OOO-012 (Effective 10-13-2017) Page 1 of 4

Florida Department of Environmental Protection

TASK ASSIGNMENT CHANGE ORDER FORM

Required Signatures: Adobe Signature

Task Assignment Number: __________________ Date: _______________ Change Order No.______________

Contractor Name: _________________________________________________________________

Contractor Representative: __________________________________________________________

DEP Contract Manager: _________ ___________

Description of Change (Use additional sheets if necessary):

Change in Task Amount

Item Cost Reimbursement Fee Schedule Total Original Task Amount:

Task amount prior to this change order:

Net increase/decrease in task amount:

Task amount with all change orders:

Change in Task Time

Original task completion date:

Completion date prior to this change:

Net increase/decrease in task period:

Completion date with all change orders:

GC894-4 03/03/2020 01

Environmental Protection Commission of Hillsborough County

Hooshang Boostani

David G. Warfel

Please see attached description.

$1,380,108.00 $1,380,108.00

$1,380,108.00 $1,380,108.00

$50,000 $50,000 $1,430,108.00 $1,430,108.00

06/30/2020 06/30/2020 06/30/2020

OOO-012 (Effective 10-13-2017) Page 2 of 4

Florida Department of Environmental Protection

TASK ASSIGNMENT CHANGE ORDER FORM

Change in Funding Information

Budget Entity Project # Grant # Org Code Fund Special Category

Object Code

EO Amount

Total:

CONTRACTOR FLORIDA DEPARTMENT OF

ENVIRONMENTAL PROTECTION

Contract Manager Date Contract Manager Date

APPROVED:

Budget Representative Date

Deputy Secretary Date

Secretary Date cc: Procurement Section (MS93) Bureau of Finance & Accounting (MS78) - 2 copies

37450300 GC894 37450401002 212001 104138 131545 JN 50,000

50,000

Hooshang Boostani

Digitally signed by Hooshang Boostani Date: 2020.03.26 09:56:40 -04'00'

03/26/2020 David G. Warfel Digitally signed by David G. Warfel Date: 2020.03.26 10:10:47 -04'00'

Griffin Kolchakian Digitally signed by Griffin Kolchakian Date: 2020.03.26 11:06:48 -04'00'

John Truitt Digitally signed by John Truitt Date: 2020.03.26 13:45:02 -04'00'

Justin Wolfe Digitally signed by Justin Wolfe Date: 2020.04.10 14:02:05 -04'00'

Pursuant to existing contract Environmental Protection Commission of Hillsborough County and State of Florida Department of Environmental Protection, GC894, Paragraph 3,B No Work may be performed under this Contract, until a Task Assignment Notification Form or Task Assignment Change Order Form has been fully executed by both Department and Local Program.

This Task Assignment Change Order is to authorize work to be performed on an additional 17 sites (see attached) within Hillsborough County Local Program per the agreed upon and fully executed GC894 Task Assignment 4 in existence between Environmental Protection Commission of Hillsborough County and State of Florida Department of Environmental Protection. 17 Sites X $4,000.00 = $68,000.00. Payment for the additional sites will be issued for the invoice in the month the first assessment PO is issued this fiscal year.

The Department has determined through projection analysis that the total funds budgeted for Incentive Payments is in excess and can be reduced by $18,000.00.

Authorize additional funding for level of effort 17 sites X $4,000 site = $68,000 Reduction in funding for Incentive Payments $18,000 Net change in funding $50,000

FAC NAME

298509064 7-ELEVEN STORE #35646

298624970 MAJIK KWIK STOP

298625048 SHELL- HILLSBOROUGH

298625056 HANDY FOOD STORE #90

298625221 UNION 76-J H WILLIAMS

298625478 CIRCLE K #2709777

298625550 TEXACO #210

298625804 TEXACO-GREENES

298627094 PIPERS MARINE

298627281 ELECTRO BAKE

298629070 MOTIVA ENTERPRISES LLC-PORT OF TAMPA TRMNL

298736540 K I GROUP INC

299045619 FORMER VALUE RENT A CAR FAC

299101592 MONEY SAVER QUALITY GAS

299202211 GALLO DE ORO

418510879 ROSSI PROPERTY

418630041 DASH IN DASH OUT FOOD MART-HWY 64

Additional Sites due to score drop