Backup Documents 04/11/2023 Item #16C 6 16c
ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP
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 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
1.
2.
3. County Attorney Office County Attorney Office giT IIirP y f Z/23
4. BCC Office Board of County
Commissioners RLIjyrp LII17/23
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 vekT o Qo J PJ'D Phone Number
Contact/ Department Zan A►met,�a ►Ite ,,,4.4,14I.tov. L3q.-ZS2-62cj �tc,.�G Crvr et:I
Agenda Date Item was 4-�`- �Z'� 0cc. Agenda Item Number r o {- dike'G
Approved by the BCC A t.—a--I-2. ' +" Ib�• rLK �-`l am
Type of Document G e rA•-i triactA sn l wt Number of Original
Attached 'e-es porisaki i%-��r [occti 00l.*cnn AV Documents Attached o6li•evcoim
PO number or account _�p •
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. (Init. Applicable)
1. Does the document require the chairman's original signature?
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.
3. Original document has been signed/initialed for legal sufficiency. (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.
4. All handwritten strike-through and revisions have been initialed by the County Attorney's
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
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
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 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 H/I( and all changes made during N/A is not
the meeting have been incorporated in the attached document. The County an option for
Attorney's 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 �rtr� an option for
Chairman's signature. I^ this line.
16C6
CERTIFICATION OF FINANCIAL RESPONSIBILITY FOR LOCAL GOVERNMENT
Collier County Public Utilities Department ,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 February 23,2023 , 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)
South County Water Reclamation Facility IW-1, IW-2 and DZMW-1
Facility Name:
Facility Address: 5600 Warren Street, Naples, FL 34113
Facility Contact: Christopher Farris
Phone Number: 239-252-6886
Latitude/Longitude of Injection Well(s):
26*05'44",-81*43'22"/26*05'43",-81*43'25"
Current Permit Number: 211999-005-UO/1 M & 211999-006-UO/1 M
Current Plugging and Abandonment Cost Estimate: $855,526.40
(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
Pro • n.
NOTARY: See Next Page
(Signature)
teele 6s 610
(Print Name)
(--"00 Cak.-.110)GYee14-• )i51-4,,tc-r- C iftrAtiCIV
(Title)
%#Ai /t/ 2 'z3
( at /
A d - Ittanclegality
/ ,
1 Assistant County Attormy
16C6
Notary Form
State of Florida
County of Col her
Sworn to (or affirmed)and subscribed before me this Iy day of April ,apa3
by egiCkL-O CG15+ o
(Name of person making statement)
CMPersonally known to me
OR
❑ Produced the following identification
Notary Signature
AIXAJ.CAPIZZI
• A•L, • MY COMMISSION#HH 144329
A �/ • °; EXPIRES:October 4,2025
�(CL (Z.ZI ..,of 6Et%''• Bonded Tfvu Notary Public Underwriters
Print, Type, or Stamp ommissioned Name of Notary Public
Apply Seal of Notary Public below- State of Florida
2