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Backup Documents 07/24/2012 Item #16F 3ORIGINAL DOCUMENTS CHECKLIST & ROUTING S LIP 16F3 TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE Print on pink paper. Attach to original document. Original documents should be hand delivered to the Board Office. The completed routing slip and original documents are to be forwarded to the Board Office only after the Board has taken action on the item.) ROUTING SLIP Complete routing lines #1 through #4 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 routing lines #I through #4, complete the checklist, and forward to Ian Mitchell (line #5). Route to Addressee(s) List in routing order Office Initials Date 1. appropriate. (Initial) Applicable) 2. 7/24/12 Agenda Item Number 16 -F -3 3. signed by the Chairman, with the exception of most letters, must be reviewed and signed 4. Jeffrey A. Klatzkow, County Attorney County Attorney JAK 7/26/12 5. Ian Mitchell, Executive Manager BCC Board of County Commissioners Documents Attached 30 2 6. Minutes and Records Clerk of Court's Office b K R -DM PRIMARY CONTACT INFORMATION (The primary contact is the holder of the original document pending BCC approval. 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, including Ian Mitchell needs to contact staff for additional or missing information. All original documents needing the BCC Chairman's signature are to be delivered to the BCC office only after the BCC has acted to approve the item.) Name of Primary Staff Linda Swisher, Ochopee Fire Control Phone Number 695 -4114 Contact appropriate. (Initial) Applicable) Agenda Date Item was 7/24/12 Agenda Item Number 16 -F -3 Approved by the BCC signed by the Chairman, with the exception of most letters, must be reviewed and signed Type of Document Volunteer Fire Assistance Grant Number of Original One Attached Applicat ion Documents Attached INSTRUCTIONS & CHECKLIST 1: Forms/ County Forms/ BCC Forms/ Original Documents Routing Slip WWS Original 9.03.04, Revised 1.26.05, Revised 2.24.05 08- MGR - 00132/33 Initial the Yes column or mark "N /A" in the Not Applicable column, whichever is Yes N/A (Not appropriate. (Initial) Applicable) 1. 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. This includes signature pages from ordinances, resolutions, etc. signed by the County Attorney's Office and signature pages from contracts, agreements, etc. that have been fully executed by all parties except the BCC Chairman and Clerk to the Board and possibly State Officials.) 2. 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 3. 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. 4. "Sign here" tabs are placed on the appropriate pages indicating where the Chairman's JAK signature and initials are required. 5. In most cases (some contracts are an exception), the original document and this routing slip JAK should be provided to Ian Mitchell in the BCC office within 24 hours of BCC approval. 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! document was approved by the BCC on 7/24/12 and all changes made during the JAK nThe meeting have been incorporated in the attached document. The County Attorney's Office has reviewed the changes, if applicable. 1: Forms/ County Forms/ BCC Forms/ Original Documents Routing Slip WWS Original 9.03.04, Revised 1.26.05, Revised 2.24.05 08- MGR - 00132/33 16F3 MEMORANDUM Date: July 31, 2012 To: Linda Swisher, Administrative Secretary Ochopee Fire Control District From: Ann Jennejohn, Deputy Clerk Minutes & Records Department Re: A Volunteer Fire Assistance Grant Application to purchase Class A Foam for Ochopee's Fire Control District Attached is the original grant application referenced above (Item #16F3) approved by the Board of County Commissioners on July 24, 2012. A copy will be held on file in the Minutes and Record's Department for the Board's Official Record. If you should have any questions, please contact me at 252 -8406. Thank you. Attachment 16F3 Florida Department of Agriculture and Consumer Services ' Division of Forestry CHgRLES N. BRON80N VOLUNTEER FIRE ASSISTANCE GRANT APPLICATION qF COMMglIONER LEGAL NAME Ochopee Fire Control Dlstlrct FORM OF ORGANIZATION: (Municipal, Fire District, Non -Profit, County) Dependent Fire Control District ADDRESS P.O. Box 70 CITY Everglades City IF COUNTY, LIST VFD'S BENEFITING FROM GRANT: STATE Fl Zip 34139 COUNTY Collier COUNTY # EMPLOYER IDENTIFICATION NUMBER (EIN) MAKE/YR.MODEL PUMP CAPACITY (GPM) IS FIRE DEPARTMENT LOCATED IN AN INCORPORATED TOWN? YES ® NO ❑ IF YES, NAME OF TOWN: Everglades City POPULATION OF TOWN: 429 PROTECTED AREA: EST. POPULATION: 4100 SIZE: (SO. MILES) 11 OO WHAT IS THE FIRE DEPARTMENT ISO RATING? IS FIRE DEPARTMENT NIMS COMPLIANT? YES ® NO ❑ CURRENT COOPERATIVE AGREEMENT WITH DOF7 YES ® NO ❑ DISTANCE OF CLOSEST MUTUAL AID FIRE DEPARTMENT: 31 2 .... �` NAME OF FIRE DEPARTMENT: East Naples Fire Dist Telephone Number: ( ) 239 695 -4114 Coyle Fred W. Co Y NUMBER OF FIREFIGHTERS: PAID: F1 7 VOLUNTEERS: f NO. OF INCIDENTS PAST YEAR: WJLDLAND FIRE Aj Z "- OTHER: 52 NO. OF FIREFIGHTERS CERTIFIED AS: WILDLAND FIREFIGHTER ! 21 WILDLAND FIREFIGHTER I!- HAS APPLICANT RECEIVED GRANT FUNDS FROM ANY SOURCE IN THE PAST 12 MONTHS? YES 0 NO ❑ IF YES, WHERE? Florida Division of Forestry AMOUNT: $ 2,06150 LIST TOTAL FUNDS RECEIVED FROM OTHER TAXING AUTHORITIES SUCH AS CITY, COUNTY, TAXING DISTRICTS (Past 12 Months) AMOUNT: $ Iv Signa R Fd tat e' � aK�� Date Signed and Submitted LIST OF FIREFIGHTING VEHICLES: TYPE MAKE/YR.MODEL PUMP CAPACITY (GPM) WATER CAPACITY (GAL.) Engine 3 Emergency One 98 05,05 1250 1000 Tanker Emergency One 2012 1250 2500 Brush 2 6 x6 73 250 750/1100 Attack Dodge 5500 250 350 ESTIMATED GRANT FUNDING REQUEST: 2,112 LIST OF EQUIPMENT OR SUPPLIES TO PURCHASE WITH GRANT FUNDS: FEDERAL $1,056 NUMBER DESCRIPTION AMOUNT APPLICANT $1,056 24 5 gallon class A foam 2,112 COUNTY $ s 2 112 not more than 50% of total. Applicant at least 50% of atching funds.) F We understand that this is a 50 percent maximum cost -share program (Cooperative Forestry Assistance Act of 1978, PL 95 -313), and that funds on deposit up to 50 percent of the actual purchase price of the items approved will be committed to our project. TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLICATION ARE TRUE AND CORRECT. THE GOVERNING BODY OF THE APPLICANT HAS DULY AUTHORIZED THIS DOCUMENT. Type Name of Authorized Representative Title Telephone Number: ( ) 239 695 -4114 Coyle Fred W. Co Y Chairman FAX: (239 ) 695 -3473 Signa R Fd tat e' � aK�� Date Signed and Submitted Email: 'r{ut�hoged Z6 k Z DACS- 1ATM51 / F s I I C e, DWIGHT E. OCK;CLEF3�C Ap d as to form and legal sufficiency: Jeft e . Klatzkow Cnnnt Attnrnev 16F3 OMB Approval No. 0348.0040 ASSURANCES -- NON - CONSTRUCTION PROGRAMS Note: Certain of these assurances may not be applicable to your project or program. If you have questions, please contact the awarding agency. Further, certain Federal awarding agencies may require applicants to certify to additional assurances. If such is the case, you will be noti ficd. As the duly authorized representative of the applicant I certify that the applicant• 1. Has the legal authority to apply for Federal assistance, and the institutional, managerial and financial capability (including finds sufficient to pay the non - Federal share of project costs) to ensure proper planning, management and completion of the project described in this application. 2. Will give the awarding agency, the Comptroller General of the United States, and if appropriate, the State, through any authorized representative, access to and the right to examine all records, books, papers, or documents related to the award; and will establish a proper accounting system in accordance with generally accepted accounting standards or agency directives. 3. Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the appearance of personal or organizational conflict of interest, or personal gain. 4. Will initiate and complete the work within the applicable time frame after receipt of approval of the awarding agency. 5. Will comply with the Intergovernmental Personnel Act of 1970 (42 U.S.C. §§ 4728 -4763) relating to prescribed standards for merit systems for programs funded under one of the nineteen statutes or regulations specified in Appendix A of OPM's Standards for a Merit System of Personnel Administration (5 C.F.R. 900, Subpart F). 6. Will comply with all Federal statutes relating to nondiscrimination. These include but are not limited to: (a)Title VI of the Civil Rights Act of 1964 (P.L. 88 -352) which prohibits discrimination on the basis of race, color or national origin; (b) Title IX of the Education Amendments of 1972, as amended (20 U.S.C. §§ 1681 -1683, and 1685 - 1686), which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. § 794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended (42 U.S.C. §§ 6101 - 6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92- 255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91 -616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) §§ 523 and 527 of the Public Health Service Act of 1912 (42 U.S.C. 290 -dd -3 and 290 ee -3), as amended, relating to confidentiality of alcohol and drug abuse patient records; (h) Title Vill of the Civil Rights Act of 1968 (42 U.S.C. § 3601 et seq.), as amended, relating to nondiscrimination in the sale, rental or financing of housing; (1) any other nondiscrimination provisions in the specific statute(s) under which application for Federal assistance is being made; and 0) the requirements of any other nondiscrimination statute(s) which may apply to the application. 7. Will comply, or has already complied, with the requirements of Titles 11 and Ill of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (P.L. 961 -646) which provide for fair and equitable treatment of persons displaced or whose property is acquired as a result of Federal or federally assisted programs. These requirements apply to all interests in real property acquired for project purposes regardless of Federal participation in purchases. 8. Will comply with the provisions of the Health Act (5 U.S.C. §§ 1501 -1508 and 7324 -7328) which limit the political activities of employees whose principal employment activities are funded in whole or in part with Federal funds. 9. Will comply, as applicable, with the provisions of the Davis - Bacon Act (40 U.S.C. §§ 276a to 276a -7), the Copeland Act (40 U.S.C. § 276c and 18 U.S.C. §§ 874), and the Contract Work Flours and Safety Standards Act (40 U.S.C. §§ 327 -333), regarding labor standards for federally assisted construction subagrcements. 10. Will comply, if applicable, with flood insurance purchase requirements of Section 102 (a) of the Flood Disaster Protection Act of 1973 (P.L. 93 -234) which requires recipients in a special flood hazard area to participate in the program and to purchase flood insurance if the total cost of insurable construction and acquisition of S 10,000 or more. 11. Will comply with environmental standards which may be prescribed pursuant to the following: (a) institution of environmental quality control measures under the National Environmental Policy Act of 1969 (P.L. 91 -190) and Executive Order (EO) 11514; (b) notification of violating facilities pursuant to EO 11738; (c) protection of wetlands pursuant to EO 11990; (d) evaluation of flood hazards in floodplains in accordance with EO 11988; (e) assurance of project consistency with the approved State management program developed under the Coastal Zone Management Act of 1972 (16 U.S.C. §§ 1451 et seq.); (f) conformity of Federal actions to State (Clear Air) Implementation Plans under Section 176(c) of the Clear Air Act of 1955, as amended (42 U.S.C. § 7401 et seq.), (g) protection of underground sources of drinking water under the Safe Drinking Water Act of 1974, as amended, (P.L. 93 -523); and (h) protection of endangered species tinder the Endangered Species Act of 1973, as amended, (P.L. 93 -205). 12. Will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C. §§ 1271 et seq.) related to protecting components or potential components of the national wild and scenic rivers system. V, B- !1(02105) Authorized for Local Reproduction Standard Fonn 424B (9- 03)Prewribed by OMB Circular A -102 13. Will assist the awarding agency ui assuring compliance with Section 106 of the National Historic Preservation Act of 1966, as amended (16 U.S.C. 470), i:0 11593 (identification and protection of historic properties), and the Archeological and Historic Preservation Act of 1974 (16 U.S.C. 469a -1 et seq.). 14. Will comply with P.L. 93 -348 regarding the protection of human subjects involved in research, development, and related activities supported by this award of assistance. 15. Will comply with the Laboratory Animal Welfare Act of 1966 (P.L. 89 -544, as amended, 7 U.S.C. 2131 el seq.) pertaining to the care, handling, and treatment of warm blooded animals held for 16F3 research, teaching, or other activities supported by this award of assistance. 16. Will comply with the Lead -Based Paint Poisoning Prevention Act (42 U.S.C. §§ 4801 et seq.) which prohibits the use of lead based paint in construction or rehabilitation of residence structures. 17. Will cause to be performed the required financial and compliance audits in accordance with the Single Audit Act of 1984. 18. Will comply with all applicable requirements of all other Federal laws, executive orders, regulations and policies governing this program. SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL TITLE Board of County Commissioners Chairman APPLICANT ORGANIZATION DATE Collier Cyur►fy Vp5d of County Commissioners SUBMITTED u 00N� ` +gaaCarr sew„ V, B -6 (02/05) Authorized for Local Reproduction) Standard Form 424B (9 -03 Prescribed by OMB Circular A -102 Appr v'd as to form and legal sufficiency: J latzkow County Attomey Form AD -1097 w94 U. S. DEPARTMENT OFAGRICULTURE Certification Regarding Debarment, Suspension, and Other Responsibility Matters - Primary Covered Transactions 16F3 This certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension, 7 CFR Part 3017, Section 3017.510, Participants' responsibilities. The regulations were published as Part IV of the January 30, 1989, Federal Re l�ster(pages 47224733). Copies of the regulations may be obtained by contacting the Department of Agriculture agency offering the proposed covered transaction. (Before completing certification, read instructions on reverse.J (1) The prospective primary participant certifies to the best of its knowledge and belief, that it and its principals: (a) are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency, (b) have not within a three -year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or Local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; (c) are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State or Local) with commission of any of the offenses enumerated in paragraph (1)(b) of this certification; and (d) have not within a three -year period preceding this application/proposal had one or more public transactions (Federal, State or Local) terminated for cause or default. (2) Where the prospective primary participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal. Collier County Board of County Commissioners AND TITLE OFA Fred W. Coyle, Chairman � W. ATTEST: DWIGHT E. , CLERK "App h "Po Cet i il9naat,rrt �1.l�� � ' FRIA Ochopee Fire Control District DA 773 -'U14 7-4:7-,o k Appro� as to form and legal sufficiency: Jeffrey latzkow County Attorney Form AD -1047 plsz! om muo INSTRUCTIONS FOR CERTIFICATION 16F3 1. By signing and submitting this form, the prospective primary participant is providing the certification set out on the reverse side in accordance with these instructions. 2. The inability of a person to provide the certification required below will not necessarily result in denial of participation in this covered transaction. The prospective participant shall submit an explanation of why it cannot provide the certification set out on this form. The certification or explanation will be considered in connection with the department or agency's determination whether to enter into this transaction. However, failure of the prospective primary participant to furnish a certification or an explanation shall disqualify such person from participation in this transaction. 3. The certification in this clause is a material representation of fact upon which reliance was placed when the department or agency determined to enter into this transaction. If it is later determined that the prospective primary participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency may terminate this transaction for cause or default. 4. The prospective primary participant shall provide immediate written notice to the department or agency to whom this proposal is submitted if at any time the prospective primary participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances. 5. The terms "covered transaction," "debarred," "suspended," "ineligible," "lower tier covered transaction," "participant," "person," "primary covered transaction," "principal," "proposal," and "voluntarily excluded," as used in this clause, have the meanings set out in the Definitions and Coverage sections of the rules implementing Executive Order 12549. You may contact the department or agency to which this proposal is being submitted for assistance in obtaining a copy of those regulations. 6. The prospective primary participant agrees by submitting this form that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency entering into this transaction. 7. The prospective primary participant further agrees by submitting this form that it will include this clause titled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion - Lower Tier Covered Transactions," provided by the department or agency entering into this covered transaction, without modification, in all lower tier covered transaction and in all solicitations for lower tier covered transactions. 8. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required to, check the Nonprocurement List. 9. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. 10. Except for transactions authorized under paragraph 6 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency may terminate this transaction for cause or default.