Backup Documents 11/10/2009 Item #16F 2
ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 16
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO F 2
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE
Print on pink paper. Attach to original document. Original documents should be hand delivered to the Board OlTIce. The completed routing slip and origin<l!
documents are to be forwarded to the Board Office only after the Board has taken action on the item.)
ROUTING SLIP
Complete routing lines #1 through #4 as appropriate for additional signatures, dates, and/or information needed. If the document is already complete with the
~xceDtion of the Chairman's signature, draw a line througJ routing lines #1 through #4, complete the checklist, and forward to Sue Filson (line #5).
Route to Addressee(s) Office Initials Date
(List in routine order)
l.
-----------------------------------
2.
-----------------------------------
,
J.
-----------------------------------
4. CAC I III 0109
---------------_.~-----------_._---
5. Ian Mitchell, BCC Office Board of County Commissioners
Supervisor
6. Minutes and Records Clerk of Court's Office
PRIMARY CONTACT INFORMATION
(The primary contact is the holder of the original document pending Bee approval. Nonnally the primary contact is thc person who created/prepared the executive
summary. Primary contact infonnation is needed in the event one of the addressees above, including Sue Filson, need to contact staff for additional or missing
infonnation. All original documents needing the BeC Chairman's signature are to be delivere.d to the BCe office only after the Bee has acted to approve the
item.)
Name of Primary Staff HAAE-eR- fIle "1 ~1n l i Phone Number 252-;;.e+;. 3 GOO
Contact JIM VON RlNTELN ("I, 252-3621
Agenda Date Item was Agenda Item Number
Approved bv the BCC 11/1 0/09 16F2
Type of Document Number of Original I Need original
Attached Agreement Documents Attached returned. Need original
signature. Stamp not
acceptable.
Initial the Yes column or mark "N/A" in the Not Applicable column, whichever is
a ro riate.
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. This includes signature pages Ii-om ordinances,
resolutions, etc. signed by the County Attorney's Office and signature pages from
contracts, agreements, etc. that have been fully executed by all parties excepl the BCC
Chairman and Clerk to the Board and ossibl State Officials.)
All handwritten strike-through and revisions have been initialed by the County Attorney's ... L
Office and all other arties exce t the BCC Chainnan and the Clerk 10 the Board
The Chairman's signature line date has been entered as the date ofBCC approval of the
document or the final ne otiated contract date whichever is a licable.
"Sign here" tabs are placed on the appropriate pages indicating where the Chairman's
si ature and initials are re uired.
In most cases (some contracts are an exception), the original document and this routing slip
should be provided to Ian Mithchell in the BCC office within 24 hours of BCC approval.
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 our deadlines!
The document was approved by the Bee on ), (enter date) and all changes
made during the meetiug have been incorporate in the attached document. The
Count Attorne '8 Office has reviewed the chan es, if a licable.
[" [.'ormsl County Forms! Bee Forms! Original Documents Routing Slip WWS Original 9.03JI4, Revised 1.26.05, Revised 2.24.05, Revised 9.18.09
INSTRUCTIONS & CHECKLIST
I.
2.
3.
4.
5.
6.
Yes
(Initial)
N/A(Not
A licable)
"'AL
1"&""
--~
"'. Co..
..~
16F2
MEMORANDUM
Date:
November 12, 2009
To:
Maryann Cole,
Emergency Management
From:
Teresa Polaski, Deputy Clerk
Minutes & Records Department
Re:
Agreement
Attached please find a copy of an Agreement (Agenda Item #16F2), as
referenced above and approved by the Board of County Commissioners on
Tuesday, November 10, 2009.
The Minutes and Records Department has retained the original document for
the public record.
If you should have any questions, please call me at 252-8411
Thank you.
Attachment (1)
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Order No. A 12659
16F;;.
I..u.d on Tu.. 06 Oct, 2009
Cre.ted on Tue, 06 Oct, 2009 by Ar1b. System
Supplier:
COLLIER COUNTY EMERGENCY MANAGEMENT
SUITE 44518075 LEL Y CULTURAL PI<!NY
NAPLES, FL 34113
Phone' 239-252-3817
F.x: 239-252-8769
Contact. CHRISTINE CHASE
Ship To:
DCA - Divilion of Emergency Mlln.gement
2555 Shum.rd O.k B"d
T.II.h....., FL 32399-2100
United st.te.
Bill To:
DCA - Division of Emergency Management
D.por1m.nt of Community Aff.lr.
2555 Shumard O.k B..d
T.n.h...... FL 32399-2100
Unit.d State.
Entty D,.cripton: D.partm.nt of Community Affair.
Org.nll.~on Cod.: 52800502001
Obj.ct Cod.: 000000-730000
Exp.n.lon Opdon: 04
Ex.mpton Statu.: Y.s
Exemption Realen?: 1 E
Deliver To:
Nicki. Ryst.r
VersionNumber: 1
R.que.ter: Nicki. Ryst.r
Ship To Cod.: UOA03q2fub,q
Distributor.?: N
5tete Contr.ct ID:
PR No.. PR4159760
R.qu.ster Phon.: 8504139943
Master Agreement JD:
MyGr..nFlorld. Cont.nt N
Method of Procur.m.nt: L. govemm.nt.l.gencyper 287.057(5)(1)13, deflned In 163.3164(10).
Shipping M.thod: B..t Way
FOB Cod.: INC-Des!
FOB Code Description; Destination freight paid by vendor and Included in price. Title passes upon receipt. Vendor files any claims.
Encumber Funds~ Yes
.. PO Start Oat.: Mon. 28 sop ?nno
PO "no !.J.te; W.d. 30 Jun, 2010
meal Year Indicator: 2010 -------
PUI# 5260
51te Code: 520000-00
Addltionallt.m Info:
Terms .nd Condldons: http:/tm.rkelpl.c..myflorld..comN.ndorlpo_lou.pdl
~ Ca.rd Order?: No
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Item De.crlptlon Part Unit Q\y Need By Unit Price Extended Amcunt
Number
1 50% of all hazard analysis completed by... each 1 None $3,188.70000USD $3,188.70000USD
50% of all hazard analysis ccmpleted by Dacember 1. 2009 and approved by tha Project Manager as speclfled In the ahached Scope of Work.
Item Da.crlptlon Part Unit Q\y Nood By Unit Prloo Extondod Amount
Number
2 50% of the remaining hazard analysis ... each 1 None $3.188.70000USD $3,188.70000USD
50% of the ramelnlng hazard analysis completed by March 1, 2010 and approved by the Project Manager as speclfled In the ahached Scope of
Work.
lt8m Description Port Unit Qty N.od By Unit Price Extended Amount
Number
3 Hazard AnalYll1 approval, dlltrlbutlon and ... each 1 None $706.60000USD $706.60000USD
Hazard Analysis approval. aistribution and notification.
Total $7,08600000USD
Status: Ordering
Comments
. SUBMITTED by David Shuffiobo1ham on Monday. Soptembor 28. 2009 at '0;54 AM v.1th commont (2 docum.n" attach.d)
See ahached Scope of Work and supporting documentaUon. CSFA No. 52.023.
Please sign and return the Scope 01 Work Acceptance Form.
Contact Person: Tim Date. Tel. No. 850-410-1272 (David Shufflebo1ham, Mon, 28 Sep, 2009)
. APPROVED by Nickle Ryster on FMday, October 2, 2009 at 5:06 PM with comment
Coding approvad. (Nic,". Ry.tor, Fri, 02 Del. 2009)
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Attachment A
PURPOSE, REQUIREMENTS, SCOPE AND SCHEDULE OF DELIVERABLES AND
SCHEDULE OF PAYMENTS
PurDose
To update the hazards analysis for all faoilities listed in Attaohment 8, which have reported to the State
Emergency Response Commission the presence of those specific Extremely Hazardous Substances
designated by the U.S. Environmental Protection Agency in quantities at or above the Threshold Planning
Quantity. The data collected under this Agreement will be used to comply with the requirements of the
Emergency Planning and Community Right- To-Know Act's planning requirements.
Reaulremenrs
A. The County shall submit a list of faciiities within the County's geographical boundaries that are
suspected of not reporting to the State Emergency Response Commission the presence of
Exiremely Hazardous Substances in quantities at or above the Threshold Planning Quantity, as
designated by the U. S. Environmentai Protection Agency.
B. The compieted hazards analysis shall comply with the site-specific hazards analysis criteria
outlined in this Attachment for eaoh facility listed in Attachment 8. The primary guidance
documents are Attachment D (Hazards Anaiysis Contract Checklist and CAMEO Guide) to this
Agreement and the U.S. Environmental Protection Agency's "Technical Guidance for Hazards
Analysis II, All hazards analyses shall be consIstent with the provisions of these documents. Any
variation from the procedures outlined in these documenls must be requesled in writing and
approved by the Division.
C. Provide an on-site visit to each Attachment B facility 10 ensure accuracy of the hazards analysis.
Each applicable facility's hazards analysis information shall be entered into the U.S.
Environmental Protection Agency's CAMEOfm software program, Each facility hazards analysis
shall include, but is not limited to, the following items:
(t) Facility Information
(a) Provide the Facility name (per Attachment 8)
(b) Facility address
Provide the physical address (no Post Office Box) of the facility.
(c) Facility Identification
Provide the State Emergency Response Commission Code
identification number (per Attachment 8) and the geographic
coordinates (latitude and longitude in decimal degrees).
(d) Facility Emergency Coordinator
Provide the name, title and telephone number (daytime and 24-hour) of the
designated facility emergency coordinator.
(e). Transportation Routes
List the main routes used (from the County line to lhe facility) 10
transport chemicals to and/or 'rom the facility.
A-I
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(f) Evacuation Routes
Based on wind direction from the North, South, East and West, identify the
route(s) from the facility to exit the Vulnerable Zone(s).
(g) Historical Accident Record
Describe any past releases or incidents that have occurred at the
facility. Include date, time, chemical name, quantity and number of
persons injured or killed (this information is available from the facility).
If it is determined that a faci Iity does not have a historicai aocident
record, that shall be noted.
(2) Hazard identification
(a) Chemical identities
Provide proper chemical name, Chemical Abstract Service (CAS)
number and natural physical state (according to exhibit C of the
Teohnical Guidance for Hazards Analysis) tor each Extremely
Hazardous Substance present at the facility at any time up to one year
prior to the site visit.
(b) Maximum quantity on-site
Express In exact pounds (not range codes) the maximum quantity of
each Extremely Hazardous Substance the facility has on-site at any
time up 10 one year prior to the site visit.
(c) Amount in largest container or interconnected containers
Express In pounds the amount of each Extremely Hazardous
Substance stored in the largest container or interoonnected containers
(this is the release amount used to determine the Vulnerable Zone).
(d) Type and design of storage container or vessel
Indicate the storage method of each Extremely Hazardous Substance,
i.e., drum, cylinder, tank, and their respective capacities (It is helpful to
indicate system types such as manifold versus vacuum as well).
(e) Nature of the hazard
Describe the type of hazard (i .e., fire, explosion) and health effects
(acute and chronic) most likely to accompany a spill or release of each
Extremely Hazardous Substance.
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(3) Vulnerability Analysis
(a) Extent of the Vulnerable Zone
For each Extremely Hazardous Substance present at a facility, previde
the estimated gecgraphical area (vulnerable zone) that may be subject
to concentrations of an airborne Extremely Hazardous Substance at
levels that could cause irreversible acute health effects or death to
human populations following an accidental release.
(b) Estimate Facility Population
Provide an estimate of the maximum number of employees present at
the facility at any given time, i.e. if the facility is unmanned except for
routine maintenance by only one person then, the number of
employees present at any given time shall be noted as one.
(c) Critical Facilities
Identify each critical facility by name and each critical facility's
maximum expected occupancy, within each vulnerable zone, which are
essential to emergency response or house special needs populations
(schools, day cares, public safety facilities, hospitals, etc.). If there are
no critical facilities within the vulnerable zone, that shall be noted.
(d) Estimate Total Exposed Population
Provide an estimate of the total exposed population (facility employees +
general population + critical facilities), within each vulnerable zone, that would
be affected in a worst case release scenario.
(4) Risk Analysis (the three ratings (Risk Assessment} at the bol1om of the CAMEOfm
Scenario Page will meet the four requirements belcw)
(a) Probability of release
Rate the prebability cf release as Low, Moderafe, or High based on
observations at the facility. Considerations should include history of
prevlcus incidents and current ccnditions and contrels at the facility.
(b) Severity of consequences of human injury
Rate the severity of consequences if an actual release were to occur
(c) Severity cf ccnsequences of damage tc property
Rate the potential damage to the facility, nearby buildings and
infrastructure if an actual release were to occur.
(d) Severity of consequences of envircnmental exposure
Rate the potential damage to the surrounding environmentally
sensitive areas, natural habitat and wildlife if an actual release were to
occur,
A-3
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D. Identify those facilities in Attachment B for which a hazards analysis was not submitted.
Supporting documentation must be provided with a list to account for the facilities for which
a hazards analysis was not completed. In addition to the facility name and the State
Emergency Response Commission Code identification number, supporting documentation
should indicate:
(1) Facility has closed or is no longer in business.
(2) Facility is not physically located in the County (indicate appropriate County location, if
known).
(3) Facility does not have Extremely Hazardous Substance(s) on-site or Extremely
Hazardous Substance(s) are below the Threshold Planning Quantity. These facilities
require:
(a) A Statement of Determination from the facility representative for the previous
reporting year; or
(b) A letter from the facility representative fully explaining why the Extremely
Hazardous Substance(s) is/are not now present at or above the Threshold
Planning Quantity and a date when the Extremely Hazardous Substance(s)
was/were removed from the facility.
E. On-Site Visits
(1) Conduct a detailed on-site visit, within the period of this Agreement, of all the facilities
listed in Attachment 8, to confirm the accuracy and completeness of information in
the hazards analysis.
(2) Submit a completed Hazards Analysis Site Visit Certification Form (Attachment E) to
the Division for each facility site visit conducted.
(3) Submit (electronicallv) a site plan map with the State Emergency Response
Commission Code identification number and in sufficient detail to identify:
(a) Location of major building(s)
(b) Lccation and identification of EHS container(s)
(c) Location of major street(s) and entrance(s)
(d) North arrow
F. Ensure that the Hazards Analysis information is reflected in the County Local Mitigation
Strategy.
Scope and Schedule of Dellverables
Deliverable 1 :
On of before December 1,2009, the County shall submit fifty (50) percent of the completed
hazards analyses of the Attachment B facilitIes to the Division for review and approval.
Deliverable 2:
On or before March 1, 2010, the County shall submit the final fifty (50) percent of the completed
hazards analyses of the Attachment 8 facilities to the Division for review and approval.
A-4
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Deliverable 3:
A. On or before June 30, 2010, the County shall provide the Division one (1) copy (electronic
format) of each approved hazards analysis. A complete copy of each apprcved hazards
analysis shall be submitted to the applicable Local Emergency Planning Committee and a
copy of the transmittal document shall be submitted to the Division.
B. The County shall notify all Attachment B facilities and applicable first responder agencies of
the availability of the hazards analyses information, and make that information available upon
request and submit proof of said notifications to the Division.
C. As appropriate, participate in a technical assistance training session provided by the Division.
Schedule of Pavments
Pavment
Deliverable #1 . 45% of the Agreement Amount
$3.188.70
Oeliverablelt2 - 45% of the Agreement Amount
$3.188.70
Oeliverablelr.l - 10% of the Agreement Amount
$708.60
Each payment shall be made upon satisfactory completion of the deliverable above and upon receipt of
an acceptable Financial Invoice (Attachment C).
A-5
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ATTACHMENT B. COLLIER COUNTY SECTION 302 FACILITIES
~eClSERC Phyolcol Addr...
EVEROLADES CITY PUllLIC WORKS - BOOSTER WJP
NORTHCOPELANDAVENUB
EVERGLADES CITY PL 34139
9
29431
MolUng Address
9
CITY OF BVEROLADES CITY
POST OFFICE BOX 110
EVERGLADES CITY FL 34139-
11018
9
22581
BMllARQ - NAPLES I GOLDEN GA TB CENlRAL OFFICB
4661 SUN SET ROAD
GOLDEN GATB FL 34116-582
BMllARQ
555 LAKE BORDER DRIVE FLAPKA0206
APOPKA PL 32703
AGMARTPRGDUCB.FARMI2
9 8355 COUNTY ROAD sSS
~OKALBB FL ~142.~0
AG-MARTPRODUCE
4006 NORTH AIRPORT ROAD
PLANT CITY FL 33563
33549
9
33621
AG MART PRODUCE. IMMOKALBEFARM
COUNTY ROAD 846
IMMOKALBB FL ~142
AG.MARTPRODUCE
4006 NORTH AIRPORT ROAD
PLANT CITY FL 33563
BARNETT FARMS
9
mGHW A Y 858 I BAST COUNTYLINB ROAD
18743 ~OKALBB FL 34143
BARNETT FARMS
POST OFFICE BOX 1144
~OKALBB FL ~143-
9
2517
FAR...\1ER.S SUPPLY
710BROWARD STREET
IMMOKALBB PL
34142-
FARMERS SUPPLY
7l0BROWARD STREBT
IMMOKALBE FL
34142
9
20BO
GARGIULO. BllN RESEARCH
25672 IMMOKALEE ROAD
IMMOKALEE PL 34142
GARGIULO
15000 OLD US }{[GHWAY 41 NORTH
NAPLES FL 34110-
HOWARD FBRTILIZBR -lMMOKALBB
2IS WEST NEW MARKET ROAD
Th1]\.[OKALEE FL 34142-
HOWARD FBRTII1ZBR
POST OFFICE BOX 628202
ORLANDO FL 32862
9
2318
CITY OF MARCO ISLAND. LlME SOFTENlNG PLANT
961 WINDWARD DRIVE
MARCO ISLAND PL 34145-
CITY OF MARCO ISLAND
50 BALD EAGLE DRIVE
MARCO ISLAND FL 34145-3528
B.l
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CITY OF MARCO ISLAND - REVERSE OSMOSIS FACIIJ1Y
415 LILLY COURT
MARCO ISLAND FL 34145-
9
22537
9
15951
9
15121
9
15950
EMBARQ - MARCO ISLAND I CENTRAL OFFICE
401 EALD EAGLE DRIVE
MARCO ISLAND PI.. 34145-271
9
2120
CITY OF NAPLES - WAlBR PLANT '2
1000 FLElSCHMANN BOULEVARD
NAPLES FL 34102
9
2)[9
CITY OF NAPLES. WWTP
1400 TIIIRD AVENUE NORTII
NAPLES FL 34102-
9
3:2254
CLASSIC BENTLEY VILLAGE
2315 LEISURE LANE
NAPLES PI.. 34110
9
27919
CLUB AT THE STRAND
5800 STRAND BOULVEARD
NAPLES PI.. 34110-139
9
9624
CLUB PELICAN BAY
6650 WATERGATE WAY
NAPLES PI..
34108.
9
22570
EMBARQ - NAPLES I CI'NTRAL OFFICE
10201 NORTIi TAMIAMl TRAIL
NAPLES FL 34108
EMBARQ. NAPLES I NAPLES AlRPORTRLS
3150 RADIO ROAD
NAPLES FL 34104-
EMBARQ - NAPLES I NAPLES MOORIN'G CENTRAL OFFICE
99026 AVENUE NORTII
NAPLES PI.. 34103-
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MRillng Add....
CITY OF MARCO ISLAND
50 BALD EAGIE DRIVE
MARCO ISLAND PL 34145-3528
EMBARQ
555 LAKE BORDER DRIVE FLAPKA0206
APOPKA FL 32703
CITY OF NAPLBS
380 RIVERSIDB CIRCLE
NAPLES FL
34102-
CITY OF NAPLES
380 RIVERSIDE CIRCLE
NAPLES FL
34102-
CLASSICRESIDBNCBS BYHYATI
2315 LEISURE LANE
NAPLES PI.. 34110
THE CLUIl AT THE STRAND
5800 STRAND BOULEVARD
NAPLES PL 34110-
THE CLUB PELICAN BAY
707 GULP PARK DRIVE
NAPLES FL 34108-
EMBARQ
555 LAKE EORDER DRIVE FLAPKA0206
APOPKA FL 32703
EMBARQ
555 LAKE BORDER DRIVE FLAPKA0206
APOPKA FL 32703
EMBARQ
555 LAKE BORDER DRIVE FLAPKA0206
APOPKA FL 32703
B.2
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:;:.CISERC P~lcol Add....
P OU A. OOLDEN OA1B W1P. 2184
4300 OOLDEN OA 1B PARKWAY
NAPLES PL 34116
9
2184
9
26355
OAROIULO . FARM 7
15000 EAST US HIGHWAY 41
NAPLES FL 34114-
9
2223
OAROIULO . OULF COAST FARM 7
14 AVENUE SOUTHEAST NEAR GOLDEN GATE
NAPLES FL 34114-
9
6855
GARGIULO - S W F FARMS
5870 COUNTY ROAD 858
NAPLES FL 34120-
9
31660
HALEAKALA CONSTRUCTION
5758 TAYLOR ROAD
NAPLES FL 34109-182
9
32936
LBVEL 3 COMMUNICATIONS. NAPLES HUT
3960 20 PLACE SOUfHWBST . NAPLES HUT
NAPLES FL
9
35531
OLD COUJER OOLF CLUB
797 WALKBRBn..TROAD
NAPLES PL 34110
9
29655
SAMS CLUB - STORE 6364
2550 IMMOKALEE ROAD
NAPLES FL 34110-
9
3619]
SYNGENTA SEEDS - NAPLES
10290 GREENWAY ROAD
NAPLES FL 34114
\VlNDSTAR CLUB
9
4343 YACHT HARllORDRIVE
35132 NAPLES FL 34112
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FLORIDA OOVBRNMENTAL UTILITY AUTHORlTY
280 WEKIV A SPRlNOS ROAD. SUITE 203
LONGWOOD FL 32779
OAROIULO
15000 OLD us HIGHWAY 41 NORTH
NAPLES FL 34110-
OAROIULO
15000 OLD US HlGHWA Y 41 NORTH
NAPLES FL 3411 0-
GARGIULO
15000 OLD US H!OHWAY41 NORTH
NAPLES FL 3411 0-
HALBAKALA CONSTRUCTION
575STAYLORROAD
NAPLES PI.. 34109-11lll29
LBVEL 3 COMMUNICATIONS
S43lNDUSTRlAL DRIVE
LEWISBERRY PA 17339
THE OLD COILlER OOLP CLUBlNC
790 MArn' HOUSE DRIVE
NAPLES FL 3411 0
SAMS BAST INe - CORPORATB COMPLIANCE
SOB SOUIHWEST 8 STREET
BBNTONVlLLE AR 72712.0505
SYNGENT A SEEDS
7500 OLSON MEMORlAL HlGHWAY
OOLDEN V AILEY MN 55427
WINDSTAR CLUB, INe
1700 WINDSTAR BOULEVARD
NAPLES FL 34112
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Attachment C
FINANCIAL INVOICE FORM
FOR
HAZARDOUS MATERIALS HAZARDS ANALYSIS UPDATE
COUNTY:
PURCHASE ORDER #
AMOUNT
REQUESTED
BY THE RECIPIENT
AMOUNT APPROVED
BY THE
DIVISION
1. First Payment (45% of contract amount) $
(50% Hazards Analyses compl8ted/submirted)
2. Second Payment (45% of contract amount) $
(50% Hazards Analyses completed/submirted)
3. Final Payment(10% of contract amount) $
(approval, distribution & notification)
$
$
$
TOTAL AMOUNT $
$
(To be completed by
the Division)
I certify that to the best of my knowledge and belief the billed costs are in accordance with the terms
of the Agreement.
Signature of Authorized Official/Title
Date
TOTAL AMOUNT TO BE PAID AS OF
THIS INVOICE $
(To be comple~ed bv the Division)
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Attachment 0
I-+Az .A'!;IT\.C: AI'oJALr~o;;l.4i [,LJ~T" c.1+6t!.t.l.u.O;;'" A~~ {"AMeD ~u 1!)5
~Ar..ILrry It-.JFDA?MAT1CJI'rJ
Facility Name {per Attachment B} (Facility page)
Facility Physical address (Facility page)
SERC Code Idenl~lcallon number {per Attacltment B, I.e. SERC#XXXXX} (Department Field on Faclll'ly page)
Latitude & Longitude in degroeslmlnut../Slcenda {i.e. 30.1917 - 84.3621) (Map Dala lab on Facility page)
Facility Emergency Coordinator name, title, phone # [Including 24 hr. number, (Contact tab on Facility page)
Transpertatien Reute(s) {frem ceunty Iinete Ihe facility) (Nete. lab en Facility page)
Evacuation Route(a) to exit the vulnerable zone (Notes lab on Facility page)
Histerical Accident Recerd (If nene, please nete) (Note. tab on Facility page)
t+AZ.ARl> 11>6NTlFICATlON (for each Extremdy Hazardou. Sub.tance en .tte)
Proper chemical name(s) (Chemical In Inventory pagels))
Chemical Abstract Service (CAS) number (Chemical in Inventory pagels})
Natural physical atate lie. mixture, pure, liquid, ""lid, gas) (Chemical In Inventory pagels), Physical State and Quantity tab)
Maxim um quanmy en-s.e in peunds (Chemical in Inventory pagels), Physical State and a.....ntity tab)
Amount In large.t container or Interconnected contalne", (Chemical In Inventory pagels)' Physical Slate and Quantity tAb)
Type and design ef sterage centainer(s) (i e. cylinder, sle.1 drum, carboy etc) (Chemical in Inventery pagels), lecation lab)
Nature ot the Oftzard {i.e., ecute, chronic, fire, pre..ure elc} (Chemical In Inventory pagels)' Physical State and Quantity tab)
Vl..tl NSRA1!.ILlT'( ANAl '1:''''.'' (for each Extremely Hazardous Subslance on o1te)
Estimate vulnerable zene {threat zone} radlu. (bottom ef Scenario pagel'}l
Feclllty Population {unmanned facll~le. minimum of one Is required for maintenance personnel} (10 Codes tab on Facility page)
Critical Facilitias {name ef facil.ie. and max occupancy for each) [if nono, please notol (Notes tab on Scenario pagels})
E5Ilmate Total Expo.ed Populatlon(.) {tacll~y + general population + cr~lcal facilities} (Notes tab on Scenario page{s})
RISK ANALYSIS (ror each Extremely Hazardous Subslance on 011e) (Scenario pagels))
The lbree ratlnR' IRI.k A....smenl1 at the bottom of the SCENARIO P AGEISl will meet lhe four reoulremenl. below
Rate probability of relee.. (I.e., low, medium or high}
Rate severity of consequences of human injury {i,Q" low, medium or high}
Rate s..ver.y of consequ..nce. ef damage te property (i.e., low, medium er high)
Rate severity of consequences of environmental exposure {Lu" low, medium or high}
DN,."'"", VI."'T." (within lbe contract period)
Completed hazard. analy.l. site vl.lt cenlflcatlon form (submItted electronically or hard copy)
Site plan map (submitted electronically) for each facility, with SERe code number and with sufficient detail to identify:
: Location of majer building(a)
I Locatien ef container(s) of Extr..mely Hazardeus Substance(.)
i Location of major street(s) and ontrance(.)
I North arrow
The data in the Facility Information, Hazard Identification, Vulnerability Analysis and Ri.k Analysis
.ection. noted above shall be submitted electronically in a CAMEOfm zip file format.
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['} 13/16
16F2
Attachment E
Name of Facility (Please print)
Name of County (Please print)
State Emergency Response Commission (SERG) Code
Name of Facility Representative (Please print)
Facility Representative Signature
Site Visit Date
Name of Inspector (Please print)
Inspector's Signature
Site Visit Date
The individuals sianina above certifv that a hazards analvsis site visit was conducted on the above date.
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ATTACHMENT "F"
METHOD OF COMPENSA nON
1.0 PURPOSE:
This AUaclunent defines the limits of compensation to be made to the County for the services set
forth in Attachment "A" and the method by which payments shall be made.
2.0 COMPENSATION.
For the satisfactory performance of services detailed in Attachment "A", the County shall be
paid the amounts in accordance with Schedule of Deliverables and Payments in Attachment "A"
for a maximum contract value of 57.086.00.
3.0 PAYMENTS:
The County shall submit an original signature invoice (3 copies) in a formal acceptable to the
Division. Payment for services shall be made at amounts shown in Attachment "A", as approved
by the Division.
Invoices shall be submitted to:
Florida Division of Emergency Management
Tim Date. Plannlm, Manaller
2555 Shumard Oak Blvd.
Tallahassee. FL 32399-2100
4.0 DETA~S OF COSTS AND FEES:
Details of the County's hilling rates for these services are contained in Attachment "A", attached
hereto and made a part hereof.
5.0 TANGIBLE PERSONAL PROPERTY:
This contract does not involve the purchase of Tangible Personal Property, as defined in Chapter
273, F.S.
Cl 14/16
16F2
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ATTACHMENT G
ADDITIONAL TERMS AND CONDITIONS
1. A later date may be agreed upon in writing by both parties to this Agreement.
2. The Division will be the sole authority for determining extenuating circumstances and
granting extensions to the deliverable deadline.
Cl 15/15
16F2
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Cl 16/16
16F2
HAZARD ANALYSIS UPDATE
SCOPE OF WORK ACCEPTANCE
The governmental entity Indentified In the Scope of Work agrees to fully perform the
specified services in Altaclunent A, Purpose, Requirements, Scope and Schedule of
Deliverables and Schedule of Payments and all other supporting documentation attached
to this Purchase Order.
Please sign and return this acceptance form prior to commencement of services to:
Tim Date, Planning Manager
2555 Shumard Oak Blvd.
Tallahassee, Florida 32399.2100
k of eourtf.
'; c/-
OOARD OF mUNTY CXX\1MISSIONERS
mILlER ::: 1:2
Fiala, Chainnan
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DefIIlY (;olUlty Attonaey