CN-550000-ASZ16-W0010000.pdf

STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION

RAILROAD CHANGE ORDER NUMBER

725-090-04A

RAIL

OGC – 12/23

Financial Project ID Roadway Description County Roadway ID Contract ID 447951-1-57-01 Bay Ave Pasco 14110000

A. 1. The CSX Company is hereby authorized to observe the following changes in the plans and or specifications to the subject Railroad Agreement, and to perform such work accordingly, further described as:

PE Review of Plans Submittals for Resurfacing Project. This includes any other work deemed necessary for this project.

Crossing 624380J - Milepost S 811.43

2. Exhibit A, Exhibit B, and Exhibit C are attached to the Railroad Change Order and made part of the below referenced Railroad Agreement.

3. The items of work covered by this Change Order are referenced to the Choose an item. Agreement of record dated Click or tap to enter a date. and no Supplemental Agreement is required.

Agreement Type: Preliminary Engineering

B. 1. Reimbursement for the cost of this Railroad Work is to be in accord with the provisions set forth in Administrative Rule Chapter 14-57 Section .011(2) as:

a. ☐ NONREIMBURSABLE

b. ☒ REIMBURSABLE

(1)☒ Force Account Method (2)☐ Lump Sum Method (3)☐ Third Party Contract Method

C. ESTIMATED COST OF WORK DUE TO THIS CHANGE ORDER

CHANGE

ORDER

DESCRIPTION

PREVIOUSLY

AUTHORIZED WORK

AMOUNT(S)

NEW AUTHORIZED

WORK AMOUNT

1 PE Review $ $10,000.00

Total amount of work previously authorized………………………………………………………… $ Total amount of new work authorized by this change order…………………………………………………………………… $10,000.00 Total amount of work authorized under agreement for this Financial Project ID……………………………………… $10,000.00 PROJECT TOTAL AMOUNT OF WORK AUTHORIZED TO DATE……………………………………………………………………… $10,000.00

Examined as to provisions and participating items of cost:

Recommended: ____________________ Approved: ____________________ Date Date

District Rail Administrator Director of Transportation Development

Kenneth Madden Justin Hall

ASZ16

DocuSign Envelope ID: 007F34DB-5A6B-4097-8449-3C7B8F653BAC

03/15/2024 | 7:28 AM EDT 03/15/2024 | 7:31 AM EDT

725-090-04A

RAIL

OGC – 12/23

EXHIBIT A

The Company shall:

1. utilize the U.S. Department of Homeland Security’s E-Verify system to verify the employment eligibility of all new employees hired by the Company during the term of the contract; and

2. include an express requirement in any subcontract that subcontractors performing work or providing services pursuant to the state contract utilize the U.S. Department of Homeland Security’s E-Verify system to verify the employment eligibility of all new employees hired by the subcontractor during the contract term.

OGC – 12/23

EXHIBIT B

The Company shall:

1. adhere to all Buy America requirements (23 CFR 635.410) to ensure that all manufacturing processes of steel and iron occur in the United States; and

2. ensure that prefabricated items that contain steel must also comply with Buy America; and

3. provide Buy America certifications that include correct language, project information, and the material’s delivery date.

OGC – 12/23

EXHIBIT C

The Company understands:

1. that while FHWA1273 does not apply to force account work performed by rail companies, FHWA-assistance is subject to Title VI (42 U.S.C. § 2000d et seq); and

2. requires appropriate assurances by providing an executed Title VI / Nondiscrimination Assurance, including Appendices A and E.

FLORIDA DEPARTMENT OF TRANSPORTATION

FUNDS APPROVAL

ASZ16

3/14/2024

CONTRACT INFORMATION

FUNDS APPROVAL INFORMATION

FUNDS APPROVED/REVIEWED FOR JASON ADANK, CPA, COMPTROLLER ON 3/14/2024

Action: Task Work Order

Reviewed or Approved: APPROVED

Organization Code: 55074010706

Expansion Option: A8

Object Code: 563000

Amount: $10,000.00

Financial Project: 44795115701

Work Activity (FCT): 127

CFDA:

Fiscal Year: 2024

Budget Entity: 55150200

Category/Category Year: 088797/24

Amendment ID: W001

Sequence: 00

User Assigned ID: CO #1

Enc Line (6s)/Status: 0001/04

Total Amount: $10,000.00

Contract: ASZ16

Contract Type: AC - RR CROSSING-PE/INSTAL (RR-XING/PE)

Vendor Name: CSX TRANSPORTATION, INC.

Vendor ID: F546000720022

Beginning Date of This Agreement: 03/13/2024

Ending Date of This Agreement: 12/31/2050

Contract Total/Budgetary Ceiling:

Method of Procurement: R - RAILROAD/UTILITIES AGREEMENT

Description: Resurfacing Within CSXT ROW

Page1 of 1

To: Michael.Pokers@dot.state.fl.us

CSX TRANSPORTATION – NEW PROJECT INITIATION FORM

Please provide the following information so that CSXT is able to accurately and appropriately process the project setup and billing.

Is this project associated with

Federal funds?

Is this project associated with

State funds?

Please describe the funding source for this project (i.e. INFRA, Section 130, State, County, Private, etc.).

Project Requirements:

Buy America

Additional procurement restrictions (Please describe below)

State Suspended and Debarred (Note - All federally funded projects are already monitored against the federal sus/deb listings)

Davis-Bacon (Please only check this box if this is a construction project that may be performed by an outside party)

CSX is subject to a state single audit as a recipient or subrecipient of funds (The only states that should apply here are FL or NC. FL must provide completed form DFS-A2-NS.)

Other If you selected Other, please describe below. Only complete this section if this project is associated with

Federal and/or State funds.

Project Sponsor - "Bill To" Information

Agency - Sponsor:

Billing Address:

Contact Name:

Phone:

E-mail:

Invoice Delivery Method:

Project Location:

Project Description:

Sponsor Project Ref.

Number (If applicable)

Signature of Applicant* Please sign, and e‐mail this form to the authorized CSX representative.

Name and Title of

Applicant

Signature of Applicant Date:

*By signing this form you are authorizing CSXT to incur costs and bill against this project. Should the project be canceled, CSXT will bill the Project Sponsor for the incurred costs. In the event the Project Sponsor is unresponsive for 90 days or more, the project will be closed;

and the Project Sponsor will be final billed for all project costs incurred.

Form Revision 7/18/23

If Email or Mail & Email is selected, please enter Email address(es) here:

Note: this is the agency that will be paying the invoice.

Note: this is the address to send the invoice for payment.

DDR - District Dedicated Revenue - State Funds 100%

Florida Department of Transportation

11201 N McKinley Drive; MS 7-501, Tampa, Florida 33612

Kenneth Madden

813-975-6407

Kenneth.Madden@dot.state.fl.us

D7RailInvoices@dot.state.fl.us

SR 39 FROM N OF CENTRAL AVE TO US 301/GALL BLVD

Pavement Only Resurfacing

447951-1

Kenneth Madden - Rail Administrator

No

Yes

Email

03/15/2024 | 7:28 AM EDT