#09-5300 (Crews Environmental)
A G R E E MEN T 09-5300
for
II Annual Contract for Emergency and Scheduled Grease, Sludge and Sewage Hauling"
THIS AGREEMENT, made and entered into on this 9 day of February 2010, by and between
Rockfill Associates Inc., dbaj Crews Erwironmental., authorized to do business in the State of
Florida, whose business address is 2700 Rockfill Road, Fort Myers, Florida 33902, hereinafter
called the "Contractor" and Collier County, a political subdivision of the State of Florida~
Collier County, Naples, hereinafter called the "County":
WIT N E SSE T H:
1. COMMENCEMENT.
The contract shall be for an initial two (2) year period, commencing on February 9, 2010,
and terminating on February 8, 2012.
The County may, at its discretion and with the consent of the Contractor, renew the
Agreement under all of the terms and conditions contained in this Agreement for one
(1) additional two (2) year period. The County shall give the Contractor written notice
of the County's intention to extend the Agreement term not less than ten (10) days prior
to the end of the Agreement term then in effect.
2. STATEMENT OF WORK. The Board of County Commissioners deemed three (3) firms
to be pre-qualified and awarded a Contract to each firm. Each awardee will enter into
an Agreement to provide emergency and scheduled grease, sludge and sewage hauling
on an as-needed basis as may be required by the County in accordance with the terms
and conditions of BID#09-5300 and the Contractor's proposal, which is incorporated by
reference and made an integral part of this Agreement. The execution of this Agreement
shall not be a commitment to the Contractor that any work will be awarded to the
Contractor. Rather, this Agreement governs the rights and obligation of the Quotation
procedure outlined in the next paragraphs and all Work undertaken by Contractor for
County pursuant to this Agreement and the procedure during the term and any
extension of the terms of the Agreement.
A. Scheduled Work: All services requested by the County that does not require a one
(1) hour site response will be considered Scheduled Work
. Scheduled Work will be performed on a time and material or lump sum basis
. For Work having a value of $50,000.00 or less, the department may select one of
the Contractors on the contract and obtain a quote. The department shall
Page 1 of8
provide a summary of Work to be performed which will afford the selected
Contractor the opportunity to submit a formal quotation for the Work. The
Contractor shall respond with the information sought within seven (7) working
days. Upon reaching a mutually acceptable cost for the Scheduled Work, a
purchase order will be awarded to the selected Contractor.
. For Work having a value over $50,000.00 the department shall solicit quotes
from all Contractors under the contract. The department shall provide a
summary of Work to be performed which will afford the Contractor(s) the
opportunity to submit a formal quotation for the Work. The Contractor (s) shall
respond with the information sought within seven (7) working days. A
purchase order will be awarded to the lowest, responsive and responsible
quoter.
. Scheduled services shall be available between the hours of 7:00 a.m. and 5:30
p.m., Monday through Friday, excluding County recognized holidays.
. Any equipment not listed in the Contractors proposal must be approved by the
County prior to commencement of work.
. In each Request for Quotation, the County reserves the right to specify the
period of completion and the collection of liquidated damages in the event of
late completion.
B. Emergency Work: All Work requiring a one (1) hour site response. Emergency
Work will be performed on a time and material basis.
. For Emergency Work, the department may select any Contractor on the
contract.
. The Contractor must be available on a twenty-four (24) hour basis, 365 days per
year
. The Contractor must provide the County with an on-call telephone number for
emergency services.
. Contractor must respond on-site within one (1) hour after notification of an
emergency by Collier County personnel
3. THE CONTRACT SUM. The County shall pay the Contractor for the performance of
the Work pursuant to the quoted price offered by the Contractor in his response to a
specific request for Quotation for Scheduled work. Quotes may be based on time and
material or lump sum, in accordance with Exhibit A, Rate Schedule. Emergency Work
shall be paid on time and material basis, in accordance with Exhibit A, Rate Schedule.
Payment will be made upon receipt of a proper invoice and upon approval by the
project manager or his designee, and in compliance with Chapter 218, Fla. Stats.,
otherwise known as the "Local Government Prompt Payment Act".
4. SALES TAX. Contractor shall pay all sales, consumer, use and other similar taxes
associated with the Work or portions thereof, which are applicable during the
performance of the Work.
Page20f8
5. NOTICES. All notices from the County to the Contractor shall be deemed duly served
if mailed or faxed to the Contractor at the following Address:
Rockfill Associates Inc., dba/ Crews Environmental
Richard Millspaugh, Vice President
2700 Rockfill Road
Fort Myers, Florida 33902
239-332-1986
239-332-7654
All Notices from the Contractor to the County shall be deemed duly served if mailed or
faxed to the County to:
Collier County Government Center
Purchasing Department - Purchasing Building
3301 Tamiami Trail, East
Naples, Florida 34112
Attention: Steve Carnell, Purchasing/ GS Director
Telephone: 239-252-8371
Facsimile: 239-252-6584
The Contractor and the County may change the above mailing address at any time
upon giving the other party written notification. All notices under this Agreement must
be in writing.
6. NO PARTNERSHIP. Nothing herein contained shall create or be construed as creating
a partnership between the County and the Contractor or to constitute the Contractor as
an agent of the County.
7. PERMITS: LICENSES: TAXES. In compliance with Section 218.80, F.s., all permits
necessary for the prosecution of the Work shall be obtained by the Contractor. Payment
for all such permits issued by the County shall be processed internally by the County.
All non-County permits necessary for the prosecution of the Work shall be procured
and paid for by the Contractor.. The Contractor shall also be solely responsible for
payment of any and all taxes levied on the Contractor. In addition, the Contractor shall
comply with all rules, regulations and laws of Collier County, the State of Florida, or the
U. S. Government now in force or hereafter adopted. The Contractor agrees to comply
with all laws governing the responsibility of an employer with respect to persons
employed by the Contractor.
8. NO IMPROPER USE. The Contractor will not use, nor suffer or permitany person to
use in any maimer whatsoever, County facilities for any improper, immoral or offensive
purpose, or for any purpose in violation of any federal, state, county or municipal
ordinance, rule, order or regulation, or of any governmental rule or regulation now in
Page 3 of8
effect or hereafter enacted or adopted. In the event of such violation by the Contractor
or if the County or its authorized representative shall deem any conduct on the part of
the Contractor to be objectionable or improper, the County shall have the right to
suspend the contract of the Contractor. Should the Contractor fail to correct any such
violation, conduct, or practice to the satisfaction of the County within twenty-four (24)
hours after receiving notice of such violation, conduct, or practice, such suspension to
continue until the violation is cured. The Contractor further agrees not to commence
operation during the suspension period until the violation has been corrected to the
satisfaction of the County.
9. TERMINATION. Should the Contractor be found to have failed to perform his
services in a manner satisfactory to the County as per this Agreement, the County may
terminate said agreement for cause; further the County may terminate this Agreement
for convenience with a thirty (30) day written notice. The County shall be sole judge of
non-performance.
10. NO DISCRIMINATION. The Contractor agrees that there shall be no discrimination as
to race, sex, color, creed or national origin.
11. INSURANCE. The Contractor shall provide insurance as follows:
A. Commercial General Liability: Coverage shall have minimum limits of $1,000,000
Per Occurrence, Combined Single Limit for Bodily Injury Liability and Property
Damage Liability. . This shall include Premises and Operations; Independent
Contractors; Products and Completed Operations and Contractual Liability.
B. Business Auto Liability: Coverage shall have minimum limits of $1,000,000 Per
Occurrence, Combined Single Limit for Bodily Injury Liability and Property
Damage Liability. This shall include: Owned Vehicles, Hired and Non-Owned
Vehicles and Employee Non-Ownership.
C. Workers' Compensation: Insurance covering all employees meeting Statutory
Limits in compliance with the applicable state and federal laws.
The coverage must include Employers' Liability with a minimum limit of $500,000
for each accident.
Special Requirements: Collier County Government shall be listed as the
Certificate Holder and included as an Additional Insured on the Comprehensive
General Liability Policy.
Current, valid insurance policies meeting the requirement herein identified shall
be maintained by Contractor during the duration of this Agreement. Renewal
certificates shall be sent to the County ten (10) days prior to any expiration date.
There shall be a thirty (30) day _ notification to the County in the event of
cancellation or modification of any stipulated insurance coverage.
Page 4 of8
Contractor shall insure that all Subcontractors comply with the same insurance
requirements that he is required to meet. The same Contractor shall provide
County with certificates of insurance meeting the required insurance provisions.
D. Pollution Liability Insurance: Coverage shall have a minimum of $1,000,000 per
occurrence bodily injury and property damage.
12. INDEMNIFICATION. To the maximum extent permitted by Florida law, the
Contractor shall indemnify and 'hold harmless Collier County, its officers and
employees from any and all liabilities, damages, losses and costs, including, but not
limited to, reasonable attorneys' fees and paralegals' fees, to the extent caused by the
negligence, recklessness, or intentionally wrongful conduct of the Contractor or anyone
employed or. utilized by the Contractor in the performance of this Agreement. This
indemnification obligation shall not be construed to negate, abridge or reduce any other
rights or remedies which otherwise may be available to an indemnified party or person
described in this paragraph.
This section does not pertain to any incident arising from the sole negligence of
Collier County.
13. CONTRACT ADMINISTRATION. This Agreement shall be administered on behalf
of the County by the Waste Water Department.
14. CONFLICT OF INTEREST: Contractor represents that it presently has no interest and
shall acquire no interest, either direct or indirect, which would conflict in any manner
with the performance of services required hereunder. Contractor further represents
that no persons having any such interest shall be employed to perform those services.
15. COMPONENT PARTS OF THIS CONTRACT. This Contract consists of the attached
component parts, all of which are as fully a part of the contract as if herein set out
verbatim: Contractor's Proposal, Exhibit A, Rate Schedule, Insurance Certificate, Bid
#09-5300, Scope of Services and Addendum.
16. SUBJECT TO APPROPRIATION. It is further understood and agreed by and between
the parties herein that this agreement is subject to appropriation by the Board of County
Commissioners.
17. PROHIBITION OF GIFTS TO COUNTY EMPLOYEES. No organization or individual
shall offer or give, either directly or indirectly, any favor, gift, loan, fee, service or other
item of value to any County employee, as set forth in Chapter 112, Part III, Florida
Statutes, Collier County Ethics Ordinance No. 2004-05, and County Administrative
Procedure 5311. Violation of this provision may result in one or more of the following
consequences: a. Prohibition by the individual, firm, and/ or any employee of the firm
from contact with County staff for a specified period of timei b. Prohibition by the
Page 5 of8
individual and/ or firm from doing business with the County for a specified period of
time, including but not limited to: submitting bids, RFP, and/ or quotes; and, c.
immediate termination of any contract held by the individual and/ or firm for cause.
18. IMMIGRATION LAW COMPLIANCE. By executing and entering into this agreement,
the Contractor is formally acknowledging without exception or stipulation that it is fully
responsible for complying with the provisions of the Immigration Reform and Control
Act of 1986 as located at 8 U.S.c. 1324, et seq. and regulations relating thereto, as either
may be amended. Failure by the Contractor to comply with the laws referenced herein
shall constitute a breach of this agreement and the County shall have the discretion to
unilaterally terminate this agreement immediately.
19. OFFER EXTENDED TO OTHER GOVERNMENTAL ENTITIES. Collier County
encourages and agrees to the successful proposer extending the pricing, terms and
conditions of this solicitation or resultant contract to other governmental entities at the
discretion of the successful proposer.
20. AGREEMENT TERMS. If any portion of this Agreement is held to be void, invalid, or
otherwise unenforceable, in whole or in part, the remaining portion of this Agreement
shall remain in effect.
21. ADDITIONAL ITEMS/SERVICES. Additional items and/ or services may be added to
this contract upon satisfactory negotiation of price by the Contract Manager and
Contractor .
22. DISPUTE RESOLUTION. Prior to the initiation of any action or proceeding permitted
by this Agreement to resolve disputes between the parties, the parties shall make a good
faith effort to resolve any such disputes by negotiation. The negotiation shall be
attended by representatives of Contractor with full decision-making authority and by
County's staff person who would make the presentation of any settlement reached
during negotiations to County for approval. Failing resolution, and prior to the
commencement of depositions in any litigation between the parties arising out of this
Agreement, the parties shall attempt to resolve the dispute through Mediation before an
agreed-upon Circuit Court Mediator certified by the State of Florida. The mediation
shall be attended by representatives of Contractor with full decision-making authority
and by County's staff person who would make the presentation of any settlement
reached at mediation to County's board for approval. Should either party fail to submit
to mediation as required hereunder, the other party may obtain a court order requiring
mediation under section 44.102, Fla. Stat.
Any suit or action brought by either party to this Agreement against the other party
relating to or arising out of this Agreement must be brought in the appropriate federal
or state courts in Collier County, Florida, which courts have sole and exclusive
jurisdiction on all such matters.
Page60f8
23. PRICING: Pricing shall be inclusive of all costs. Payment shall be full compensation for
all services,labor, tools, equipment, travel and any other items required for project
completion and/ or completion of services.
IN WITNESS WHEREOF, the Contractor and the County, have each, respectively, by an
authorized person or agent, hereunder set their hands and seals on the date and year first above
written.
ATTEST>'
Dwight:,E. Brock, GlerkgfCourts
~.. ., . , . ..~ -
BOARD OF COUNTY COMMISSIONERS
COLLIER COUNTY, FLORIDA
By:
Dated: :
..lit; :.o.tt......
It....... II' II
By: ~W. ~
Fred W. Coyle, Chairman
Rockfill Associates Inc.,
dba/ Crews Environmental
Contractor
~-)nl-dd
1d~ ~.
/
Signature
By:
-r~ L I-bMC/~T-Jt/ 1T?4IeU-
Type/ print witness name
d~?~
Second Witness
FiZ~Y~'~-J R-~ <Lo
Type/ print witness name
t:,6i:Il( U. ;, fJ1~~-r ~BJOtpr
Typed signature and title
Approved as to form and
;g!iiKL;
~ County Attorney
~CbTt~ ~nl' h
Print Name
Page 7 of8
Exhibit A
Rate Schedule
Tanker Size
Scheduled
2,500 Gallon Tanker
5,000 Gallon Tanker
10,000 Gallon Tanker
Hourly Sum of all Three Tankers
$ 200.00/hr
$ 200.00/hr
$ 500.00/hr
$ 900.00/hr
Emergency
$ 300.00jhr
$ 300.00/hr
$ 700.00/hr
$ 1300.00/hr
Specialty equipment; tankers require prior approval from the County
Page80f8
. ~Jlb~ CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY)
OPIO JR I 04/14/10
ROCKF-1
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER QF INf.QRMATIOt
" ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Rider Insurance Group, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
9180 Estero Pk Commons Blvd #9 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW
Estero FL 33928
Phone: 239-992-9711 Fax:239-947-8076 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER "- Endurance American Specialty
INSURER B:
Rockfill Associates INSURER C:
DBA Crews Environmental
P.O. Box 27 INSURER 0:
Fort Myers FL 33902
I INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICA TED, NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR NSRI TYPE OF INSURANCE POLICY NUMBER tRT1l1~~rt6~ b2~lfrM~b~ LIMITS
GENERAL LIABILITY EACH OCCURRENCE $1,000,000
-
A X COMMERCIAL GENERAL LIABILITY ECC10101022500 04/13/10 04/13/11 UAMAlit: $
PREMISES (Ea occurence)
I CLAIMS MADE D OCCUR MED EXP (Anyone person) $
X Pollution PERSONAL & ADV INJURY $
-
GENERAL AGGREGATE $1,000,000
-
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $
I n PRO- nLOC Claims Ex 1,000,000
POLICY JECT
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
- $
ANY AUTO (Ea accident)
-
ALL OWNED AUTOS BODILY INJURY
- $
SCHEDULED AUTOS (Per person)
-
HIRED AUTOS BODILY INJURY
- $.
NON-OWNED AUTOS (Per accident)
-
- PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
=1 ANY AUTO OTHER THAN EAACC $
AUTO ONLY: AGG $
EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $
tJ OCCUR D CLAIMS MADE AGGREGATE $
$
R DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION I. WC STATU- I IUJ~-
AND EMPLOYERS' LIABILITY Y/N TORY LIMITS
ANY PROPRIETORlPARTNERlEXECUTIVn EL EACH ACCIDENT $
OFFICERlMEMBER EXCLUDED?
(Mandatory in NH) EL DISEASE - EA EMPLOYEI $
If ~es, describe under
S ECIAL PROVISIONS below E L. DISEASE - POLICY LIMIT $
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
COLLIEC DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ~ DAYS WRllTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
Collier County Board of County IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
Commissioners REPRESENTATIVES.
3301 Tamiami Trail East AUTHORIZED REPRESENTATIVE
Jennifer J. Rider
NaDles FL 34112
ACORD 25 (2009/01)
@ 1988-2009 ACORD CORPORATION. All rights reserved.
-
Crews Environmental, Rockfill Associates Inc., dba:
Endorsement Number: 3
Endurance
Automatic Additional Insured - Owners, Lessees or Contractors
This endorsement, effective 4/13/2010 attaches to and forms a part of Policy Num ber
ECC 10 I 010225-00. This endorsement changes the Policy. Please read it carefully,
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
CONTRACTORS POLLUTION LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization:
Any person(s) or organization(s) whom the Named Insured agrees, in a
written contract, to name as an additional insured. However, this status
exists only for the project specified in that cont.ract.
The person or organization shown in this Schedule is included as an insured, but
only with respect to that person's or organization's vicarious liability arising out
of your ongoing operations performed for that insured.
FEI-319-ECC-0708
ACORDN CERTIFICATE OF LIABILITY INSURANCE CSR SP I DATE (MM/DDIYYYY)
CREWS -1 02/15/10
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMA liON
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Stewart & Sons Insurance, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P.O. Box 60029 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Ft. Myers FL 33906-0029
Phone: 239-936-8844 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: Cincinnati Ins. Co. 10677
Rockfill Associates,Inc.D,A INSURER B:
DBA Crews Environmental & or INSURER C:
Robert & Paula Himschoot
2700 Rockfill Rd INSURER 0:
Fort Myers FL 33916 INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
LTR INSR TYPE OF INSURANCE POLICY NUMBER rD'ATE rMM/DDNY I P~k~~Y(MM/DDNYT LIMITS
GENERAL LIABILITY EOACH OCCURRENCE $ 1000000
- 11/01/09 11/01/10 UAMAl;jl: .
A X COMMERCIAL GENERAL LIABILITY CAP5893052 PREMISES (Ea occurence) $ 500000
I CLAIMS MADE ~ OCCUR MED EXP (Anyone person) $ 10000
PERSONAL & ADV INJURY $1000000
-
GENERAL AGGREGATE $ 2000000
-
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2000000
I .1Xl PRO- nLOC
POLICY JECT
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
- $ 500000
ANY AUTO (Ea accident)
-
ALL OWNED AUTOS BODILY INJURY
- $
A X SCHEDULED AUTOS CAP5893052 11/01/09 11/01/10 (Per person)
-
~ HIRED AUTOS BODILY INJURY
$
X NON-OWNED AUTOS (Per accident)
-
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
==1 ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESs/UMBRELLA LIABILITY EACH OCCURRENCE $ 1000000
A !J OCCUR D CLAIMS MADE CAP5893052 11/01/09 11/01/10 AGGREGATE $ 1000000
$
R DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND I TORY LIMITS I IUE~-
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? EL DISEASE - EA EMPLOYEE $
If yes, describe under
SPECIAL PROVISIONS below EL DISEASE - POLICY LIMIT $
OTHER
A Leased/Rented CAP5893052 11/01/09 11/01/10 Ded:$1000 $150000
Equipment
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Collier County is named as Additional Insured with respect to General
Liability coverage for any and all work performed on behalf of Collier
County.
CERTIFICATE HOLDER
CANCELLA liON
COCOL-3 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ~ DAYS WRITTEN
COLLIER COUNTY BOARD OF NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
COUNTY COMMISSIONERS
3301 TAMIAMI TRAIL EAST IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
NAPLES FL 34112 REPRESENTATIVES,
AUTHOR :7E~TIVE
./"" _ .-lc'" \ -
...
ACORD 25 (2001/08)
@ACORD CORPORATION 1988
ACORO(fJ CERTIFICATE OF LIABILITY INSURANCE I DATE (MMIDDlYYYY)
~ 2/9/201 0
PRODUCER Alliance Insurance Solutions LLC THIS CERTIFICATE IS ISSUED AS A MA TIER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
PO Box 1777 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
St Petersburg, FL 33731 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
727-497-1247 INSURERS AFFORDING COVERAGE NAIC#
www.ins4blz,com
INSURED Thrive HR FL 1, LLC INSURER A: SUNZ Insurance ComDanV 34762
8902 N. Dale Mabry Hwy INSURER B:
Suite102 INSURER c:
Tampa FL 33618 INSURER 0:
I INSURER E:
,...---,
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. N01W1THSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
I~~ ~~ TVD" nt: INSURANCE POLlCY NUMBER C2T~q~~'Zg= b~!fecrM~~ LlMITS
~NERAL lIABlUTY EACH OCCURRENCE $
I-- COMMERCIAl GENERAL LIABILITY rv~~~~J9la~:7~ncel $
I-- OCLAIMS MADE D OCCUR MED EXP (MY one person) $
I-- PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
n'LAGG~nE LIMIT APMS PER: PRODUCTS-COM~OPAGG $
POLlCY . ~~R,: LOC
~OMOBILE LIABILITY COMBINED SINGLE LIMIT $
ANY AUTO (Ea accident)
I--
I-- ALL OWNED AUTOS BOOIL Y INJURY
$
SCHEDULED AUTOS (Per person)
I--
I-- HIRED AUTOS BODILY INJURY
$
NON-OWNED AUTOS (Per accident)
-
PROPERTY DAMAGE $
(Per accident)
~RAGE UABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN EAACC $
AUTO ONLY: AGG $
EXCESS I UMBRELLA LIABIUTY EACH OCCURRENCE $
~ OCCUR D CLNMS MADE AGGREGATE $
$
~ DEDUCTIBLE $
RETENTION $ $
A WORKERS COMPENSATION WCPEOOOOO03201 1/1/2010 1/1/2011 ,( wc STATU-T 10~.
AND EMPLOYERS' UABIUTY YIN
/lJolY PROPRlETOR/PARlllERlEXECUTlVE D E.L EACH ACCIDENT $ 1 000 000
OFFICERlMEMBER EXCLUDED? E.L, DISEASE. EA EMPLOYEE $
(Mandatory in NH) 1 000 000
g~~CI~.~~Jv'i~1g'Ns below E.L. DISEASE. POLICY LIMIT $ 1,000,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
coverape provided for all leased employees but not subcontractors of: Crews Environmental
state 0 Florida Coverage Only
CERTIFICATE HOLDER
CAN CELLA TION
70923 SHOULD ANYOFTHEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
Collier County Board of County Commissioners DATE THEREOF, THE ISSUING INSURER WILL ENOEAVOR TO MAIL 30. DAYS WRITTEN
3301 Tamiami Trail East NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. BUT FAILURE TO DO SO SHALL
Naples FL 34112 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KINO UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES, *10 Day. for Non-Payment of Premium.
AUTHORIZED REPRESENTATIVE ~~~!&~
Douglas Lilak
ACORD 25 (2009/01)
@ 1988-2009 ACORD CORPORATION. All rights reserved.
CERT NO.: 5827984 Renee CaX'rano
P:954-8S2-2023 2/9/2010 12:23:23 PM Page 1 of 1
:,/.,.
ACORDN CERTIFICATE OF LIABILITY INSURANCE CSR SP I DATE (MMIDDIYYYY)
CREWS-1 02/15/10
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Stewart & Sons Insurance, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P.O. Box 60029 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Ft. Myers FL 33906-0029
Phone: 239-936-8844 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: Cincinnati Ins. Co. 10677
Rockfill Associates,Inc.D,A INSURER B: -
DBA Crews Environmental & or INSURER C:
Robert & Paula Himschoot .
2700 Rockfill Rd INSURER 0: .. - .. -
Fort Myers FL 33916 INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
NSR[ POLICY NUMBER PD9..~~~MM/DD1YYl I POL I LIMITS
LTR TYPE OF INSURANCE DATE MM/DDIYY)
GENERAL LIABILITY EACH OCCURRENCE $ 1000000
-
A X COMMERCIAL GENERAL L1ABILlTi CAPS893052 11/01/09 11/01/10 ~!:'~~"':.r: ~ ~_"~" - $ 500000
PREMISES (Ea occurence)
I CLAIMS MADE ~ OCCUR MED EXP (Anyone person) $ 10000
PERSONAL & ADV INJURY $ 1000000
-
GENERAL AGGREGATE $ 2000000
-
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2000000
I ./il PRO- nLOC
POLICY X JECT
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
- $ 500000
ANY AUTO .. (Ea accident) .
-
ALL OWNED AUTOS BODILY INJURY
- $
A X SCHEDULED AUTOS CAP5893052 11/01/09 11/01/10 (Per person) .
-
..!... HIRED AUTOS BODILY INJURY
$
X NON-OWNED AUTOS (Per accident)
-
- PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
R ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESs/UMBRELLA LIABILITY EACH OCCURRENCE $1000000
A ~ OCCUR D CLAIMS MADE CAP5893052 11/01/09 11/01/10 AGGREGATE $ 1000000
$
R DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND I TOW/ ~I~II$S ~r IOrr-
ER
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? E.L DISEASE - EA EMPLOYEE $
If yes, describe under
SPECIAL PROVISIONS below EL DISEASE - POLICY LIMIT $
OTHER
A Leased/Rented CAP5893052 11/01/09 11/01/10 Ded:$1000 $150000
Equipment
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Collier County is named as Additional Insured with respect to General
Liability coverage for any and all work performed on behalf of Collier
County.
CERTIFICATE HOLDER
CANCELLA TION
COCOL-3 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
COLLIER COUNTY BOARD OF -
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
COUNTY COMMISSIONERS
3301 TAMIAMI TRAIL EAST IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
NAPLES FL 34112 REPRESENTATIVES.
AUTHOR ~ E~TIVE
-" _.....-'C , -
-
ACORD 25 (2001/08)
@ACORDCORPORATION 1988
j
~
ACORV@ CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DDIYYYY)
~ 2/9/2010
PRODUCER Alliance Insurance Solutions LLC THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
PO Box 1777 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
St Petersburg, FL 33731 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
727-497-1247 INSURERS AFFORDING COVERAGE NAIC#
www.ins4biz.com
INSURED Thrive HR FL 1, LLC INSURER A: SUNZ Insurance ComDanv 34762
8902 N. Dale Mabry Hwy INSURER B:
Suite102 INSURER c:
Tampa FL 33618 INSURER D:
I INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOIWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ~~ TYf'F OF INSURANCE . POLICY NUMBER m~~~~'Jg= ~!f€iM~~~ LIMITS
LTR
GENERAL LIABILITY EACH OCCURRENCE $
- ~~~~~J9E~~~~ce\
- 3MMERCIAL GENERAL LIABILITY $
- CLAIMS MADE D OCCUR MED EX? (Anyone person) $
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
GEN'L AGG~nE LIMIT APFlS PER: PRODUCTS-COM~OPAGG $
I POLICY ~bl,9;: LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
- $
ANY AUTO (Ea accident)
t--
t-- ALL OWNED AUTOS BODILY INJURY
(Par person) $
SCHEDULED AUTOS
~
- HIRED AUTOS BODILY INJURY
(Per accident) $
- NON-DWNED AUTOS
PROPERTY DAMAGE $
(Per accident)
~RAGE L1ABILIlY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
::5ESS I UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR D CLAIMS MADE AGGREGATE $
$
R DEDUCTIBLE $
RETENTION $ $
A WORKERS COMPENSATION WCPEOOOOO03201 1/1/2010 111/2011 ./ I WCSTATlJ-.1 IOJii-
AND EMPLOYERS' LIABILITY Y/N
ANY PROPRlETORlPARTNERlEXECUTlVE D E.L. EACH ACCIDENT $ 1 000 000
OFFICERlMEMBER EXCLUDED?
(Mandatory in NH) E.L, DISEASE - EA EMPLOYEE $ 1 000 000
~,m;I:sp~"c5-.ila'lg~s below E.L. DISEASE. POLICY LIMIT $ 1,000,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Coverage provided for all leased employees but not subcontractors of: Crews Environmental
State of Florida Coverage Only
CERTIFICATE HOLDER
CANCELLATION
70923 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
Collier County Board of County Commissioners OATE THEREOF, THE ISSUING INSURER WILL ENOEAVOR TO MAIL 30' DAYS WRITTEN
3301 Tamiami Trail East NOTICE TO THE CERTIFICATE HOLDER NAMEO TO THE LEFT, BUT FAILURE TO DO SO SHALL
Naples FL 34112 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES. '10 Days for Non-Payment of Premium.
AUTHORIZED REPRESENTATIVE
Douglas Lilak au~;1!:&~
ACORD 25 (2009/01)
@ 1988-2009 ACORD CORPORATION. All rights reserved.
CERT NO.: 6827984. Rent!:e Carrano
P: 954-862-2023 2/9/2010 1.2: 23: 23 PM Page 1. of 1.
ITEM NO.: 10, ~~- ~ t9l \
RECEIVED:
~f \;~
\,r V"
~~L,;v~~
~ ~({ Yl/
s11 ) )D
~)l1
..,
FILE NO.:
ROUTED TO:
DO NOT WRITE ABOVE THIS LINE
REQUEST FOR LEGAL SERVICES
Date:
April 29, 2010
To:
Office of the County Attorney
Attention: Jeff Klatzkow
From:
Dianna Perryman., Contract Specialist
Purchasing Department, Extension 4270
st2-.'T
D\U. 5)'S
Re: Contract: #09-5300 "Emergency and Scheduled Grease, Sludge,
and Sewage Hauling"
Contractors: Dixie Drainfields
V Crews Environmental
Southern Sanitation
BACKGROUND OF REQUEST:
This Contract was approved by the BCC on February 9, 2010, Agenda /
Item 16.C.1 V
This item has not been submitted.
ACTION REQUESTED:
Contract review and approval.
OTHER COMMENTS:
Jeff, please forward to the Chairman of the Board of County
Commissioners for signature after approval. If there are any questions
concerning the document, please contact me. Purchasing would appreciate
notification when the documents exit your office. Thank you.
c: George Yilmaz, Wastewater
MEMORANDUM
TO: Ray Carter
Risk Management Department
FROM: Dianna Perryman, Contract Specialist
Purchasing Department
DATE: April 29, 2010
RE: Review of Insurance for Contract: 09-5300 "Emergency and
Scheduled Grease, Sludge, and Sewage Hauling"
Contractors: Dixie Drainfields
vCrews Environmental
Southern Sanitation
This Contract was approved by the BCC on February 9, 2010, Agenda Item
16.C.1
Please review the Insurance Certificates for the above-referenced contract. If
everything is acceptable, please forward to the County Attorney for further
review and approval. Also, please advise me when it has been forwarded.
Thank you. If you have any questions, please contact me at extension 4270.
dod/DP
C: George Yilmaz, Wastewater
mausen_g
From:
Sent:
To:
Cc:
Subject:
RaymondCarter
Monday, May 03,20101 :39 PM
perryman_d
DeLeonDiana; YilmazGeorge; mausen_g; HerreraSandra
Contract 09-5300 "Emergency and Scheduled Grease, Sludge, and Sewage Hauling"
All, I have approved the certificate(s) of insurance provided by Crews Environmental for contract 09-5300. The contract
will now be forwarded to the County Attorney's Office for their review.
Thank you,
Ray
~ Cah.t.eh.
Manager Risk Finance
Office 239-252-8839
Cell 239-821-9370
Under Florida Law, e-mail addresses are public records. If you do not want your e-mail address released in response to a public records request, do not send
electronic mail to this entity. Instead, contact this office by telephone or in writing.
1
www.sunbiz.org - Department of State
Page 1 of2
Home
Contact Us
E-Filing Services
Document Searches
Forms
Help
No Events
N~}'(tonl..ist Retum-LQ..l..H;j
No Name History I Submit I
prevlQusQrLI..J$t
Detail by Entity Name
Filing Information
Document Number P93000051115
FEI/EIN Number 650437217
Date Filed 07/21/1919
State FL
Status ACTIVE
Principal Address
2700 ROCKFILL RD
FT. MYERS FL 33916 US
Changed 02/17/1994
Mailing Address
P,O, BOX 27
FT. MYERS FL 33902-0027 US
Changed 10/16/1997
Registered Agent Name & Address
HIMSCHOOT, ROBERT 0
2700 ROCKFILL RD,
FT. MYERS FL 33916 US
Name Changed: 06/27/2000
Address Changed: 10/16/1997
Officer/Director Detail
Name & Address
Title PO
HIMSCHOOT, ROBERT 0
2700 ROCKFILL RD
FT. MYERS FL 33916 US
Title V
HIMSCHOOT, MICHAEL D
2700 ROCKFILL RD.
FT, MYERS FL 33916
Title V
MILLSPAUGH, RICHARD N
2700 ROCKFILL ROAD
http://www.sunbiz.org/scripts/cordet.exe?action=DETFIL&in~doc_number=P9300005111... 2/512010
www.sunbiz.org - Department of State
FORT MYERS FL 33916
Title' TS
HIMSCHOOT-MITCHELL, THERESA L
2700 ROCKFILL RD.
FORT MYERS FL 33916
Annual Reports
Report Year Filed Date
2008 03/09/2008
2009 03/24/2009
2009 06/29/2009
Document Images
QJlj29/2QOg-- AN.t-JUA'-_Ri::PQRT [
03/24/2009 __ ANNUAL Ri::PORT [
03!OW2008~~ANW,JAL Rr::PQRT [
03/2J/2007 __ ANNUALRr::PORT [
031211200B~~ANNUAL Rr::PQRT [
01/00/2005 -ANNUAL REPORT [
03/18/2004-- AN NlJAL Rr::PORT [
04/04/2003__ANNUALRi::PORT [
04/28/2002 --ANNlJALRr::PORT [
09/00/2001__ ANNlJALRi::PORT [
06/27/2000 .~~ ANNlJALBr::PORT [
04/J8/2000 -~ANNlJAL REPORT [
04/27/1999 ~-ANNlJALBr::EORT [
00llol1998~~ANNUALRi::PORT [
JO/19!J99Z~~.ANNlJALRr::PORT [
08!04/199Z~~ANNUALRi::PORT [
00/19/J997 ~~.ANNlJALRr::PQRT [
O~2-.O./192.B..:.._ANNlJAJ.,~R.!::'pQRT [
04!24!1~9B -- ANNlJALRi::PORT [
05/01j199.o......-nAN.r"H..JAL..RI;PORT [
View image in PDF format
View image in PDF format
View image in PDF format
View image in PDF format
View image in PDF format
View image in PDF format
View image in PDF format
Vi.ew image in PDF format
View image in PDF format
View image in PDF format
View image in PDF format
View image in PDF format
View image in PDF format
View image in PDF format
View image in PDF format
View image in PDF format
View image in PDF format
View image in PDF format
View image in PDF format
View image in PDF format
Note: This is not official record, See documents if question or conflict.
Previous on List
Next on List
No Events
No Name History
Return To List
]
]
]
]
]
]
]
]
]
]
]
]
]
]
]
]
]
]
]
]
I Horne I Contact us I Document Searches I E-Filing Services I Forms I Help I
Copyrigtlt and Privacy Policies
Copy,-ight 2007 State of Florida, Department of State.
Page 2 of2
Entity Name Search
[ Submit I
http://www.sunbiz.org/scripts/cordet.exe?action=DETFIL&in~ doc _ number=P9300005111... 2/5/2010
Entity Name;
RLS#
CHECKLIST FOR REVIEWING CONTRACTS
~oo~L:h'\ l
\0 ?\2-C~ O\~ Il
Entity name correct on contract?
Entity registered with FL Sec. of State?
Os~C-irtk S I~C r
LYes
:LZY es
No
No
Insurance
Insurance Certificate attached?
Insured registered in Florida?
Contract # &lor Project referenced on Certificate?
Certificate Holder name correct (BCC)?
Commercial General Liability
General Aggregate Required $
Products/CompVOp Required $ \ fA" \ \
Personal & Advert Required $ .
Each Occurrence Required $ \ '(V'\. \ \
FirelProp Damage Required $
Automobile Liability
Bodily Inj & Prop Required $ \ fY\ \ \ \
Workers Compensation
Each accident Required $ S CO ~ Provided $~\ \.(
Disease Aggregate Required $ Provided $_ Y'Y'\; \.(
Disease Each Empl Required $ Provided $ , ~~. \(
.
Umbrella Liability
Each Occurrence Provided $ \ \'Oi \I
Aggregate Provided $ . I . I
Does Umbrella sufficiently cover any underinsured portion?
Professional Liability
Each Occurrence Required $K Provided $
Per Aggregate Required $. ProvIded $
Other Insuran~e \ '0 ('\ . I
Each Occur Type: . ~ Required ~ rt" \ \
. \\ \ \.-~ _ 'lSb\l-
County required to be nameG as addi ional insured?
County named as additional insured?
Provided $ ~'('f'\; \ \
Provided $ l L .J I
Provided $ \ Y"i" i \ \
Provided $ l.I 'J
Provided $ SoD' L
No
No
No
No
Exp. Date ~ B
Exp. Date
Exp. Date~ ' t. ) I
Exp. Date
Exp. Date
EXPDate~?
EXPDate~ ')~e-e ,d 1
ExpDate ~f,tl' \ - \- ir'\~C{
ExpDate . _~ ~ ~
\ ~ C\.(\...._ '. " Or
Exp Date ~ CO~~l!fc~
Exp Date , I , , e'/.-(!" lO;J..e...S
~s _No e,rY'Y J
~
-$s
Provided $ 5 CO \L
Exp, Date
Exp, Date
EXPDate~ \ \ I
Provided $ \ yY'\~ \ \
\\\, \ \:0
-Oes
V- Yes
No
No
Indemnification
Does indemnification meet County standards?
Is County indemnifying other party?
~Yes
Yes
~~
Performance Bond
Bond requirement referenced in contract?
If attached, expiration date of bond
Does dollar amount match contract?
Agent registered in Florida?
Yes
No
Yes
Yes
No
No
Signature Blocks
Correct executor name in signature block?
Correct title of executor?
Executor authorized to sign for entity?
Proper number of witnesses/notary?
Authorization for executor to sign, if necessary:
Chairman's signature block?
Clerk's attestation signature block?
County Attorney's signature block?
~:
~::
~
~
No
No
No
No
No
No
No
Attachments
Are all required attachments included?
ReVie~e~ Initials: ~rJ,)
Date: /1/
04-COA-OI03/22