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Home My WebLink About20181456.tiffRESOLUTION 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 between 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, and 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 7th day of May, A.D., 2018. BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO ATTEST: dith,v;ok Weld County Clerk to the Board BY: AP Deputy Clerk to the B Co y Attorney Date of signature: D6-0//er Steve Moreno, Chair rbara Kirkmeyer Pro -Tern c� Sean P. Conway EXCUSED Julie A. Cozad EXCUSED C—� Mike Freeman cc: GT/C�), AG 010-08-�8 2018-1456 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 May 3, 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 reimbursement of these costs. Therefore, Buildings and Grounds is recommending approval for of this application to the fund for reimbursement of the $32,436 used for this remediation activity. If you have any questions, please contact me at extension 2023. Sincerely, Toby Taylor Director 2018-1456 7 5o oo ao Colorado Petroleum Storage Tank ORIGINAL REIMBURSEMENT APPLICATION Tank Owner/ Operator (2017) Fund THIS FORM MUST BE USED FOR THE ORIGINAL APPLICATION FOR REIMBURSEMENT After the Applicant has established eligibility, Short Form S is used Applicant Entity Type. Applicant's Full Legal Name Contact Person Mailing Address (must match W 9) Reimbursement Mailing Address (if different, must match Remit on W-9): W-9 Information: Site Name County of Weld Government Toby Taylor Event # RAP #.. CDLE%0PS'Intem I'Use only 12728 Social Security # or Federal Tax ID # 84-6000813 Phone # 970 356 4000 ext 2023 'Fax # 970 304 6532 Street PO Box 758 City- Greeley Remit Entity Street State® CO Zip- 80632 City State® Is the applicant a new applicant to the Fund' Weld County Repair Garage Zip Email. ttaylor@weldgov corn Email Yes Site Address: Site Ownership History' Street: 1399 N 17th Avenue City Greeley Applicant acquired site on [date] from [name] State. CO Zip: 80631 Is the site leased' Current owner of site, if not applicant: Name Address Phone# Date Acquired List all known previous owners of site, dates of ownership and property usage* Complete this section only if you want the representative to be the primary, contact and copied on all correspondence. Applicant's Representative (if applicable). Name Palmetto Environmental Group Address 4995 York St City Denver Total from Listing of Costs, last column. Less reimbursement from any other source (see #4) NET REIMBURSEMENT REQUEST Dates of work covered by this Application From State CO Zip 80216 Email• mail@palmetto environmental corn Phone # 303 825 8117 Fax # 303 534 5049 7/6/17 To 12/31/17 $32,436.60 $32,436.60 "Fr Facility ID: Event`ID AMPS " ' +RLVistons i J "7.7,;""" 1 OPS'Tethsiical;Revii ewer, OPS'Ft rid'Arialyst:, ; r �Revise'd FtoinfiDate - Revised 8/4/17 Pnor versions of this application will not be accepted ;For'OPS,Use Only _--_,, ' � ' e Ib to Received` byPOPS a 'C�' _... RTAtoy;�„iat _vT'ipz.F➢'" •-+G` „ Re-viseiilro,)Date_ "Ainount,Afte 4onverted.; Page 1 of 4 020/8 / 44OJ1 RELEASE INFORMATION "Release" means any spilling, leaking, emitting, discharging, escaping, leaching, or disposing of a regulated substance from an aboveground or underground storage tank into groundwater, surface water, or soils. [CRS 8-20.5-101 (14); 5 8-20.5-303(1)1 1 Was this release caused by a third- party? No If so, provide the name of the third - party and their contact REIMBURSEMENT INFORMATION 2 Will there be additional reimbursement applications for this release? V Yes 3 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: I ' No 4 Has Applicant received, source other than the settlements including other reimbursement: $ or does Applicant expect to receive, compensation for corrective action costs from ANY Colorado Petroleum Storage Tank Fund, including lawsuits, insurance settlements (other third -party), judgments, insurance contributions from other parties? If yes, state amount of . Identify source of reimbursement, including court case name and number, if applicable: No 5 List all insurance policies covering this site at date of release - include additional page(s), if necessary): Carrier Name: County Technical Services Policy # Colorado Counties CAPP Phone annually # 303-861-0507 Agent's Name: Allen Chapman Effective Dates: 1/1/2017 - 12/31/2017 renewed Does policy cover cleanup of petroleum contamination? Limited Pollution Coverage at $25,000 Carrier Name: County I echnical Services Policy # Colorado Counties CAPP Phone # 303-861-U507 Agents Name: Allen Chapman Effective Dates: 1/1/2017 - 12/31/2017 Does policy cover cleanup of petroleum contamination? Limited Pollution Coverage at $25,000 Provide the information below for any applicable insurance policy: 6 Policy Number Deductible Amounts Paid to Date Amounts Claimed and/or Expected to be Paid in the Future 7 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 or applicant employees. No 8 Has any other Applicant sought reimbursement for costs incurred for this release? If yes, explain. Include other Applicant's name, address, phone number, and Reimbursement Application number(s): ' No Revised 8/407 Prior versions of this application will not be accepted Page 2 of 4 By submitting this application, the Applicant affirms, certifies and agrees as follows: 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 shalt 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,relmbursement 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 U.S.C. 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 payment. - 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 U.S.C. 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.fundsbe 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). •13. Each,additional request by Applicant for,reiinbursement 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 payment. 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 revlew'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 bythe 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. Revised 8/4/17 'Prior versions of this application will not be accepted Page 3 of 4 Signatory Page Applicant: County of Weld Applicant's Full Legal Name: 84-6000813 Social S , u ' y # or Federal Tax ID # Signature of Applicant or Authorized Officer Steve Moreno, Chair Board of County Commissioners %AY 072018 Date Print Name Ft 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/cdle/ops Revised 8/4117 'Prior versions of this application will not be accepted Page4of4 c2 /1 145 , Form W -9 (Rev. December 2014) Department of the Treasury Internal Revenue Service Request for Taxpayer Identification Number and Certification Give Form to the requester. Do not send to the IRS. a t 1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank. County of Weld 2 Business name/disregarded entity name, If different from above 3 Check appropriate box for federal tax classification; check only one of the following seven boxes: ❑ Individual/sole proprietor or 0 C Corporation ❑ S Corporation ❑ Partnership 0 Trust/es-tate single -member LLC ❑ Umitedllability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ► Note. For a single -member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for the tax Classification of the single -member owner. ❑ Other (see instructions) ► 5 Address (number, street, and apt. or suite no) 1150 "O"' Street, PO Box 758 e City, state, and ZIP code Greeley, CO 80632 7 List account number(s) here (optional) 4 Exemptions (codes apply only to certain entities, not individuals; see Instructions on page 3): Exempt payee code (if any) Exemption from FATCA reporting code (if any) ~SS to scem•xs m.ivp, d auskla rM US) Requester's name and address (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name givenon line 1. to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor,.or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. Note. If the account is in•more than one name, see the instructions for line 1 and the chart on page 4 for guidelines on whose number to enter. Social security number or Employer identification number 8 4 6 0 0 0 8 1 3 Part II Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct. taxpayer identification number (or I am waiting for a number to be Issued to me); and 2. I amnot subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I.am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject. to backup withholding; and 3. I am.a U.S. citizen or other U.S. person (defined below); and •4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 aboveif you have been notified by the IRS that you are currently subject to,backup•withholding because•you have failed to report ail interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of 'secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA); and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the Instructions on page 3. Sign Here Signature °` ., Q.4a Q . U.S. person ► CY General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future. developments. Information about developments affecting Form W-9 (such as legislation enacted after we release it) is at www.ks.gov/fw9. Purpose of Form An Individual or entity (Form W=9 requester) who Is required to file an information return with thelRS must obtain your correct taxpayer Identification number (RN) which may be. your social security number (SSN), individual taxpayer Identification number (MN), adoption taxpayer identification number (ATM), or employer Identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are. not limited to, the following: • Form 1099-INT (interest earned or paid) • Form 1099-DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) •Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions). • Form 1099-K (merchant card and third party network transactions) Date I. Form 1098 (horse mortgage Interest). 1098-E (student loan interest). 1098-1' (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form -W-9 only if you are a U.S. person (including a resident alien), to provide your correct.11N. If you do not return Far W-9 to the requester with a TIN, you might be subject to backup withholding. See What Is backup withholding? on page 2. By signing the filled -out form, you: 1. Certify that the TiN you are giving Is correct (or you are waiting fora number to be Issued), 2. Certifythatyouare not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. if applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business tenth subject to the withholding tax on foreign partners' share of effectively connected income, and 4. Certify that FATCA code(s)entered on this form (If any) Indicating that you are exempt from the FATCA reporting, is correct. See What Is FATCA reporting? on page 2 for further information. Cat No. 10231X Form W-9 (Rev. 12-2014) Colorado Petroleum Storage Tank Fund Photocopy additional pages as necessary LISTING OF COSTS Primary Invoice #1 Contractor Name Dates of xx/xxlxx Beginning Work2 Proof of Payment Invoice Amount Amount Submitted for Reimbursements xx/xxlxx Canceled Checks Other Ending Check # Check Amt 7199 Palmetto 7/6/17 12/31/17 AFF $32,214.46 $32,214.46 7200 Palmetto 7/6/17 12/31/17 AFF $222.14 $222.14 NOTES: TOTAL SUBMITTED FOR REIMBURSEMENT CONSIDERATION:l $32,436.60 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 (date(s) work was actually performed, not the Invoice date): 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 COLE 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. REV 3116/12 PALMETTO ENVIRONMENTAL GROUP LLC Affidavit: Proof of Payment (Revised .1 /5/.2016) This form should be used when an applicant submits not required if copies of canceled checks or other Please note the following requirements. • This form must be reproduced on the o Affidavits that are not on the • This form must be signed by the payee, • Use a separate affidavit for each contractor. • Do not use this form if there is any affiliation More information is available in Section 8-2 (b) an affidavit as proof of payment for costs bank confirmations of payment are provided. company letterhead of the payee (not the applicant's payee's letterhead will not be accepted. not the applicant. or relationship between the applicant and (2) of the Petroleum Storage Tank Regulations. claimed for reimbursement. This form is letterhead). the payee. Applicant Information Applicant Name: County of Weld Site Name: Weld County Repair Garage Site Address: 1399 N. 17th Avenue City: I Greeley I State: 1 CO I ZIP: .I 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. V Invoice # Invoice Date Amount Paid Invoice # Invoice Date Amount Paid 7199 1/17/18 $32,214.46 7200 1/17/18 $222.14 • 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 material fact with the intent to defraud. Signature: Date: 3 -� , _hp Printed Name: I ohn I Prindpal I Phone #: 303.825.8117 D. Drafts I Title: Company (Payee) Name: I Palmetto Environmental Group Company (Payee) Mailing Address: 14995 York St City: Denver I State: I CO I ZIP: 180216 .I Notary Public Certification Subscribed and sworn to before me in the county this Z14% day of treCiet / of 0ewry- , State of 64- , t / , 2O/ErMICHAEL R. CRITCHLEY PUBLIC Notary Public Printed Signature: My Commission Expires: Name: /m r )u G pyv 46 j1 I.e NOTARY riiM / Noway 03 20114071422 2/ /ova.O MY COMMISSION EXPIRES FEBRUARY 1, (303) 825-8117 O fax (303) 534-5049 O 4995 York Street o Denver, Colorado 80216 DAKOTA DRILLING, INC. 1380 UMATILLA STREET DENVER, COLORADO 80204 (303) 893-2810 Invoice Date: 7/17/2017 Bill To: Palmetto Environmental Group LLC 4995 York Street Denver, CO 80216 Attn. Accounts Payable Department Invoice #: Client PO #: Driller: Job Location: 00170587 1399 Glen A Melonas 1399 N. 17th Ave., Greeley CO, Weld Cty. QUANTITY - . ITEM NO: DESCRIPTION I PRICE AMOUNT 7 500 Drlg Fees - SSA 6 boc;,,,S D.S. 1 d -1'p - d ,st.0f-X 1a -C.1- 14S $135.00 $945.00 REMITTANCE ADDRESS 1380 Umatilla Street, Denver CO 80204 Federal Tax ID #: 84-1236770 Thank you for your Business!!! Billing Questions: Ph. 303-893-2811 Fx. 303-893-2808 TERMS - NET 45 SubTotal Amount Applied $945.00 $0.00 AMOUNT DUE $945.00 PNoCI;C; PoIH'?D IICS.' 06 -ID _ _ ;60248902001 60248902002' ,60248902003, ",6024890200. 60248902005' • 460248902006'.' .,PaseAnaiyticai':Services, L_4c 9608.Loiret Blvd:: - ieriexa KS• 86219 Phone: (913)599-_5665 -" 'ww,w.pacelabs'com oid I'6 Johntoraffs Palmetto; Environmental• 4995 YorkStreet Denver C.O <80216 _ _::303-825,8417 x107 ", Inyoice`Nurntier: 1.7.6003.10:1;9_ Date @7/27/2017' Total Amount Due: _$1,420:00' Please'Remrt`;;To . Pace: Analytical 5ervices P O Box 684056 Chicago IL 6,069&405.6'. • Client Number/Client. ID , Purchase Older No Pace Project : Mgr Mims' ,Page. "fr ' --s-.�- 160-506268,al Pmetto _ _'e •— _.. Heathers Wilson _• r k, Net 30 Days • 1 - • elienttprojecfr1399'N•1z7THAVE , _ti +Pace'FrojectNO:"60248902 Report `gent To .John Drafts Palmetto Environmental• +Comments::_• • •Cllent5N me , P,almetto. •SamplerRece:ved 7/18/2017_ Quantityilinit Description '5'Ea 801:'5: Ethylene'Glycol 1 ;Ea 8615FEthylerierGlycol 1._: 5 Ea 8260iMSVV5035A Prep 1 Ea• 8260+Volatile:Organics by GCIMS' r; x 1.,Ea 8270 MS$V PAH by, SIM 5 Ea, 9071.,Chl & Grease -1f Ea • HEM;;-�Oiland,Grease = IAL'""YTICAL�C.HARGES� ' = - Method Matrix Solid Water: 'EPA 8260 - •Solid r -0,&_503-00/i360', Water• IEPA 8270 by SIM`, Solid: + IEPA 90717, •Soli''; :EPA 1664A .'. Water,„ Price Total $60 00 - .: $6or0Q,. •$60 00. $10000!! s50Ut00 $10Uf0o $1'0000 $1"OOi00r $100x00 $60`00. - $300Y00 $60"00' • $60c00" • haiytisairsototal• $1 43Q O0 : • Samples Received:fo•r,analysis:, ,• • ClientSample ID` PSB=02, 6 1,91 1' • pSli 03 @ 10';',1 24 PSB-04 45'1'0.1.2 • PSB-05,4•1,16 12 Total Numt≥er of.Cha`rges 19 ;_ ' ° - 7/11/4017 c7/1'8/2017 7/1:8/2017'' 7/18/201:2: ; 7r/18/20:17- 7/,1,8/20:17c _'TotalkInvoice1Amount $1;420300 ... Page fro , : `. t'1:5°Y% MONTHLY`FINANGE.CH/ARGE/ASSESSED AFTER 30'DA• YS;`OR TERMS OF CONTRACT'_ ' '.PLEASE'REFERENCE THE INVOICENUMBER ON ALL REMFFTtANCE ADVICE - - - :AN'EQUAL OPPORTUNITY EMPLOYER .- 'Please complete and' etum: Copt of>invo,ce with your peyment. 'INVOICE TOTAL Amounf Paid:' • Check No Customer No: 60.54 268 nvoicecNo.,1r'760031,019 Sold i1 F� John+Drafts PalEnwr0rlmental 4metto 995 York Street ,-'' �Denve k,GO"'8.021.'6-= 303S825-81s1i7.x1`07 Y _ Client Number/ClientID Purchase Order ..' _ No Pace Project Mgr 1 Tanner Page __-...,_160506268/Palrrmetto _, - 'i y JileatherWison +.:Net3ODays t t 1 A = CIle»t Naine;Pahnettiii ` Sample Received'9/28/2O 7; 9/28/2Q:17 t8' 59:oo 9/28/201748 50:Q0 9/28/20r17r8 50 00 9/28/20117 8 50:oo 9/28/20j17+8 50.00' _ •9/28/20.1i7 8 50 00' X9/28/20;1.7 8 50 00 9/28/201e'r0 50 OO If you Have anyqueshons, Olease'contact Heather?Wilson atPace 'Phone 1,(913)563 1407 Emarl hea ria:6wilson@pecelep:e1om 'lea'sercomplete andiretum copysoftmvorcetwtthsyourpayment i,iount*F3 • heck N6: '•176003558 Total; $150 00 $r1 200(00=' , $fi5 00 $520r00p �Arialytical Subtotal t$ir7.•2000;: DAKOTA DRILLING, INC. 1380 UMATILLA STREET DENVER, COLORADO 80204 (303) 893-2810 Invoice Date: 11/28/2017 Bill To: Palmetto Environmental Group LLC 4995 York Street Denver, CO 80216 Attn. Accounts Payable Department Invoice #: 00171002 Client PO #: 1399 Driller: Jose S. Casillas Job Location: 1399 N. 17th St., Greeley CO, Weld Cty. QUANTITY ITEM NO. DESCRIPTION PRICE 'AMOUNT 1 581 Potholing and/or Asphalt/Concrete Cores (12") $110.00 $110.00 66 525 Support Truck Mileage . $2.50$165.00 — 210 505 Drlg Fees - HSA' / $18..00 $3,780.00-- 209 570 Well Construction - 2" $18.00 $3,762.00-- 2 517 Decon ' $100.00 $200:00 — 264 520 Rig Mobe-Demobe' $4.00 $1,056.00-- 9 340 . 55 Gal Drum DOT 17H ' $60.00 $540.00 0-41)\ REMITTANCE ADDRESS 1380 Umatilla Street, Denver CO 80204 Federal Tax ID #: 84-1236770 Thank you for your Business!!! Billing Questions: Ph. 303-893-2811 Fx. 303-893-2808 Net 31 SubTotal bTota l I Amount Applied $9,613.00 $0.00 AMOUNT DUE $9,613.00 Js;,.nrHCCMP41t'i-1 0j'.0-/1: ENVP.0P: 5, (/'2eAnaIYtica www.pacelabs.com Sold To: John Drafts Palmetto Environmental 4995 York Street Denver, CO 80216 303-825-8117 x107 INVOICE Pace Analytical Services, LLC 9608 Loiret Blvd. Lenexa, KS 66219 Phone: (913)599-5665 Invoice Number: 1760040727 Date: 12/19/2017 Total Amount Due: $2,155.00 Please Remit To: Pace Analytical Services, LLC P.O. Box 684056 Chicago, IL 60695-4056 ;Client Numbit'kOant4lD ' M = :::*00:8 e,plierMP , . PaetPivjectMgr ::.,,... ,f • >Temrs,-- Net 30 Days aPeSe - - ... 60-506268 / Palmetto ._ Heather Wilson 1 Client Project 1399 N 17TH AVE Pace Project No: 60259363 Report Sent To: John Drafts, Palmetto Environmental Comments: Client Name: Palmetto Sample Received: 12/2/2017 Quantity Unit Description 7 Ea, 8260 VOCs 1 Ea 8270 MSSV PAH by SIM 7 Ea 9071 Oil & Grease 7 Ea TPH-DRO ANALYTICAL CHARGES Method Matrix Solid EPA 8270 by SIM Solid EPA 9071 Solid EPA 8015B Solid Price Total $150.00 $1.050.00' $160.00 $160.00 t $65.00 $455.004- $70.00 $490.00.1. Analytical Subtotal $2,155.00 Samples Received for analysis: Lab ID Client Sample ID Total Number of Charges 22 Received 60259363001 MW -01 @ 9'-10.5' 60259363002' MW -02 @ 9'-10.5' 60259363003 MW -03 @ 9'-10.5' 60259363004 MW -04 ® 8'-9.5' 60259363005 MW -05 ® 8'-9.5' 60259363006 MW -06 8'-9.5' 60259363007 MW -07 @ 9.25'-11' 12/2/2017 3:00:00 12/2/2017 3:00:00 12/2/2017 3:00:00 12/2/2017 3:00:00 12/2/2017 3:00:00 12/2/2017 3:00:00 12/2/2017 3:00:00 If you have any questions, please contact Heather Wl/son at Pace. Phone: 1(913)563-1407 Email: heather.wilson@pacelabs.com Total Invoice Amount $2,155.00 Page 1of1 "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 $2,155.00. Amount Paid: $ Check No: Customer No: 60-506268 Invoice No: 1760040727 e WASTE MANAGEMENT HHow Contact 'Us. To setupy ur arire profile, sign up for wiles statements, nenageyour account, view friday sdiedules, pay y our invoice or schedule a pidalp INVOICE Customer ID: Customer Name: Service Period: Invoice Date: Invoice Number. ya rte' ''�� • $ x- g:;�� - i�,ar� -,,Your. Payment Payme xlu.a If fu8 payment of the invoiced amount is not received within your contractual terms, you may be charged a n o>diy late large of 2.5% of the unpaid amount, with a rririrnum muddy d>age of $5. or such late Berge allowed under applicable law, regulation or contract ''"°Payments, , (4,288.64) Adjustments 0.00 Page 1 of 2 1-75337-74009 PALMETTO ENVIRONMENTAL 11/01/17-11/30/17 12/01/2017 0022904-0308-4 Your Total -Due If payment is received after 12/30/2017: $ 55.00 See Reverse for Important Messages Current Charges 50.00 Total"Due 4 50.00 Details for Service Location: Palmetto Environmental, 4995 York Street, Denver Co 80216-2245 Customer ID: 1-75337-74009 iDe iption"j vT' W. • --.,. g` t�°�`a." 1:::x.3 ' f. "': y 4,-,-,:c`-',Vi; " ?). S Tic e-,..2 Qua >tii M awie r" ,-"s ;r _•�'TA�smo nt of Vehicle #: none 11/09/17 1671424 0.00 Profile processing fee 1.00 ECH 50.00 50.00 Profile # 126080co 0.00. Generator weld county (1399 n 17th eve) 0.00 Ticket Total 50.00 Total Current Charges ₹ ,^ 50.00. wwsra rnwnnormr� WASTE MANAGEMENT PO BOX 43350 PHOENIX, AZ 85080 (877) 273-6727 (970) 686-2800 TICKET COPIES 0002721 NX 0\V Please detach and send the lowerportion with payment .- - - (no cash or staples) Invoice Date 1 2/01/201 7 Payment Terms Total Due by 12/30/2017 If Received after 12/30/2017 Invoice Number 0022904-0308-4 Total Due $ 50.00 $ 55.00 Customer ID (Include with your payment) 1-75337-74009 Amount 0308000017533774009000229040000000500000000005000 6 7335 {03-P02723-11 10306112 PALMETTO ENVIRONMENTAL 4995 YORK STREET DENVER CO 80216-2245 THINK GREEN! Ii1111111111'lIIIII'I"'Iii11111111"1i1'rll111111111111111r1'Iii WASTE MANAGEMENT- NORTH WELD LANDFILL PO BOX 78251 PHOENIX, AZ 85062-8251 hfitted on 308-0010039-0308-3 aceAnalytical n www.pacelabs.com Sold To: John Drafts Palmetto Environmental 4995 York Street Denver, CO 80216 303-825-8117 x107 INVOICE Pace Analytical Services. LLC 9608 Loiret Blvd. Lenexa. KS 66219 Phone: (913)599-5665 Invoice Number: 1760041202 Date: 12/27/2017 Total Amount Due: $2,120.00 Please Remit To: Pace Analytical Services, LLC P.O. Box 684056 Chicago, IL 60695-4056 .:6 dfentfi unite bei�tuoirt`1D1' 3: 1Puiclisse tr eilii, 1 r = Pa'ee'irigclMgr as ' Te.L2._ ' - L:Paf e- i 1 - 60-506268 / Palmetto Heather Wilson Net 30'Days Client Project 1399 N' 17th Ave Pace Project No: 60259928 Report Sent To: John Drafts. Palmetto Environmental Comments: Client Name: Palmetto Sample Received:12/9/2017 Quantity Unit Description ANALYTICAL CHARGES Method Matrix Price Total 7 Ea 8015 Ethylene Glycol 7 Ea 8260 Volatile Organics by GC/MS 3 Ea. 9071 Oil & Grease 7 Ea HEM. Oland Grease Water EPA 50306/8260 Water EPA 9071 Solid EPA 1664A Water $60.00 $420.00 $150.00 $1,050.00 $65.00 $195.00 $65.00 $455.00 Analytical Subtotal $2,120.00 Samples Received for analysis: Lab ID Total Number of Charges 24 Client Sample ID Received 60259928001 MW -01 © 28' 60259928002 MW -02 @ 17' 60259928003 MW -04 ® 20' 60259928004 MW -01 60259928005 MW -02 60259928006 MW -03 60259928007 MW -04 60259928008 MW -OS 60259928009 MW -06 60259928010 MW -07 12/9/2017 12/9/2017 12/9/2017 1219/2017 12/9/2017 12/9/2017 12/9/2017 12/9/2017 12/9/2017 12/9/2017 Total Invoice Amount $2,120.00 Page 1 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 .Please complete and return copy of invoice with your payment. INVOICE TOTAL $2,120.00 Amount. Paid: $ Chedi No: Customer No: 60-506268 Invoice No: 1760041202 Palmetto Environmental Group LLC 4995 York Street Denver, CO 80216 Voice: (303) 825-8117 Fax: (303) 534-5049 Weld County 1105 H Street PO Box 758 Greeley, CO 80632 Weld County Garage 1399 N 17th Ave. Greeley, CO 80632 Invoice Number: 7199 Invoice Date: Jan 17, 2018 Page: 1 'ioi tomerl0 CustomerROc " Payment}erms .! Weld ; Net 20 Days s .•.-.,..friV�' pP_ [� .•rt: .- 'M 4.11,430-6.1iode_ s k'4• ! ;Ship"Date ::';'*-61.6-r.'-(7---- 1 . a .„ „.atB Mail Delivery 12/31/17 2/6/18 .,- `Qyairtitjr E -7,: . y I- .. - ` 4 ;.1:_„- ; D`escrip .0ii x hUnit Pricer ;Amont - l 1.00 Environ Environmental Billing Fees, See attached sheet for detail. 32,214.46 32,214.46 Check/Credit Memo No: Subtotal 32,214.46 Sales Tax Total Invoice Amount 32,214.46 Payment/Credit Applied TOTAL, >• �' .,: � � s _..• ,. _ .- r _ � - t � C N t. - 32,214;.48 - , ti Palmetto Environmental Group RCR for Event 12728 Dates 070617-123117 REP 1/1 Client Name: Billing Address: City, State, Zip: Site Name: Site Address: City, State, Zip: Weld County Government 1105 H Street PO Box 758 Greeley, Co 80632 • Weld County Garage 1399 N 17th Street Greeley, Co 80632 12728 Start Date: 26 7/6/2017 End Date: 12/31/2017 CONSULTANT INVOICE t SUBCONTRACTOR INVOICE 8 SUBCONTRACTOR NAME EMPLOYEE NAME DATE OF WORK RASE OF WORK CODE jTASK OR LABOR CODE (TLC) TASK DESCRIPTIO N • t - A -.3 t j I4• cc n 7 i 0 7199 Michael Critchley 7/12/2017 28 . k 5.4 Drill prep 196362 hour 1.00 $97.00 $97.00 $97.00 '7199 John Drafts 7/12/2017 28 k. 5.3 Drill prep/site visit IR5395 how 4.50 $117.00 $526.50 $526.50 7199 7/12/2017 26 k 9.4 mileage miles 116.00 $0.54 $62.64 $62.64 7199 Michael Crltchtey -7/13/2017 28 k ' 5.4' Drill prep IR6362 how 1.00 $97.00 $97.00 .597.00 7199 Mkhael Critchley 7/14/2017 28 k. 5.4 Drill prep IR6362 hour 0.50 $97.00 $48.50 548.50 7199 John Drafts 7/14/2017 2B k 5.3 Drill prep 165395 hour 1.00 $117.00 $117.00 $117.00 7199 Mkhael Critchky 7/17/2017 28 k. 5.4 Drill support IR6362 hour 1.00 $97.00 597.00 $97.00 7199 Bryce Goldade 7/17/2017 28 k 55 Drift geologist hour 10.00 $83.00 . $830.00 $830.00 7199 7/17/2017 28 k. 9.4 mileage miles 127.00 $0.54. $68.58 568.58 7199 170587 Dakota 7/17/2017 28 k 2.1 drilling feet• 125.00 57.56 5945.00 $141.75 51,086.75 7199 1760031019 Pace 7/27/2018 2B k 6.6 oil and grease samples '5.00 . $60.00 $300.00 $45.00 $345.00 7199 1760031019 Pace 7/27/2018 28 k. 6.11 VOC samples 5.00 $100.00 $500.00 $75.00 $575.00 7199 1760031019 Pace 7/27/2018 28 k 6.30 PANS samples 1.00 5100.00 $100.00 $15.00 $115.00 7199 1760031019 Pace 7/27/2018 28 k ' 6.99 &kcal samples 5.00 560.00 $300.00 $45.00 $345.00 7199 1760031019 Pace 7/27/2018 28 y. 6.6 o8 and grease samples 1.00 560.00 $60.00 $9.00 $69.00 7199 1760031019 Pace 7/27/2018 26 g. 6.11 V0C samples 1.00 $100.00 $100.00 $15.00 $115.00 7199 1760031019 Pero 7/27/2018 2B g.. 6.99 glycol samples 100 $60.00 $60.00 $9.00 $69.00 7199 Bryce Goldade 7/17/2017 28 g. 4.1 sample well. wells 1.00 $100.00 $100..00 $100.00 7199 Mkhsel Critchley " 7/28/2017 28 i. 5.3 Data review 196362" hours 2.50 $117.00 $292.50 $292.50 7199 , Bryce Goldade 8/14/2017 28 i. 5.7 drafting figures hours 4.50 $58.00 $261.00 $261.00 7199 Bryce Gelded* " 8/15/2017 28 i. 5.5 SCR hours 5.50 $83.00 $456.50 $456.50 7199 fared king 8/16/2017 28 1 5.7 drafting figures. hours 1.00 $58.00 $58.00 558.00 7199 Bryce Goldade 8/16/2017 28 i. 5.5. SCR hours 5.00 $83.00 $415.00 $415.00 7199 ' Bryce added* 8/17/2017 28 1. 5.5 SCR hours. 4.00 $83.00 $332.00 $332.00 7199 Bryce Goldade 8)18/2017 2B i. 5.5 SCR hours. 5.00 583.00 $415.00 5415.00 7199 tared king" 8/22/2017 28 j. 5.7 drafting figures hours 1.00 $58.00 $58.00 $58.00 7199 Iohn Drafts 9/5/2017 2B I, 5.3 SCR review IR 5395 hews 1.00 $117.00 $117.00 $117.00 7199 ' Bryce Goldade 9/5/2017 2B i. 5.5 SCR hours 1,50 583.00 $124.50 $124.50 7199 Katie Drafts 9/5/2017 2B i• 5.9 Compile and submit SCR hours 2.50 547.00 $117.50 $117.50 7199 tyler kalous ' 9/25/2017, 2B , k 5.6 waste line assessment hours 9.50 $65.00 $617.50 $617.50 7199 brianformanek . 9/25/2017 28 k 5.5 waste line assessment hours 9.50 583.00 $788.50 .$788.50 7199 . tyler tabus 9/25/2017 28 - k 5.6, waste line assessment hours 3.50 565.00 5227.50 5227.50 7199 brlenformanek 9/25/2017 28 k 5.5 waste line assessment hours 3.00 $83.00 $249.00 5249.00 7199 9/25/2017 28 k. 9.4' mileage miles ' 128.00 $0.54 $69.12 $69.12 7199 1760035589 Pace •10/5/2017 2B k. 6.6 oil and grease samples 8.00 565.00 5520.00 $78.00 $598.00 7199 1760035589 Pace 10/5/2017 2B k 6.11 V0C samples 8.00 $150.00 $1,200.00 $180.00 51,380.00 7199 Jared king 10/23/2017 28 k. . 5.5 waste profile hours 0.50 $88.00 .$44.00 $44.00 7199 Jul Jones ' 10/24/2017 28 k • 5.5 waste line yardage calm hours 4.00 $88.00 $352.00 ( $352.00 7199 John Drafts ' 11/27/2017 28 k '_5.3 setup drilling/well locate 165395 hours. 2.50 $117.00 529250 $292.50 Palmetto Environmental'Group RCR (or Event 12728 Dates 070617-123117 REP'# Client Name: Billing Address: .City, State, Zip: Site Name: Site Address: City, State, Z p: Weld County Government 1105 H Street PO Box 758 Greeley, Co 80632 Weld County Garage 1399 N 17th Street • Greeley, Co 80632 Start Date: 26 7/6/2017 End Date: 12/31/2017 CONSULTANT INVOICE P SUBCONTRACTOR - INVOICE a SUBCONTRACTOR NAME EMPLOYEE NAME DATE OF WORK PHASE OF WORK CODE f C) HTMTY CODE (AO O U ix TASK DESCRIPTION • t . ) . .. 8 g C k- O i a. le i .. 7199 Bryce Goldade 11/27/2017 28 • k. 5.5 drill setup/notice of intent hours 3.50 583.00 5290.50 $290.50 7199 Michael Cncchky 11/28/2017 28 It. 5.4 Drill support 166362 hours 1.00 597.00 597.00 $97.00 7199 Bryca Goidade 11/28/2017 28 k. 5:5 travel and drill hours 10.50 $83.00 $871.50 $871.50 7199 Bryce Goldade 11/29/2017 28 k 5.5 travel and drill. hours 9.25 583,00 $767.75 $767.75 7199 171002 Dakota 11/27-28/17 28 k. 2.1 drilling feet 210.00 $18.00 53,780.00 5567.00 $4,947.00 7199 171002 Dakota 11/27-28/17 28 k. 2.2 mobllltatlon miles 264.00 $4.00 51,056.00 $158.40 $1,214.40 7199 171002 Dakota 11/27-28/17 2B k 2.4 well construction feet 209.00 $18.00 $3,762.00 $564.30 $4,326.30 7199 171002 Dakota 11/27-28/17 26 k. 2.8 decon day 2.00 $100.00 $200.00 530.00 5230.00 7199 171002 Dakota 11/27-28/17 28 k 8.14. pothole hours 1.00 $110.00 $110.00 $16.50 $126.50 7199 171002 Dakota 11/27-28/17 28 k 8.15 pothole mileage miles 66.00 5250. 5165.00 $24.75 5189.75 7199 171002 Dakota 11/27-28/17 2B k 14.4 drums each 9.00 $55.00 $495.00 $74.25 $569.25 7199 11/27-28/17 26 k. 9.4 mileage miles 256.00 $0.54 . $138.24 $138.24 7199 11/27.28/17 28 k. 12.1 mist field supplies days 1:00 512.00 $12.00 $12.00 7199 11/27.28/17 28 k. 12.4 PID days 1.00 575.00 575.00 575.00 7199 11/27.28/17 28 k 13.15 hard auger days 1.00 $25.00 525.00 $25.00 7199 11/28/2017 28 k. 13.17 survey eoulpment days 1.00 $45.00 $45.00 $45.00 7199 11/28/2017 2B k. 13.19 traffic control days 1.00 $25.00 $25.00 $25.00 7199 •1760040727 Pace 12/19/2017 28. k. 6.6 oil and grease samples 7.00 $65.00 $455.00 $68.25 $523.25 7199 1760040727 Pan 12/19/2017 28 k. 6.11 V0C samples 7.00 $150.00 $1,050.00 5157.50 51,207.50 7199 1760040727 Pace 12/19/2017 26 k. 6.30 PANS samples .. 1.00 $160.00 $160.00 $24.00 $184.00 7199 1760040727 Pace 12/19/2017 28 k 6.3 TEPH samples 7.00 $70.00 $490.00 573.50 $563.50 7199 0022904-0303-4 waste management 12/1/2017 2B k: 11.99 waste profde each 1.00 550.00 550.00 57.50 557.50 7199 John Drafts 12/4/2017 26 5.3 project review for sampling 155395 hours .0.75 5117.00 $87.75 $87.75 7199 John Drafts12/6/2017 2B ,9. q. 5.3 sample discussions and prep IR5395 hours 1.25 $117.00 $146.25 $146.25 7199 Bryce Goldade 12/6/2017 28 _ 9. 5.6 sample discussions and prep, hours 1.50 565.00 $97.50 $97.50 7199 Bryce Goldade ' 12/7/2017 28 ,j. 5.6 travel and develop wells hours 8.00 $65.00 $520.00 5520.00 7199 • John Drafts 12/7/2017 28 g. 5.3 sample and development support 165395 hours 1.00 5117.00 5117.00 $117.00 7199 12/7/2017 28 9. 4.1 wells samples wells 7.00 $100.00 $700.00 $700.00 7199 12/7/2017 28 9. 9.4 mileage miles 129.00 $0.54 $69.66 569.66 7199 Bryce Goldade 12/8/2017 2B 5.6 package samples proof coo hours 1.00 565.00 $65.00 $65.00 7199 John Drafts 12/8/2017 28 .� 5. 5.3 chain review package out 185395 hours 0.50 $117.00 $58.50 $58.50 7199 1760041202 Pace 12/27/2017 2B 9. 6.6 on and grease samples 7.00 $65.00 $455.00 $68.02 . $523.02 7199 1760041202 Pau 12/27/2017 26 9. 6.11 VOC samples 7.00 5150.00 51,050.00 $157.50 51,20750 7199 1760041202 Pace 12/27/2017 28 ,$. 6.99 glycol samples 7.00 560.00 5420.00 563.00 .5483.00 7199 1760041202 Pau 12/27/2017 26 k. 6.6 oil and grease samples 3.00 565.00 5195.00 $29.25 $224.25 7200 4 z. 1$ Labor l$22,214.46j.011'5222.141 hours 1.00 5222.14 5222.14 $222.14 Palmetto Environmental Group LLC 4995 York Street Denver, CO 80216 Voice: (303) 825-8117 Fax: (303) 534-5049 '7,BiltTo: Weld County Government 1105 H Street PO Box 758 Greeley, CO 80632 Invoice Number: 7200 Invoice Date: Jan 17, 2018 Page: 1 Weld County Garage 1399 N 17th Ave. Greeley, CO 80632 ",�Custoiner'ID ' F ,.._, q;..+e' eb � '� �Ct tioirserPOy .a . , .-�:....---z,-_,,,......, r.+,v rp_ . .. .....i .. PaymentTert s _.. _..- ..v„...,-+H',,,r Weld -.... I I Net 20 Days - .r il u Shtpp(i g`Mett'o.. :.I. __ ' ShiiiDatex ,r r r i- e,i- a -Dale, Mail Delivery 12/31/17 2/6/18 ;Quartity > ,,,,,,ti.,,,...:;,..,„...z. Y M Item ' -.1,:":"' ,.tDescrtptlai ' r:''' t_llnit Price r Aount` 1.00 AppFee Reimbursement Application Preparation 222.14 222.14 Check/Credd Memo No: Subtotal 222.14 Sales Tax Total Invoice Amount 222.14 Payment/Credd Applied � ��' a _ .' TOTAL - - 1 ,.. .r _ , '�' �..... -- _ -. �' r _.....424,- s 1q- Client Name: Billing Address: City, State, Zip: Site Name: Site Address: City, State, Zip: Event #: Weld County Government 1105 H Street PO Box 758 Greeley, Co 80632 Weld County Garage 1399 N 17th Ave Greeley, Co 80832 12728 Palmetto Environmental Group LLC Consultant Listing #: C-335 Invoice$: 71c0 Invoice date: , hits Job#: #WC17th Page: ( of 0 Start Date: 7/6/2017 End Date: 12/31/2017 PHASE OF WORK CODE [PWC) ACTMTY CODE (AC) TASK OR LABOR CODE (TLC) z 0 F a r- F E m QUANTITY UNIT RATE REQUESTED IMBURSEMENT SUBTOTAL REQUESTED EIMBURSEMENT MARKUP REQUESTED REIMBURSEMENT SUBTOTAL BY ACTIVITY AND TASK GROUP TOTAL REQUESTED REIMBURSEMENT a� . Rai7tiiti,rserna t�Appl, etioRreparetionL� .. _.:::._ 4.,'&-='.--,4',.i•_ - .. ._.__,.. }. _ _.........__.....v.,.. -._. __ _ ,_ ...._:.� Z. Labor . •. 4 ' z. r 15 Labor ($22214.46(.01)=$222.14) • hours ' 1.00/ $222.14 $222.14 L_....------- $222.14 TLC -15 group -Labor Subtotal $222.14 Activity Code z. Subtotal $222.14 TOTAL 4Z COSTS: $222.14 PHASE OF WORK CODE AND DESCRIPTION ' EFS TOTAL COSTS 4 'Reimbursement Application Preparation $ 222.14 GRAND TOTAL $ 222.14 Hello