CN-370000-GC923-T2CO4.pdf
PDF 534 KB Posted
- Contract number
- GC923
- Issued by
- Florida
About this file
This is a Task Assignment Change Order Form (OOO-012) issued by the Florida Department of Environmental Protection dated May 23, 2019. The document pertains to a task assignment with Polk County, with Steve Jarrett serving as the contractor representative and Roger Ruiz as the DEP Contract Manager. The change order was approved by Griffin Kolchakian (Budget Representative) and Teresa Booeshaghi (Contractual Authority).
The change order increases funding for variable inspections by $9,500.00 under Task Assignment Number GC923-2, Change Order No. 4. The original task amount was $259,950.00, which was increased to $285,450.00 prior to this change order. With the additional $9,500.00 in this change order, the total task amount with all change orders is $294,950.00. The task completion date remains June 30, 2019. Funding is allocated from Org. Code 37450104000 with E.O. code JD, Object Code 132500, Budget Entity 37450300, and Special Category 104138, with a total amount of $294,950.00 designated for Year 00. Copies of this change order are to be distributed to the Procurement Section (MS93) and two copies to the Bureau of Finance & Accounting (MS78).
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Text version
OOO-012 (Effective 09-14-2015) Page 1 of 2
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:
GC923-2 05/23/2019 4
POLK COUNTY
Steve Jarrett
Roger Ruiz
Increase of Funds for Variable Inspections in the amount of $9,500.00
259,950.00 259,950.00
285,450.00 285,450.00
+9,500.00 +9,500.00
294,950.00 294,950.00
06/30/19 06/30/19 9,500.00 06/30/19
OOO-012 (Effective 09-14-2015) Page 2 of 2
Florida Department of Environmental Protection
TASK ASSIGNMENT CHANGE ORDER FORM
Change in Funding Information
Org. Code E.O. Object Code Budget Entity
Special Category
Grant # Year Amount
CONTRACTOR FLORIDA DEPARTMENT OF
ENVIRONMENTAL PROTECTION
Contract Manager Date Contract Manager Date
APPROVED:
Budget Representative Date
Contractual Authority Date cc: Procurement Section (MS93) Bureau of Finance & Accounting (MS78) - 2 copies
37450104000 JD 132500 37450300 104138 00 $ 294,950.00
Digitally signed by Steven Jarrett DN: C=US, OU=Storage Tank Regulation, O=Florida Department of Health in Polk County, CN=Steven Jarrett, E=steven.jarrett@flhealth.gov Reason: I have reviewed this document Location:
Date: 2019-05-23 10:56:40 Foxit Reader Version: 9.4.0
Steven Jarrett 05/23/2019 Roger Ruiz Digitally signed by Roger Ruiz Date: 2019.05.23 12:01:51 -04'00'
Griffin Kolchakian Digitally signed by Griffin Kolchakian Date: 2019.05.23 15:00:35 -04'00'
05/23/2019
Teresa Booeshaghi Digitally signed by Teresa Booeshaghi Date: 2019.05.23 15:47:00 -04'00'
05/23/2019
File details come from the government source that posted it. Updated .