Backup Documents 12/13/2022 Item #16C11 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP ! bell
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.
ROUTING
Complete routing lines#1 through#2 as appropriate for additional signatures, and/or information needed. If the document is already complete with the
exception of the Chairman's signature,draw a line through routing lines#1 through#2,complete the checklist,and forward to the County Attorney Office.
Route to Addressee(s)(List in routing order) Office
Initials Date
I.
2____
3. County Attorney Office County Attorney Office _
,1Akkit3 12/292 Z
4. BCC Office Board of County
Commissioners tun/02 c P/Z 2
5. Minutes and Records Clerk of Court's Office `1
INF 1 42-P-Pra- (di gq
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 Phone Number
Contact/Department CHRIS T004ER 'Fe D A / Pub ')."3/ -2 SA -4/6 5
Agenda Date Item was Agenda Item Number
Approved by the BCC I .I ►31 ao Aa I , . C. * y I
Type of Document(s) Number of Original
Attached C.STVIrFtGk toly oP ctpmppa_Kicron+sxt;tyyDocuments Attached 1
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(instead of stamp)? 'r-
2. Does the document need to be sent to another agency for additional signatures? If yes,
provide the Contact Information(Name;Agency;Address;Phone)on an attached sheet. N f A
3. Original document has been signed/initialed for legality. (All documents to be signed by
the Chairman,with the exception of most letters,must be reviewed and signed by the
Office of the County Attorney.) C..
4. All handwritten strike-through and revisions have been initialed by the County Attorney /
Office and all other parties except the BCC Chairman and the Clerk to the Board. NiI A
5. The Chairman's signature line date has been entered as the date of BCC approval of the
document or the final negotiated contract date whichever is applicable. _N I/�
6. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's
signature and initials are required.
7. In most cases(some contracts are an exception),the original document and this routing slip
should be provided to the County Attorney Office at the time the item is uploaded to the
agenda. Some documents are time sensitive and require forwarding to Tallahassee within a c0-f-
certain time frame or the BCC's actions are nullified. e aware of your deadlines!
S. The document was approved by the BCC on 1%/13 it and all chap es made during /Aisno
the meeting have been incorporated in the attached document. The County Attorney an option ,,
Office has reviewed the changes,if applicable. this line.
9. Initials of attorney verifying that the attached document is the version approved by the N/A is not
BCC,all changes directed by the BCC have been made,and the document is ready for the an option for
Chairman's signature. this line.
Pe(ease_ e . I ecec J coo, fio CA `s�/ Todd
I:Forms/County Fortes/BCC Forms/Original Documents Routing Slip WWS Original 9.03.04;Revised 1.26.05;2.24.05;11/30/12;4/22/16;9/10/21
CERTIFICATION OF FINANCIAL RESPONSIBILITY FOR LOCAL GOVERNMENT
Collier County Public Utilities Division a unit of local government of
the State of Florida, hereby certifies that it has unconditionally obligated itself to have the
financial resources necessary to close, plug, and abandon its underground injection well(s)
and related monitoring wells, as required by Chapter 62-528, Florida Administrative Code. It
is further understood that the cost estimate to conduct plugging and abandonment,
established on May 12,2022 , shall be updated thirty (30) months after the date
of permit issuance and this obligation shall incorporate accumulated inflation costs. An
increase exceeding 10 percent compared with the amount stated below shall require submission
of an updated certification form.
Injection Wells and Monitoring Wells Covered By This Agreement:
(attach additional sheet if necessary)
North County Regional Water Treatment Plant IW-1, IW-2&DZMW-1
Facility Name:
Facility Address: 8005 Vanderbilt Beach Road, Naples, FL
Facility Contact: Christopher Todd, Plant Manager
Phone Number: 239-252-4165
Latitude/Longitude of Injection Well(s): 26* 14' 43.73" / -81' 40' 42.53"
Current Permit Number: 325802-002-U0/1 X/325802-003-UO/1 X
Current Plugging and Abandonment Cost Estimate: $693,947
(total for all injection and monitoring wells)
It is hereby understood that the cancellation of this certification may not take place without
the prior written consent of the Secretary of the Florida Department of Environmental
Protection.
NOTARY: See Next Page
(Sig ure)
William L. McDaniel,Jr., Chairman
(Title) Approv ' t „klinn and legality
(Date) Jeffrey A. patz,fc w,County Attorney
ATTEST:
CRYSTAL K. KIN�E=L CLERK
.�
Deputy Clerk 6
AtteSt as to Chairman's
signature only.
16C11
Notary Form
State of Florida
County of: C(j//'Cr
Sworn to (or affirmed) and subscribed before me this a day of Vece ZU , 2622
by W`f/rani fl/CDGtVe ( Jr
(Name of person making statement)
ElPersonally known to me
OR
❑ Produced the following identification
Notary Signature
Act;g.crt Otfcl
Print, Type, or Stamp Commissioned Name of Notary Public
Apply Seal of Notary Public below- State of Florida
r„"s MADISON BIRD
* * Commission 7 FW 1$3717
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