Backup Documents 06/27/2017 Item #16C2 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP b C
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 JAK -;
4. BCC Office Board of County
Commissioners ��45/ -A \ck
5. Minutes and Records Clerk of Court's Office (
rl- l It a'' 's7'
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 Howard Brogdon,Public Utilities Phone Number 252-5252
Contact/Department
Agenda Date Item was 6/27/17 Agenda Item Number 16-C-2
Approved by the BCC
Type of Document Certification 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 JAK
2. Does the document need to be sent to another agency for additional signatures? If yes, JAK
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 JAK
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 JAK
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 JAK
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 JAK
signature and initials are required.
7. In most cases(some contracts are an exception),the original document and this routing slip JAK
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 6/27/17 and all changes made during the JAK -r.r.-WO
meeting have been incorporated in the attached document. The County Attorney's `i: 'aieiAioe.ire:
Office has reviewed the changes,if applicable. l®. :4`s9r:
9. Initials of attorney verifying that the attached document is the version approved by ,A-j: c
BCC, all changes directed by the BCC have been made, and the document is rea for the r , ,i ��+Y�°i i
Chairman's signature. �5 iiW II10C:.
PLEASE CONTACT HOWARD BROGDON (5252) WHEN RE• 1 Y -72,4-`'^k a''^ - -
[04-COA-01081/1344830/111:Forms/County Forms/BCC Forms/Original Documents Routing Slip WWS Or:'nal 9.03.04,Revised 1.26.05,Revised 2.24.05;
Revised 11/30/12
16C2
MEMORANDUM
Date: July 7, 2017
To: Howard Brogdon, Public Utilities
From: Teresa Cannon, Deputy Clerk
Minutes & Records Department
Re: Certificate of Financial Responsibility for Local Government
Attached is the original of the document as referenced above, (Item #16C2) approved
by the Board of County Commissioners on Tuesday, June 27, 2017.
If you have any questions, please contact me at 252-8411.
Thank you.
16C2
CERTIFICATION OF FINANCIAL RESPONSIBILITY FOR LOCAL GOVERNMENT
Collier County Board of County 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 3\7:1�,l--\ , 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: NCRWTP IW-1 AND DZMW-1
Facility Address: 8701 Vanderbilt Bch Rd, Naples, FL
Facility Contact: Howard Brogdon
Phone Number: 239-252-4166
Latitude/Longitude of Injection Well(s): 26 deg 14' 45" N 81 deg 40' 39" W
Current Permit Number: 50581-569-U0/11
Current Plugging and Abandonment Cost Estimate: 292'790
(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
(Signature) t -16 ‘4"'
(Print Name)
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16C2
Notary Form
State of Florida
County of: C0\\ —
Sworn to (or affirmed) and subscribed before me this-110(N day of''Qw\ ,7-c)V--A
by � ..rvc A. ..\\---Kcx.��a y"-' ,
(Name df person making statement)
Personally known to me
OR
El Produced the following identification
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Notary Signature
Print, Typ or Stamp Commissioned Name of Notary Public
Apply Seal of Notary Public below - State of Florida
tir8�'t.po VIRGINIA A.NEST
I .r ' Notary Public-State of Florida
Commission k GG 093412 6
I � PP= My Comm.Expires Jun 23,2021
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8orded through National Notary Assn.
Approv • •f',• •
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Jeffrey A. 1 la 4115•,County Attorney
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