CN-370000-GC904-223BCO4.pdf

Funding Information:

Org. Code E.O. Object Code Budget Entity Appropriation

Category Grant # Project # Year Amount

☐ Additional Funding Information attached on separate page.

Rev. 8/17/2020

STATE OF FLORIDA

DEPARTMENT OF ENVIRONMENTAL PROTECTION

Task Assignment Change Order This Change Order is entered into between the Parties named below and amends the Task Assignment (TA) and any previous TA Change Orders (TACO) as follows:

1. TA Number: TACO Number: Contract Number:

TACO Description:

2. Parties State of Florida Department of Environmental Protection (Department)

Department’s Project Manager: Department’s Project Manager Phone:

Contractor Name: (Contractor ) ntractor’st ’s Project Manager: ontractor’s t’s Project Manager Phone:

3. Project Number:

(If different from TA Number) Project Name:

4. ☐ There are no changes to the TA compensation.

☐ The compensation of the TA is changed to the amounts indicated below:

Amended Price Price Prior to TACO ☐ Fixed Price:

☐ Fixed Unit Rate: (Extended Price)

☐ Cost Reimbursement:

Total TA Value:

5. ☐ There are no changes to the TA Expiration Date.

☐ The TA Completion Date is changed from ______________ to ______________ (a total of ______ days).

6. ☐ There are no changes to the Attachments.

☐ Attachment ___ is replaced with Attachment -____.

7. ☐ No Additional Changes.

☐ Additional Changes:

8. All other terms and conditions of the TA remain in effect. If and to the extent that any inconsistencies may appear between the TA and this TACO, the provisions of this TACO shall control.

IN WITNESS WHEREOF, this TACO shall be effective on the last date signed below.

State of Florida Department of Environmental Protection

CONTRACTOR Department Name:

Title: Secretary or Designee

(Authorized Signature) (Authorized Signature) Date:

☐ Additional signatures attached on separate page.

GC904-223B 4 GC904

Geosyntec is submitting for an extension on Task 2 and Task 3 deliverable due dates. Geosyntec had to waiting on approval from EPA before conducting the additional assessment activities.

Melissa Brock 850-245-8922 Contractor Contractor

Contractor Contractor

Contractor

Geosyntec Consultants Joe Applegate 850-556-8419

Petroleum Products Corp

$ 56,877.95

$ 0.00 $ 56,877.95 Completion

Completion✔ 05/02/2024 06/04/2024 33

TACO3 changes Task 2 deliverable due date from 2/22/2024 to 3/22/2024, Task 3 deliverable due date from 3/1/2024 to 4/5/2024, and POS end date from 5/2/2024 to 6/4/2024.

Geosyntec Consultants

Joe Applegate

Project Manager

Joseph Applegate Digitally signed by Joseph Applegate Date: 2024.01.12 14:35:03 -05'00'

Jennifer Farrell

Digitally signed by Jennifer Farrell Date: 2024.01.12 16:05:24 -05'00'

450202000 JG 139900 37450300 087889 NA NA 23 $ 56,877.95

Task Assignment Notification/Change Order Deliverables and Invoice Schedule Attachment

WCP TAFORM 01_18

Contract Number:

Task Assignment #:

Change Order #:

Deliverables:

Deliverable Deliverable Due Date

Invoice Schedule:

Requirements for Invoice Submittal Amount to be Invoiced

TOTAL COST

GC904

GC904-223B

$ 56,877.95

Updated HASP

Interim Remedial Report

Waste Manifest

Updated HASP

Waste Manifest

Interim Remedial Report

07/17/2023

03/22/2024

04/05/2024

$ 48,513.43

$ 0.00

$ 8,364.52

Florida Department of Environmental Protection-Division of Waste Management-Petroleum Restoration Program

Request for Change - Authorization for Change in Scope of Work

068732818 Contract #: GC904 PO #: GC904-223B Petroleum Product Corp Contractor: CO #: 4 Brittany.Anding Contractor Phone: CO Type: Date Extension Only

(850) 245-8856 FDEP Cost Share %: 100.00% Ref #: 904-223B Brittany.Anding@floridadep.gov

TASK PAY ITEM UNIT OF MEASURE PAY ITEM PRICE UNITS EXTENDED PRICE

Task Change Order Subtotals

2 -$ 3 -$

Period of Service: -$

Total Authorized Cost (FDEP Share: 100%)

Contractor Representative: J. Brooks Baldiwn 1/12/2024 (Print Name) (Date)

FDEP Task Manager: Brittany Anding (Print Name) (Date)

Administrative Reviewer:

(Print Name) (Date)

Reviewer (optional):

9-Digit Facility ID #:

Facility Name:

Task Manager Phone:

Task Manager Email:

This is an authorization for the costs associated with the change in quantities of services being provided and/or deliverable due dates. In order for these costs to be paid, these changes must be processed through a change order to the purchase requisition and a revised Purchase Order issued by MFMP prior to initiating work.

DESCRIPTION

Description of Change and Justification: Include complete description of who, what, where, when, how and why.

Geosyntec is submitting for an extension on Task 2 and Task 3 deliverable due dates. Geosyntec had to waiting on approval from EPA before conducting the additional assessment activities.

Geosyntec Consultants 850.528.2268Task Manager Name:

(Signature)

3/22/2024 4/5/2024

Deliverable Name

Interim Remedial Report/Tabulated Spreadsheet Waste Manifest(s)/Photos/Field Notes (if necessary)

*For reimbursable pay items the cost listed is a "not to exceed" amount. Fees will be reimbursed for the pay item based on the actual invoice. Please note, the unit of measure for these items will be displayed as dollars for invoicing purposes. Please refer to the Scope of Work for additional description of these items.

(Signature)

5/2/2024 6/4/2024

Previous End Date New End Date

(Signature)

Previous Due Date New Due Date

2/22/2024 3/1/2024

Page 1 of 2F&TS Schedule of Pay Items 10-06-22

1/12/2024

Florida Department of Environmental Protection-Division of Waste Management-Petroleum Restoration Program

Request for Change - Authorization for Change in Scope of Work

068732818 Contract #: GC904 PO #: GC904-223B Petroleum Product Corp Contractor: CO #: 4

9-Digit Facility ID #:

Facility Name: Geosyntec Consultants

Technical Approval (optional):

Cost Center Approval (optional):

Page 2 of 2F&TS Schedule of Pay Items 10-06-22