LUST Invoice

Please route separately to Finance & Accounting

State Cleanup Program Services Change Order & Invoice

Task AsslgnmMt # FAC.ID# FDEP Contract # Conraclor# lnvolc,i #

GC654-108A 638517150 GC654 00080 160416

KWIK STOP-KAREN'S �-04/_ 0_1_/1_5 __ to��03�/=29�/1�6'---- FadlltyName Partod or SeNice (PoS)

LAKE BUTLER UNION

City �ncl Counly

Vendor Remit Payment To: Ill To:

Environmental Consutllng & Technology, Inc.

3701 Northwest 98th Street lot1da Dept of EJ\\lironmenlal Prolectio<l

Bureau of Petroleum Storage Systl!fns

----------------------�0 600 Blair Steno Road, MS 4575

Gainesville, FL 32606 allahassee. Flortda 32399-2�00

FEIO # : 59-2921038

Agent: Susan M. McConnell ttn SPSS Aeccultlng

Telephone: 352-332-0444

(1) (2) (3) (4) (5) Invoicing Point Origlrial Amoonl Chango AmOU'll New Total Previously Invoiced

(yip/•)

10 1st Event S26.637.01 S7, 150. 28 $33,788.19

2w 2nd Event $0.00 $35,784.75 $35,784.75

30 3rd Event S0.00 S0.00 S0.00

40 4th Event $0.00 SO.OD SO.OD sD 5th Event SO.DO S0.00 S0.00 sO 6th Event $0.00 so oo so.co

10 Remedial Systems $0.00 SO.OD $0.00 aw Final Dellverable $520.54 ($520 54) $0.00 oG] Retainage $3,017.61 S4,712.72 $7,730.33

Total $30,176.06 $47,127.21 sn,303.21 I

S1gn.,1Ure by authorized �ntracto, reprnscn!alive afflnns !Ml !his Invoice Is wbmlned In accordance with tho Tuk Ass1Qfll!19nt and certllies any change request.

Jiµj ,(n1 If/, � .;:Sa,:.in:.:•a.;.n :.::.M:..:;, Me..:c.:;Co::.:.n::..::na:.:.:11'-------- '6;;;;;..Clor Repre$enlative S1gna1U1e Pnnt Name

FOEPI\.P Use Only Ma,y.J lnyojce Coqecdons OI OICMH!Y) Manual Corrections Made By (print name):

Approved By (print contractor rep. name):

Date Approvo<l

Al>!>roval Method (orde one). phone fa>: email othor ____ _

DEPILP Use Only:

$33,788.19

S0.00

S0.00 so.co

SO.OD

$0.00

SO.OD

S0.00

S0.00

$33,788.19

TOPCLOCK #1

Reason

ESTART CLOCK #1

Reason

ESTART CLOCK 12

I ccr1ffy, by e...;dence of my slgnature below, lhe above lnformalion Is IM! and correct, the goods and seMC8' have been ahfaci.orily received and payment Is now due. t !Marsland that the oflic.e ol lh• State Chief Flnanc;al Olficor rvsvrves right to require add banal documel1a!l9n anato, 10 conducl periodlc;,-1 audits o,'JJY •�men�� ii, � / I Data Complete lnvace Recer,,ed > / 1 / j b .,.,'-/���_vnG______,l��{O--'Uc....:;..v,v--__ �J thi�.,, 1---, f_b

. \) S>e I ( K_ k o(f e > Sile M

Gfr r

]EIUre

Prinlcd Name ob nue Dale Sen,,ces Rendered 4/1 /I'> - ?/ I b/ I �

Dalo Services Approved

Temptalo-060112·SC >.11

2/19/J b Flnal lnvQJce

Date

Invoice Data

02/16/16

06115/16 PoS Exlanded to �'

G_ :'°•J ,.. '""

�c_,

- "I, :.o S:: o....:...

.. u

:t

C-OSt Center ti

37450401000

�IFYIEO

:..n

�...J

U"l

N

::.-� -·- _ ..• r

FDEP/1.P Received Dale Stamp

(6) (7) Due This Invoice Balance

$0.00 SO.OD

S35,784.75 / S0.00

S0.00 S0.00

$0.00 S0.00

S0.00 so.co

SO.DO S0.00

$0.00 SO.DO

S0.00 SO.OD

S7 730.33 S0.00

$43,515.08 $0.00

Date

Date

Date

·,!?�7 r ., Finance t. Aca>untlng Recelvad Date mackey_l Pencil mackey_l Typewritten Text mackey_l Pencil mackey_l Typewritten Text 106A mackey_l Typewritten Text

LUS

mackey_l Typewritten Text mackey_l Reviewed

Florida Department of Environmental Protection-Division of Waste Management-Bureau of Petroleum Storage Systems

Task Assignment Template

Page 1 of 2 Karens Kwik Stop 654-106A

Task Assignment #: GC654-106A FDEP/LP Site Mgr: RUSSELL RHODES Facility Id #: 638517150 Site Name: KWIK STOP-KAREN'S FDEP Share: 100.00%

Contractor #: 00080 Contractor Name: ENVIRONMENTAL CONSULTING & TECHNOLOGY, INC. Applicant/Owner Share: 0.00% Date: 03/04/16 Total: 100.00%

Work Description:

Allowed Cost Number of Items Item Cost Change

Amount Change Costs Template Total Cost

Section A: Packaged Work Scopes 1 Pumping Test or Multi-phase Pilot Test (using in-house personnel) $2,681.26 $0.00 $0.00 $0.00 2 Air Sparging and/or Vapor Extraction Pilot Test (using in-house personnel) $2,491.81 $0.00 $0.00 $0.00 3 Monthly O&M Visit $929.04 $0.00 $0.00 $0.00 4 Monthly Telemetry Allowance (Non RAI) $60.00 $0.00 $0.00 $0.00 5 RAI Monthly O&M Allowance - Small System $3,029.90 $0.00 $0.00 $0.00 6 RAI Monthly O&M Allowance - Medium System $3,550.80 $0.00 $0.00 $0.00 7 RAI Monthly O&M Allowance - Large System $4,180.81 $0.00 $0.00 $0.00 8 RAI Supplemental O&M Monthly Allowance - Thermox/Catox Treatment $519.40 $0.00 $0.00 $0.00

Section A Subtotals: $0.00 $0.00 $0.00 Section B: Office Activities, Part I

1 Proposal Preparation $584.88 $0.00 $0.00 $0.00 2 File Review $636.20 $0.00 $0.00 $0.00 3 Permits $796.95 $0.00 $0.00 $0.00 4 Site Health & Safety Plan $372.81 $0.00 $0.00 $0.00 5 Notice of Discovery of Contamination Package (Initial or TPOC) $295.27 $0.00 $0.00 $0.00

Section B Subtotals: $0.00 $0.00 $0.00 Section C: Field Activities

1 Mobilization (2 person) $884.62 $0.00 3.0 $2,653.86 $2,653.86 2 Mobilization (1 person) $494.33 $0.00 2.0 $988.66 $988.66 3 Drilling Setup (2 person) $264.19 $0.00 $0.00 $0.00 4 Drilling Setup (1 person) $160.79 $0.00 $0.00 $0.00 5 SB for Soil Screening or Piezometer Install (≤ 10 ft) (2 person) $258.21 $0.00 $0.00 $0.00 6 SB for Soil Screening or Piezometer Install (≤ 10 ft) (1 person) $154.82 $0.00 $0.00 $0.00 7 SB for Soil Screening or Piezometer Install (> 10 ft to ≤ 30 ft) (2 person) $387.32 $0.00 $0.00 $0.00 8 SB for Soil Screening or Piezometer Install (> 10 ft to ≤ 30 ft) (1 person) $232.23 $0.00 $0.00 $0.00 9 SB for Soil Screening or Piezometer Install (> 30 ft) (2 person) $516.42 $0.00 $0.00 $0.00

10 SB for Soil Screening or Piezometer Install (> 30 ft) (1 person) $309.64 $0.00 $0.00 $0.00 11 Well Install (≤ 20 ft) (2 person) $528.38 $0.00 $0.00 $0.00 12 Well Install (≤ 20 ft) (1 person) $321.59 $0.00 $0.00 $0.00 13 Well Install (> 20 ft to ≤ 40 ft) (2 person) $792.56 $0.00 6 $4,755.36 $4,755.36 14 Well Install (> 20 ft to ≤ 40 ft) (1 person) $482.38 $0.00 $0.00 $0.00 15 Well Install, double cased (≤ 40 ft) (2 person) $1,585.13 $0.00 $0.00 $0.00 16 Well Install, double cased (≤ 40 ft) (1 person) $964.76 $0.00 $0.00 $0.00 17 Recovery or Multi-Phase Well Install (≤ 40 ft) (2 person) $1,040.08 $0.00 $0.00 $0.00 18 Recovery or Multi-Phase Well Install (≤ 40 ft) (1 person) $626.51 $0.00 $0.00 $0.00 19 Air Sparging/Injection Well Install (≤ 40 ft) (2 person) $390.03 $0.00 $0.00 $0.00 20 Air Sparging/Injection Well Install (≤ 40 ft) (1 person) $234.94 $0.00 $0.00 $0.00 21 Soil VE Well Install (≤ 40 ft) (2 person) $258.21 $0.00 $0.00 $0.00 22 Soil VE Well Install (≤ 40 ft) (1 person) $154.82 $0.00 $0.00 $0.00 23 Well or Piezometer Abandonment (1 person) $107.73 $0.00 $0.00 $0.00 24 Recovery or Multi-phase Well Abandonment (1 person) $236.75 $0.00 $0.00 $0.00 25 Well Sampling with Water Level (2 person) $263.77 $0.00 7 $1,846.39 $1,846.39 26 Well Sampling with Water Level (1 person) $160.38 $0.00 2 $320.76 $320.76 27 Water Level or Free Product Gauging (1 person) $24.39 $0.00 $0.00 $0.00 28 Free Product Gauging & Bailing (per well) (1 person) $126.72 $0.00 $0.00 $0.00 29 Area Survey (2 person) $1,056.75 $0.00 $0.00 $0.00 30 Area Survey (1 person) $643.17 $0.00 $0.00 $0.00

Section C Subtotals: $0.00 $10,565.03 $10,565.03 Section D: Other Field Work

1 Other Field Work $0.00 $6,863.35 $6,863.35 $6,863.35 2 Other Field Work $0.00 $0.00 $0.00 3 Other Field Work $0.00 $0.00 $0.00 4 Other Field Work $0.00 $0.00 $0.00 5 Other Field Work $0.00 $0.00 $0.00

Section D Subtotals: $0.00 $6,863.35 $6,863.35 Section E: Other Equip. Rental Cost(s)

1 Other Equipment $0.00 $0.00 $0.00 2 Other Equipment $0.00 $0.00 $0.00

Section E Subtotals: $0.00 $0.00 $0.00

Second Event

Comments / Notes

Cost Share Information

Template

ChangeOriginal

Florida Department of Environmental Protection-Division of Waste Management-Bureau of Petroleum Storage Systems

Task Assignment Template

Page 2 of 2 Karens Kwik Stop 654-106A

Task Assignment #: GC654-106A Facility Id #: 638517150 Site Name: KWIK STOP-KAREN'S Date: 03/04/16

Allowed Cost Number of Items Item Cost Change

Amount Change Costs Template Total Cost

Section F: In-house Service Cost(s) 1 Laboratory $0.00 $0.00 $0.00 2 Drilling $0.00 $0.00 $0.00 3 Direct Push $0.00 $0.00 $0.00 4 Construction $0.00 $0.00 $0.00 5 Other $0.00 $0.00 $0.00

Section F Subtotals: $0.00 $0.00 $0.00 Section G: Subcontractor Cost(s) Sub Markup = 10.00% Unit Cost Do not include markup

1 Laboratory (from worksheet) $0.00 $0.00 $0.00 $0.00 2 Laboratory $0.00 $2,442.16 $2,686.38 $2,686.38 3 Mobile Lab $0.00 $3,200.00 $3,520.00 $3,520.00 4 Drilling $0.00 $0.00 $0.00 5 Direct Push $0.00 $11,111.26 $12,222.39 $12,222.39 6 Construction $0.00 $0.00 $0.00 7 Non-Capital Equip. and/or Materials $0.00 $0.00 $0.00 8 Remedial Equip./System Lease $0.00 $0.00 $0.00 9 Disposal $0.00 $380.00 $418.00 $418.00

10 Other (Describe) $0.00 $0.00 $0.00 Section G Subtotals: $0.00 $18,846.77 $18,846.77

Section G1: Remedial System Purchase Do not include markup 1 Remedial System Costs $0.00 $0.00 $0.00 2 PAC Remedial System Costs $0.00 $0.00 $0.00

Remedial System Subtotals: $0.00 $0.00 $0.00 Section H: Office Activities, Part II

1 General / SA Report Field Work x Multiplier Field Work = $17,428.38 Field Work Costs (Secs C & D) = $0.00 20% $0.00 $0.00 1.0 $3,485.68 $3,485.68

2 Letter or NPDES Report $308.00 $0.00 $0.00 $0.00 3 O&M Quarterly Report $1,795.41 $0.00 $0.00 $0.00 4 O&M Annual Report $3,312.95 $0.00 $0.00 $0.00 5 Pilot Test Plan $796.67 $0.00 $0.00 $0.00 6 Pilot Test Report $1,391.37 $0.00 $0.00 $0.00 7 Level 1 LSRAP or RAP Modification $1,528.63 $0.00 $0.00 $0.00 8 Level 2 LSRAP or RAP Modification $2,992.72 $0.00 $0.00 $0.00 9 Level 3 LSRAP or RAP Modification $5,309.45 $0.00 $0.00 $0.00

10 Level 4 LSRAP or RAP Modification $8,770.31 $0.00 $0.00 $0.00 11 Level 1 Remedial Action Plan $13,171.60 $0.00 $0.00 $0.00 12 Level 2 Remedial Action Plan $17,540.62 $0.00 $0.00 $0.00 13 As-built Drawings (P.E. red lined) $674.13 $0.00 $0.00 $0.00 14 Construction Drawings and Specs $3,707.61 $0.00 $0.00 $0.00 15 RAC Bid Package Solicitation/Evaluation $2,091.24 $0.00 $0.00 $0.00 16 RA Startup Report $2,604.07 $0.00 $0.00 $0.00 17 Soil Source Removal or Site Characterization Screening Report $1,929.93 $0.00 $0.00 $0.00 18 Natural Attenuation Plan $1,178.26 $0.00 $0.00 $0.00 19 Long Term Natural Attenuation Plan $308.00 $0.00 $0.00 $0.00 20 Remedial Action Interim Report $578.38 $0.00 $0.00 $0.00 21 General Remedial Action Report $1,178.26 $0.00 $0.00 $0.00 22 NA or Post RA Monitoring Quarterly Report $578.38 $0.00 $0.00 $0.00 23 NA or Post RA Monitoring Annual Report $1,445.04 $0.00 $0.00 $0.00 24 Well Abandonment Report $266.78 $0.00 $0.00 $0.00 25 Initial Map & Table Generation $2,032.96 $0.00 $0.00 $0.00 26 Other Report Type (backup spreadsheet) $0.00 $0.00 $0.00

Section H Subtotals: $0.00 $3,485.68 $3,485.68

Due Date Deliverable / Documentation Interim Deliverable

Final Deliverable Information (Specify only if selected for this event) Original Change Total Deliverable # 0 Event Total: $0.00 $39,760.83 $39,760.83 Deliverable Due 06/15/15 Subtotal (less retainage): $0.00 $35,784.75 $35,784.75

Period of Service to: 12/12/15 Retainage (10%): $0.00 $3,976.08 $3,976.08

Invoice Previous This Event Invoice Original Change Total # 1-6 Events $33,788.19 $35,784.75 # 2 2nd Event $0.00 $35,784.75 $35,784.75 # 7 Remedial Systems $0.00 $0.00 # 7 Remedial Systems $0.00 $0.00 $0.00 # 8 Final Deliverable $0.00 $0.00 # 8 Final Deliverable $0.00 $0.00 $0.00 # 9 Retainage $3,754.25 $3,976.08 # 9 Retainage $0.00 $3,976.08 $3,976.08 Work Order Total $37,542.44 $39,760.83 Event Template Total $0.00 $39,760.83 $39,760.83 Template-060112-SC.xlt

Second Event

Comments / Notes

ChangeOriginal

This Event Template Totals

Deliverables

Template

This Event Template Invoice Totals (less Retainage)Cumulative Work Order Totals (less Retainage)

$77,303.27

Total $69,572.94

$0.00 $0.00

$7,730.33