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Backup Documents 09/26/2017 Item #16C6 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLI L TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO (,� C 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 4. BCC Office Board of County Commissioners V114/ g Z--k`�—\ 5. Minutes and Records Clerk of Court's Office Tai)11 4qP6-) 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 Qde0 se,. €mots I 4-'1/4,, ?L{ Contact/ Department . vt‘ \ t r-tJ I�q� � to"� � c 4i,ts(.ccuev to lit< v kta) Agenda Date Item was A enda Item Number -}d P. Approved by the BCC C ( kb-C4, z..w�r c de kCit)Qtc i 055 I)4'1e Type of Document n OA- rt.Ctri_c-iAl Number of Original Attached YDS�r11`iiSo�t s (Oc c ,tk rn ')ocuments Attached 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 s Yes N/A(Not appropriate. (Initial) Applicable) 1. Does the document require the chairman's original signature? 0N:6), 2. Does the document need to be sent to another agency for additional signatures? If yes, N l A 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 J(re# by the Office of the County Attorney. 4. All handwritten strike-through and revisions have been initialed by the County Attorney's 0 1 A 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 N/Pr 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. l) /{ - 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 q-)2-11 and all changes made durbak. the meeting have been incorporated in the attached document. The County Attorney's Office has reviewed the changes,if applicable. 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 p Chairman's signature. 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 C6 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 June 23,2017 , 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: SCWRF IW-2 AND DZMW-1 Facility Address: 5600 WARREN STREET, Naples, FL 34113 Facility Contact: CHRISTOPHER FARRIS Phone Number: 239-252-6886 Latitude/Longitude of Injection Well(s): 26 deg 05' 42" N 81 deg 43' 22" W Current Permit Number: 211999-003-U0/1M Current Plugging and Abandonment Cost Estimate: $391 ,575 (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. La/4NOTARY: See Next Page r (Signature) Item# ie v� Agenda .► (Print Name) Date Date c ' -v-ncxy\ Recd 61.-1,-k-1 (Title) (Date) provedopo f and legality ATTEST L_ DWIGHT E: CCK,CLERK_ rm'{-�,` 1 Scott R.Teach,Deputy County Attorney 6105. CLULL__Ni , A0,0C , =lanai (1) signature only. Notary Form 16 C 6 State of Florida County of: C \\\ )— Sworn to (or affirmed) and subscribed before me this ZIkklay of'e ""'6e v , Zo VA by c."—Pctir� • ©Nr (Name of person making statement) Personally known to me OR 0 Produced the following identification C--- A-2.-,--&—&-7(e. Notary S nature v\ ,r‘‘q • em Print, Type,or Stamp Commissioned Name of Notary Public Apply Seal of Notary Public below- State of Florida ;•''''av"r�'-•. VIRGINIAA.NEET . Notary Public-State of Florida it) Commission*GG 093412I1 ;;�o ` o7My Comm.Expires Jun 23.2021 Barded through National Notary Assn. imbiniirgeroliilmillPmi • 2 0