HomeMy WebLinkAboutR05-123 Env Health Director to sign agreements for state reimbursement funds for basalt yard mitigation
Commissioner t2 ! moved adoption
oft~oIUtion: BOARD OF COUNTY COMMISSIONERS
COUNTY OF EAGLE, STATE OF COLORADO
RESOLUTION NO. 2005-
RESOLUTION AUTHORIZING THE DIRECTOR OF THE EAGLE COUNTY
ENVIRONMENTAL HEALTH DEPARTMENT TO
SIGN DOCUMENTS AND EXECUTE AGREEMENTS ON BEHALF OF EAGLE
COUNTY REQUESTING STATE REIMBURSEMENT FUNDS FOR EXPENSES
INCURRED DURING THE BASALT ROAD AND BRIDGE YARD
ENVIRONMENTAL MITIGATION
WHEREAS, Eagle County ("County") has been implementing a Corrective Action Plan
("CAP") associated with leaking underground storage tanks at the Basalt Road and Bridge Yard
since 1996 and during this time the Director of Environmental Health has been the point of
contact for the County regarding this environmental mitigation effort; and
WHEREAS, certain costs associated with the County's environmental mitigation are
reimbursable through the Colorado Petroleum Storage Tank Fund; and
WHEREAS, in the interest of making timely requests for state reimbursement funds, the
Director of Environmental Health seeks the authority from the Board of County Commissioners
("Board") to sign documents and execute agreements on behalf of Eagle County requesting state
reimbursement funds for expenses incurred during the Basalt Road and Bridge Yard
environmental mitigation; and
WHEREAS, the first application, attached hereto as Exhibit "A" and incorporated by
reference, requests $36,912.36 from the Colorado Petroleum Storage Tank Fund and is the first
of at least two anticipated applications; and
WHEREAS, the Board is desirous of designating the Director of Environmental Health
as its authorized representative to sign documents and execute agreements on behalf of Eagle
County requesting state reimbursement funds for expenses incurred during the Basalt Road and
Bridge Yard environmental mitigation; and
NOW, THEREFORE, BE IT RESOLVED BY THE BOARD OF COUNTY
COMMISSIONERS OF THE COUNTY OF EAGLE, STATE OF COLORADO:
THAT, the Board hereby designates the Director of Environmental Health as its duly
appointed representative to sign documents and execute agreements on behalf of Eagle County
requesting state reimbursement funds for expenses incurred during the Basalt Road and Bridge
Yard environmental mitigation.
THAT, the Board of County Commissioners finds, determines and declares that this
Resolution is necessary for the public health, safety and welfare of the citizens of the County of
Eagle, State of Colorado.
MOVED, READ AND ADOPTED by the Board of County C~missioners of the
C~le, State of Colorado, at its regular meeting held the . cr- day of
J 1 ' 2005.
COUNTY OF EAGLE, STATE OF
COLORADO, by and Through Its
BOARD OF COUNTY COMMISSIONERS
ATTEST:
By:
c~~
Tom . Stone,
Commissioner
Commissioner seconded adoption of the foregoing resolution. The roll
having been called, the vote was as follows:
Commissioner Am M. Menconi
Commissioner Peter F. Runyon
Commissioner Tom C. Stone
This Resolution passed by vote of the Board of County Commissioners of
the County of Eagle, State of Colorado.
::;-;J
j 1
U
September 13, 2005
Colorado Department of Labor and Employment
Division of Oil and Public Safety- Fund Unit
633 1 ih Street, Suite 500
Denver, Colorado 80202-3660
Subject: Reimbursement Application Submittal
Eagle County Road and Bridge Facility - Basalt Shop (Event ID 859)
165 West Sopris Drive, Basalt, Colorado
Enclosed please find the Eagle County Reimbursement Application and Bilateral
Reimbursement Agreement (Application) for the above-referenced property (the site).
The Application has been cOillpleted in full by Eagle County's environmental consultant,
Weston Solutions, Inc. (Weston@).
Weston, while completing the Application, spoke with Ms. Cindee Floro-Gardner with
the OPS Fund Unit about Weston billing Eagle County with lump sum invoices since the
project work started in 1996. In order to complete the Application in the OPS Fund
Unit's preferred format, Weston summarized billing in time and material format invoices.
Therefore, the original lump sum invoices are not included because all reimbursable costs
are included in the time and materials invoice.
If you have any questions or require any additional information, please contact me at
(970) 328-8757 or Jonathan Anstey, Weston Solutions, Inc. at (303) 729-6178.
Sincerely,
Raymond P. Merry, REHS
Director, Departillent of Environmental Health
enclosure
cc: Weston: Project File (06668.016,001; 2.5)
(BLN, IP A)
EXHIBIT
1.
~ A
.D
:9
Cm.ORADO PETROLEUM ( REIMBURSEMENT APrL.ICA TION and
STORAGE TANK FUND
, B~ATERALRaMBURSEMENTAGREEMENT-Om~NAL
THIS FORM MUST BE USED FOR THE ORIGINAL APPLlCA nON FOR REIMBURSEMENT. Submit CDLE/OPS internal use only
the original and one photocopy of this application. After the applicant has established eligibility,
Short Form S (substantially equivalent to Exhibit A) is used. RAP #
Eligibility Person who bears no responsibility for release [per ~8-20.5-206(3) or
t:8J Tank owner/operator ~8-20.5-303(3) CRS]:
category (attach Tank Addendum) o Property owner o Tank owner/operator OLender
requested (attach appropriate Affidavit and other supporting documentation)
Applicant's full Eagle County Colorado Social Security # or Fed. tax 10 #
legal name 84-6000762
Contact Name: Mr. Raymond Merry, REHS Phone #: (970) 328-8757 Fax #: (970) 328-8788
person
Mailing address Old Courthouse Building
P.O. Box 179
550 Broadway ,
Eagle, CO 81631-017 Ej.Mai"~~\.ay.merry@eaglecounty. us
\-) v
Reimbursement \:)
mailing address Same As Above.
("
(if different) ../""', \.:v <. ~\">
Applicant is (check one): 0 Corp. o Partnersh)~:~,\DS>ole Proprietor o LLC I8l Other (explain): County Government
Site name Basalt Road and Bridge Facilit~(OPS Event ID: 859)
Site address 165 Sopris Drive
Basalt, Colorado 81621, Eagle County
Applicant acquired site on [date] 3 April 1947 from Unknown
Current owner of site, if not applicant:
Name Same As Above
Address
Site ownership Phone
history List all known previous owners of site, dates of ownership and property usage:
E. H. Gray, dates and usage are unknown.
Complete this section only if you want the representative to be the primary contact and copied on all
correspondence.
Applicant's Name: Ben Noller E-Mail: b.noller@westonsolutions.com
representative Address: 143 Union Blvd., Ste. 810, Lakewood, CO 80228
(if applicable)
Phone #: (303) 729-6152 Fax #: (303) 729-6101
Total from Listing of Costs, last column. $ 36,912.36
Less reimbursement from any other source (see #11) - 0.00
NET REIMBURSEMENT REQUEST $ 36,912.36
Dates of work covered by this application From: July 1996 through April 2005
I RELEASE INFORMATION
Page I ofl2
. "Release" means any spilling, leaking itting, discharging, escaping, leaching, or d/4 ng of a regulated substance from an
aboveground or underground storage lank into groundwater, surface water, or soils. [0-20.5-101 (14); 8-20.5-303(1) CRS]
1 When did release Unknown, prior to release discovery date.
happen?
2 On what date was 8 July 1996
release discovered?
3 When was release Suspected Release Report - 8 July 1996 (via telephone to Ms. Jane Bral- OIS)
reported? Confirmed Release Report -12 July 1996
4 To what agency was DOLE OIS (now OPS)
release reported?
5 How was release Hydrocarbon impacted soil was discovered during the installation of a sewer line
discovered? approximately 10 feet downgradient from the USTs.
6 Describe release The tanks were reported to be in good conditions during the inspection upon removal. Soil
occurrence (how did it staining was observed surrounding the associated piping system. Therefore, the release is
happen?) assumed to be from the tank piping system.
7 Volume of release Unknown, assumed to be a slow piping leak for an unknown period of time.
8 Describe actions taken Soil excavation, limited by underground utilities. Groundwater sampling and monitoring.
in response to release
REIMBURSEMENT INFORMATION
9 Will there be additional reimbursement applications for this release? I2J Yes D No
10 Except for this remediation, is there any relationship - personal, financial, or otherwise - between applicant and DYes I2J No
any company or person who performed work for which reimburs~ment is claimed? If ves, explain.
11 Has applicant received, or does applicant expect to receivEl'lotft~ation for corrective action costs from ANY DYes I2J No
source other than the Colorado Petroleum Storage Tank FU9d? es, give amount of that reimbursement
$ .. ' Identify source ~~~eilJ1bUrSement, including court case name and
number, If applicable. ../".. \ \).
.......... \,'v}-. \)
12 List all insurance policies covering this sif'e.''i;lf'date;'6f release (attach additional page, if necessary):
\. \~.
Carrier name Eaale Countv Government (self-insured) Policy # NI A
Agent's name N/A and phone number (970) 328-8880
Does policy cover cleanup of petroleum contamination? 0 Yes [8J No (Attach copy of policy)
Carrier name Policy #
Agent's name and phone number ( )
Does policy cover cleanup of petroleum contamination? 0 Yes 0 No. (Attach copy of policy)
Carrier name Policy #
Agent's name and phone number ( )
Does policy cover cleanup of petroleum contamination? 0 Yes 0 No. (Attach copy of policy)
13 Has any other applicant sought reimbursement for costs incurred for this release? If yes, explain, Include other DYes I2J No
applicant's name, address, phone number, and reimbursement application number(s).
14 Is current applicant requesting Fund eligibility to transfer from another applicant? If yes, submit Transfer of DYes I2J No
Eligibility form.
15 Do any costs claimed for reimbursement represent work performed by the applicant or applicant's employees? I2J Yes D No
If yes, submit Affidavit Regarding Work Performed by Applicant,
TECHNICAL INFORMATION
16 List all Technical Reports pertaining to this remediation submitted prior to this application:
Name of ReDort Name of ComDanv who PreD8red ReDort Date Submitted
Notification of Suspected Release Report Roy F, Weston, Inc 7/8/96
Notification of Confirmed Release Report Roy F. Weston, Inc. 7/12/96
Revised UST Closure Report and CAP Roy F, Weston, Inc, 12/22/96
Monitoring Report Roy F. Weston, Inc 6/9/97
Quarterly Groundwater Monitoring (May 1997) Roy F. Weston, Inc. 7/25/97
Response to COLE/OIS Request for CAP and Submittal
of Quarterly Monitoring Report (May 1997) CAP Roy F, Weston, Inc 7/29/97
Quarterly Monitoring Report (August 1997) Roy F. Weston, Inc. 11/4/97
Submittal of Quarterly Monitorinq Report (November 1997) Rov F. Weston, Inc 2/97
Page 2 of 12
Submittal of Quarterly Monitoring F1 i (March 1997) Roy F. Weston, IncI 5/98
Submittal of Quarterly Monitoring Rbt"Jrt (June 1997) Roy F. Weston, Inc 8/98
Quarterly Monitoring Report (November 1998) Roy F. Weston, Inc. 3/4/99
May 1999 Semi-Annual Monitoring Report Roy F. Weston, Inc. 7/28/99
Submittal of November 1999 Semi-Annual Monitoring Report Roy F. Weston, Inc 11/29/99
Submittal of May/June 2000 Annual Monitoring Report Weston Solutions, Inc. 6/20/00
Revised CAP Roy F. Weston, Inc 4/4/00
2004 Annual Monitoring Report Weston Solutions, Inc, 4/30/04
Revised CAP Investigation Report Weston Solutions, Inc. 4/6/05
Bilateral Reimbursement Agreement
WHEREAS, authority exists in the Law and Funds have been budgeted, appropriated and otherwise made available and
sufficient unencumbered balance thereof remains available for payment in Fund Number 130, APPR Code 796; and
WHEREAS, required approval, clearance and coordination has been accomplished from and with appropriate agencies; and
WHEREAS, pursuant to Colorado Revised Statute (C.R.S.) 8-20.5-101, et seq., the Applicant is making application to the State
for reimbursement of certain costs incurred for cleanup of certain leaking petroleum storage tanks.
By submitting this application, the Applicant affirms and agrees that:
1. The Applicant certifies, under penalty of law, that applicant is the appropriate person to request reimbursement, and that
this document and all attachments were prepared under applicant's direction or supervision in accordance with a system
designed to assure that qualified personnel properly gathered and evaluated the information submitted.
2. The Applicant above is the owner/operator or duly authorized agent of the owner/operator responsible for this facility.
The Applicant is responsible for assuring compliance with all applicable state and federal regulations.
.." .,
3. The information submitted by the Applicant is to the best o( ~.RPIi~t'S knowledge and belief, true, accurate and
complete. Applicant understands that by filing this apJ;?Jlcat~A. with the Colorado Department of Labor and Employment
(COLE) for consideration by the Petroleum Storage Tarii~\9Q,!11Mhtee (Committee), applicant agrees to return to the
Committee upon its demand the entire award app~'Qt ril~eceive or any other amount the Committee considers
appropriate if (a) applicant misrepresented or ~l'Qit ~nY fact, either in writing or orally, relevant to the determinations
made by the Committee or the COLE; or (b) ap ~i.~anf i1s to complete, to the Committee's or the COLE's satisfaction, the
corrective action. . ,
y
4. The Applicant will not be entitled to obtain any other reimbursement from any source other than the State for the same
costs or work reimbursed by the State. Any reimbursement the Applicant receives or is entitled to, including insurance
proceeds, is the property of the State of Colorado to the extent of payment made by the State from the Petroleum Storage
Tank Fund and, if received, shall immediately be paid to the State.
5. To the extent payment is made from the Petroleum Storage Tank Fund, the Applicant hereby assigns to the State of
Colorado any rights the Applicant may have which may allow the Applicant to seek and obtain recovery from any other
entity for the costs or work reimbursed by the State, including the right to recover from insurance companies.
6. The Applicant shall not submit any further claims for reimbursement from the State for the site(s) and work identified
herein, other than an amendment to the application or protest of the Fund Payment Report, if any, for work not heretofore
reimbursed.
7. In addition to any other legal rights the State of Colorado may have, the State shall have audit and on-site inspection
rights for 3 years after payment.
8. The expenses listed in this application are an accounting of the most reasonable expense available for compliance.
9. The Applicant shall provide any formal or informal environmental assessment information to any future owner upon
request.
10. In the event the Applicant breaches these conditions, the State of Colorado, in addition to any other remedies, at law or
equity, shall be entitled to immediate repayment on demand of all amounts paid to the Applicant; and in the event that the
State is required to take legal action to enforce any of the provisions contained herein or elsewhere, the State shall be
entitled, in addition to any damages owed, to its costs and reasonable attorney fees incurred for such enforcement.
11. At all times during the performance of this remediation, the Applicant shall strictly adhere to all applicable federal and
state laws, rules and regulations that have been or may hereafter be established, including without limitation 42 U.S.C.
6991 and C.R.S. 8-20.5-101, et seq., and associated regulations,
Page 3 of 12
12. The State may allocate more or les~ 1s to this remediation than has been requ~ i by the Applicant. The Fund Payment
Report included as Exhibit B, doclt .1ts the amount that will be processed and.. _..d once the reimbursement request is
approved.
13. The Committee has the authority and the right to designate funds be paid on pro-rata basis when the Petroleum Storage Tank
Fund balance prevents payment in full pursuant to C.R.S. 8-20.5-206(e)(2).
14. Each additional request for reimbursement from the Petroleum Storage Tank Fund will require submittal of a new
supplemental application and the issuance by the Petroleum Storage Tank Committee (PSTC) of a new Fund Payment
Report for payment.
15. Pursuant to 7 C.C.R. 1101-14, Article 8, an Applicant may file a protest ofthe Fund Payment Report if the Applicant
disputes a decision by the Petroleum Storage Tank Committee as stated on the Fund Payment Report. An Applicant may
petition the Committee to review its decision. A Protest must be submitted within 60 days of the date of the Fund
Payment Report. See 7 C.C.R. 1101-14, 8-8. The Applicant shall use the Protest of Fund Payment Report provided by the
Division of Oil and Public Safety of the Colorado Department of labor and Employment.
16. The Petroleum Storage Tank Committee will authorize the maximum amount to be paid by the State on this
reimbursement request as shown in the Fund Payment Report, included as Exhibit B, with this Reimbursement
Application.
Page 4 of 12
[ SPECIAL PROVISIONS I
1. CONTROLLER'S APPROVAL. CRS 24-30-202 (1)
This contract shall not be deemed valid until it shall have been approved by the Controller of the State of Colorado or such assistant as
he may designate.
2. FUND AVAILABILITY. CRS 24-30-202 (5.5)
Financial obligations of the State of Colorado payable after the current fiscal year are contingent upon funds for that purpose being
appropriated, budgeted, and otherwise made available.
3a. INDEMNIFICATION (APPLICABLE TO NON-GOVERNMENTAL APPLICANTS).
The Contractor shall indemnify, save, and hold harmless the State, its employees and agents, against any and all claims, damages,
liability and court awards including costs, expenses, and attorney fees incurred as a result of any act or omission by the Contractor, or
its employees, agents, subcontractors, or assignees pursuant to the terms of this contract.
3b. INDEMNIFICATION (APPLICABLE TO GOVERNMENTAL APPLI~t~~
To the extent authorized by law, the Contractor shall indemnif~ ~,...1ind hold harmless the State against any and all claims,
damages, liability and court awards including costs, expenses,\all a orney fees incurred as a result of any act or omission by the
Contractor, or its employees, agents, subcontractors, or \:1~sign~ pursuant to the terms of this contract.
,-'"\\,,,,'>
No term or condition of this contract shall be construed qrintetpreted as a waiver, express or implied, of any of the immunities, rights,
benefits, protection, or other provisions for the partiesipf the Colorado Governmental Immunity Act, CRS 24-10-101 et seq. or the
Federal Tort Claims Act, 28 U.S.C. 2671 et seq, as applicable, as now or hereafter amended.
4. INDEPENDENT CONTRACTOR RELATIONSHIP. 4 CCR 801-2
THE CONTRACTOR SHALL PERFORM ITS DUTIES HEREUNDER AS AN INDEPENDENT CONTRACTOR AND NOT AS AN
EMPLOYEE. NEITHER THE CONTRACTOR NOR ANY AGENT OR EMPLOYEE OF THE CONTRACTOR SHALL BE OR SHALL
BE DEEMED TO BE AN AGENT OR EMPLOYEE OF THE STATE. CONTRACTOR SHALL PAY WHEN DUE ALL REQUIRED
EMPLOYMENT TAXES AND INCOME TAX AND LOCAL HEAD TAX ON ANY MONEYS PAID PURSUANT TO THIS CONTRACT.
CONTRACTOR ACKNOWLEDGES THAT THE CONTRACTOR AND ITS EMPLOYEES ARE NOT ENTITLED TO UNEMPLOYMENT
INSURANCE BENEFITS UNLESS THE CONTRACTOR OR A THIRD PARTY PROVIDES SUCH COVERAGE AND THAT THE
STATE DOES NOT PAY FOR OR OTHERWISE PROVIDE SUCH COVERAGE. CONTRACTOR SHALL HAVE NO
AUTHORIZATION, EXPRESS OR IMPLIED. TO BIND THE STATE TO ANY AGREEMENTS. LIABILITY. OR UNDERSTANDING
EXCEPT AS EXPRESSLY SET FORTH HEREIN. CONTRACTOR SHALL PROVIDE AND KEEP IN FORCE WORKER'S
COMPENSATION (AND SHOW PROOF OF SUCH INSURANCE) AND UNEMPLOYMENT COMPENSATION INSURANCE IN THE
AMOUNTS REQUIRED BY LAW. AND SHALL BE SOLELY RESPONSIBLE FOR THE ACTS OF THE CONTRACTOR, ITS
EMPLOYEES AND AGENTS.
This Special Provision is not applicable to other State of Colorado departments, agencies, or institutions of higher education
reimbursements.
5. NON-DISCRIMINATION.
The Contractor agrees to comply with the letter and the spirit of all applicable state and federal laws respecting discrimination and
unfair employment practices.
6. CHOICE OF LAW.
The laws of the State of Colorado and rules and regulations issued pursuant thereto shall be applied in the interpretation, execution,
and enforcement of this contract. Any provision of this contract, whether or not incorporated herein by reference, which provides for
arbitration by any extra-judicial body or person or which is otherwise in conflict with said laws, rules, and regulations shall be
considered null and void. Nothing contained in any provision incorporated herein by reference which purports to negate this or any
other special provision in whole or in part shall be valid or enforceable or available in any action at law whether by way of complaint,
defense, or otherwise. Any provision rendered null and void by the operation of this provision will not invalidate the remainder of this
contract to the extent that the contract is capable of execution.
At all times during the performance of this contract, the Contractor shall strictly adhere to all applicable federal and State laws, rules,
and regulations that have been or may hereafter be established.
7. VENDOR OFFSET. CRS 24-30-201 (1) & CRS 24-30-202.4
Pursuant to CRS 24-30-202.4 (as amended), the State Controller may withhold debts owed to State agencies under the vendor offset
intercept system for: (a) unpaid child support debt or child support arrearages; (b) unpaid balance of tax, accrued interest, or other
charges specified in Article 21, Title 39, CRS; (c) unpaid loans due to the Student Loan Division of the Department of Higher
Education; (d) owed amounts required to be paid to the Unemployment Compensation Fund; and (e) other unpaid debts owing to the
State or any agency thereof, the amount of which is found to be owing as a result of final agency determination or reduced to judgment
Page 5 of 12
as certified by the controller.
This Special Provision is not applicable to InteraQency or Interqovernmental reimbursements.
8. SOFTWARE PIRACY PROHIBITION GOVERNOR'S EXECUTIVE ORDER
No State or other public funds payable under this Contract shall be used for the acquisition, operation or maintenance of computer
software in violation of United States copyright laws or applicable licensing restrictions. The Contractor hereby certifies that, for the
term of this Contract and any extensions, the Contractor has in place appropriate systems and controls to prevent such improper use of
public funds. If the State determines that the Contractor is in violation of this paragraph, the State may exercise any remedy available
at law or equity or under this Contract, including, without limitation, immediate termination of the Contract and any remedy consistent
with United States copyright laws or applicable licensing restrictions.
9. EMPLOYEES FINANCIAL INTEREST. CRS 24-18-201 & CRS 24-50-507.
The signatories aver that to their knowledge, no State employee has any personal or beneficial interest whatsoever in the service or
property described herein.
10. BRIBERY, CORRUPT INFLUENCES, AND ABUSE OF PUBLIC OFFICE.
The signatories aver that they are familiar with CRS 18-8301, et. seq., (Bribery and Corrupt Influences) and CRS 18-8-401, et. seq.,
(Abuse of Public Office), and that no violation of such provisions is present.
Page 6 of 12
The Parties Hereto r 'e Executed this Bilateral ReimK 3ement AQreement
Eagle County Colorado State of Colorado:
Bill Owens, Governor
By:
Raymond Merry, REHS Date Leroy J. Williams, Jr. Date
Director, Department of Environmental Health Acting Executive Director
Eagle County Colorado Department of Labor and Employment
84-60007!?2
Social Security Number or FEIN
Signature of Applicant or Authorized Officer Date
Mr. Raymond Merry, Director, Department of Environmental Health
Print Name & Title of Authorized Officer
Corporations:
(A corporate attestation is required. A corporate seal is
required, if available.)
Attest (Seal) By
(Corporate Secretary or Equivalent)
ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER
CRS 24-30-202 requires that the State Controller approve all state contracts. This contract is not valid until the State
Controller, or such assistant as he may delegate, has signed it. The contractor is not authorized to begin performance until the
contract is signed and dated below. If performance begins prior to the date below, the State of Colorado may not obligated to
pay for the goods and/or services provided.
STATE CONTROLLER DESIGNEE:
Susan J. Meade
By
Date
Page 7 of 12
( f
, SUBMIT THE FOllOWING DOCUMENTS AND THIS CHECK LIST
FOR AN ORIGINAL APPLICATION
This document is part of the application. It MUST be filled out and INCLUDED with your application.
Copies of forms can be accessed on the OPS website at http://oil.cdle.state.co.us (State Fund Section/Fund Forms)
Directions: Place a check f") in the boxes to the left that indicates the required documents listed below are included with this
application. Failure to supply the necessary information outlined in these boxes will result in your application being returned
to you as "Incomplete".
Two copies of the "Reimbursement and Bilateral Agreement-Original" application form. One of these copies must have an
1. original signature with the proper signatory authority. If the applicant is a corporation, signature must be by the corporate
president or vice president and the corporate secretary or equivalent must attest the application. The president or vice
president can deleQate siqnatory authority. Said authority must be on corporate letterhead.
2. An original and one copy of the "Client Notification (Form MHN)". Both the applicant and the consultant must sign the MHN form.
3, Two copies of the CDLE/OPS form - "Listing of Costs", Note: The Listing of Costs MUST BE IN ORDER BY date of work
performed with the earliest date listed first.
An original with a notarized seal and one copy of the CDLE/OPS form "Affidavit: Proof or Payment" listing each invoice as
outlined on the "Listing of Costs"." The affidavit must be on company letterhead.
OR - Cancelled checks with the front of the check encodinq the amount of the check orovinq that the check cleared the bank.
OR - An original and one copy of the CDLE/OPS form: "CPA Certification". The affidavit must have an original signature
4, and all information at the bottom of the affidavit must be completed including the CPA's license number, State where issued
and expiration date.
OR - If applicable, an original with a notarized seal and one copy o!!he CDLE/OPS form: "Affidavit of "Work Performed by
Employees of Listed Applicant B Part 1 (Employer)". The affidavJt\must have an oriqinal signature of the listed applicant.
OR - If applicable, an original with a notarized seal and one cO(5y>of til'efCDLE/OPS form: "Affidavit of Work Performed by
Applicant". The affidavit MUST have the original and certifiedstl'inatures of both the consultant/contractor and the applicant.
5, Two copies of invoices to support each cost. The invoices Mt),$T be in order by date of work performed and should match the
order of the Listing of Costs.> \; ~
Colorado's Reasonable Cost Guidelines apply to all work perfbrrrled July 1, 1997 forward with respect to costs only. The invoice
format must be in accordance with the Reasonable Cost Gu,ideltnes, Article 3, Parts 3 and 4. Phase of Work, Activity and Task and
Labor codes must be on every invoice for each cost - includIng utilities - regardless of when the work was performed.
Note: Failure to record each of these codes for each cost requested will result in a deficiency letter and the application review
process will halt. Additionally, the time clock will stop and no interest will accrue.
FOR TANK OWNER/OPERATOR APPLICANTS ONLY
Note: The amount requested on the Original application MUST exceed the deductible of $10,000.00.
6, Two copies of CDLE/OPS form "Tank Addendum". This addendum MUST be filled out in its ENTIRETY listing all tanks
including tanks that were closed in place and/or removed. (One original signature required)
7, A copy of the most recent Station Inspection orior to the release discovery,
METHOD OF RELEASE DETECTION PERFORMED
Directions: Place a check ("j) in the box to the left of the appropriate method that accurately describes the method of release
detection performed at the time of release discovery. If one method applies to both tanks and lines, please check all of the
appropriate boxes. THIS INFORMATION MUST MATCH WHAT IS LISTED ON THE TANK ADDENDUM FORM.
Tank Line Leak Detector Method
Daily Inventory with Monthly Reconciliation (Note: This method may only be used for a maximum of
10 years after installina a new tank or uoaradina an existino tank with corrosion protection).
Manual Tank Gauging (Note: Only tanks of 1000 gallons capacity or less may use manual tank
gauging as the sole method of release detection. Tanks between 1001 and 2000 gallons capacity
may use this method if combined with annual tank and line tightness testing. The 1 O-year extension
as noted above also aoplies.)
Automatic Tank Gauaina (ATG)
Statistical Inventory Reconciliation (SIR)
Interstitial Monitorina
Vapor Monitorinq
~ -V Ground Water Monitoring
~ -V Tank Tightness Tests
Line Tightness Tests
Leak Detector Operations Tests
ASTs only: Ullage
ASTs only: Visual Inspections (single-walled tanks)
ASTs only: Visual Inspections (double walled tanks, checking that interstitial monitoring is functioning)
ASTs only: Line Tightness Tests for pressurized underground lines
ASTs only: Leak detector Operations Tests for pressurized underground lines
Page 8 of 12
I ORDS SUBMITTED WITH APPLlCATlt
Directions: Place a check ('v) in the bo; to the left of the release detection records that are being submitted with this
application. These records should coincide with the method of release detection performed at the time of release discovery
and should also be within the timeframe requested. Unless noted, all items under each method are required to be submitted.
NOTE: If tanks were not operating for either the six months or the 24 months prior to release discovery, then the records required will
be for the six months prior to when the tanks were properly closed or emptied (and in temporary closure).
Inventory Control
Dailv inventory with monthly reconciliation (Gallons pumped x .01 + 130 qallons) for the last full 6 months prior to release discovery
The last 2 annual tank tiqhtness tests for the 24 months prior to release discovery OR
The most recent 5 year tank tiqhtness test prior to release discovery (if annual testing was not required)
The last 2 annual line tiahtness tests (if pressurized lines) for the 24 months prior to release discovery OR
The last line tiqhtness test performed on suction lines within 3 years of release discovery
The last 2 annual leak detector operations tests (if pressurized lines) for the 24 months prior to release discovery OR
Leak detector operations tests are not required because system has suction lines -
RELEASE DETECTION RECORDS ARE NOT AVAILABLE FOR THE FOLLOWING MONTHS:
ATG
ATG data for tanks or tanks and lines for the last 6 months prior to release discovery documenting 1 valid test per month
The last 2 annual line tiqhtness tests for the 24 months prior to release discovery (if ATG does not cover lines)
The last 2 annual leak detector operations tests for the 24 months prior to release discovery (if A TG does not cover lines)
Inventorv control data for the last full 6 months prior to the release discovery (if applicable)
RELEASE DETECTION RECORDS ARE NOT AVAILABLE FOR THE FOLLOWING MONTHS:
\<>
SIR ..... '\
SIR data for the last full 6 months prior to the release discovery > >')
The last 2 annual line tiqhtness tests for the 24 months prior tb. fE!leaSe discovery (if SIR does not cover lines)
The last 2 annual leak detector operations tests for the24monu;ts prior to release discovery (if SIR does not cover lines)
RELEASE DETECTION RECORDS ARE NOT AVAILABLEf'OR THE FOLLOWING MONTHS:
Corrosion Protection
The latest 3 vear cathodic protection test prior to release discovery
10 yeart5 year internallininq inspection (if applicable)
Manual Tank Gauaing
Weekly manual tank qauqinq records for the last full 6 months prior to release discovery
The last 2 annual tank tiqhtness tests for the 24 months prior to release discovery (if tank is between 1000 & 2000 qallons)
The most recent 5 year tank tiqhtness test prior to release discovery (if applicable and if tank is between 1000 and 2000 qallons)
The last 2 annual line tiahtness tests for the 24 months prior to release discovery (if tank is between 1000 and 2000 aallons)
The last 2 annual leak detector operations tests for the 24 months prior to release discovery (if lank is between 1000 and 2000 gallons)
RELEASE DETECTION RECORDS ARE NOT AVAILABLE FOR THE FOLLOWING MONTHS:
The following records are required for any other types of Monthly Monitoring used (for USTs) not already checked on this oaae:
6 months of release detection records prior to release discovery
The last 2 annual tank tiqhtness tests for the 24 months prior to release discovery
The most recent 5 year tank tiqhtness test prior to release discovery (if applicable)
The last 2 annual line tiahtness tests for the 24 months prior to release discovery
Line test for suction lines performed within the last 3 years of release discovery
The last 2 annual leak detector operations tests (if pressurized lines) for the 24 months prior to release discovery
RELEASE DETECTION RECORDS ARE NOT AVAILABLE FOR THE FOLLOWING MONTHS:
AST records
Ullaae records for the last full 6 months prior to release discovery
Monthly visual inspections for the last full 6 months prior to release discovery (single-walled tanks) OR
Monthly visual inspections for the last full 6 months prior to release discovery (double walled tanks also checking that interstitial
monitorina is functioninq)
RELEASE DETECTION RECORDS ARE NOT AVAILABLE FOR THE FOLLOWING MONTHS:
MAIL TO: If you have any questions please consult the
Colorado Department of Labor and Employment OPS website and/or contact OPS via the
Division of Oil & Public Safety - Fund Unit "Technical Assistance Line" at (303) 318-8547.
1515 Arapahoe Street OPS website: http://oiI.cdle.state.co.us
Tower 3 Suite 610
Denver CO 80202-2117
Page 9 of 12
COLORADO PETROLEUM L1ST1N.G...OFCOSTS
STORAGE TANK FUND
...,.".-...
Canceled Check3
Primary Dates ofWork2 AIliO!Jl'ltSubmitt~(j
Invoice #1 Contractor Name (xx/Xx/xx - xx/Xx/xx) Check # Check Amt. Other 4 Invoice Amount for Reilli bUl'$ement5
453392 Weston Solutions, Inc, 7/12/96- 9/1/96 AFF $5,095.31 $5,095,31
458441 Weston Solutions, mc, 9/2/96 - 11/1/96 AFF $1,258,10 $1,258,10
465981 Weston Solutions, hlC, 11/2/96 1/1/94 AFF $2,972.31 $2,972.31
473782 Weston Solutions, mc, 1/2/97 - 3/1/97 AFF $134,72 $134,72
496686 Weston Solutions, 1nc, 3/2/97 - 8/1 /97 AFF $741.57 $741.57
512902 Weston Solutions, Inc, 8/2/97 - 12/1/97 AFF $868.28 $86828
530331 Weston Solutions, Inc, 12/2/97 -3/1 '/98 AFF $910,65 $910,65
553867 Weston Solutions, Inc, 3/2/98 - 8/1/98 AFF $68923 $689,23
568591 Weston Solutions, Inc, 8/2/98 - 10/1/98 AFF $519,64 $519,64
571138 Weston Solutions, hlC, 10/2/98 12/1/98 AFF $494.37 $494.37
581248 Weston Solutions, hlC, 12/2/98 -4/1/99 AFF $238,03 $238,03
MA Y2004-02290 Weston Solutions 4/27/04 - 5/6/04 AFF $1,259,66 $1,259,66
DEC2004-04487 Weston Solutions 10/1/04 12/24/04 AFF $11,455,91 $11,605,91
MAR2005-04394 Weston Solutions, hlC, 12/24/04 - 3/18/05 AFF $6,748.50 $7,420.60
APR2005-03338 Weston Solutions, mc, 3/18/05 - 4/22/05 AFF $2,704,00 $2,704,00
TOTAL SUBMITTED FOR REIMBURSEMENT CONSIDERATION -I $ 36,912.36 I
1 List all PRIMARY invoices. If invoice does not clearly identify work performed, add that information to the invoice copy submitted with the application.
2 List invoices in order by the date of work performed.
3 If proof of payment is by canceled check, back of canceled check is also required if the dollar amount is not encoded by the bank on the front of the check.
4 If proof of payment is by payee affidavit or CPA Certification, use following codes: AFF = Affidavit. CPA = CPA certification of payment. Use COLE forms.
5 List only ALLOWABLE costs. If amount requested differs from invoice amount, identify on the invoice any cost for which reimbursement is NOT requested.
Page 10 of 12
TANK ADDENDUM
Colorado Petroleum Storage Tank Fund Revised 2005
Directions: Place a check (..J) or write the requested information in the box below each tank or line.
Please use the codes on page 2 as needed and list several codes per box if necessary. Photocopy additional pages as necessary.
Tanks Tank1 I Tank 2 Tank 3 Tank 4
AST
..; {Tag 5387*1) ..J (Tag 5387-2)
UST
Installation Date In 1962 In 1962
Caoacity (oallons) 520 575 ,
Product stored Diesel Gasoline
Double-walled (D) or sinole-walled (S) S S - "
Tank material (use codes on oaae 2) S S <: . -
UST Removed in UST Removed in '(;<"
Date of compliance with 1998 (USTs) or 1996 {ASTs) upgrades
Written documentation must also be oroyided1(see oaae 2***) 1996 1996 " -~
Methods of compliance with 1998 (USTs) or 1996 (ASTs) UST Removed in UST Removed in (',.
upgrades (use codes on page 2) 1996 1996 \/
-'
RD3 - UST Removed RD3 - UST Removed 'v
Tank release detection method (use codes on page 2) "
in 1996 in 1996 (J.'
Is tank in use? (Y or N) N N
Date tank emotied 7/30/1996 7/30/1996
Date tank oermanently closed 7/30/1996 7/30/1996
Closure in place (filled with an inert material) (Y or N) N N
Tank removed (Y or N\ Y Y
Lines Linels) Linels) Linels) Linels\
Pressurized (P) or Suction (S) S S
Double-walled (0) or sinale-walled (S) S S
Pioina Material (use codes on paqe 2) S S
(ASTs only) Lines aboveground (A) or underground (U) or
None{N) :u U l,-,~,
Line Release Detection Method (use codes on paqe 2) Unknown Unknown
Tyoe of line leak detector Electronic (E)/ Mechanical (M) Unknown I Unknown ,- ,
Methods of compliance with 1998 (USTs) or 1996 (ASTs) Piping removed in Piping removed in
upgrades (use codes on page 2) 1996 1996
APPLICANT CERTIFICATION
I certify under penalty of law that I have personally examined and am familiar with the information submitted in this and all attached documents and that based on my inquiry of those
individuals immediately responsible for obtaining the information, the information is true, accurate and complete.
Signature of Applicant or Representative knowledgeable of tank system me/Affiliation to Applicant Date
C:lDocuments and Settings\rmerrylLocal SettingslTemporary Internet Filesl0LK29lReimbursement Application _ 050505,doc
Page 11 of12
CODING TO BE USED FOR TANK ADDENDUM
***Types of acceptable documentation formeetinq upqrade requirements
Copy of permit from OPS
Copy of invoice from contractor 000 performed the upgrade, showing specifically what was done
Please contact your Fund Analyst for additional information/questions.
Tank and piping material codes: Methods of compliance with 1998 (UST) and 1996
S STEEL (AST) upgrade requirements
STI-P3 STI-P3 (Coated and cathodically protected steel) IC Impressed current (Tk/Piping/Cnctrs)
CS Cathodically protected steel GV Galvanic anodes (TklPiping/Cnctrs)
LS Internally lined steel L Internally lined
JKT Jacketed steel (Secondarily contained) FRP Fiberglass reinforced plastic piping
FRP Fiberglass reinforced plastic FLEX Flexible plastic piping
COMP Composite tank (Laminate bonded to steel)/ Clad NC No electrolyte contact (Tk/Cnctrs- ASTs only)
FLEX Flexible plastic AG Aboveground piping
Overfill Prevention
SF Sail float valve overfill protection
Release Detection Codes for tanks and line FV Fill tube valve overfill protection
RD1 Inventory control with monthly reconciliation AL External audibleNisible alarm
RD2 Manual tank gauging Spill Control
RD3 Annual tank tightness test! 5 year test (if applicable) SS Spill bucket
RD4 Automatic tank gauge (A TG) OK Diking (ASTs only)
RD5 Statistical inventory reconciliation (SIR) 1M Impounding (ASTs only)
RD6 Interstitial monitoring SC Secondary containment tank only (ASTs only)
RD7 Vapor monitoring wells
ROB Water monitoring 'Neils
RD9 Annual line tightness test
RD10 Detection in sump double wall
RD11 Ullage records (ASTs)
RD12 Monthly visual inspections (ASTs)
CIDocuments and SettingslJmen)'ILocal SetlingslTemporaJ)' Internet FiIeslOLK29lReimbursement Application 050505,doc
Page 12 of 12