -01 60278392002 MW -02 60279392003 MW -03 60279392004 MW -04 60279392005 MW -05 60279392006 MW -08 60279392007 MW -07 Total Number of Charges 7 Received 9/1/2018 8:24:00 9/1/2018 8:24:00 9/1/2018 824:00 9/1/2018 824:00 9/1/2018 8:24:00 9/1/2018 8:24:00 9/1/2018 824:00 If you have anyquestions, please contact Heather Afton at Pace. Phone: 1(913)563-1407 Email: heather.wItson@pacefabs.com Total Invoice Amount $1,060.00 Page 1 of 1 "1.5% MONTHLY FINANCE CHARGE ASSESSED AFTER 30 DAYS OR TERMS OF CONTRACT. PLEASE REFERENCE THE INVOICE NUMBER ON ALL REMITTANCE ADVICE. AN EQUAL OPPORTUNITY EMPLOYER Please complete and return copy of invoice with your payment. INVOICE TOTAL $1,050.00 Amount Paid: $ Check No: Customer No: 60-506288 Invoice No: 1860057278 INVOICE n aceAnalyfical www.pacelabs.com Sold To: John Drafts Palmetto Environmental 4995 York Street Denver, CO 80216 303.825-8117 x107 60-506268 / Palmetto Pace Analytical Services, LLC 9806 Lolret Blvd, Lenexa, KS 86219 Phone: (913)599-5885 Invoice Number: 1860063932 Date: 11/29/2018 Total Amount Due: $1,050.00 Please Remit To: Pace Analytical Services, LLC P.O. Box 684056 Chicago, IL 60695-4056 Heather Wilson mamas, Net 30 Days Client Project: 1399 N 17TH Pace Project No: 60287681 Report Sent To: John Drafts, Palmetto Environmental Comments: Client Name: Palmetto Sample Received: 11/27/2018 Quantity Unit Description 7 Ea 8260 Volatile Organics by GC/MS ANALYTICAL CHARGES Method Matrix EPA 50308/8260 Water Price Total $150.00 $1,050.00 Analytical Subtotal $1,050.00 Samples Received for analysis: Lab ID Client Sample ID 60287681001 MW -01 60287681002 MW -02 60287681003 MW -03 60287681004 MW -04 80287681005 MW -05 60287681006 MW -06 80287681007 MW -07 Total Number of Charges 7 Received 11/27/2018 9:55:00 11/27/2018 9:55:00 11/27/2018 9:55:00 11/27/2018 9:55:00 11/27/2018 9:55:00 11/27/2018 9:55:00 11/27/2018 9:55:00 If you have any questions, please contact HeatherWlson at Pace. Phone: 1(913)56'3-1407 Email: heath or.wdson@pacelabscom Total Invoice Amount $1,060.00 "1.5% MONTHLY FINANCE CHARGE ASSESSED AFTER 30 DAYS OR TERMS OF CONTRACT. PLEASE REFERENCE THE INVOICE NUMBER ON ALL REMITTANCE ADVICE. AN EQUAL OP PORTUNRY EMPLOYER Please complete and return copy of invoice with your payment. INVOICE TOTAL $1,050.00 Amount Paid: $ Check No: Customer No: 60-506268 Invoice No: 1860063932 Page 1 of 1 Hello