Backup Documents 04/26/2016 Item #16C 2 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 16 L 2
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 Attomey Office.
Route to Addressee(s) (List in routing order) Office Initials Date
1.
2.
3. County Attorney Office County Attorney Office SRT 4-26-16
4. BCC Office Board of County .-b b`-\
Commissioners VW// A\- i \t+b
5. Minutes and Records Clerk of Court's Office ( 'yvk J
UV�/ 20:44444
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 informat of
Name of Primary Staff �r �C �` �' 239-25
7 1
Contact/ Department \ �. Ate-, J�1-- .
Agenda Date Item was April 26,2016 Agenda Item Number 16C2
Approved by the BCC
Type of Document Certificate of Financial Responsibility Number of Original One
Attached Documents Attached
PO number or account n/a
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 szt- £sR`f'
2. Does the document need to be sent to another agency for additional signatures? If yes, SRT
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 S'
signed by the Chairman,with the exception of most letters,must be reviewed and signed ' t
by the Office of the County Attorney.
4. All handwritten strike-through and revisions have been initialed by the County Attorney's SRT
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 SRT
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 SRT
signature and initials are required.
7. In most cases(some contracts are an exception),the original document and this routing slip SRT
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 L-11-4-llvand all changes made during S'
the meeting have been incorporated in the attached document. The County 4i
Attorney's Office has reviewed the changes,if applicable. q
9. Initials of attorney verifying that the attached document is the version approved by the
BCC,all changes directed by the BCC have been made,and the document is ready for the
Chairman's signature.
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I:Forms/County Forms/BCC Forms/Original Documents Routing Slip WWS Original 9.03.04,Revised 1.26.05,Revised 2.24.05;Revised 11/30/12
16 C 2
MEMORANDUM
Date: April 27, 2016
To: Alicia Abbott, Project Manager
Collier County Public Utilities
From: Martha Vergara, Deputy Clerk
Minutes & Records Department
Re: Certification of Financial Responsibility for Local Government
Attached for your record is one (1) original of the document referenced above,
(Item #16C2), approved by the Board of County Commissioners on April 26,
2016.
The original document will be held in the Minutes & Records Department in the
Board's Official Records.
If you have any questions, please call me at 252-7240.
Thank you.
Attachment
16 C
CERTIFICATION OF FINANCIAL RESPONSIBILITY FOR LOCAL GOVERNMENT
The Collier County Board of Commissioners , 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 March 28,2016 , 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)
Facility Name:
South County Regional Water Treatment Plant
Facility Address: 3851 Utilities Drive, Naples, FL
Facility Contact: Steve Messner
Phone Number: (239) 252-6937
Latitude/Longitude of Injection Well(s): 26° 09' S2"N / 81 40' 58"W
Current Permit Number: 173528-005-006-U0/1I
Current Plugging and Abandonment Cost Estimate: $518,100
(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
(Si_•.ture) Attest:
DWIGHT E.RROCK BOARD OF COUNTY COMMISSIONERS
Court of C• '
s OOLLIER COON FLORIDA
(Print Name)
Nay, l.•� �,i�•i By: "�,
Deputy Ierk Donna Fiala, Chairman
Title Dated: ' Y`t� • ` L�' Ic
( ) AueS 5LV C11.,,,.;,,Ats
(Seal) ,
• n ure on�►.
A.•,•ved s r an a ality:
(Date)
or
Scott Teach
Deputy County Attorney
1
16C 2
Notary Form
State of Florida
County of: Collier
Sworn to(or affirmed)and subscribed before me this2-Lday of %.vvA ,Zolh
by --\:)orrcA. �‘oaal. , ,
(Name of person making statement)
Personally known to me
OR
Produced the following identification VVCk.._
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Notary ignature
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Print,Te,or Stamp Commissioned Name of Notary Public '
Apply Seal of Notary Public below-State of Florida
VIRGINIA A.NEE
...IV,P.Ud,,,io ..` c Notary Public^_S1ate of
Florida
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My Comm.Expires Jun 23,2017
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, Commission# FF 11938
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