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Home My WebLink About20183833.tiffAPPR RESOLUTION RE: APPROVE APPLICATION FOR 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 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 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 3rd day of December, A.D., 2018. BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO ATTEST: d) Jl 140;4 Weld County Clerk to the Board Deputy CI • . =D�S� Attorney Ste e Moreno, Chair an P. Con ay lie A. Cozad Date of signature: 11' 1 / I' 1 GG=gG( lT(sc.),GiCTC3G) 1131/161 2018-3833 BG0020 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 November 21, 2018 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. Therefore, Buildings and Grounds is recommending approval for of this application to the fund for reimbursement of the $83,312.67 used for this remediation activity. If you have any questions, please contact me at extension 2023. Sincerely, Toby Taylor Director 2018-3833 /213 3fapR�p 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 remediation costs relative to this occurrence. � r a Cfll: to , use n�i l CD tar' < 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: 32761 Applicant's Full Legal Name: Weld County Government Social Security # or Federal Tax ID # 846000813 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 Complete this section only jf yt u want the representative to be the primary act contand copied on all correspondence, Applicant's Representative (if applicable) Name Palmetto Environmental Group Address 4995 York St. Email: mail palmetto-environmental.com City Denver State CO Zip 80216 Phone # 303.825.8117 Fax # 303.534.5049 Total from Listing of Costs, last column: $83,312.67 Less reimbursement from any other source (see #5): NET REIMBURSEMENT REQUEST: $83,312.67 Dates of work covered by this application: From: 1/1/18 To: 6/30/18 s � Y k : ti r , ro �7PS l7se Only � � il YK is ' •�Y`,�` - a`..:E, *S o yC �.. :.'- .S . .. .z. ( f ht �. _ �' .- .:�'..�Y...S.,:, `�`t..::. ox ....j' Factll y lD i�' .ti �Y lr, ::₹c<, :,(. z v-,;,3 ter `f -r M�ci Ty e. i 3 $ *-� .t. t'' _ f s.:... ? : .:. :f fs �`." r' - s� . ,P i u 3, hs 'f'e'z s. f : � _ - ,— }� r �}. .s x5 ah' f`....,=,b.,. :...,r.^ : a; *� ..,>. : ,icy s; � *.; ,,.. :,�F�c { spate>Receiyed b QPS x y«* r� f. $} w -.i R�� 'Y =:F A �: o F�' 'i P Ererii ID ki {Crf�<` 3 �'...h T4r. 3;y k� -w 4;$ .Y E, �' :�``r.�, 'Cam 4... ay. F��wr, v Y i+''["',,� 2'M '4- p9 ® +z,, i ,` ;Tess! c. RrleyierS;< U � t'.y„- q :� �SiS-� �-.< t-�.��c 4 _ t i h - .$'. 9 5' 1 4 i. 5 i � Y Y y3 f a 3wfik X�� }' n $ F � h. c rr' 3�4�. �J'k 14. ' 3� tYx •#S `k'q 4i_. ' kx � Y3 iSV3Lt f t . A � v? €'. �• r "' 'X ��fii CtlS� � }X-�t�➢'4,'<�++1 2�<y Yh_5� : TXt a aSt•'i may, .! d `,j• . �e�e F� # <`2? <L'"f..' "S� Ra-i t' Y ' p� Di y3z �< .xSkt-£ „ 64#AV �nNl�lS411`i.S �y h § S �.Y � ?�}, $.�:� 8'+E. '.i0. 'S.y ors. 5,,> '{ K� : "z �''�€ 4 ihA t N. ��p 4�'S s' T * 3 � ?A"��4 ₹,} J i ..S'3. S Zf R S_ M .4"Z '3y §"fir "`� � f k (BPS in on .::.,,+l..'' ar;, i k -Ss* ' { a7 s rs .kW,a`.d Jr #5` r 6 Se r path " �'� € :;�p*l a₹ 4 v", }'\ iq,cs; `a -+q ,p: '{' w. x x eYISe� oa at 'a f?wgd '? l g.., ..fit.:, .. &5 ,`.t, "'4 mOUF t fteC ®llvLrted 'G. ��<e. q* ye 3 k -+F Pg-3S33 REV 8/4/17 *Prior versions of this application will not be accepted Page 1 of 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: IIDD 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 there have been any changes to insurance from that submitted with the Original Application, provide updated information with this Application (in the same format 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. DoNO 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 appication 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 Site. 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 for 3 years after nrvmPnt. 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 is 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 nwvment. 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 Applicant: Weld County Government Legal Name of Applicant 84-6000813 Social Security Number or FEIN DEC 0 3 2018 Signature of Applicant or Authorized Officer Steve Moreno, Chair, Board of Weld County Commissioners Date Print Name a 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 opt8'-38'33 REV 8/4/17 'Prior versions of this application will not be accepted Page 4 of 4 RE: COLORADO PETROLEUM STORAGE TANK FUND REIMBURSEMENT APPROVED A TO SUBSTANCE: Elected icial or Department Head APPROVED AS TO F Cont APPROVED AS TO FORM: County Attorney Colorado Petroleum Storage Tank Fund Photocopy additional pages as necessary LISTING OF COSTS Primary Invoice #1 Contractor Name Dates of Work2 nchoc/xx xx/xx/xx Beginning Ending Proof of Payment Invoice Amount Amount Submitted for Reimbursements Canceled Checks Other4 Check # Check Amt 8078 Palmetto 1/1/18 6/30/18 AFF $82,487.79 $82,487.79 8078Z Palmetto 1/1/18 6/30/18 AFF $824.88 $824.88 TOTAL SUBMITTED FOR REIMBURSEMENT CONSIDERATION: $83,312.67 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 by canceled check, back of canceled check is also required 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 Pi E\VIROiN „ENF:,, GRJLP LLC Affidavit: Proof of Payment (Revised 1/5/2016) This form should be used when an applicant submits an affidavit as proof of payment for costs claimed for reimbursement. This form is not required if copies of canceled checks or other bank confirmations of payment are provided. Please note the following requirements. • This form must 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 applicant and 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: ( 80631 Payee Information and Certification Check the following, as appropriate. ® 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. Invoke # Invoice Date Amount Paid Invoice # Invoice Date Amount Paid 8078 9/25/18 $82,487.79 8078Z 9/25/18 $824.88 • 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 disclose a materia fact with the intent to defraud. Signature: i�z / Date: ic, 7/6:„ ./c:f Printed Name: I Jo n D. Drafts I Title: I Principal ( Phone #: 303.825.8117 Company (Payee) Na e: I Palmetto Environmental Group Company (Payee) Mailing Address: 14995 York St City: I Denver I State: I CO I ZIP: 1 80216 Notary Public Certification Subscribed and sworn to before me in the county of llbl'�►AgCVCRITCHLEY , State of L_ (1�c , this b) day of ; �.�z� Nf�T& 7 V UBLIC Notary Public Printed Name: I ' 'v/1;� <r SPATE OF COLORADO ,WARY ID 20114071422 EXPIRES FEBRIJARY7, 2020 Signature: <,, - My Commission Expires: -) lam; ) `e (303) 825-8117 a fax (303) 534-5049 a 4995 York Street a Denver, Colorado 80216 www.pacelabs.cotn INVOICE 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 66219 Phone: (913)599.5665 Invoice Number: 1860043498 Date: 02/08/2018 Total Amount Due: $1,650.00 Please Remit To: Pace Analytical Services, LLC P.O. Box 684056 Chicago, IL 60695-4056 Client Number/Client ID .. Purchase DrtlerNo ce ro eciM r ' ��r.� � a�#�l �1�'rms . ..... s ` Pa age 60-506268 / Palmetto Heather Wilson Net 30 Days 1 Client Project: 1399 N 17TH Pace Project No: 60263294 Report Sent To: John Drafts, Palmetto Environmental Comments: Client Name: Palmetto Sample Received: 2/3/2018 Quantity Unit Description ANALYTICAL CHARGES Method Matrix Price Total 6 Ea 8015 Ethylene Glycol 6 Ea 8260 Volatile Organics by GC/MS 6 Ea HEM, Oil and Grease Water EPA 5030B/8260 Water EPA 1664A Water $60.00 $150.00 $65.00 $360.00 $900.00 $390.00 Analytical Subtotal $1,650.00 Samples Received for analysis: Lab ID Total Number of Charges 18 Client Sample ID Received 60263294001 MW -02 60263294002 MW -03 60263294003 MW -04 60263294004 MW -05 60263294005 MW -06 60263294006 MW -07 2/3/2018 8:59:00 2/3/2018 8:59:00 2/3/2018 8:59:00 2/3/2018 8:59:00 2/3/2018 8:59:00 2/3/2018 8:59:00 Total Invoice Amount $1,650.00 If you have any questions, please contact Heather Wilson at Pace. Phone: 1(913)563-1407 Email: heatherwilson@pacelabs.com 'x"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 $1,650.00 Amount Paid: $ Check No: Customer No: 60-506268 invoice No: 1860043498 Page 1 of 1 CORING AND SAWING, ;Nab. 9630 Dallas St., Henderson, CO 80640 Phone: 303-422-3885 Fax: 303-431-9661 www.deandreacoring.cotn COD INVOICE INVOICE NO: INVOICE DATE: PAYMENT TERMS: CUSTOMER #: PURCH ORDER #: CONTRACT #: ORDERED BY: 164480 02/07/18 " C O D Account** CODCUS JOB SITE: WELD COUNTY MAINTENANC... 1399 N 17TH AVE GREELEY, CO DATE WORK ORDER DESCRIPTION 02/06/18 02/06/18 02/06/18 137132 137132 137132 ELECTRIC SLAB SAW SERVICE CALL (COURTESY DISCOUNT) ELECTRIC SAW (30HP) 275' FEET X 8 INCH DEEP CONCRETE TRENCH FOR PIPING C.O.D. ADMIN PROCESSING FEE ITOTAL: Please make checks payable to DEANDREA CORING & SAWING... AMOUNT 0.00 1,306.25 52.25 $1,358.60 1 Slab Sawing • Wall Sawing • Core Drilling • Hand Sawing • Electric Sawing • Floor Grinding Hinhwav .1rtint S:anlinn * e7re..,�,C.,... ..d n _.: - . ° United Rentals BRANCH J00 1926 SE FRONTAGE ROAD FORT COLLINS CO 80525 970-482-9999 970-224-2005 FAX Al ua� rl U] W A 'd Or WELD COUNTY MAINTENANCE 1399 N 17TH AVE GREELEY CO 80631-9562 Office: 303-825-8117 Cell: 720-474-0967 4.1.1069 1 MB 0,421 05350S21.901 1304211 1-1 0 tIII[hiililll1ulillllgll111111IinIIi[iliIliullilliPIi1Ii'il PALMETTO ENVIRONMENTAL 4995 YORK ST DENVER CO 80216-2245 4 WEEK BILLING INVOICE # 154346640-001 Customer # Invoice Date Date Out Billed Through UR Job Lon UR Job # Customer Job ID P.O. # Ordered By Reserved By Salesperson : 990874 : 02/23/18 : 02/07/18 09:00 AM : 03/07/18 00:00 : 1399 N 17TH AVE, GRE : 35 : WELD COUNTY : TYLER KALOUS : DALTON RANDALL : LOUIS HOLLOWAY II Invoice Amount: $3,523,45 Terms: Due Upon Receipt Payment options: Contact our credit office 212-333.8600 Ext. 84829 REMIT TO: UNITED RENTALS (NORTH AMCRICA),INC. PO BOX 840514 DALLAS TX 75284-0514 RENTAL ITEMS: Qty Equipment Description 1 902/5036 BACKHOE BUCKET 36" 1 10578124 BACKHOE/LOADER OVER 10SHP 4WD EXT-A-HOE Make: JOHN DEERE Model: 410L Serial: 1T041OLXAHF308922 Meter out: 876.70 SALES/MISCELLANEOUS ITEMS: Qty Item 1 SMM FEE 1 ENVIRONMENTAL SERVICE CHARGE 1 DELIVERY CHARGE 1 PICKUP CHARGE Minimum Day 415.00 Meter in: .00 [SMM/MCI] [ENV/MCI] COMMENTS/NOTBS: BRIAN FORMANEK (720)474-0967 BILLED FOR FOUR WEEKS 2/07/18 THRU 3/07/18 09:00 AM TO SCHEDULE EQUIPMENT FOR PICKUP, CALL 800-UR-RENTS (800-877-3687) WE ARE AVAILABLE 24/7 TO SUPPLY YOU WITH A CONFIRMATION $ IN ORDER TO CLOSE THIS CONTRACT Week 4 Week 1039.00 Amount N/C 2599.00 2,599.00 Rental Subtotal: 2,599.00 Price Unit of Measure Extended Amt. 51.980 33.780 115.000 115.000 EACH EACH EACH EACH Sales/Misc Subtotal: Agreement Subtotal: Rental Protection: Tax: Total: 51.98 33.78 115.00 115.00 315.76 2,914.76 389.85 218.84 3,523.45 •3\ V"7 THIS 4 WEEK BILLING INVOICE IS ISSUED SUBJECT TO THE TERMS AND CONDITIONS OF THE RENTAL AGREEMENT, WHICH ARE INCORPORATED HEREIN BY REFERENCE. A COPY OF THE RENTAL AGREEMENT IS AVAILABLE UPON REQUEST. You Can Now Access invoice History and Update Purchase Orders Online To Ciyn Uµ canhot UPGentrei&uppe#@eeeem Page: 1 ° United Rentals° TRENCH SAFETY BRANCH 467 791 SAST 64TH AVE. DENVER CO 80229 303-329-8648 303-329-6247 FAX ID 43 TO -r1 N rn w A b 09: b WELD COUNTY MAINTENANCE 1399 N 17TH AVE GREELEY CO 80631-9562 Office: 303-825-8117 Cell: 720-474-0967 4.1.10861M50.421 13551 521.501 064813 1.1 0 ff 11 iilfliilllll'lllllllllrll+ll'lillliiuili)Illll IIIl)l))IIIlrlllfI' PALMETTO ENVIRONMENTAL 4995 YORK ST DENVER CO 80216-2245 RENTAL ITEMS: • Qty EE uipment Description 12 944/9924 ROAD PLATE 5' X 10' 1 944/9895 CROSSING PLATE LIFT SCREW 1.25" 1 330/7180 CHAIN PLATE BRIDLE 1 LEG 1/2" X 4' BRIDLE4' 1 LEG 173050 COMMENTS/NOTES: CONTACT: BRIAN FORMANEK CELLII: 720-474-0967 GEN RENTS DROPPING OFF EQUIPMENT IN THE AM - JOBSITE AT EXACT ADDRESS Minimum 11.62 4 WEEK BILLING INVOICE # 154392610-002 Customer # : 990874 Invoice Date : 04/04/18 Date Out : 02/08/18 10:00 AM Billed Through : 04/05/18 00:00 UR Job Loc : 1399 N 17TH AVE, GRE UR Job # : 35 Customer Job ID: P.O. # :WELD COUNTY Ordered By : BRIAN FORMANEK Reserved By : SHELBYLYN HONE Salesperson : SARAH CAPORICCI -,, F_-..,.., .-......:..__....'--`:..... _ 'e_,.,.,,>u!......�≥.:its'?-.r.��tY.sGax['3^x:K•c-i:a; Invoice Amount: $4,119.02 Terms: Due Upon Receipt Payment options: Contact our credit office 212-333-6600 Ext. 84829 REMIT TO: UNITED RENTALS (NORTH AMERICA),INC. PO BOX 840514 DALLAS TX 75284-0514 Day Week 4 Week 11.62 79.50 267.75 6.00 6.00 19.00 37.00 4.41 27.57 109.00 BILLED FOR FOUR WEEKS 3/08/18 THRU 4/05/18 10:00 AM TO SCHEDULE EQUIPMENT FOR PICKUP, CALL 800-UR-RENTS (800-877-3687) WE ARE AVAILABLE 24/7 TO SUPPLY YOU WITH A CONFIRMATION # IN ORDER TO CLOSE THIS CONTRACT Rental Subtotal: Agreement Subtotal: Rental Protection: Tax: Total: Amount 3,213.00 37.00 109.00 3,359.00 3,359.00 503.85 256.17 4,119.02 3()1'1 THIS 4 WEEK BILLING INVOICE IS ISSUED SUBJECT TO THE TERMS AND CONDITIONS OF THE RENTAL AGREEMENT, WHICH ARE INCORPORATED HEREIN BY REFERENCE. A COPY OF THE RENTAL AGREEMENT IS AVAILABLE UPON REQUEST. You Can Now Access invoice History and Updafo Purchase Orders Online Mtel6uppert aorn Page: 1 Sold To: INVOICE John Drafts Palmetto Environmental 4995 York Street Denver, CO 80216 303-825-8117 x107 Pace Analytical Services, LLC 9608 Loiret Blvd. Lenexa, KS 66219 Phone: (913)599-5665 Invoice Number: 1860044014 Date: 02/19/2018 Total Amount Due: $2,880.00 Please Remit To: Pace Analytical Services, LLC P.O. Box 684056 Chicago, IL 60695-4056 Client Nu�}ber/Client lD ',.SisP...+s47<.il.:: <.. r ...,,,,,k.,... .. .."w��i'rw € Purchase O de -/,No 3, %tom:.., hY ...,to,)d1-,sr. �L .. , r x : ° `" a ?troleeff g ;Terms** y .... ... � Pa�e�`' 60-506268 / Palmetto Heather Wilson Net 30 Days 1 Client Project: 1399 N 17TH AVE Pace Project No: 60263688 Report Sent To: John Drafts, Palmetto Environmental Comments: 2 day TAT (100% Rush Surcharge) Client Name: Palmetto Sample Received: 2/10/2018 Quantity Unit Description ANALYTICAL CHARGES Method Matrix Unit Discount/ Price Surcharge Total 4j) 1 Ea 8015 Ethylene Glycol Water ,,,,i,R 11 Ea 8260 MSV 5035A Prep EPA 8260 Solid (B�� 1 Ea 8260 Volatile Organics by GC/MS EPA 5030B/8260 Water fa.(k, 11 Ea 9071 Oil & Grease EPA 9071 Solid --/ 1 Ea HEM, Oil and Grease EPA 1664A Water .,{s $60.00 200% $120.00 $75.00 200% $1,650.00 $75.00 200% $150.00 $40.00 200% $880.00 $40.00 200% $80.00 Analytical Subtotal $2,880.00 Samples Received for analysis: Lab ID Total Number of Charges 25 Client Sample ID Received 60263688001 CO -W -W @ 6' 60263688002 WOD-W @ 5' 60263688003 WOD-W-N @ 5' 60263688004 CO -W -N @ 8' 60263688005 CO -W@ 12' 60263688006 CO -W -E @ 8' 60263688007 WOD-E @ 5' 60263688008 WOD-E-N @ 4' 60263688009 CO -M @ 5' 2/10/2018 9:30:00 2/10/2018 9:30:00 2/10/2018 9:30:00 2/10/2018 9:30:00 2/10/2018 9:30:00 2/10/2018 9:30:00 2/10/2018 9:30:00 2/10/2018 9:30:00 2/10/2018 9:30:00 Total Invoice Amount $2,880.00 "9.5% 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 $2,880.00 Amount Paid: $ Check No: Customer No: 60-506268 Invoice No: 1860044014 Page 1of2 INVOICE aceAnalytika 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 66219 Phone: (913)599.5685 Invoice Number: 1860044014 Date: 02/19/2018 Total Amount Due: $2,880.00 Please Remit To: Pace Analytical Services, LLC P.O. Box 684056 Chicago, IL 60695-4056 lie rum er C lien t!D Pr tiaseiOrrler NYo PacePro ect,Mgra =, Terms"' _ . Page,, iiii 60-506268 / Palmetto Heather Wilson Net 30 Days 2 Client Project: 1399 N 17TH AVE Pace Project No: 60263688 Report Sent To: John Drafts, Palmetto Environmental Comments: 2 day TAT (100% Rush Surcharge) Samples Received for analysis: Lab ID Client Sample ID Received 60263688010 CO -M -E @ 5' 60263688011 CO -M -W @ 5.5' 60263688012 MW -01 2/10/2018 9:30:00 2/10/2018 9:30:00 2/10/2018 9:30:00 Client Name: Palmetto Sample Received: 2/10/2018 if you have any questions, please contact Heather Wilson at Pace. Phone: 1(913)563-1407 Email: heather. wilson@pacelabs.com Page 2 of 2 **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 0 United Rentals. BRANCH J00 1926 SE FRONTAGE ROAD FORT COLLINS CO 00525 970-482-9999 970 224-2005 FAX WELD COUNTY MAINTENANCE 1399 N 17TH AVE GREELEY CO 80631-9562 Office: 303-825-8117 Cell: 720-474-0967 3.1.643 1 M6 0.421 05435321.001 807706 1-1 0 III'ytllnilliIIiIIluIIII'IIIIIIIIIIIIIIUIIIIIIIIIIIIInIIuIII PALMETTO ENVIRONMENTAL 4995 YORK ST DENVER CO 80216-2245 4 WEEK BILLING INVOICE # 154437491-001 Customer # Invoice Date Date Out Billed Through UR Job Loc UR Job # Customer Job ID P,O. # Ordered By Reserved By Salesperson : 990874 : 02/24/18 : 02/09/18 12:00 PM : 03/09/18 00:00 : 1399 N 17TH AVE, GRE 35 :WELD COUNTY : BRIAN FORMANEK : DALTON RANDALL :LOUIS HOLLOWAY II Invoice Amount: $3,017.28 Terms: Due Upon Receipt Payment options: Contact our credll office 212-333-6600 Ext. 84829 REMIT TO: UNITED RENTALS (NORTH AhERICA),INC. PO BOX 840514 DALLAS TX 75284-0514 • • RENTAL ITEMS: Qty Equipment ' Description 1 10361072 BACKHOE BREAKER Make: FURUKAWA Model: KF9FSP Serial: F9-6970 SALES/MISCELLANEOUS ITEMS: Qty Item 1 ENVIRONMENTAL SERVICE CHARGE 1 DELIVERY CHARGE 1 PICKUP CHARGE COMMENTS/NOTES: BRIAN FORMANEK (720)474-0967 BILLED FOR FOUR WEEKS 2/09/18 TURD 3/09/18 12:00 PM Minimum 350.00 [ENV/MCI] TO SCHEDULE EQUIPMENT FOR PICKUP, CALL 800-UR-RENTS (800-877-3687) WE ARE AVAILABLE 24/7 TO SUPPLY YOU WITH A CONFIRMATION # IN ORDER TO CLOSE THIS CONTRACT Day Week 4 Week Amount 350.00 999.00 2269.00 2,269.00 Rental Subtotal: 2,269.00 Price Unit of Measure Extended Amt. 29.490 95.000 95.000 EACH EACH EACH Sales/Misc Subtotal: Agreement Subtotal: Rental Protection: Tax: Total: 29.49 95.00 95.00 219.49 2,488.49 340.35 188.44 3,017.28 al_ Au 1.O THIS 4 WEEK BILLING INVOICE IS ISSUED SUBJECT TO THE TERMS AND CONDITIONS OF THE RENTAL AGREEMENT, WHICH ARE INCORPORATED HEREIN BY REFERENCE. A COPY OF THE RENTAL AGREEMENT IS AVAILABLE UPON REQUEST. You Can Now Access Invoice History and Update Purchase Orders Online To Sign Up, oantael- iRGentrel6upert@yfeem Page: 1 WASTE WVIANAGEIVIE&r Visit wm.com To setupyourcnane profile, sign up for paperless statements, manage your account, view holiday schedules, payyour invoice or schedule a pickup Customer Service: (877) 273-6727 INVOICE Customer ID: Customer Name: Service Period: Invoice Date: Invoice Number: May 01, 2018 If full payment of the invoiced amount is not received within your contractual terms, you may be charged a monthly late charge cf 2,5% of the unpaid amount, with a minimum monthly charge of $5, or such late charge allowed under applicable law, regulation or contract. Page 1 of 3 1-75337-74009 PALMETTO ENVIRONMENTAL 03/01/18-03/31/18 04/02/2018 0023464-0308-8 If payment is received after 05/01/2018: $ 1,554.41 =Precious Balance payments Adjustments ; + Current Charges — j Total Due 50.00 + (50.00) + 0.00 1,516.50 1,516.50 Details for Service Location: Customer ID: 1.75337-74009 Palmetto Environmental, 4995 York Street, Denver CO 80216-2245 Description - Date Ticket Quantit Y . • Unit of Measure Rite " Amount -�� - Vehicle#: h1 Unspecified contaminated soil, pmt sp. W. Haz-substance response fee yards Profile # 126080co Generator weld county (1399 n 17th aye)O Manifest#:422805 Ticket Total Vehice#: h1 Unspecified contaminated soil, pmt sp. W. Haz-substance response fee yards Profile # 126080co Generator weld county (1399 n 17th aye) Manifest#: 422768 Ticket Total 03/09/18 03/09/18 1702209 1702288 18.00 18.00 YDS YDS 16.50 16,50 0.00 297.00 6.30 0.00 0.00 0.00 303.30 0.00 297,00 6.30 0.00 0.00 0.00 303.30 WASTE MANAGEMENT WASTE MANAGEMENT PO BOX 43350 PHOENIX, AZ 85080 (877) 273-6727 (970) 686-2800 TICKET COPIES Please detach and send the lowerportlon with payment 04/02/2018 Payment Terms Total Due by 05/01/2018 If Received after 05/01/2018 - (no cash or staples) 0023464-0308-8 Total Due $1,516,50 $1,554.41 Customer ID (Include with your payment) 1-75337-74009 Amount 0308130001753377400900023464000001516500000©151650 9 0068277 01 A8 0.405 "AUTO T1 0 ➢092 80216 -224595 -001 -P68345 -I1 10306L1 8 Illlillil'liltilllrllllllrlii1111.111ullll'lll'Illi'I"III11'IIir PALMETTO ENVIRONMENTAL 4995 YORK STREET DENVER CO 80216-2245 THINK GREEN; I'1'uHllhIIuIIihIlriurlllIIIhIllII1III'rllil'i11,Ir11111IiIiiIi WASTE MANAGEMENT- NORTH WELD LANDFILL PO BOX 78251 PHOENIX, AZ 85062-8251 Pnnrrd an an H_nninniq_nlnR_q WASTE MANAGEMENT Customer ID: Customer Name: Service Period: Invoice Date: Invoice Number: Page 3 of 3 1-75337-74009 PALMETTO ENVIRONMENTAL 03/01/18-03/31/18 04/02/2018 0023464-0308-8 Details for Service Location: Customer ID: 1-75337-74009 Palmetto Environmental, 4995 York Street, Denver CO 80'216-2245 Description ,. Date Ticket . Quantity , , Unit of Measure Rate Amount Vehicle#: h1 03/09/18 1702338 0.00 Unspecified contaminated soil, pmt sp. W. 18.00 YDS 16.50 297.00 Haz-substance response fee yards 6.30 Profile 4 126080co 0.00 Generator weld county (1399 n 17th aye) 0.00 Manifest*: 422769 0.00 Ticket Total 303.30 Vehicle*: h1 03/12/18 1702599 0.00 Unspecified contaminated soil, pmt sp. W. 18.00 YDS 16.50 297.00 Haz-substance response fee yards 6.30 Profile # 126080co 0.00 Generator weld county (1399 n 17th aye) 0.00 Manifest*: 422 770 Ticket Total 0.00 303.30 Vehide#: h1 03/22/18 1705898 0.00 Unspecified contaminated soil, pmt sp, W. 18.00 YDS 16.50 297.00 Haz-substance response fee yards 6.30 Profile # 126080co 0.00 Generator weld county (1399 n 17th eve) 0.00 Manifest*: 422771 0.00 Ticket Total 303.30 Total Current Charges 1,516.50 THINK GREEN Printed on < ---- GENERATOR NON -HAZARDOUS 1. Generator ID Number WASTE MANIFEST 1 A 2. Page 1 of 6 3. Emergency Response Phone 800-424-9300 4. Waste Tracking Number - 1 5. Generator's Name and` Mailing Address Generators Project Address (if different than mailing address) WELD 9 N COAVE GREELEY CO 80631 Generator's Phone: (720) 474- 0967I 6. Transporter 1: Complete Company Name and Address Transporter Phone 'fi-�Z�S I icGr?vt?r-Ii-si j1° C'- R!-11 C? 1t,p,s,� C S `i) t() -?S ��5 7. Transporter 2: Complete Company Name and Address Transporter Phone i b' 8. Designated Disposal Facility Name and Site Address Facility's Phone: NORTH WELD LANDFILL 40000 WELD COUNTY ROAD 25 AULT CO 80610 (' 7t?) 686- 2800 9. Waste Shipping Name, Description, & Profile Number 10. Containers 11. Total 12. Unit No. Type Quantity Wt./Vol. NbN (WASTE REGULATED SOLID OIL IMPACTED SOIL/DEBRIS) 12608000 / E y,s z. 13. Regulatory Agency: Colorado Department of Public Health and Environment 4300 Cherry Creek Drive South Denver, Co 80222-1530 Emergency Notification: CHEMTREC (800) 424-9300 24 -hour Toll Free Number 14. Bill to & Account Number: CustomerAcet #: N 1003E Customer Name: PALMETTO ENVIRO GROUP LLC 1 Contractor/Generator Certification: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and labeled/ placarded, and are in all respects in proper txtndition for transportation according to applicable national and state governmental regulations. I hereby certify that the above described waste is not a hazardous waste defined by federal, state or local regulations and does not contain regulated quantities of PCB's or radioactive materials. Generator's/Offeror's Printed/Typed Name Signature Month Day Year Dr t .,/ CI Rim,,4 K { --- I 5Ii I1 ITRANSPORTER 16. Transporter Acknowledgement of Receipt of Materials Transporter 1 Printed/Typed Name S' Month Day Year N �� ` I I AI ignature monIth Transporter 2printedlrype� Day Year I I I I <ps, DESIGNATED FACILITY 17. Special Handling Instructions 18. Discrepancy Indication Space: 19. Ticket # Initials of Person noting discrepancy__ Signature Date 20. Management Method/Location J.ftrrtifftt^1 Monofiil Location: 21. Designated Facility Owner or Operato Certific n of receipt erials covered by the manifest except as noted in Item 18 Prin Name Signature .f nth Day Year , 169-BLC-© 6 10498 (Rev, 9/14) ....,. _..x, ., a.,�...,,.. , §, ,....�a �t ,,...�_ ..ax....�_ ,,.� �,r.�....,.� .x �yve�.l�t�,` s�.....x,c„ •+�.,� ;. �,�siMl4�� ,...;a2"3`°`� ut3b�.x e,,,a' � r_x x` L?u'M�'�.�,.�.r'�.,�`z9v.� � '� GENERATOR NON -HAZARDOUS WASTE MANIFEST N 1 Generator ID Number / A 2. Page 1 of g 1 3. Emergency Response Phone 9- v P 800-424-9300 4. Waste Tracking Number 5. Generator's Name and Mailing Address Generator's Project Address (if different than mailing address) WELD COUNTY 1399 N 17TH AVE GREELEY CO 80631 Generator's Phone: (720) 474_. 097 6. Transporter 1: Complete Company Name and Address Transporter Phone /II (2-0 , - i- X/ de,t,i 1 r yv�. `Z�u lCo � . i r -7- -f\ u P70,v G e t,.),- I 7. Transporter 2: Complete Company Name and Address Transporter Phone I` 8. Designated Disposal Facility Name and Site Address Facility's Phone: NORTH WELD LANDFILL 40000 WELD COUNTY ROAD 25 AULT CO 80610 70 686- 2: I'S 9. Waste Shipping Name, Description, & Profile Number 10. Containers' ' ' 12. Unit No. TypeOuantity PION REGULATED SOLID STE OIL IMPACTED SOIL/DEBRIS) 12608000 2. 7 13. Regulatory Agency: Colorado Department of Public Health and Environment 4300 Cherry Creek Drive South Denver, Co 80222-1530 Emergency Notification: CHEMTREC (800) 424-9300 24 -hour Toll Free Number 14. Bill to & Account Number: Customer Acct #: N 10039 Customer Name: PALME I ID ENVIRO GROUP LLC 15. Contractor/Generator Certification: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and labeled/ placarded, and are in all respects in proper condition for transportation according to applicable national and state governmental regulations. I hereby certify that the above described waste is not a hazardous waste defined by federal, state or local regulations and does not contain regulated quantities of PCB's or radioactive materials. 7 Generator's/Offeror's Printed/Typed Name Signature Month Day Year 3e- t_, �3- -v f o g r✓1 N t' 1 tr I .3 I I to TRANSPORTER 16. Transporter Acknowledgement of Receipt of Materials Transporter 1 Printed/Typed Name Si a Month Day Year rode re v� I . �� l '- 13 I 111 Transporter 2 P'nted/Typed Name nature Month Day Year I I I DESIGNATED FACILITY 17. Special Handling Instructions a 18. Discrepancy Indication Space: 19. Ticket # '--.—c) Z%( k =_ Initials of Person noting discrepancy Signature Date 20. Management MethodfLocatio Ian fill .•'�" Monofill Location: t� 21. Designated Facility Owner or Operattor: Certiticatlo>n ece ptot materials covered by the manifest except as noted in Item 18 Pr Name , Signature Mypth Yew ,""'--. ,,,pay 169-BLC-U b`10498 (Rev. 9/14) CWM! NON -HAZARDOUS WASTE MANIFEST N 1. Generator ID Number / A 2. Page 1 0l 1 3. Emergency Response Phone 800-424-9300 4, Waste Tracking Number F' 5. Generator's Name and Mailing Address Generator's Project Address (if different than mailing address)WELD COUNTY 1399 N 17TH AVE GREELEY CO 80631 Generator's Phone: ( 720) 474- 0967 I 6. Transporter 1: Complete Company Name and Address Transporter Phone l�%i a1--i: _ r- v ? "1 �0iZL # tl �Lv nsporter 2: Complete Company Name and Address Transporter Phone 8. Designated Disposal Facility Name and Site Address Facility's Phone: NORTH WELD LANDFILL 40000 WELD COUNTY ROAD 25 AULT CO 80610 { 970) 686- 2800 9. Waste Shipping Name, Description, & Profile Number 10. Containers 11. Total 12. Unit No. Type Quantity Wt.Nol." cc a cc 1ON REGULATED SOLID STE OIL IMPACTED SOIL/DEBRIS) 126080 O / z 2. s i 13. Regulatory Agency: Colorado Department of Public Health and Environment 4300 Cherry Creek Drive South Denver, Co 80222-1530 Emergency Notification: CHEMTREC (800) 424-9300 24 -hour Toll Free Number 14. Bill to & Account Number: Customer Acct #: N 10039 Customer Name: PALMETTO ENVIRO GROUP LLC 15. Contractor/Generator Certification: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, marked and labeled/placarded, and are in all respects in proper condition for transportation according to applicable national and state packaged, P P P P PP� governmental regulations. I hereby certify that the above described waste is not a hazardous waste defined by federal, state or local regulations and does not contain regulated quantities of PCB's or radioactive materials. r �t Generator'slDtferor's Printed/Typed Name Signature Month Day Year f;)Qt/fn/ '' /a rah )`O,2Gk1 yr K I 13 —f------ --� cc w 16. Transporter Acknowledgement of Receipt of Materials cc a Transporter 1 Printed/typed Name re Month DayYear J©,S�. Tel Q L[AZ i L 1 13 I/ I aTransporter 2 Printed/Typed Name ignature VMonth Day Year, vt 17. Special Handling Instructions � ~ < 18. Discrepancy Indication Space: 19, Ticket 0 / 1 I3 .r[ DESIGNATEI Initials of Person noting discrepancy Signature Date 20. Management Method/Location Landfill .,_ Monofill Location: 3 21. Designated Facili caner or Op or: Cedificaf n of recei or materials covered by the manifest except as noted in Item 18 Printed/Typed N he Signature Month Day Y ar 169-BLC-©6 10498 (Rev. 9/14) fw4 j cwn1I ,....,.,.. ,. ......��. �..a. _..,....e?.Ca it� � •�`Z._..k ��'.,..+... _.... �..�,.` �,.�..�k��7..kckt<:�a�a,..4�.. L � } � � '*zy' �..;.r� � a �3 w -,g "��aes�`�.��3k `{.; :��'"". NON -HAZARDOUS WASTE MANIFEST N 1 Generator ID Number / A 2. Page 1 of 1 3. Emergency Response Phone 800-424-9300 4. Waste Tracking Number 5. Generator's Name and Mailing Address WELD COUNTY 1399 N 17TH AVE GREELEY CO 80631 Generator's Phone: (720) 474 0987 Generator's Project Address (it different than mailing address) 6. Transporter 1: Complete Company Name and Address 4(r.., L iNe' 's t�`ri ✓pl t f'� .�d C W I� 0Nom ~ () fle-6LlJ Li Ui �,L I Transporter Phone C - F':; -..-c, ) 1 F . 7. Transporter 2: Complete Company Name and Address Transporter Phone 8. Designated Disposal Facility Name and Site Address NORTH WELD LANDFILL 40000 WELD COUNTY ROAD 25 AULT CO 80610 70)886- 2800 Facility's Phone: 9. Waste Shipping Name, Description, & Profile Number 10. Containers 11. Total 12. Unit No. T e Type Quantity Wt.Noi, PEON (WASTE REGULATED SOLID OIL IMPACTED SOIL/DEBRIS) 126080CO /5 74:3 .: z. 13. Regulatory Agency: Colorado Department of Public Health and Environment 4300 Cherry Creek Drive South Denver, Co 80222-1530 Emergency Notification: CHEMTREC (800) 424-9300 24 -hour Toll Free Number 14. Rill to & Account Number: Customer Acct #: N 10039 Customer Name: PALMETTO ENVIRO GROUP LLC 15. Contractor/•Generator Certification: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and labeled/ placarded, and are in all respects in proper condition for transportation according to applicable national and state governmental regulations. I hereby certify that the above described waste is not a hazardous waste defined by federal, state or local regulations and does not contain regulated quantities of PCB's or radioactive materials. Generator's/Offeror's Printed/Typed Name Signature Month Day Year 4 - 1--...--___,, 6fz' ,4 t' ? X► f'n� i . /, ,, 13 t ,2- 11 TRANSPORTER 16. Transporter Acknowledgement of Receipt of Materials Transporter 1 Printed/Typed Name Sign Month Day Year �� 3 o� I �, /� 13 1 /2 I /8 Transporter 2 rinted/Typed Name ignature Month Day Year 1 I I -. DESIGNATED FACILITY 17. Special Handling Instructions i1v 18. Discrepancy Indication Space: 19. Ticket # Z( r4 Initials of Person noting discrepancy Signature Date 20, Management MethodiLocation Landfill Monofill Location: 21. Designated Facility Owner or Operator: Certification of receipt of materials covered by the manifest except as noted in Item 18 Printed/TypedNa Q I Signature 2ii nth Day Yeaf 169-BLC-0 6 10498 (Rev. 9/14) CwMI GENERATOR NON -HAZARDOUS WASTE MANIFEST N 1. Generator ID Number / A 2. Page 1 of 1 3. Emergency Response Phone 800-424-9300 4. Waste Tracking Number - ¢ 5. tN 1 399 7TOE GREELEY CO 80631 Generator's Phone: ( 720) 474— 0967 I 6. Transporter 1: Complete Company Name and Address '8(3(vz ( Transporter Phone h` 4a 0L 5 L Ir _, u,,,-/nll 'Ic 3 S Co i<t 24 I-- Lk-) P OA) Lo 3q3-- g;-73/, -0 7. Transporter 2: Complete Company Name and Address Transporter Phone 8. Designated Disposal Facility Name and Site Address Facility's Phone: NORTH WELD LANDFILL 40000 WELD COUNTY ROAD 25 AULT CO 80610 (970) 686- 2800 9. Waste Shipping Name. Description, & Profile Number 10. Containers 11. Total 12. Unit No. T e Type Quantity WLNoi. 111 (WASTE 1ON REGULATED SOLID OIL IMPACTED SOIL/DEBRIS) 1260800O le ./ I r�r 13. Regulatory Agency: Colorado Department of Public Health and Environment 4300 Cherry Creek Drive South Denver, Co 80222-1530 Emergency Notification: CHEMTREC (800) 424-9300 24 -hour Toll Free Number ix s 14. Bill to & Account Number: Customer Acct #: N 10039 Customer Name: PALMETTO ENVIRO GROUP LLC 15. Contractor/Generator Certification: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and labeled/ placarded, and are in all respects in proper condition for transportation according to applicable national and state governmental regulations. I hereby certify that the above described waste is not a hazardous waste defined by federal, state or local regulations and does not contain regulated quantities of PCB's or radioactive materials. F; Generator's/Offeror's Printed/Typed Name Signature a-----1 Month Day Year f„LLs TRANSPORTER 16. Transporter Acknowledgement of Receipt of Materials Transporter 1 Printed/T ped Name Sig Month Day Year Transporter 2 Planteped Name nature Month Day Year I I I ; a 1 <„IN DESIGNATED FACILITY -� 17. Special Handling Instructions 18. Discrepancy Indication Space: 19. Ticket d � OD S `% e8 *}1 Initials of Person noting discrepancy Signature Date 20. Management Method/Location Lan. ' Mono ill Location: 21. Designated Facility Own or Operator: Certifi . 'fn of receipt of materials covered by the manifest except as noted in Item 18 4 DI 1e Signature Da., Year 169-BLC-O 6 10498 (Rev. 9/14) www.pacelabs.com INVOICE Sold To: John Drafts Palmetto Environmental 4995 York Street Denver, CO 80216 303-825-8117 x107 Pace Analytical Services, LLC 9606 Loiret Blvd. Lenexa, KS 66219 Phone: (913)599-5665 Invoice Number: 1860045818 Date: 03/22/2018 Total Amount Due: $115.00 Please Remit To: Pace Analytical Services, LLC P.O. Box 684056 Chicago, IL 60695-4056 client 1iiiifier/Client ID 60-506268 / Palmetto Purchase Order No :: Pace Projec fgr. Heather Wilson Terms, Net 30 Days Page 1 Client Protect: 1399 N 17TH Pace Project No: 60266202 Report Sent To:John Drafts, Palmetto Environmental Comments: Client Name: Palmetto Sample Received: 3/17/2018 Quantity Unit Description 1 Ea 9071 Oil & Grease 1 Ea Subcontracted Outside Pace ANALYTICAL CHARGES Method EPA 9071 Matrix Solid Solid Price Total $40.00 $40.00 $75.00 $75.00 Analytical Subtotal $115.00 Samples Received for analysis: Lab ID Total Number of Charges 2 Client Sample ID Received 60266202001 CO -W@15' 3/17/2018 3:00:00 If you have any questions, please contact Heather Wilson at Pace. Phone: 1(913)563-1407 Email.: heather.wilson@pacelabs.com Total Invoice Amount $115.00 **1.5% MONTHLY FINANCE CHARGE ASSESSED AFTER 30 DAYS OR TERMS OF CONTRACT. PLEASE REFERENCE THE INVOICE NUMBER ON ALL REMITTANCE ADVICE. AN EQUAL OPPORTUNITY EMPLOYER Please complete and return copy of Invoice with your payment. INVOICE TOTAL $115.00 Amount Paid: $ Check No: Customer No: 60-506268 Invoice No: 1860045818 Page 1 of 1 ConcreteLY Cutting Co.L.L.C. P.O. Box 2006 Loveland, CO 80539 PH: (970) 391-1432 - FAX: (970) 203-9069 TO: Invoice # JOB DATE (311 JOB ADDRESS CITY and STATE -r CONTACT PERSON TOTAL AMOUNT DUE P.O.# JOB# Signature EXPERIENCE - QUALITY - AFFORDABLE - Bonded & Insured - We Appreciate Your Business Terms (unless otherwise specified); Net 30 days 1.5% interest (18% Interest) will be charged on all past due accounts. WHITE = ORIGINAL INVOICE YELLOW = CUSTOMER STORE 1547 Brighton,CO 2440 Buckley Road Brighton, CO 80601 RENTAL HOURS Mon -Sat: 6 AM - 10 PM Son: 7AM-8PM CONTRACT #: 167864 Status: CLOSED Palmetto environmental 6780 EAST CEDAR AVE. APT 607 Denver, CO 80224 (720) 474-0967 Deposit Trans: Charge Trans: Register #: 90 Register #: 90 Transaction #: 14887 Transaction #: 15157 PO #: weld Date: 03/29/18 #Deposit #:1547180329073232816786458 PO #: 0 Date: 03/29/18 ()Deposit #: 1547180329073232818786458 Agent Name: BRIAN FORMANEK Date Out: Date Due: Date In: 03/29/2018 - 823 AM 03/30/2018 - 823 AM 03/29/2018 - 4:45 PM Contract Created By: Checked In By: ciw5800 jmk3889 Tool Description Vibratory Plate Compactor 20" (06-600-06683) Charges Amount Tool Rental Fee $83.00 SubTotal $83.00 Rental Subtotal Damage Protection* Tax Deposit - PAID 03/29/18 (VISA ending 2801) -$1.00 $83.00 I $8.30 $7.77 Balance Charged $98.07 (VISA ending 2801) Outstanding Balance $0.00 10% of Rental Subtotal if applicable. RENTAL FEE CALCULATOR DISCLAIMER Home Depot uses a Rental Calculator to insure our customers to get the lowest rates possible for the time they had the tool. TERMS & CONDITIONS__... ------ I agree that no representative of The Home Depot is authorized to make any promise, warranty or representation to me other than those reflected in writing in the Agreement. I agree to the Terms & Conditions and understand that the Agreement cannot be modified or changed except in writing signed by both parties. With respect to equipment I am renting, I have received the equklment referenced in the Agreement. In the event that I am returning equipment, I acknowledge and agree that i am returning the listed rental equipment, the total charges are correct, and additional charges may apply if the equipment Is returned damaged. tyres aii .6„ • • - 2815 35TH AVE, GREELEY,,CO 80634 970. 506-0662 CASSIF DORRANCE STORE :MGR. 1515 0,0001 85660 03/30/1B 11 56 AM CASHIER E - 0040'9;579 20FT REBAR <A ' ,:1/2 IN X 20 Fl REBAR `2097:50 , 150500 4100.1235 BOTTLE WATER -1i2 LITER WATER 24PK 81i1955364666 24"B.OLTCUT.IR <A> 2.1:97 \�24' BOLT• PUTTERS. SALTOTATLAX 112.25 f TAT .$188.70 XXXXXXXXT 01 VISA USD$ ,188 70. QUTEi C0LDEr(79192G/3011791 1 A Chi,Rexcl. •,,, AI A00000000310 O •" -43484;15345205649534,- TVR0080008000 IAD 06010A0360200.2 TsI:F800 ARC 00 P .0 ;-#/J0B NAME :.::,1399.. . . I 1111 l ll III l loll I IIl IIII 111 I l 515 01 85660 03/30/2018 0402'` RETURN POLICY DEFINITIONS PO _ICY ID DAYS POLICY EXPIRES ON A 1 - 90 06/28/2018 THE HOME DEPOT RESERVES 'THE R IGHf1 TO LIMIT / DENY RETURNS. PLEASE SEE THE RETURN .POLICY SIGN IN BLOKES FOR DETAILS. 10858 JAKE 'JABS 'BLVD FIRESTONE, CO 80504 (3031678-1100 i 1552 00001 00628 03/30/18 :07:55 AM CASHIER, BETH 0000-593-087 WIRE MESH A> 129.97 • 5FC X=150FT CONCRETE REINFORCE MESH 039645691717 5"..EXP JOIN'�•<A> 1/2"R4"X5 EXRANSIoN;.JOINT 203.15 ' 6.30 P45242517633 SDS1-/2X6-<A> MILWAUKEE 1/21,-)cSDS:BIT. 1/2°�4" X!'6,8:27 SUBTOTAL 144.54 TAX + PIE + RTF 9.97 TOTAL' $154.51 XXXXXXXXXXXx2801 VISA • AUTH CODE 09012G/9017095 USD$'154.TA Chip Read > TA 1 AID A00000110031010- /4348415345205649534 TVR 0080008000 IAD .06010A03602002 TSI F800 - ARC 00 P.O.#/JOB NAME: 1399' !J1ll!flhillliliff1I1tI11L!iI--,. Il�llllll� !I Ill 552 01:.-.00628. 03/1,/2018 0407 RETURN POLICY DEFINITION: P9E'I Y ID DAYS POLICY EXPIRE: N A T THE.1OME DEPOT RESERVES THERIGHTTTO LIMIT / DENY RETURNS. PLEASE SEE THE RETURN POLICY -SIGN IN STORES FOR DETAILS. \ ,.'..,v ».7:- f2 ) ' ; S ' i \/I, , 9 .« . / ° $% � w © b 6z ii a : «+ PRECAUTION « » fir » . .: pL ,,TES � /d d 6 s n C / Adc (a i I t ac // Gal'` :(.`_ F= _ GY in Diem' _ • WARNiNG; bit `Sea importahi haliih 0(arn}ation on reverse.: PAECAUT16N ifer pdomacion Important° paiyij 0.) ud Ail 11 011811D: ;- , i5,:dtmrte- .,,e s h ,e meets_ fesfp ar e t a d ds for..the: irii`: ' si ri fed ' n't `° �:` ' -' �_�....- _ x.�e g; �.o.,fll$_fron#,bu#�`if�jt:is'<aliered.� b the:customer"or if ddition al a er i - Y. , _ .,r.1 - , #. s.addedItmay npt;per•(armas ::cTesignated,4nd; s omen must'asu ' ` u s e h'a#;:,lsk'�'AII'eoh'r m.t s cee t #rucks=which:are:dif`�•` ,R.. •_ ec,#ed:;#o1,drlve��ff.�' -en esta6Tisbed, raadway,shall eo;so af"the:nsk-:e11he:custonner,e customernsbaU mdetnrilf�yld �aa Mart'arietta from any damage �u�r�i may result , �,. f;,,, toippr s=Stan tlard ,Terms and_ Conditions. app ;(copy: available_ atsite ,-(MU).; Ga"' :Mf,. :,= 'rYl!gRNING^.,-., .:.:_i Beelmpd.yo ntheaItIriaf,,orr iatlon'o revar₹e. :'PAECAt►TI OfV`:' ,- l',-... oa)meeaniapar'a,l. ...-" J . ��js`;cp�cre,teti ;eets,'the'sta 'rtls;°fqi-:tbe rii"ix�dE by: tk e', cusfa'rtier;'ar 11 1ditional wales; is added` the`,customer must assume=.that-:risk: All-concre ;an?esfo6lisl ocri'Dadwa `!:inderAn1s _M eriais•:Standard..Termsand Conditions a l • pply�(�opy: _availableat:Site'i3ffice, pEuvOlys TicsET 'Greeley F pt #1 North Plant a`•dress: 3800;"E" ;Street Greele.. CO: 80632 Dispatd $03;-833-5477 Main Office: 8120Gage Street . ' h•; Frederick,:;CO` :605-16 Phone; `303=666-6657; Fax 303-666 6743 ORDER#`';`: .�Slf97. CU.+~'.T00ERID..'., O P:9 JJUM ERfJ 8'$ _ M1 t i:Fti• .4t.iiXj* fw ZON• ,. P' '•! �J ' .'. .- r,$ :, r . : 5 - '•"• - P TIME , F : lb A7E 4 �: 2'17' ,fe.:9f/ DRIVER � +l d ? SOLD:T P -: DEL'LV0itr o.F,T.SS 9: 4 i" 14 . i v :. Faa t'V cr1 TRUCK . SLUMP -C SPEC INST 1. ..041-41:, t,1, lilEN w - , c DUE AT JOB ta0rArl'' a 7 11S EOAD " WANTiTY ndl FYr t.IS D _ QUANTITY:. " • DELIVERED • ,1i7'M MIX CODE MIX J • .,. ',' DESCRIRTIOo( t } x •.., UNf T (Sf :M 5UB UNIT ' f > ' PI IC . ,,� EXTENDED PRIDE j Giii-�•'^- -- :.. £. -as+.4 ri� "Y!; i!�• t..t,,.... ;4, ti•�^.''rv:hs�b, r'w,. G+ ,s rl.._�il" !'�k'r 4•, •((,,,,� 3{.•`' ti�� v .'6:4 i ., t':',He:?�`.''�:: ..._ .�. __..�jj...... ;F• .'•R,'.•S•. -.::-. • r?` •Ti:�.r.ry !«rt'i�{,er {{��[ . ?+ ".Y : '��::=.�,'{.::�� i. 'e'� } ,�dryry �'#�sti"F...d.�r:.,f h -4 ,.''�+;d� - .W� _ — �'i +yy�� j'�' y' �y �Tlp!{a`ry �g�1 iFf:', ..7':r: L;•. X;IJ +E - •7•�'R :-.T 1_i4'F'.9'.."-.TMa�•t r -. ��}}ypy _ yyw W.FiR'F.:ylr� }n�F�T�.". { ' y. it _ r3 IK.. ! .'I "�.: .. �. r" lir':' .c __.*5+ I.... r4i.-'''.f�':,[ •.1.�' i t - � Ht•�•:�} it°yd.?�,1. _,cam hiiP �� -}.t�•- ..i,:,..i ��. •A€•+'Yr�: o: -. , - .}^,�}'v.:-P,;i 1, i utv . ..tl.iAV � y'$g.- - r�N�-.:'a✓n`^"..- M f We.4 ..IF•� µ.:A'Y^N•Sc rl ;{;G Zyi".•.�,t�nn. �","4 _' v`,A $(nUDi'IR aT •71•151 WATEFi;ADUED�OhJ:1Q8 _ c -/'FARM' •FREE UNL'o, INGTIME•• l� g hA(df PER YARD:;'.''t Ti ALLOWED (Moist " z `� ,,,.:••••', ,. toll ` ,1 4s �k..,'ax'�. —..A.- -,- s 1 wi0•,TAL i^ ' l , � R gESTEO BY " Y' CYUNPER& _ ,Y. '.11.1: .s COMMENTSl ^} s * 1 R� 0 7 4 S - 4, . P... d#f3 LEAVE PEA1 T • ,.'"•:,..,,,,,,....,,,, ; WE'JOB i is ',..,..:,...-..v..,12,,,,,,:, FAR POUR' -t' ' �, ; FINISH P¢UP - 4 r - i LEAVE 1 n151 .... W m ARRIVE PLANT . ... _ ...., TRUCN TIME ' TR ; Ay.O Y iry'+.,1,1.4+2{ $ fl }=",-: :Y: ,ric t itid4f A.- Y:.?o 36fa , t Invoice PA M JOHN DRAFTS 4995 YORK STREET DENVER, CO 80216 QUANTITY HAROLD'S EXCAVATING SERVICE, LLC. 4038 COUNTY ROAD 21 FORT LUPTON, CO 80621-8435 PH:(303) 857-0315 FAX:(303) 857-0316 P.O. NUMBER DATE 4/20/2018 TERMS DESCRIPTION 3=6-18 Haul concrete out: 3 Truck hrs.: 5 End dump Truck hrs.: Dump fees: 30 30 tons of squeegee: 3-9-18 Haul out contaminated dirt: 7 End Dump Truck hrs.: 3-12-18 Haul out contaminated dirt: 5 End dump Truck hrs.: 3-22-18 Haul 1 load of dirt in and haul i load of dirt out: 50 50 tons of sand: 7 End dump Thick hrs.: 4-10-18 Haul concrete out 5 End dump Truck: Dump fees: Thank you for your business. NET 10 INVOICE # 6214 PROJECT 17th Ave, Greeley RATE 90.00 100.00 300.00 12.00 100.00 AMOUNT • 270.00 500.00 300.00 360.00 700.00 100.00 500.00 7.00 100.00 100,00 100.00 TOTAL 350.00 700.00 500.00 100.00 $4,280.00 IIIIIIIII1111111III INVOICE aceAnalytica! �.�ceb�mm www.pacelabs.com Sold To: John Drafts Palmetto Environmental 4995 York Street Denver, CO 80216 303-825-8117 x107 Paco Analytical Services, LLC 9608 Loiret Blvd. Lenexa, KS 66219 Phone: (913)599-5665 Invoice Number: 1860049415 Date: 05/17/2018 Total Amount Due: $900.00 Please Remit To: Pace Analytical Services, LLC P.O. Box 684056 Chicago, IL 60695-4056 ��lY '� "di ""�. Y � A' b � f oig �: 3 -' L ' aayy. i. omewi e or V N ,Y ``�fi�' .T Y P" y N Pac M1 '`zitfit, V-2414.11-:,,,'. Net 30 Days j .'�'a. 1 } 60-506268 / Palmetto Heather Wilson Client Project: 1399 N 17TH Pace Project No: 60270302 Report Sent To: John Drafts, Palmetto Environmental Comments: Client Name: Palmetto Sample Received: 5/12/2018 Quantity Unit Description 6 Ea 8260 Volatile Organics by GC/MS ANALYTICAL CHARGES Method Matrix EPA 50306/8260 Water Price Total $150.00 $900.00 Analytical Subtotal $900.00 Samples Received for analysis: Lab ID Total Number of Charges 6 Client Sample ID Received 60270302001 MW -01 60270302002 MW -02 60270302003 MW -04 60270302004 MW -05 60270302005 MW -06 60270302006 MW -07 5/12/2018 1:40:00 5/12/2018 1:40:00 5/12/20181:40:00 5/12/2018 1:40:00 5/12/2018 1:40:00 5/12/2018 1:40:00 if you have any questions, please contact Heather I'Wson at Pace. Phone: 1(913)563-1407 Email: heather.wilson@pacelabs.com Total Invoice Amount $900.00 **1.5% MONTHLY FINANCE CHARGE ASSESSED AFTER 30 DAYS OR TERMS OF CONTRACT. PLEASE REFERENCE THE INVOICE NUMBER ON ALL REMITTANCE ADVICE. AN EQUALOPP0RTUNRY EMPLOYER Please complete and return copy of Invoice with your payment. INVOICE TOTAL $900.00 Amount Paid: $ Check No: Customer No: 60-506268 Invoice No: 1860049415 Page 1 of 1 Hello