Okaloosa County BOCC — November 3, 2015 — Final Payment documents

CONTRACT CLOSE-OUT CHECKLIST (To Be Prepared by the Purchasing Services Coordinator) DATE: October 26,2015 TO: Contracts & Grants Manager, Finance Department Contracts & Grants Office SUBJECT: Contract No. C95-0124-WS MANAGING DEPARTMENT: WATER & SEWER CONTRACTOR'S NAME: TEST AMERICA PROJECT TITLE: TESTING & LAB SAMPLING The attached has met the final payment contract requirement in subject contract. Yes No 1. Final Invoice X 2. Completed Contract/Lease Payment Approval Form X ] 3 Close-Out Documents Yes No N/A a. Signed Release of Lien L] [l X b. Proof of Completion Advertisement [] L] X c. Certificate of Insurance L] L] X d. Consent of Surety to Final Payment [l L] X e. Proof of Performance/Payment Bond ] O X Continuation 12 Months Following Final Payment Yes No 4, Agenda Request X Ol St Remarks B /0 FE-15 ervices OOTI’ DATE (v4- 042 CONTRACT/LEASE PAYMENT APPROVAL FORM COMPLETE AND FORWARD TO THE NEXT DEPARTMENT COMPLETED BY DEPARTMENT DATE: 10/14/2015 VENDOR NAME: TEST AMERICA s VENDOR #: 008016 CONTRACT/LEASE#: (C95-0124-WS - TASK COUNTY/FEMA VENDOR BUDGET ORDER # PROJECT # ACCOUNT # AMOUNT § INVOICE # (0f Applicable) (if Applicable) DEPARTMENT # 4014333 4101 534900 206.25 TOTAL | $ 206.25 \X\V/ APPROVED FOR PROGRESS PAYMENT (please sign. as applicable and date) CONTRACTOR'S ENGINEER/ARCHITECT/PROJECT MANAGER: DATE: COUNTY SUPERVISOR/PROJECT MANAGER: / ,> Al N / N AL ¢ At DATE: JO /S 75~ T i = = g . ; 102/5[2015 DEPARTMENT DIRECTOR \X )u(\\ LM\ DATE \)6\ CONTRACTS & GRANT MANAGER: DATE: COUNTY ADMINISTRATOR: DATE: (Payments>$25,000.) = = == —1| FINAL PAYMENT FINAL PAYMENT YES__ NO __ (If "Yes", forward to Purchasing Services Coordinator for Close-Out) DATE: 10/26 /15 PURCHASING DIRECTOR: @Lu C?IfihafL Zan [eto b [} ' (Per Initial Agreement) %fl)ATE: - 27/ CONTRACTS & GRANTS MANAGER. Y W (All Contracts) DATE: COUNTY ADMINISTRATOR APPROVAL: (Per Initial Agreement) DATE: BOARD APPROVAL: (Per Initial Agreement) COMPLETED BY FINANCE - ACCOUNTS PAYABLE ONLY FISCAL YEAR: DATE RECEIVED: REVIEWED BY: TestAmerica THE LEADER IN ENVIRONMENTAL TESTING Invoice/Credit No. 40143333 Invoice Date September 30, 2015 Terms See Below Federal Tax ID 23-2919996 Remit to TestAmerica Laboratories, Inc. PO BOX 204290, Dallas, TX 75320-4290 Bill to: Room 115 Board of County Commissioners-Finance Attn: Accounts Payable 101 James Lee Blvd East Crestview, FL. 32536 Ship to: Okaloosa Co. Water and Sewer 250 Roberts Blvd. Fort Walton Beach, FL. 32548 P.O. Number W.O. Number Contract Number Work Ordered by Purchase Order not required Mr. Phillip Arnett Job Description Site Name SDG Number Invoice Contact See below Mr. Phillip Arnett Job No. Job Description | Receipt Date Quantity Unit Price Amount Method/Test Description J109638-1 Mid-County System /01464044 - Radiologic 08/13/2015 900 - Gross Alpha 1.00 e.n 33.75 33.75 903.0 - RAD 226 1.00 X 82.50 82.50 904 - RAD 228 1.00 e 90.00 90.00 O & Q&_b., W\ 3o\ 5 Project Number Client Number Project Manager Subtotal $206.25 40003142 437047 Mike Nance Latest Sample Receipt Date Latest Report Date Phone Number Total $206.25 08/13/2015 09/28/2015 (251) 666-6633 This invoice falls under TestAmerica Laboratories Inc. Standard T&C's of Net 30 Days unless superseded by another valid contract vehicle in For proper credit, please include invoice number on all remittance. TestAmerica Pensacola - 3355 McLemore Drive, Pensacola, FL 32514 place at the time these services were rendered. Page 1 of 1