Backup Documents 05/08/2018 Item #16C 1 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP c
1
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE
Print on pink paper. Attach to original document. The completed routing slip and original documents are to be forwarded to the County Attorney Office
at the time the item is placed on the agenda. All completed routing slips and original documents must be received in the County Attorney Office no later
than Monday preceding the Board meeting.
**NEW** ROUTING SLIP
Complete routing lines#1 through#2 as appropriate for additional signatures,dates,and/or information needed. If the document is already complete with the
exception of the Chairman's signature,draw a line through routinglines#1 through#2,complete the checklist,and forward to the County Attorney Office.
Route to Addressee(s) (List in routing order) Office Initials Date
1.
2.
3. County Attorney Office County Attorney Office JAK 5/8/18
4. BCC Office Board of County AS 104)
Commissioners Jvk 6.4
5. Minutes and Records Clerk of Court's Office
PRIMARY CONTACT INFORMATION
Normally the primary contact is the person who created/prepared the Executive Summary. Primary contact information is needed in the event one of the
addressees above,may need to contact staff for additional or missing information.
Name of Primary Staff Phil Snyderburn/Solid and Hazardous Contact Information 239-252-0920
Contact/Department Waste Management Division
Agenda Date Item was May 8,2018 Agenda Item Number 16C1
Approved by the BCC
Type of Document Florida Department of Environmental Number of Original 1
Attached Protection's offer to pay for and have their Documents Attached
appointed contractor investigate a historic fuel
discharge at the Old Fuel Island site at the -
Government Complex. thy
PO number or account
number if document is
to be recorded
INSTRUCTIONS & CHECKLIST
Initial the Yes column or mark"N/A"in the Not Applicable column,whichever is Yes N/A(Not
appropriate. (Initial) Applicable)
1. Does the document require the chairman's original signature Original w/Witness JAK
2. Does the document need to be sent to another agency for additional signatures? If yes, JAK
provide the Contact Information(Name;Agency;Address;Phone)on an attached sheet.
3. Original document has been signed/initialed for legal sufficiency. (All documents to be JAK
signed by the Chairman,with the exception of most letters,must be reviewed and signed
by the Office of the County Attorney.
4. All handwritten strike-through and revisions have been initialed by the County Attorney's JAK
Office and all other parties except the BCC Chairman and the Clerk to the Board
5. The Chairman's signature line date has been entered as the date of BCC approval of the JAK
document or the final negotiated contract date whichever is applicable.
6. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's JAK
signature and initials are required.
7. In most cases(some contracts are an exception),the original document and this routing slip N/A
should be provided to the County Attorney Office at the time the item is input into SIRE.
Some documents are time sensitive and require forwarding to Tallahassee within a certain
time frame or the BCC's actions are nullified. Be aware of your deadlines!
8. The document was approved by the BCC on 5/8/2018 and all changes made during JAK
the meeting have been incorporated in the attached document. The County
Attorney's Office has reviewed the changes,if applicable.
9. Initials of attorney verifying that the attached document is the version approved by the w'fr't
BCC,all changes directed by the BCC have been made,and the document is ready for the
Chairman's signature. ____
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MEMORANDUM
Date: June 6, 2018
To: Phil Snyderburn, Principal Environmental Specialist,
Hazardous Waste Management
From: Martha Vergara, Deputy Clerk
Board's Minutes & Records Department
Re: FEDP Contractor for the investigation of a historic fuel
discharge at the Old Fuel Island site at the Government
Complex
Attached for your records is a scanned copy of the original document referenced above,
(Item #16C1) approved by the Board of County Commissioners on Tuesday, May 8,
2018.
The Minutes and Record's Department will hold the original in the Board's
Official Records.
If you have any questions, please contact me at 252-7240.
Thank you.
1 6 C
oapott Florida Department of Rick Scott
tot)
Governor
0 Environmental Protection
Carlos Lopez-Cantera
, •
Bob Martinez Center Lt. Governor
2600 Blair Stone Road
00 0, Tallahassee, Florida 32399-2400 Jonathan P. Steverson
t'Ott Secretary
PETROLEUM RESTORATION PROGRAM
LOW-SCORED SITE INITIATIVE APPLICATION&CONTRACTOR SELECTION SHEET
The Low-Scored Site Initiative (LSSI) Applicant responsible for the eligible petroleum discharge(s)may use this 3-page
application to select a qualified Contractor pursuant to Chapter 62-772,F.A.C.,Procurement Procedures for the Department
of Environmental Protection's (FDEP) Petroleum Restoration Program (PRP) to implement a LSSI assessment and/or
remediation at the site referenced below, provided that the PRP determines that such activities are appropriate. If the
applicant is not the real property owner,a copy of the responsible party agreement or other documentation demonstrating
the Applicant's responsible party status must be submitted with this application. Completed forms must be accompanied
by a cost proposal and should be sent to the letterhead address,Mail Station 4580,Attention: Rob Perlowski. If you would
like to discuss this with an FDEP representative,please call Graham Witt at 850-222-6446 x260,Chris Bayliss at 850-245-
8866,or Joel Johnson at 850-877-1133 x3701.
Part 1. FDEP Facility Name and Identification#(required)
a, Name of Facility/Site: Collier Cnty-Old Fuel Island
b. FDEP Facility Identification#: 11/9103613
Part 2. Real Property Identification and Current Ownership Verification(required): This information must match that listed
in the applicable County Property Appraiser's Office or provide updated information by submitting a copy of the latest deed recorded
with the County records.
a. Real Property Street Address of Record: 3301 Tamlami Tr, Naples, FL
b. Parcel#or Property Identification#of Record: 00389600008
c. Legal Property Description of Record(may attach legible copy):
Please see attached
d. Name of Current Real Property Owner(s)of Record: Collier County
Mailing Address(required): 3335 Tamiarni Tr E, Ste 101, Naples, FL 34112
Telephone#(required):( )
E-Mail Address:
e. If There is Any Reason Why the Property Appraiser's Records May Not Be Accurate,Provide an Explanation and Attach
Documentation:
N/A
REMAINDER OF THIS PAGE IS LEFT BLANK INTENTIONALLY
9/1/2016 Page I 1
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Part 3. Entity Applying for LSSI(required)
a. Name of the Entity Applying for LSSI(if business,include name/title of representative):
Collier County-
b. (Check One): X Current Real Property Owner Or Other Responsible Party
c. Contact Information of the LSSI Applicant:
Mailing Address(required): 3335 Tamiaml Tr E, Ste 101, Naples, FL 34112
Telephone#(required):
E-Mail Address:
Part 4. LSSI Contractor Selection(required): Please check one of the options below. You may request that the FDEP select the
cleanup contractor or you may select a specific cleanup contractor.
Who is selecting the contractor? X Current Real Property Owner Or Other Responsible Party
Select only one of the contractor ontions listed below:
l A PRP Agency Term Contractor: Co,Name: MAS Environmental, LLC DFP Contractor ID#: 1338
El A qualified PRP Contractor,provided that pricing levels&conditions can be negotiated on the best terms to the DEP:
Co.Name: DEP Contractor IDI:
Rep.Name&Title:
Rep.Phone#&E-mail:
Li The FDEP will select qualified PRP Contractor through an informal request for quote in accordance with Rule 60A-
L002,F.A.C.
REMAINDER OF THIS PAGE IS LEFT BLANK INTENTIONALIN
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9/1/2016 Page 12
1' 6 C I.
Part 5. Real Property Owner Affidavit(required): This certificate must be completed and signed by the current real
property owner in the presence of a witness if participating in the Petroleum Restoration Program's Low-Scored Site
Initiative. No work will be authorized on your site until this sheet is accepted by the Department. The contractor selection
option chosen above cannot be changed once this LSSI Application and Contractor Selection Sheet has been approved by
the PRP unless poor performance by the contractor is affirmatively demonstrated, The name in Part 5.a. must match that
1 isted in Part 2.d.C
a. I, O I i ( r1(' C.3 c1 to hereby certify that:
(Current Real Properly Owiwe
b. If 1 selected a contractor,that the contractor selected in Part 4 of this form is authorized to perform work in the
Petroleum Restoration Program's Low-Scored Site Initiative on the real property identified in Parts I and 2 of this
form.
c. That the contractor I selected, if applicable,has not offered any remuneration in cash or in kind directly or indirectly
in exchange for selecting them as my contractor,
d. If applicable,that I have not solicited or accepted remuneration in cash or in kind directly or indirectly from the
contractor in exchange for selecting them as my contractor,
e, That I acknowledge that soliciting or accepting remuneration in cash or in kind directly or indirectly in exchange',for
selection of a contractor is prohibited pursuant to Section 376.3071(6),F.S.,and may result in the loss of eligibility
for State funded petroleum contamination cleanup assistance at this site.
f. That I have read and understand the site closure endpoints and the contractor selection options available under LSSI
and that I agree to accept a LSSI No Further Action closure if the criteria specified in paragraph 376.3071(1 2)(b),
Florida Statutes are met.
g. That the infon : ion listed .ov' is true and correct to the best of my knowledge.
' , I
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______
Signature .r Cu 'eal Property Owner Date
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Print Current Real Property Owner Name and, if property owner is a corporation,LLC or other entity,title
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Signature of Witness to the Owner's Signature Date
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Witness email dress Witness phone number
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Jeffrey A. K . zk«. ,County Attorney i Deputy Cleric 410
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Attest as to Chairma
signature'only. .
1 6 C 1
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