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S ta tea f Was h i n g ton ;~~[;:,Yc~r~o::,s cr~:~~~~:n~~,C~~/~~~~:' s,::.~~~.~~:,~o'::
Dept of Ecology :JttrvicIIIJ.Showcompl.,edelallloreachilem. .
11ail Stop, PV-ll 8,l.n'J./"
Olympia, WA 98504 ~~ ~/ C 84000373
~ 7 n f' . . Y.'ndQf'~ C. Well.. I h.r.by certify und.., plnall)' 01 perjury 11'111 Ill'
r- ~ r:..'t'~ pi ~ and 101, 1"'ld h"lln 'f' plop., charg.. lOI m"'fl,l., mar
J VENDOR OR CLAIMAN~ (War,s'" is to be psysblt!J4)/ I 4., 't I~ .I~~'.' 0,.. ell '''!/'ll,had 10 It''l S,.,. 01 WUhlllglOIl. IlId 'hal ,II
~~r (; .aC9d~lIml'h'lf nd/ct """'ICI. rlnd,rld hawI ba.n provld,d .Ilhoilt
Jefferson County " C{~</' 0 .(""~.j.tlo ~ ".grO.lInd.olt.c..C'..d.cotor.n.l.on.to"g'n.....
Dept. of Public ,Works ~ .\, 0" ,.9~.'Q l-AI O~
Courthouse '7<',,<"<:,0.~" lX:l/".~~ 1'\~
Port Townsend, y,7A 98368 '. '<'"%"Q,,'~ fSIGNI/oj....I() I
r' "/ .."".~,., '..C'" "_~_Q~
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FEDERAi..t:D.HO. OR $0041. SECURITY NO. (for A_por1"'lI P...onll a......c.. CO'lIrICI PI._lllol.A. .:: ~ .
AGCNCY U:;( QNLY
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DATE
1-_.,
1. Total Amt. of Grant
DESCFlIPnOH
QUANTITY UNIT
UHIT
PRIce:
AVOUNT
FOR "GENCY
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(REV: See
"ilt-",..ned vnll,-,he
2
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4.
Total Amt. Retained to Dat
5.
Current Reauest
1644.01
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Grant Remaining 1-(3+4+6+7
9. Percent of Pro;ect''Comolet 94%
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State of Washington
,Dept. of Ecology
Hail Stop PV-ll
Olympia, WA 98504
aO'HCY UIH OWL"
_ A~~~:.~I~:'.~'~D~C:" - \ _
P~~jU~'.-o:.~
INSTRUCTIONS TO VENDOR OR CU./fAANT: Submjt lhi, 'arm
in triplie.,. '0 claim paym.,,' tor mlll.ri.'" mefche"d.,. cr
urvic... Show complofe de,.1I lot .ach ilam.' .
WCC 84000373
iVEHDOiiOR CLAIMANT . (Warrant;s 10 be payable ~
Jefferson County
Dept. of Public Works
Courthouse
Port Townsend, WA 98368
V,ndo,', Certlflcat.. I n.rlb)' urhty wnd,r pI"all)' 01 ~rj"ry lhlt ,he
111m. and 10111. lilt.d hll,ln .,. pl'op.r chlrg.. 10/ mltlfll'l. m...
chandl.. Of .."",lcI' Ii,.,ni,hld to Ii'll 5111101 Wuhlnglon. .l'Id thai .u
goodalt,tmllhld ,"d/Of ..nrle.. r.nd.rad hi'" baan prO""dlid .ilno.d
dl,crimltlalion on thll grounde of r.el. cr..d. calOl, nalio"al Dl'igin, .....
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DAn DII!&CRIPTlOH QUANTJTY UNIT UNIT A"OUNT FOR AGENe't'
PRICE USE
--- 1--" (REV:
l. Total Amt. of Grant $29~0.00 See
,'--- ~, ""''''-h
2 "''''''0' "'~~ ",.,'Thi-~ ?7?' , ~
3. Total Prior Payments 1077.13
4. Total Amt. Retained to Date 0
-'
5. Current Reauest 1644.01
6 "~,, """ m> ; ~ n
-- [7_. l\T~r n.mr P;:ty;:thlo I"f1niro ' ~ I A n
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8. Grant Remai~i~g 1-(3+4+6+7 178.86 -
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9. Percent of Pro~ect.ComDlet 94%
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'''''''0'''0 "Wl .n....,.., DATI
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BUSINESS COMPUTER SYSTEMS LEASING, INC.
IB02 136 PL NE
SUI TE2
BELLEUVE,WA 98005
..
PHONE (206) 364,1671
NEW PHONE 206-451-3456
BAY SHORE ENTERPRISES
301 LANOF ILL Ro
PT TCWNSENO WA 98368
(, Due DATe ." ReFeReNCE ND.
07/01/8400675
LESSEe AGREES TO PAY A LATE CHARGE OF 5% OF
ANY RENTAL PAYMENT NOT RECEIVED WITHIN FIVE
DAYS OF THE DUE DATE PI..US APPLICABLE SALES TAX.
PAGE
UNIT STATE :'cooE"' DATE OESCRIPTION CURRENT CHARGES TOTAL
NUMBER. CREDIT. eR
BALANCE FORWARD 138.36
H 06120 LATE CHARGE BAYSHORE ENTERPR 13.84
TOTAL 13.84
WA AA 07/01 LEA SE COST 12B .35
MACINTOSH W/PRINTER
WA AB 07101 LEASE SALES TAX 10.01
UNIT TOTAL 138.36
.
BUSINESS COMPUTER SYSTEMS LEASING, INC.
1802 136 PL NE
SUITE 2
BELLEUVE.WA 98005
.
PHONE 1206) 364,1671
NEW PHONE 206-451-3456
BAY SHORE ;:NTERPRI SE S
301 LANDt-ILL RD
PT TOWNSEND WA 9B368
(O=;~;T;B4 REF~R~:~:D'
LESSEE AGREES TO PAY A LATE CHARGE OF 6% OF
ANY RENTAL PAVMENT NOT RECEIVED WITHIN Five
DAYS OF THE DUE DATE PLUS APPl.ICABLE SALES TAX.
ITATI "COOl. O'ESCRI'TION' '
WA AA 06/01 LEASE COST
MACINTOSH W/PRINTER
WA AB 06/01 LEASE SALE S TAX
UNIT TOTAL
CURRENT CHARQU
.., CREOIT.CR
'. ,'TO't:AL:.:.' '
128.35
10.01
138.36
6'f.J -~
I 'IS, ;1$
u
PLEASE PA V
THIS AMOUNT
o.......c....._
'---
.
.
BUDGET -- CURRENT TO MAY 31,1984
CATEGORIES BUDGET ACTUAL DIFFERENCE 1. expended
Container3 $15000.00 $0.00 $15000.00 0.001.
Safety Package $1000.00 $246.02 $753.98 24.601.
Office Supplie~ $550.00 $100.00 $450.00 18.18i(
Tel ephone $1000.00 $656.00 $344.00 65.60i(
Poeta'ge $2500.00 $359.05 $2140.95 14.36i(
Transportation $1875.00 $320.00 $1555.00 17.071.
Adverti~ing/promo $2500.00 $441.42 $2058.58 17.661.
Printing $1500.00 $446.61 $1053.39 29.771.
Insurance $1100.00
Uti1itie~ $625.00
Rentals $200.00 $234.00 ($34.00 ) 117.001.
Miecell aneOUll $1200.00 $0.00 $1200.00 0.001.
Bookkeeping $6900.00
Capital Expenditure22 $22100.00 $5200.00 $1690(1.00 23.531.
Wage IBenefib $B2240.00
Advi~ory Commitee $1000.00
~
....
IIIL...'
.
-.
Minutes, Week of August 6, 1984
Page 5:
Public Works re:
Problems on Elkins Road at jail site: Two problems
OIlElklns Road were outlined by Brlan Shelton: 1)
A water line installation at the jail site has' torn
up an existing oiled road and 2l The access points
from the parking lot to the jail site need to be im-
proved. Paving of the Elkins Road is not in the
scope of work for the jail's paving contract.
Chairman Brown advised that when the paving contractor
is at the situ the road should be paved as well as
the jail parking lot. Brian Shelton will contact
David Johnston, Architect and Ralph Hall, Project
Manager, to discuss these problems.
State Liquor Control Board re; Two applications for special
occasion licenses: Pope ~TBlbot's two appllcatlomtor speclal occasion
rL"Eenses were approved on the moti.on of Commissioner Pitts, seconded
by Chairman Brown,
The meeting was recessed on Monday evening and r.econvened
with Commissioner Pitts and the Chairman in attendance on Tuesday morning.
20 .jt: JOBID OPENING re: For pre-engt~eered and prefabricated can~py
and reipfo~ced concrete sl,ib::--fr,e-[o oW~lds were opened at t e
appolnted tlme tor the c,jiloj:iy and reinforced concrete slab to be located
at the Jefferson County SanitaL"y Landfill:
Optional Total
Bidder Canopy/Slab Approach Slab incl. Tax
Amdall Construction, $12,027.00 $ 3,718.00 $16,973.11
Port Ludlow
Nordland Construction 23,165.14
Engineer's Estimate 7,000.00 4,000.00 11,858.00
Commissioner Pitts moved to accept the bids and have the engioneer check
them for possible errors and mak" a recommendation. Commissioner Brown
seconded the motion.
Fred Hill re: l'roE,9.sed Threshold Determination for Gravel Pit
Project on.'Highw~l ~~: RacherNathanson, Assistant Planner, revLewecl the
Environmental C~ect st Addendum for this proposed gravel production pro-
ject to be located on Hiwny 20 near the Airport Cutoff Road, for the
Board and seven ar~resldents. Only the items that wer.e changed on the
checklist were reviewed. In uddltlon to these comments Rachel noted
the following:
Air: If complalnts were recelved from'surr.ounding property owners
about fHtlin~ dust, the Olymplc Air Pollution Control ARency
would rnonif:or the s l tun t I un und if the SI;ate standu".ds 11 rl) not
being mer: the projecL "oul d be fIned at' possibly shut down.
\~ater: The State Deparr:men!; of Ecology would be responsible for complainr
made Hbll\lt posslht., "Illl,pel-Ing wl.th wlIt;er ril\hts Hnd could requJ.<:'c
that a hydnllo,\,\ L.:"I s I: udy I>e done.
The suggested mit Ign::ivo.l m""Sln-"',, were reviewed and 11 lctl:elC' f".orn ~:rs,
Junet A. Daley, Olympic C"I"''':I'''''''', was rencJ into the re"onl,
Chairman Brown a,;'<ed tho,,,, PI'.,,,u,,' 1',"0 comments and/or qUi.!stl.ons.
Mr', Daley, own,,,. uf Oiy,"pic (;."":"11..,,,,,, tocuteu lIcross the sr:reel: from
tho llroject sl!." sLntad L!o"r II... <,....Id live ,"if:h the mining uperation
that; \.:1 presently conduc"<,d ilL 1.111" slr:e, bur: feels the proposed pro.lec:;
is in direct vlulutlon pC !'h.: ,I.'II',ol',;on County ComprelHmr;lve Pl.an, He
.-J.J'ited concern,; "I>nut: II \1"1'.,,, ~~J 'I','"fflc, :\l o.lcunornl,t' effecr; on IIdlol.n-
yl;~~businesscs ""d III rlJ")I",.'I,y \"11.., ,j, lie does not Sl'e I'!lil" ':~f,s pro:1ecr:
, "",be considl!"I.'t1 envlro"IU,'nt" I Iv non-significant until "I'lldl,e,; uro doni!
at least" Vl.",,'.
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VENDOR'S COPY
'T ~: Ecot~:~NC' NAM, .=---~J 461-0 ~~;~~@>> VEND~":R~~~:r~H~~~:~~V,~:E
H.JFFFfRSON r.0I;I\T~_r--_G-p'L_01362 __ 11158"lNI' 06~
INVOICE AMOUNT
_~: RHEI1ENCE
.::-~' YlAW NUMB(I1 ._h~~Cf DISCOUNT
1 I I 1 Ii:
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~--- ---A-GENCi'NAME. - ...--;--. -1
------
State of Washington
Department of Ecology
Mail Stop PV-ll
Olympia, WA 98504
AOIEHC'I' UFo! 0.111.."
-.:~r,",.~~co~i. -\.. .~~:u~ ~;:."
INSTRUCTIONS TO VENDOR OR CLAlIAAHT: Submj, 'hi, form
in 'ripllca,. 10 claim payman, lor mat.ria'., marchandi.. or
..rvic... Show compl.'. dat.1I flY .ach I'am, .
393140502
I~R CLAIMANT . (Warrant;s to be payable ~
Jefferson County
Department of Public Works
Courthouse
Port Townsend, WA 98368
Vendor', C.rutlcat.. I hat.by cartify unda' plnall, of ",'j"", I".' the
Itlrna and 10111. lillad ....,.In If. proper c.h.'VI' 101 mallll'!', ..."'.
enlndl.. M unric.. lurni,had 10 Ii'll SIIII 01 W.thington. arid Ihal.'
good. fllml.hed Illdlor .arvh:.. rlnd."d h... b.,,, pro....e.d wilhoul
dl.crltniflllion on 'hI ClfOllfld. of reel. ClI.d, eolOf'. lIanon.' origin, ....
or age. ~
BY
(r.lGN"'...o
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nirp~rnr
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c;,_?_Rc;,
(DATE)
f'iDEA'.a.L,.D NO. OR SOCIAl. SECURJTY NO. (If. "IIPO"I'" ....._1 a_.. c..".cl...,-..IDIJIl.S,
PAft DEICIUP1lON QUAN'1lTY UNIT UNIT AMOUNT FOfl AGENCY
'Ra use
-- f--'
j l. Total Amount of Grant, 26 400 00
2. Total Exoenses'to.Date 25 492.84
",;:+-~ 1 'o~; ~~ P.,AQ .,.,
_. " . . n_ ~- 439.35
3,957.34
6. Amount Retained this Reaues 5% 197.87
h~. Npt: Amollnt p"y"hle Tn; " 17~q47
Ia-~U - A~" ~p -
..._... .-_.
9. Percent of project Complete 100%
.-.....- .-.. . --.-.-------.----.-.. '.
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, AFRS ACCOUNT CODE
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~EV.$-n
AGENCY NAME
INSTRUCTIONS TO VKNDOII Oil CLA'''''''NT. SUbMIT TI-I19 FO"M IN TRIPLICATE
~~",c;.~~ITME ~~~~~t~:RO~...~~T~tRI:'~~S. MI:RCHANDISE OR 6ERVICE5. 6HOW
State of Washington
Department of Ecology
Mail Stop PV-ll
Olympia, WA 98504
AGENCV P R OR AUTHORIZATION NO
393140502
INVOice HER OA,TE
<">
Dec. 40- 1~84 ,.
OJ
~ .
y~~~~~': ~~~~FI~~~E'TOIT ^~; 1!~~~Tf~fll~~~~ ,~N2:Ui!1tlPc~II!c.7;J~~~
MATERIALS. MERCHANDiSE OR SEIlVICES fURNI~~ TO ~HE STAT-E OF
WASHINGTON, AND THAT ALL GOODS FUI1Nj~ Af'l~/OII SEIlVICES
~~~~E,:~f ~l~~C:~ft'llf~~~v~gigll,W:J~gg~"A~:tWI~\I~.~TJg~ 8; "b1E
,,'\ o~Cher No.1 .::i: ~ ;'
~:e.b ;1
,~ jSIGN IN INl<) '-..l . ..
sistant Director of~ublic Works
(TlTLEI
DESCRIPTION UNIT AMOUNT
PRiCE
1. Total amount of 26,400.00
2. Total expenses to date 18,195.00
1---
3. Total prior payments I 0
"--- -
4. Total amount retained to date 0
5. Current request 8'1.08
- -.
6. Amount retained this request 5% 3.'1,3.5 ~
7. Net amount payable this request I ~) 49,n
8. Grant remaining 1-(3+4+6+7)
9. Percent of project complete 70%
~
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(lit !NOCll' f'nOJ OIlJ OIlJ("T NUJ.lnCR
OJ,..p- 62 .12. OfJo 34 13 00
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L& I.ESAC
OLYMPIA, WA
.
AFFIDA VIT OF
WAGES PAID
ON PUBLIC WOIlKS CONTI~ACT
.
.
DEI'ARTMENT OF LABon AND INDVSTllIES
EMPI,OYMENT STANDARDS DIVISION
Olympia, W A 98504
STATE OF VVASHINGTON
,.nn..",...}'"
~g~:~!b~~~~f~,tJj:~:l~.i:i:~;~L.'~~:~:,~.~?~.~
County in Which Work Performed . .-;.f.::.E_t:..lo':.".50.Q~I."'''...............n...
~::~o~a~;~~~,C:t~~;e~;},,/;I~:?'~'t~~;"iZ1""""N~'tj""'"..,........,...
COUNTY OF .....,.'.......mn.......... n"~"'m_
In compliance with RCW 39,12,040 I. the undersigned. being a duly authorized representative of
_mA,b_d.&.\..b......,G,C!,.;t.!c"..,k.e.,.J,!:::!'~"....n".??LL,~..b!!..$J~!,",!;...Dt.o.....m...i~d:::m'h..':!,i.J..l.e~..._\1!.~!....~JlJ4,~..n..............
CContractor or Subcontractor) (Address)
do hereby certify that the following rates of hourly wage and hourly fringe benefits have been paid to the
laborers, workmen and mechanics employed by me upon the project described above and that no laborer,
workman or mechanic has been paid less than the "prevailing rate of wage" as determined by the Indus-
trial Statistician of the Department of Labor and Industries.
List below each classification of labor employed by you upon the project described above and the rate of
hourly pay and hourly fringe benefits paid to each classification.
Please Note
If apprentices have been employed on this project, provide this additional information: name and/or regis-
tration number and stage of progression,
Craft Rate of Rate of Hourly
Hourly Pay Fringe Benefits Paid
G\Ye-e,..;r;~ /7. ~ '-- , t..,'ji/ _
J..."b",.... /'-/. "11, ~,~/)
I v-o...1 \tV",.. K.".- /'ii'.&</ /../"",-
NOTE: Attach Additional ShcetJ as Needed.
A~..J.~..I...n~r.:1.'S~,.....G...I~!5:::.m......."......:..'..'..n'
~~~;.;;;;;?:'..n'......"...."...."m...m'
(Title)
Subscribed and sworn to before me
thISn'..d".~." day of...n:\,.\~'~'~t\.~'t, ~
19~_:\.
~..~!L~~:\..~~
NOlarv PubUc fn and for the Stare of Wa.hfngton,
rt'rid'"g in Wa.hlngton.
INSTRUCTIONS:
1. Pursuant to ncw 39.12,040 copies of this form must I
contrncwrs,
2. Complete this form in triplicate nnd have It notarized.
a, Submit nil forms for certificntion to: Employment Stnndards Division. Department of Lnbor nnd Industries,
o.,nernl Administration Buildin", Olympin, Washinllwn 98501,
4. Fllo II certlned copy with the AlVardlnll Alfency.
c;ON'l'nACTORS Arm RESI'ONSlIlLE Fon OBTAINING AND FILING AFFIDAVITS of the sun.
CONTllACTon..<;. This i. required by IIIW and payment. cnn not Inwfully be mode until such affidavits
ll", ftlod.
.',,, ',' : .;,' : ::". ,':; ,f..Al. VI(O,I'!", ,.",' " ,,',:>: ::":'::.'('::';''''-'~;-~.,.,,':',:,;;:,
I h~~b)' ~rtir)', ,'hat -.a~~o~di'n;,:~o_'~'h~';~lc'r~tei'arid r~'i~8;~"~'~~nt. h'er_~"in' ~'~~'r~;': .,'
to 1he prev~I~I,n!J ,~a,.~re~~~~,~~~". '~\Y' 3~.12:~,~""~,~~~,:~~.n""la,t~~.~~~;.:",~,,::,,
. INDUSTRIAl.' STATISTICIAN',;, .',.,.
RTMENT . I,ADOn ANDINDlISTRIES:
~""...".,~~;...~,.~.:.~)L".'"
~o1.:""'.:t
G
~
,
.
PAYMENT RECEIVf:D
-
DEe 1 31984
L& I.ESAC
OLYMPIA, WA
.
AFFIDA VIT OF
WAGES PAID
ON PUIIJ.JC WORKS CONTlUCT
DEPARTMENT OF LABOR AND INDVSTllIES
EMPLOYMENT STANDARDS DIVISION
OI)'1npla, W A 98504
STATE 'OF WASHINGTON
A wa rd ing Agency ,),<;.I::F.:!';!".~,"'!\l.....(9..lhy.r.:i........e~,~~.!~.....0..?.'!:~.~
Con tract N urn ber .....,~g.2.G?,9.,........,..... ................,.........,...,..,.............,.
~:~: ;~~~a~~~;;:~:;d..::::=~!j~JJ::::;;/:~:I'4x:~L:::::::::::::::::::::::
County in \\'hich \Vork Performed . .';.E.F.:.'C.~.50.Q..~....................h...
~:a~a~Os~a\;~~~~tCoofuJn~;;,~;l.;,1'I~1?,Bufy~~..~...'....N;..d...'..................
COUNTY OF .m''''''''''''''''''''''',m.",,,,,,,,,,,,,,,
"""""...Jss,
In compliance ,,,ith ReW 39,12.040 I, the undersigned, being a duly authorized representative of
-."A"h..J"g"b"..,."G,!::,,,;T.r.:,,,,,c.;e,,,,I.~!,s..,,,,,,,,,,??LL,l,,&!!,Sk.~.~,.P.t::,,,,.,..,,,,I:kd..,,.,h..~;".I,!:'~.,,.,l-:V~L.7..,~~,,,,~=,,,,,,,.,""..,,,,
' (Contractor or Subcontractor) (Address)
do hereby certify that the fOllOWing rates of hourly wage and hourly fringe benefits have been paid to the
laborers, workmen and mechanics employed by me upon the project described above and that no laborer,
workman or mechanic has been paid less than the "prevailing rate of wage" as determined by the Indus"
trial Statistician of the Department of Labor and Industries.
Li&t below each classification of labor employed by you upon the project described above and the rate of
hourly pay and hourly fringe benefits paid to each classification.
Please Note
If apprentices have been employed on this project. provide this additional information: name and/or regis"
tration number and stage of progression,
Crafl Rate of Rate 01 Hourly
Hourly Pay Fringe Benefits Paid
CtlV-p.ef'/T r:;...- /7.")..'L '2,$'1 __
J'-tk,~v- l'-/. "If> ~,4) -"
11"0...1 WP"'~~_ l'ii,p'l 1.-/, / ",- .._
NOTE: Attach Addltlonal Shrets as Needed.
AJ"1.J.~..L..CCf,!.Y.:v.::"'..mG).'::/,:s......".........,..".."......
~,~t~Z;;J?.".....",......"".""..........,
(Tltht)
Subscribed and sworn to belore me
~ '11
this....Cl..,.'.._,m day oL""'N ~I.l,~.t'\.~-;:. t>-
19~,::\,.
"~,-'ll:l~,~I\r.\r\.~
.'.otarJl PubliC' In and for tht Stare 01 \\'cuhfngron.
r~ddin{1 in Washington.
1.&1 lJ~t' On11
I hereby cmir)' Tholl accurding 10 the wage ralC'i and (rinl1e' benefits hNcin ~"nrn
10 Ihe prc\ailing WHAl(' fc-quircmcnti o~.~w J9.1.:!,040 hAve been .alih(ird.
n)',....,
DEe 2 1 1984
..,.... 0011(':.,.............._................................
INSTHUCTIONS:
1. Pursuant to HCIV 39,12.040 copies o{ this Corm must h
conlrnctors.
2, Comple'" this form in triplicate and have it notarized,
3, Submit nil form. {or certificntion to: Employment Stnndnrds Division. Department oC Lnbor nnd Industries,
General Administration Building, OI~'mpia, Washington 98504.
,I, File" cerlili,'d eUI'Y wilh the Awnrding Agency.
CONTHACTORS AIU: m:SI'ONSIBU: FOH OBTAINING AND FILING AFFIDAVITS o{ the SUB.
CONTRACTORS, 11,is is r<.quired hy law nnd payments can not l/lwCull~' be mnde until Huch /lflidllvits
liT<! tilod.
...r::.... ,
..
OF WASHINGTON
ICE VOUCHER
.
-Scr..-v T /2-0$'-6'?-
,I..
AGENCV NAME
INaTRUCTIONS TO vaN DO" 0" CLAIMIl.IoIT. SUOMIT HIlS FORIo4 IN TAIP'l-IC"TE
TO CL..IM ""'I'MI.NT FOR ......TIt.H...l..S M[RCHANDISE OR &[RVICES. .HOW
COMPl.eTE DtT"1I.. ,.OR [...eH ITEM
State of Washington
Department of Ecology
Mail Stop PV-ll
Olympia, WA 98504
AGENCY P R A AUTHORIZATION NO
393140502
Dec. 4, 1984
WASHlNorON, AND THAt ALL COODS fUIIN,SHfD ANDIOIl SERVICES
VENDOR OR CLAIMANT IlfNDEllfD HAVE BEEN PIlOVIDED WITHOUT DISCIIIMINATION ON T"'
GIIOUNDS OF RACE. ''''HD. COlOII '~A'IONAl OIlICIN SEX, 011 AGE
Jefferson County Public Works VOUC~NO' 1
Courthouse BV ~a &...-
Port Townsend. WA 98368 (SIGN IN INI(I
- Assistant Director of Public Works
/TITLEI
I DATE DESCRIPTION QUANTITY UNIT UNIT AMOUNT FOR AGENCY
PRICE USE
. l. Total amount of grant -J --- 26,400.00
-- -- -- - - -- .----- --- ----"-
2, Total expenses to date 18,195.00
i 3. -~--t---- .. -
Total prior payments I 0
----- --- - - -- ~- - - ---,- ~,
14. Total amount retained to date 0
--1--- ---
5. Current request 9,097.50
, - -.--- -. --- ----
6. Amount retained this request 5% i 454.88
7. Net amount payable this request 8,642.62
8. Grant remaining 1-(3+4+6+7) 4,102.50
---,--- -r-- -
9. Percent of "oJ... '0""" =::::::j::::f==- 70%
-------- - -- . --
DOCUMENT # LIQUIDATION DATE
m rllfD ,.. ~.~. I'.' '''AIL CAlli""" 'IJHI""INO DOC. N., co..... '''''0. rD'O''"c''llUCEIVED BY
DIll'. 0" UNll' "CCClvca 'D- .,. 0111 UNIT IIIIIlCIIVCD ., I DAl'1. 0' IIIICCII'" 'lilT. eH""ac
ACCOUNT CODE AMOUNT
fUND APPRO'. 'tOGRAM OBJECT LIQUIDATION NET INVOICE
1-
ItcllYltl TOTAL'
IV
"- lOAm
~C:l~':::,~ \':,ftOVED 1 ,NYO'C' DAlI' INVOICE NO I GlOSS, 'NY AM' ,'lCOUN! '" N(I lNV. AMr. VOUCHU NO. W".....Nr NO.
VENDO.'S CUTlfICATE. I HEJlEB'r' CEIITIF'r' UNDEIl' PENALTY OF PE~JUII'r'
THAT THE ITEMS AND TOTAtS llSTfD HEll'flN AIl'E FIl'OPEIl' CHAIl'CiES FOR
MATERIALS Mfll'CHANDISE Oil' srllVICES fUIINISHED TO THE STATf OF
~,
..,. ..,. ..,. ..,. ..,.
00 ~ 00 00
00 ...... ...... ......
~I ...... ~ ~ " ..,.
~ ~ 0 0
...... :::; ......
...... ~ ~ ~
'" ~
2 ~ 0 " '" M
I- ~ M ..,. 0
I N ;::; ::; ..,.
0 ~ N
N N N N N
.,
" " to
0 '" " '"
'" 0 '"
~I U '" "",... "'"
'" .. "'''' to "''''
'" > 0.... '" 0....
El " ~'" 3 "'"
0 '"
u u u '" u
I 0 ,;
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'"
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".... 0 0 .. 0
~ i': J> u .... u
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...'" .... '" ....
"'" '" '" '"
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'"
~ 0 ~ M " N 0
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It 00 00 00 ~ 00 '"
~ wI ...... ...... ...... ...... '"
~ '" 00 ..,. N M 0
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It N 00 .... M ~
!I! "" 00 "" ~ ....
~ 00 00
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"
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..
!
- . AMDALL CONSTRUCTION eO" INC.
, COUNTY OF JEFFERSON 10
51 A TE OF W A5HING10N 981 Tala Shore Drive, Port Ludlow, WA 98365
Address
Work done 10 November 30, 1984 County Road Project S0563
Date December 3, 1984 Estimate No, 2nd and Final
Unit Price. Quantity Toea. prevloua Prellnt
1, 1250 sq. ft, Canopy and Reinforced L.S. 12,027 00 100% 12,027 00 7,217 00 4,810 00
Concrete Slab Complete
2.
3.
4.
5.
6.
7,
8.
9,
10,
11.
----
12.
13,
14.
15.
-
16.
17,
18.
. W.S.S,T. @ 7.8% 938 11 938 11 56 92 375 19
-- --
20,
Totals 2,965 11 12,965 11 7,77S 92 5,185 19
- -- 388 (~59 -,
5% >lH retained as per contract 648 26 648 26 99 27;/
2,316 85 12,316 85 7,390 93 4,925 92
Warrant No. Total Amt,~25.92
1 hereby certify on honor that the abovc estimate Is based upon ae~ents and that the same Is
true and correct. ~ ~ _ _ _ _ _
County En,lneer
I, the undersigned, having first been duly sworn. do hereby depose and say that the above bill Is tme and
correct; that the work was actually performed and material lurnlshed as therein charged; and that there
Is due me this date, according to contract, the sum 01 S 1,.925.92 , and that the same or any part
the~TffO-r-been paid. U LJ
(Sign ,,)~~:1IU"-~ './),.Q corC ,..4,Q(7,_M7': a~,
Subscribed and sworn to beCore me this Date / 0 -~c.j . 10.12.!:/-
day 01 ,10_, Ordered Paid
By
Counl)' Auditor Chllrmln. Bond or COUhl)' Comml..loner.
(SEAL)
i
~ ""',i "" ',.,./~, .~ "
'l. n..," .',; lo.... "... .I,d..:_.' ,,-
DATE 8/31/84 . JEFFERSON COUNTY PU~C WORKS
SOLID WASTE VOUC. WARRANT .
VOUCHER . 1
TO- PORT TOWNSEND LEADER VENIIOR . POR4C
226 ADAMS
PORT TOWNSEND WA 98368
BARS DESCRIPTION
DATE INVOICE NO. ****M***M DESC ********* AMOU~
****************************************************_.***********~************.
* * *
7/25/84 * 942000 * CALL FOR BIDS-CANOPY/CONC.SLAB * 38.~
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * *
* * TOTAL * 38.::
* * *
*********************************************.*~**.**.----_...._--*............
*
AUDITED BY --------------- DATE --------- * ORDERED PAID BY ---------------
*
* DATE ----------
I. THE UNDERSIGNED DO HEREBY CERTIFY UNDER *
PENALTY OF PERJURY. THAT THE MATERIALS HAVE *
BEEN FURNISHED. THE SERVICES RENDERED OR * -------------------------___
THE LABOR PERFORMED AS DESCRIBED HEREIN. *
AND THAT THE CLAIM IS JUST. DUE AND UNPAID *
OBLIGATION AGAINST JEFFERSON COUNTY. AND THAT ----------------------------
I AM AUTHORIZED TO AUTHENTICATE AND CERTIFY *
TO SAID CLAIM. *
* ----------------------------
*
--------------------------- .
PUBLIC WORKS * JEFFERSON COUNTY COHHI88IONE~
~,~
'.
.
AMDAL CONSTRUCTI'~OMPANY, INC,
TO
JF JEFFERSON
"WASHINGTON
Address 981 Tala Shore Dri.ve, Port Ludlow WA 9836!
.work done to
October 24, ,.-1~~,84
County Road Project S0563
Date
October 25, 1984
Estimate No.
Unit
Quantit)'
Total
Previous
Prelllnt
Price.
1.1250 sq. ft. Canopy & Rei.nforc~d
-eo,,~. e lc SlaL
2,
.~ _~L
,~
60%
cornpletl~'
3.
4,
5.
6,
7.
8:
9,
.-
10.
11,
12,
13.
14,
15.
16,
17,
-1---
----
18.
:W.W.!>.S.T. @7.8%
938 11 562 92 0 562 92
----
12,96511 -- 2J9 92 0 .779 92
648 25 388 99 0 388 99
12.31685 ,390 93 0 ,390 93
20.
Totals
510% retained as per contract
Warrant No. Total Amt..$.Z....;3.JLO~
I hereby certily on honor that the above estimate Is based upon actua~e~:~J~ments and that the same Is ,
true and correct. ~-f::J:Jt1'&...f;<<;::.. __ ___
County En,lnoer
I, the undersIgned, havrng !lrst been duly sworn, do hereby depose and say that the above bill Is true and
correct; that the work was actually performed and material furnished as therein charged; and that there
is due me this date, according to ,~et, the sum of $ 7 . 390 . 93 , and that the same or any part
there~s...not b,n paid, ;/ (, /. Q
(Slgn'h~-,- .....l)~ 0 for ~h.a..Q cL,d: (J ~
Subscribed and sworn to before mo this Date /0-.;9-<1 . 19M
day of
,19_,
Ordered PaId
'~", ~. ,t/ /);
By.... " .'..
Chairman, Board 01 County CommllllonGfI
Cou"t)' Auditor
(SEAL)
~.~...__;2~:':::'.;~~.~i~~~~t...._.~..l< .-1..;' .._.;..... .,. .'1__ t ~
.
.
AMDAL
CONSTRUCTION
COMPANY, INC.
October 24, 1984
Jefferson County Engineers
County of Jefferson
Port Townsend, Washington 98368
RE: PRE-ENGINEERED & PRE-FABRICATED 1,250 sq,ft. CANOPY & SLAB
Gentlemen:
Following is a Cost Break-Down on the above caPtioned proiect:
1. Bond, Pennit, etc. 1,000.00
2. Concrete Slab 2,500.00
3. Canopy Material 3,717.00
4, Canopy Installed 4,810.00
TOTAL $12,027.00
Draw Request #1
1,000.00
2,500.00
3,717.00
o
$7,217.00
t.
Since:e1y, , ~
~.0"-...,4.1'
Dean W. Amdal
AMDAL cct-lSTRUCTION COHPANY, INC.
lMA:ra
Enclosure
_'~'.2214
"111111'.....1'1(""[ [JRlyf
."Wi',ur"flo/l.wAU,l)b'J
f,fJli!..llnJ(.lI(m~,O
"'l"l~I.I":JlLf
.....
r, _ .'
(' .
APPENDIX A
PROJECT DESCRIPTION
GRANTEE:
Jefferson County
PROJECT NO.: 393140502
PROJECT TITLE: Jefferson County Curbside Collection Project
COMPLETION DATE: September 30, 1984
NARRATIVE DESCRIPTION: This project includes the expansion of the concrete floor
and corresponding canopy covering construction of the existing recycling facility
and the purchase of a conveyor belt, compactor unit fDr the collection of cardboard
and newspaper, six forklift two cubic yard dumpsters, and four metal 14 cubic yard
drop boxes. Prior to purchase and construction, all plans and specifications, and
bid docuwents must be reviewed and approved by the Department of EcolDgy (WDOE).
The bid documents shall conform with'WDOE requirements for construction plans and
specifi cati Dns and estimates dated January 28, 1974. The county is requi red to
receive WaOE approval on their bid process prior tD the county awarding the bid,
ESTI MATED
MAJOR PROJECT EST! MATED REQUEST ,FROM ESTIMATED DATE
ELE1~ENT PROJECT COST REF, 39 GRANT OF CO~lPLET!ON
1. Conveyor Belt ,/ $3,500,00 $1,750.00 August I, 1984
2. Compactor Uni t'/ 2,000,00 1,000,00 August I, 1984
3: Six Dumpsters,/' 3,000.00 1,500,00 August I, 1984
4, Four 14 cu, yd, {6,200,00 3,100.00 August 1, 1984
Metal Drop Boxes
5. Cor.c rete Floor" 3,300.00 1,650,00 August I, 1984
6. Metal Building Canopy,/ 6,000.00 3,000,00 August I, 1984
7, Contingency @ 10% 2,400.00 1,200,00
TOTALS: $26,400.00 $13,200.00
.
APPENDIX A
PROJECT DESCRIPTION
.
GRANTEE:
Jefferson County
PROJECT NO.: 393140502
PROJECT TITLE: Jefferson County Curbside Collection Project
COMPLETION DATE: September 30, 1984
NARRATIVE DESCRIPTION: This pr'oject includes the expansion of the concrete floor
and correspondin9 canopy coverin9 construction of the existing recycling facility
and the purchase of a conveyor belt, compactor unit for the collection of cardbDard
and newspaper, six forklift tWD cubic yard dumpsters, and four metal 14 cubic yard
drop boxes. Prior to purchase and construction, all plans and specifications, and
bid documents must be reviewed and approved by the Department of Ecology (WDOE).
The bid documents shall conform with WDOE requirements for construction plans and
specifications and estimates dated January 28, 1974. The county'is required to
receive WDOE approval on their bid process prior to the county awardin9 the bid.
ESTIMATED
MAJOR PROJECT ESTIMATED REQUEST FROM ESTIMATED DATE
ELEMENT PROJECT COST REF. 39 GRANT OF COMPLETION
1- Conveyor Belt $3,500.00 $1,750,00 August I, 1984
2. Compactor Unit 2,000,00 1,000.00 August I, 1984
3, Six Dumpsters 3,000,00 1,500.00 August I, 1984
4, Four 14 cu. yd, 6,200,00 3,100.00 August I, 1984
Metal Drop Boxes
5, Concrete F1Dor 3,300.00 1,,650,00 August I, 1984
6. Metal Building Canopy 6,000.00 3,000.00 August 1, 1984
7, Contingency @ 10% 2,400,00 1,200.00
TOTALS: $26,400,00 $13,200.00
.
,
AMENDED
APPENDIX A
PROJECT DESCRIPTION
GRANTEE:
Jefferson County
PROJECT NO.: 393140502
PROJECT TITLE:
Jefferson County Curbside CollectIon Project
COMPLETION DATE: December 31, 1984
NARRA TIVE DESCRIPTION: This project includes the expansion of the concrete floor
and corresponding canopy covermg construction of the existing recycling facility and
the purchase of a conveyor belt, compactor unit for the collection of cardboard and
newspaper, six forklift two cubic yard dumpsters, and four metal 14 cubic yard drop
boxes. Prior to purchase and construction, all plans and specifications, and bid documents
must be reviewed and approved by the Department of Ecology (WDOE), The bid documents
shall conform with \VDOE requirements for constructIon plans and specifications and
estimates dated January 28, 1974. The county is required to receive \VDOE approval
on their bid process prior to the county awarding the bid.
ESTIMA TED
MAJOR PROJECT ESTIMA TED REQUEST FROM ESTIMA TED DATE
ELEMENT PROJECT COST REF. 39 GRANT OF COMPLETION
1. Conveyor Belt $ 3,500.00 $1,750.00 December 31, 1984
i. Compactor Unit $ 2,000.00 $1,000.00
3, Six Dumpsters $ 3,000.00 $1,500.00
4. Four 14 cu, yd. $ 8,200.00 $4,100.00
Metal Drop Boxes
5. Concrete Floor $ 3,300.00 $1,650.00
6. Metal Buildmg Canopy $10,000.00 $5,000.00
7, Contingency @ 10% $ 2,400.00 $ I ,200,00
TOTALS: $32,400.00 $16,200.00
..-
.
.
AMENDED
APPENDIX A
PROJECT DESCRIPTION
GRANTEE:
PROJECT TITLE:
Jefferson County
PROJECT NO.: 393140502
Jefferson County Curbside Collection Project
COMPLETION DATE: December 31, 1984
NARRATIVE DESCRIPTION: This project includes the expansion of the concrete floor
and corresponding canopy covering construction of the existing recycling facility and
the purchase of a conveyor belt, compactor unit for the collection of cardboard and
newspaper, six forklift two cubic yard dumpsters, and four metal 14 cubic yard drop
boxes. Prior to purchase and construction, all pJans and specifications, and bid documents
must be reviewed and approved by the Department of EcoJogy (WDOE). The bid documents
shall conform with WDOE requirements for constructIOn plans and specifications and
estimates dated January 28, 1974. The county is required to receive WDOE approval
on their bid process prior to the county awarding the bid,
ESTlMA TED
MAJOR PROJECT ESTlMA TED REQUEST FROM ESTlMA TED DATE
ELEMENT PROJECT COST REF. 39 GRANT OF COMPLETION
I. Conveyor Belt $ 3,500.00 $1,750,00 December 31, 1984
2. Compactor Unit $ 2,000.00 $J,OOO.OO
3, Six Dumpsters $ 3,000.00 $1,500,00
4. Four 14 cu. yd, $ 8,200,00 $4,100.00
Metal Drop Boxes
5. Concrete Floor $ 3,300,00 $J,650.00
6. Metal Building Canopy $10,000.00 $5,000.00
7. Contingency (cl 10% $ 2,400,00 $1 ,200.00
TOTALS: $32,400.00 $ J 6, 200.00
.iI
APPEND I X A
PROJECT DESCRIPTION
GRANTEE:
Jefferson County
PROJECT NO.: 393140502
PROJECT TITLE: Jefferson County Curbside Collection Project
COMPLETION DATE: September 3D. 1984
NARRATIVE DESCRIPTION: This project includes the expansion of the concrete floor
and CDrrespondin9 canopy covering construction of the existin9 recyclin9 facility
and the purchase of a conveyor belt, compactor unit for the collectiDn of cardboard,
and newspaper, six forklift two cubic yard dumpsters. and 'four metal 14 cubic yard
drDp boxes. Prior to purchase and construction. all plans and specifications. and
bid documents must be reviewed and approved by the Department, of Ecology (WDOE).
The bid documents shall conform with'WDOE requirements for construction plans and
specificatiDns and estimates dated January 28, 1974. The county'is required to
receive WDCE approval on their bid process prior to the county awardin9 the bid.
ESTIMATED
MAJOR PROJECT ESTIMATED . REQUEST . FROM ESTIMATED DATE
ELEMENT PROJECT COST REF. 39 GRANT OF COMPLETION
1- Conveyor Belt ,/ $3.500~00 2)127 $1.750.00 August 1. 1984
2. Compactor Uni tV 2.000.00 ~'11 1.000.00 August 1. 1984
3: Six Dumpsters,/ 3.000.00 'Z,13/f 1.500.00 August 1. 1984
4. Four 14 cu. yd. @)200.00 ~'11~ 3.100,00 August 1. 1984
Metal Drop Boxes ,\ "
, ':J;;',.,
5. CDncrete Floor;" "i3.30'0;03/~165' 1,650.00 August 1. 1984
6. Metal Building CanoPY/,6.000.0 3,000.00 August 1. 1984
7. CDntingency @ 10% 2.400.00';, 1,200.00
,--
TOTALS: $26.400.00 ~~ ..,;"8 $13,200.00
.
.
APPENDIX A
PROJECT DESCRIPTION
GRANTEE:
Jefferson County
PROJECT NO.: 393140502
PROJECT TITLE: Jefferson County Curbside Collection Project
COMPLETIDN DATE: September 3D, 1984
NARRATIVE DESCRIPTIDN: This project includes the expansion of the concrete floor
and corresponding canopy covering construction of the existing recycling facility
and the purchase of a conveyor belt, compactor unit for the collection of cardboard
and newspaper, six forklift two cubic yard dumpsters, and four metal 14 cubic yard
drop boxes. Prior to purchase and construction, all plans and specifications, and
bid documents must be reviewed and approved by the Department of Ecology (WDOE).
The bid documents shall conform with WDOE requirements for construction plans and
specifications and estimates dated January 28, 1974. The county is required to
receive WDOE approval on their bid process prior to the county awarding the bid.
ESTIMATED
MAJOR PRDJECT ESTIMATED REQUEST . FROM ESTIMATED DATE
ELEMENT PROJECT COST REF. 39 GRANT OF COMPLETION
1. Conveyor Belt $3,500.00 $1,750.00 August I, 1984
2. Compactor Unit 2,000.00 1,000.00 August I, 1984
3. Si x Dumpsters 3,000.00 1,500.00 August I, 1984
4. Four 14 cu. yd. 6,200.00 3,100.00 August 1. 1984
Metal Orop Boxes
5. Concrete Floor 3,300.00 1,650.00 August I, 1984
6. Metal Buildin9 Canopy 6,000.00 3,000.00 August 1. 1984
7. Contingency @ 10% 2,400.00 1,200.00
TOTALS: $26,400.00 $13,200.00
Slale of
'v\B..<,hi~i'\( >11
0<'1)( 1m 1 )(,Ilt
orB...'ology
.'n"""'''''
1 ... ~
~ ~ .....~...~
.
.
APPLICATION FOR GRANT ASSISTANCE
SOLID WASTE
PROJECT NO.
DATE RECEIVED
PART I - GENERAL INFORMATION
1.
APPLICANT
a. Name .JEFFERS ON COUNTY
d. Address (Street or P.O. Box Number, Town/City. State and
Zip Code) COURTHOUSE
PORT TOWNSEND, WA 98368
k= u. DepO;irtment/Division
PUBLIC HORKS
c. Congressional District SECOND e. County JEFFERSON
2. PROJECT TITLE JEFFERSON COUNTY CURBSIDE COLLECTION PROJECT
5.
TOTAL COST OF PROJECT
$ 24 ;000
PROJECT PERIOD
From: June I, 198Lf
TYPE OF APPLICANT (Check Appropriate Box or Boxes)
4. TOTAL GRANT REOUESTED
$ 12,000
To: August I, 1984
6.
o State
t!$ County
DCitv
D ~ Purpose Di.trict
D Other (Specify)
./. TYPE OF GRANT
a. ~New
B. PROJECT a. State
LOCATION ,'ASHINGTCN
c. Municipality
9. I'ROJECT a. ,~.l.g~rNGTON
AREA
c. Municipality
b.. 0 Continuation (Current Grant Number)
b. County
JEFFERSON
d. Congressional District
SECOND
b. ~'IH'!~RSON
d. ~~~bw80na' District
10. DOES PROJECT REOUI RE CLEARINGHOUSE NOTIFICATION? [IVe. D No
11. HAS AN ENVIRONMENTAL ASSESSMENT BEEN MADE FOR THIS PROJECT
OR FOR A COMPREHENSIVE PLAN WHICH INCLUDES THIS PROJECT? IllVe' D No
12. HAS AN ENVIRONMENTAL IMPACT STATEMENT BEEN MADE FOR THIS
PROJECT OR FOR A CLASS OF PROJECTS INCLUDING THIS PROJECT? DVe. Ul No
13. IS THE PROJECT COVERED BY A CURRENT APPROVED PLAN? ~Ye' D No
14. GIVE NAME OF CONTACT PERSON
.. Name GARY ROPE
b. Title SOLID PASTE MANAGER
c Add,,:n d, Phonjl No. (Include Are. Code)
'CUUlfrtIOUSE, roRT TOI"NSEND, I'!A 98368 2~~2.20...5....--__
15. -OFFICIAL OR AGENCV TO WHOM CHECKS ARE TO BE MAILED
a. Ti.le ,JI':F'Fl,RSON CO. D.P.H. b. Addre..
16. SUBMISSIONS TO OTHE'1-1,2ENCIES
.:CV 1)-.0.1 t(n\Hll 'J,II
.- -
- PART \I - BUOGET -
APPUCANT'S NAME PROJECT NO.
JEFFERSON COUNTY
SECTION A - CALCULATION OF SOLID WASTE GRANT
ITEMIZE ALL ELIGIBLE COSTS
TOTAL REOUESTED ESTIMATED DATE OF
ITEM UNIT COST PROJECT COST FROM GRANT DELIVERY OR COMPLETION
(1) (2) (3) (4) (5)
Conveyor Bel t $ 3,500 $ 1,750
Compactor Unit 2,000 1,000
under carriage
FORKLIFT DUMPSTER 3,000 1,500
(6)
Metal Drop Boxes 6,200 3,100
Concrete - 3,300 1,650
Canopy 6,000 3,000
TOTALS
SEE A'ITACHMEl IIA"
Administrltion Not Eligible
Other Indirect
Costs Not Eligible
TOTALS $24,000 $24,000 June 1, 1984
g:y O'CJo.l ,.,_ I
.
L...._._. .._.._.._.._.._J. "
w~xz, T
1.Jf-rl<"o.S'I
A
y'
A,/'
/
8fS/~
Icy'; 11
2 r ....----.
47~
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. Bayshore Enterprise
; Canopy Addition
Pacific Metal Buildings
'..C :1 Ed RAdley, Genoral Contractor
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I
f DEPARTMENT OF I.ABOR AND INDUSTRIES
EMPI.OYMENT STANDARDS DIVISION
Olympia, WA 98504
.
.
AFFIDA VIT OF
WAGES PAID
ON PUBI.IC WORKS CONTRACT
STATE OF VVASHINGTON
A wa rd iog Agency........ ........ ................................ ..... ,.... ............................
Co ntract N urn ber ...... ..... __............. ...... ....... ........-.. ........ ........ ......................
g::; ~:~~a~~;;,~;~~d.::::::~i~i:;?JJ:~::;::L~:Ii:~:~:::::::::::::::::::::::::
County in Which Work Performed . .-:;.F.:.E.c.JC".~..:.~.J..........................
~;:~Os':a:~~~~tc:t~~;e~~),,~.I~~.F...rty~~..e1........N~..ti......................
COUNTY OF ...................................
.}s.
In compliance with RCVV 39.12.040 I, the undersigned, being a duly authorized representative of
_....A.J~.Jdb....G!::!.ili:...(.~.J.'"',s,..?tLL!.b1.sJ"!.<~Q~,,....i~.d:::..h~!'..!.'.!~....H<t.'....7..~.J..".~:..........
(Contractor or Subcontractor) (Address)
do hereby certify that the following rates of hourly wage and hourly fringe benefits have been paid to the
laborers, workmen and mechanics employed by me upon the project described above and that no laborer,
workman or mechanic has been paid less than the "prevailing rate of wage" as determined by the Indus-
trial Statistician of the Department of Labor and Industries.
List below each classification of labor employed by you upon the project described above and the rate of
hourly pay and hourly fringe benefits paid to each classification.
Please Note
If apprentices have been employed on this project. provide this additional information: name and/or regis-
tration number and stage of progression.
Crafe. Ruteor Rate of Hourly
Hourly Pay Fringe Benefits Paid
C"vec>";Y; ~ /7.")..'- ?..';i I
J.,."k,,,v- tl..', "1b ..",. ,LI3
11""..1 \tv...... K"-;: ...- /'6")" (../.1.,,-
NOTE: Attach Additional Shl"et. 8' Nreded.
At'.IJ.~J....{;~/iv........(~....{~!~....
gy:~~~~~1.tl~;:;;:;?..
(Title I
Subscribed nnd sworn to before me
. f)\
this...o.....k.::::':.. day oL..\..\e~""'l~.\::.t., t>-
19~.::l.
~., (\_~~$:):...~ l\t\I\.~
Notarll Public In and for Ihf' Slor,. of Wa.hlngton,
,,..~dfnQ in Wo.hlnglon.
LAI VI' Only
I hereby r.tftiry thai Iccordinl to the wile rllet Ind rrinae bcnefiu herein Iworn
to the prevlilin. waJe rcquircmenu or RCW 39.12.040 hive: been Illillie-d.
INDllSTRIAI. STATISTICIAN
DEPARTMENT OF I.ABOR AND INUVSTRIES
INSTRUCTIONS:
ny:
f)ale:.
1. Pursunnt to Hew :J9.t2.040 copies of this fo,m must he completed !'y the controctor qnd eoch of his sub.
controctors.
2. Complete this form ;n triplicnte ond hove it notorized.
:t. Submit nil forms for certificotion to: Employment Stondords Division, Deportment of 1..obor ond Industries,
General Administration Build;nll, Olympln, Washillllt.on 9R51l-l.
4. File 0 certln(!d copy with the Awardlnll' All'ency.
CONTRACTORS ARF: HF:SPONSllll.F: FOH OBTAINING AND FILING AI,'F'IJ)AVlTS of the SUB.
CONTHACTORS. ThiH io requir..d by low and paymentR con not lawfully be made until ouch offidovits
ore filoo.
.......z." ,
~
'woo
Smith'ractor
& Equipment Co.
MONTESANO
206/249-SB98
PORT ANGELES
206/457.0S58
3607 20TH ST. EAST. TACOMA, WA 98424
206/922-8718
TRANSACTION
INVOICE
INVOICE
INVOICE
517
8230
t0073500 JEFFERSON COUNTV
CUSTOMER: OEPT. OF PUBL IC WORKS
COURTHOUSE
PORT TOWNSENO. WA 98368
OATE
7/26/64
6/27/84
SMITH TRACTOR
& EQUIPMENT CO.
.
ALL CHARGES ARE DUE THE
10TH OF THE FOLLOWING MONTH.
1 ~% PER MONTH WILL BE ADDED
TO PAST OUE ACCOUNTS. THIS
IS 18% ANNUALL Y.
6/27/84 10073500
DATE CUSTOMER
OUNT
~t
.t68.36
~/.~ ~J/ L/vJ.
. f~:>1',iP.
~
OVER 80
INVOICE
5170
6230
.1 >/"'/
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.
6/27/64
.
.
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.
35-?-r-H- .
168.36
.
.
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5 5.47
.
.
AMDAL
CONSTRUCTION
COMPANY, INC.
October 24, 1984
Jefferson County Engineers
County of Jefferson
Port Townsend, Washington 9836B
.
Gentlemen:
RE: PRE-lliGINEERED & PRE-FABRICATED 1,250 sq.ft. CANOPY & SUIB
Following is a Cost Break-Down on the above captioned pro;ect:
Draw Request #1
1,000.00
2,500.00
3,717.00
o
1. Bond, Permit, etc. 1,000.00
2. Concrete Slab 2,500.00
3. Canopy Material 3,717.00
4. Canopy Installed 4,810.00
10TAL $12,027.00
__!litlEc!:.ely, ./-:-. -- ~
c.___ ~~
Dean W. Amcial
AMDAL ~STRUcrION <nIPANY, lNC.
OOA:ra
Enclosure
$7,217.00
1OI1U,0I2I4
9fll TALA SHOAE DRIVE
PORT lUOlOW.WA~8Je5
CONSTRUCTION NO
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No 13 Ol,...T~
MADIIY LR.L. I CHICK ^ 3
DATI. I 0/10/ All I DATI
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.
.
PROPOSAL
TO: Board of Jeffe":;ull County Con.lli ss i oners
Courthouse
Port Townsena, ,,~. 98~btl
Gentlemen:
The undersigned propu>es ano agrees if this proposal i~ acc"p~co,
to provide all n"c~:;~"ry lIIachinery, tools and equipment "nd all
other llleans of constr~ction to do all the work and in the l1Iuon"r
ther-uin prescribed ""U occoroing to the requir"ments of the Engi-
neer i1S tllerein set funh at and for the total sum set forth
below as specified. A(~ deviation from the required specificd-
~ons shall be shown un a separate sheet and be maoe a part of
Jklh ~i d..
Item Unit Descri tion Unit Price Totdl
.'
~,
',j: ~
-:;.
t::t'I. PAPER DUMPSTER $1839.00 $3678.00
2 EI,. GLASS OUMPSTER $1971. 00 $3942.00
7.8% Sub-total
Sales tax ~ t ::;
TOTAL BID
Jlel ivery 1st unit,10 days after. award of contract.
~; ~<,' t.o. De de.l~vered at one week J.ntervals.
~;, ..~ IUd Bond is encloscu.in the amount of 1:410 ??
"i"
t
The
,~CllPalW Name
.~ :
~clres.s
Four 3easons Welding_Machine. Tnc.
'/i,
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Z ;$tvPa~re of Authorized Uffical
.<<.~'~d thi5~odY ur October
-M' '. .
~ ~lO C~LIES WITH ALL S~ECIFICATIONS AS STATED
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419 H~lines Place
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.
PiWPOSAL
TO: Board of Jdf"r"oJll Coullty Co,,,,1i ssioners
Courthouse
POrt Towns"nll, ~ll~bti
Gentlemen:
The unders1 gned prol'u>,,~ and agrees if thi s propos..l is ':ll;C"l'l"ll,
to provide all neLc-,'""Y llIochinery, tools dnu equiplllent ..no 011
other lIleans of constr.~tion to UO all th., work dno in the lIl"nlle"
theruin prescri beu ",,,, "ccordi ng to th.: re'lui relllents of till.: Engi-
neer 4$ tl1erein set ""'lh dt "flU for the tutal sum Silt torth
below as specifieu. Any (j"viation frolll the required specifiC"-
tions $hal1 be s/Iown un .. separate sh.,et anu be llIade a part of
t111$ bid.
I tell
1 2
2 2
Unil Il"scri tion Unit Price TUl" 1
r.:" ~ PAPEU. DUMPSTER 3lt')jj. i.l; . ')0
Eh. GLA~S DUMPSTER ~: >'1 J . (.'C ~ ::"j':~:-.. :~:)
Sales till< .t
.,
Sub-total
':.
.)';/,>.:. '](;
'J '.i.~. ".:,
TOTAL 810
({l:};
!,.:,.~~r
.": ~ 't. 1',
.l)eHvery 1:;,- :w,".l:, u..ys after award of contract.
.' to D(~ a~'_~~'I\,:~.,11 ;)!,' .\'~" ,: ::'.l' I~V:I;:..i.
61 lid Bond is enclos"J in the aAlOunt of ....i, .,..
.' . ~1:
CCllPd~ NiIlIIe
:;-.:~u:. :;::<.::: :r.~: .." i : : :.,'_':';,..
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-;
::::re of Aut~'~r~lc'di~ffiC"l~J>;Z)'Zt'~,
Il.~d thi5~ddY uf_ I''''<i~. 191>4 /
II1D CDMPLlESI/.IIILALL ~~r:CJfJC"I.10I!S AS ~..!I\UIl
Cashier~ Check 2149383
PeoplesBank
l'fOf't[$.....'.ONAl BANK Of WASltlNQTON
Il["'DOHIC['SE"'''~f,W''' NI11
19.10/1250
1357-000916
Remitter Four Seasons
dme
Dale October 15, 1984
Pay to 1he
Order of -JEFFEIls:lN COUNTY TREAS~-----
$ *****594.36........MM..M..
:.~DHC~~),NI'..c::' (;'i n .:':11:'1':;:; .,.r."~
POUTO.Hl>E.HOU 7"%:lI'-;;ac:.~
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COUNTY OF JEFFERSON .. ...TO AMDAL CONSTRUCTI~~ANY, INC.
STATE OF WASHINGTON
Address 981 Tala Shore Drtve, Port Ludlow WA 9836
Work done to October 24, 1984 County Road Project S0563
Dale October 25, 1984 Estimate No. 1
Unit pricu Quantlty Tot.al prevloua PUlCIni
1. 1250 sq. ft~.Canopy.& Retnrorc d .~+-- 60%
complet ,
2.
3.
4.
5.
6.
7.
B.
-
9,
10.
11.
12.
13.
14.
15.
-
16.
17,
18.
H, W.~3,S.T. @7 .8% 938 11 562 92 0 562 92
- --
20.
Totals 12,965 11 7,779 92 0 ,779 92
-
5J()% retained as per contract 648 25 388 99 0 388 99
12.316 85 ,390 93 0 ,390 93
Warrant No. Total Amt.~...J!.L
I hereby certUy on honor that the above estimate Is based upon a~ments and that the same Is
trua and correct. 'jji .
t<t-tJ ....__~""' ___
County En,ln..,
I. the undersigned, having first been duly sworn. do hereby depose and say that the above bill Is true and
correct; that the work was actually performed and material furnished as therein charged; and that there
Is due me this date. according 'Uet. the sum of $ 7.390,93 . and that the same or any part
ther~r~rbjn paid. .f, 0 ~ () ~.,.
(Sign m\ - ....~.. 0 Cor ' A 12
,
Subscribed and sworn to beCore me this Date / c>-c9C./ ,19~
day 0' .19_. Ordered p~ /_ ,
.4', /9/..-ii:
Dy ;7_........c.._~, --1 ."t\;
Counl, AudJ\Or Chairman. Bolrd 01 County Comml..lon."
(SEAL)
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PROPOSAL
TO: Board of Jeff~r'soll County Conuni ssi oners
Courthouse
Port Townsend, w~. 98368
Gentlemen:
The undersigned proposes and agrees if this proposal is accepted,
to provide all necessury machinery, tools and equipment and all
other means of construction to do all the work and in the manner
therein prescribed and according to the requirements of the Engi-
neer as therein set ionh at and for the total sum set forth
below as specified, Any deviation from the required specifica-
tions shall be shown on a separate sheet and be made a part of
this bid.
Item Quanti ty Uni t Descri tion Unit Price Total
2 EA. PAPER DUMPSTER
2 2 EA. GLASS DUMPSTER
Sub-total
Sales tax dt. 'J;
TOTAL BID
Del i very
days after award of contract.
5'" Bid Bond is enclosed in tile amount of
Company Name
Address
Signature of Authorized Offical
Dated this_day of
, 19B4
BID COMPLIES WITH ALL SPECIFICATIONS AS STATED
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PROPOSAL
TO: Board of Jefferson County Commissioners
C ou rthou se
Port Townsend, Wa. 98368
Gentlemen:
The undersigned proposes and agrees if this proposal is accepted,
to provide all necessary machinery, tools and equipment and all
other means of construction to do all the work and in the manner
therein prescribed and according to the requirements of the Engi-
neer as therein set forth at and for the total sum set forth
below as specified. Any deviation from the required specifica-
tions shall be shown on a separate sheet and be made a part of
this bid.
Item Quantity Unit Descri ti on Uni t Pri ce Total
2 EA. PAPER DUMPSTER
2 2 EA. GLASS DUMPSTER
Sub-total
Sales tax at %
TOTAL BID
Delivery
days after award of contract.
5% Bid Bond is enclosed in the amount of
Company Name
Address
Signature of Authorized Offical
Dated thiS_day of
, 19B4
BID CONPLIES WITH ALL SPECIFICATIONS AS STATED
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JEFFERSON COUNTY
DEPARTMENT OF PUBLIC WORKS
PROJECT/WORK AUTHORIZATION
AREA
SOLID WASTE LANDFILL
AREA CODE: N/A
PROJECT NO:[U 000563
Recycling Center Improvements
PROJECT NAME Sour"" S"p"ration
TYPE OF WORK Canopy and concrete
BREAKDOWN OF WORK ITEMS:
1250 Sq. Ft. Canopy (J45do" """.....;..~ bel)
3240 SQ. Ft. of 5" concrete. t?/o~/c,JI,)
finished and formed . .
COST ESTIMATE:
$6,000.00
5,000.00
/,,~# <::t?",r/H~No/
~u~"UeEL .f 2 ;I/::!iI'~t::r/t>.u
-:. /00.00
~ 800,0"
t /~ 9,",00
TOTAL:~,6e6.66
SUBMITTED
July 18, 1984
k~ll2L-
APPROVED: ~
BY:~
DIRECTOR F PUBLIC WORKS
198:/
BY: Bruce Laurie/Carter Breskin
ROUTE TO: INITIAL ~
~ ASS I STJlNT DIRECTOR ~ [I] ACCOUNTING
0 ROAD SUPERINTENDENT 0 BOARD OF COUNTY
COMMISSIONERS
12 CONSTRUCTION ENGINEER L 0
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· Jefferson County ·
Certificate of Occupancy
Permit No.
?rIR~
Owner Jeff. Co. and Bayshore
Enterprises
Legal Description & Address
S R T 30 R lw
301 Cou99i landfill Rd.
Pt, Townsend
Area Approved New bUilding
Area approved complies With require_
ments of UBC fOr Group R
Division 1 of OCCupancy.
This area approved for use as classUied
aboye'Nicnael Ajax 12/04/84
\
; ( I '\ _\
11/, ) " L', '\,
Date
--
(1) OWNER: Nam<-.l4..-. ,.VENJJeR.J:J,JJE:..
(2) LOCATION OF WELL: county_-::r...~eE.e:.eJaN.
WATER WELL REPORT
ST-ATB.OP WASHINGTON. PermJt No. .... _~
Addr__R-+. 1,.-BiJY- ~.P.+LJ1JiJ.!..\AE:H'f)ULE-".
-I~ _\~ See1- T3.o.Jl,. -t/Ju W....
BearlrlJ' and d.1sUnce from sectJOD or subdivision corner
(3) PROPOSED USE: Domestic PC Industrial 0 MunlcJpal 0
In1gOltion 0 Test Well 0 other 0
(4) TYPE OF WORK: Owner's nwnber of well
(U mro than one).... __________
New well Method: Du6 0 Bored 0
Deepened. Cable!J( Driven 0
Re-cond.Jt!oaed 0 Rot.ill"7Pd Jetted 0
(5) Dm~NS~ONS: Dlamator ct will __4-_ Inch..,
Drill '-/)_0--41. Depth 01 completed we'll..-3.D_o.--A.
(6) CONSTRUCTION DETAILS: ,
Casing instalIed:_G._" Dlam, from -.!L ft, ..,.;2f~::,
'I'hreaded 0 _" D1am. from _ tt. to _ ft.
.. Welded~ .. Dlam. from it. to ft.
Perforations: Yes 0 No r1
Type of perforator uatw'
. SIZE of perfcrationl tn. by ____ in.
_ perforations from _ tt. to __ ft.
_ perlontiolUl from _ ft. to __ ft.
perlorationl trom. ,eSGR.ft.: ~~ ft.
Screens: y.."jJ No 0 SI!1 !'PBUIU. J..~~'t;;,.. /1'" I,
""'''''2' ama. _u.:z:t:,Io
Tn>eSZ. ~.s...:Er~ Model ho_~_.
- DWn, ::R.S1ot .1%a -JR- from .;l.'19~:;"t, to~~/!!.
- - DI-=a-~lot ,lze +.s:- froni71~'11t. to ~qr"
Gravel packed: Yes 0 No rt
Cravel plaC't'd from
'''''S.:u.tace seal: Yes)(! No 0 T. ,wpat ~;p,!" 7;''71./..1'''7 ;;,ft"
Material used ta 5ul6~q~.J1d~-I'f~~'f!.,~.r.
Did an,. atrau contain unUSAbl. w.ter? Yea 0 No
.....,~-'_:.:,;:,;;".~-'~._..;...,;;=-T7Pe..ot.w.tuf Depth of av.t4-___
-~.::::':-.f~Od at.,-1Illna strau orl'____
(7) pU1\fP: ManUf.cturer'. Nam.
--'-,.."" c T7P<>:-'
HP
~ (8).""~ATEB. LEVELS: ~:';.~:~.M~-Y~~?A'?~g.~#~
'-~;"U';.I.~ ~Ql.13---4t. .,.Iow top of ,.,..u Date._~A/.7~
Art.ulan pnuu.re 'bI. pCI' aquue lneb D.tll___
ArtesiaD "".ter ill C"QntroUed b"_~'iive.erej--
(9) WELL TESTS:
w... . pu.o::ap test mad.' Va 0
Yield: ,aJJm1n. W'ttb
Duwdown u amount _aiel' level Is
Jowenod below rt.Uc level
No'" U yes, b, .hom1____.__....._.__
" f1...!irawdown atter hn.
(10) WELL LOG:
i~~~~?c~~::~~~~/1e';.~~dC~~~t~ ~ ~r~t~'tth~~lJ'f~tvt':..~n:
nratum. penetrated. with at lelUt onll entry lor each change ollonnatton.
MA~ mOM ~
.so ,'L.
~
'~
" ""
Sth
" So "
.. " ,-,- !!;q~
"
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"
n ri
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4 .;J01
~
Work ItaJ1 _:2.S: Jg.9.-S: Complllllad..-
WELL DRILLER'S STATEMENT:
''n,Js "wen was drilled under my juriJ;dlctfon and thbl report ...
~~~_ to_~e best of my knowledae and belief.
nll'<<t,ri:~W'~.~~.ttfllt~; :: :'~~r'i::~I)Pump lurned 0'" '''''.tlll level
::~~~~~~~ ~~:';~~:! :~:'~~~ ~~.~:~~~=:J~;~~~: ::~~~~~~~::
naJ,~:~:.~~~~_,'...J:I;~-;;;==D=~~-;. dnwdo~ .f~r![.. ___...".hn.
Ar1esla.n t!ow___.. ___.., ...,..._..__~~.,'.p.m. D.I..._....";.././~ ...?tS:__~~
Temper."U'. 01 w.'ltr~ W.. . th.mJcaJ .n&l,y.t. m.d.' rt 0 No t(
es;,""'''.rH> ~- .. ftf'>?t '( I~C 0.1/1
,~.'~UI~Cr.n ":~1r IU9J!: ADDITIONAL SIIErrS IF m:CESSAJ\Y)
IC"r.o'O.~1
NAME..s:r..qj,(IJN.,._'P.g,'ll.i,.N.G:.._J~~()...;;e.~,..__
(Penon, t\zm. or corpo...tJonJ (Type or prlntJ
Addr~.!ta"-AB.ax._l,."'J,.,._._~.,~G,l.liri:J.,_,fUA..?J::fJ
D~'oI-<>': I.;~I!J.. ",,'J;n'''''-.I.It: 011 ~~Q7
[SlgnedJ,_O~~..L~........._....._,_.._.__.__.._,_. ~
(WeU DrtllerJ _
[.Ie.rue No..,t7...?I.,'Z:l..._,._,..._,_... D.l~..I..7._..", JD.Z.,r'"
~a
,
;<':. .W~.tiR''r'E~L ~EPORT,. ,c: ..,APPJj'~lJO~ No.:"
' ,."""",' .'(:':.., .i..STAT,E OFW~S~GTON:.., ""E 'P<<mJ.NO. :"'~"~'.'!r;}
)"O\VNEat'>i:;;;~~LhA~.~...:R~}& :, ,j.C>..J.O "," ;';;i;:.;;.;' -'::'J..L.d,d.L.1k.IPidL1.ii:.it.rl...kdeik' 2.1.. ~ 6 g:':;'!;;'
fl.q.c.A:r:r.ON}~F..,;W!3=Lr~:"oun;;,tZr.L-c!!:.~....., ';" "~';:"&s..~:;:.sE.!1t ..SJt}.I~ ..s...E:!~'s.;~_f.'L r.3.aN:;li~e~-;'
'!';{;P~~'d';;';;ti,,'J' i;;,';;;''';~'Uo'''or ,ubdJ~I~I~~"~~;"~rl," ",,' "}.^";;""'~"';;'''':;'\''}';::~'''':~:;'':.'''" ,: 'i:,">).,:'; "; ;::;;'::,::~:-':,:.\';li:J;":';;:
t,;,,,,,,~~:,.f,f~,;;?,",,",_~,,,,_:~,'~O,.,.~,'~~,,,~~,:;,';..,.'.,~.:,+'..~,',';'~._~,.'!,',E:',;..,;,~'.'~"_~t.~f,:,,~r~,'.,J'~~,.u,:,:l, h,-:~,'ot'i,~;:, i,~,&~,~,," !~,"oo:,",,-~, "'~'."~'~~":'~'~~"~ob '(IO>':WELL, l.OGi :, 9",.;:;'';;;t,:,?'" ':';:~:',:A$A'''",e:,':<.: r',~;r
'.... "V ' . :. "'. ~ . '. t=~~l'ci:n~::i1~~~r,";'~'g~c~,:';",;I~:,;z: ,u,::Or~I~1 ..:.. :",.
i''';~~'!J!:i]~it~i~~-'- -,-~ -::~~,..- ,. - ,-'.
:,;1~ffl~~~~~~~t2!;'i~;~T:c:~~'+:d~ L~~~~~~:
W"C6Y"CONSTRUCTION DETAILS: PIVJ /+t-'16kC
';:~:;"~7:..;.-~''1-<''.;...', ;',j"l:l":'~"1~.~''''1 ......, ~~g'>':"'~: ..... ;;., ,"';,., ." :'~.- 022 ~
1~fc?~,~;,I5~~~~~ I,,~:_~~::~:~::::~= E: ~~;~
~.~~r!or~~~:~_iaq ~,..N~ ~ ,.; ~.
~",'- ~ ol.pertorator~.
,~IfJI..~7eE: .. '~~E -~C~
'::'",'S:..-::cc_, -'?nu"i!"=::' ';~-:'-/.k~!:!.P.LJJ=,dAL___
r.... -:r'-,;3':'~, 'r3pe,:"~."I.A.L~~~ Modt!l No______
",,"::,Dl~:~ SID. afze _LQ."" from ~2'l_ It, to :;'~'L- ft,
-:;'~j.=...:.6-r:. _~~t_~..~ Slot _ire ....-_ from tlif.._ It. tot2st~_ K
:...;;..,.:., Gravel pa.cked: Yea 0 No is 51.. 0' ...vel: __.._,__. ~
. ,. ~:.. .. Gravel"placed from - ft. to _ _...._ ft.
.z.
<rL"c'
t..t
,
J
r,; I ~
, :I
I
,!f)-
~ .,. W
",
Surface seal: Yes W No a To what dt'plht __..~...__ n..
Ma'erlal ...r<! In ..aL../3::.dh.o./A:../.....C.!,"-y:..,__..____
___h_ ,_Dt~_~~L nrata contain unUBabJe water' Yea 0 No fJ
::'":...,-::::':::"=;:'::'I)'pe~of:1r.tert~_._ ~Ptb ot strata______
;...,~-~'7drthod"Ot "aJII1&' atral.l Otf...___.h_..__~_~_.___,_._.._.._.
.: (7) p'U~fp; ~'~ufactUN''''' Name_._____..__.______.........._
..Type: -.-----..-.-----.._ HP___.....___
'''-''''(S)'lVAT.EUcLEVELS:' Land..un". ,'.v.uo",l1.A7,1 ~ 7tJ
-:-=-- SLllt'i~ 'I~vel h.:2.c.~'W"__h_-n~::~:wm.::n o7:~~ve~ate/i2':~?-'::~Dn
Arte-clan Preutlre ---...-....---.Jbs. per IIquare inch DatC'...._.._.._.................
A.rteaJlU1 w.t.,. 11 tttntrolle-d by-.----(c.p;-v;;fv.~.;ie..'j'....._.-.
..,
~
/
(9) WELL TESTS:
Drawdown Is amount WaleI' level 11
lowllrtod below lI1at1c~ f.vel
No ~ It yn. by whomt......._....._
n. drawdown afte~!!.:
, .
Work It.arted.~=./s:: .-........-. I~"-... COmPI.,t.d._.L~_,:", 2...._......, JUm.
WELL ORlL/.f:R'S STATEMENT:
IUNT. AODlTIONA.L SU.F..ETS IF' N!:Ct.:S~AnY,
This well was drJlled under my Jurf~dlcllon and this report J.
true to the best ot my knowlcdQ'c and beUer.
NAME.nJ.1."f.!.'r.?"l."Lz:l'.i!4.d...4..,..Ih..................,....",.,.."....,..,
(renan. ftrm. or ~orpo"'UOn) (Type or Print)
^ddr......e.IJ..LJ.::r.:/.j/....,t.0;~,((.(,I.i.~,..{~~,(1.,~:?l:!..~...........
.. ,.L.-' //7 II
(51.nod)" t..J6.:<'1....<'4CL'..-.t."u", {Jd;:.ydf.dL~,f..!...J.
I/'v<, J',{W,.J;, I 7.3 (w," Drlllar) -lor D
Lleons. No.., , ,..,....,~,........,....,...., n.!.,/l?..,........,..,.........,. IO,!!,...
.nl!'C'~::iur~t.,~~n:'etl!~~~:: ~~I''i~:~)Pump turned olr) (""at.r Jeve!
.=~~.:Z'.~:='!:"..,~..'.-~..'b7~::..~':~':
n.II~::::~,..i:k'..~:I/.,;~:;.:;.;;:~" "rowOo,"" .nrr..::f..."" hn.
...11.....n ftow~...______._.___.._. .._... I'.,...m. Oa._.._.. .._....-._....__....~.._....w.~.._.
,..rn~ntuN of 'IAI.I.r~~?". WAI.. C'tl.ml<'AI ana',)'11I m.de? V... 0 No r.a
<-
.
.
PART II - BUDGET
APPLICANT'S NAME Jefferson County Department of I PROJECT NO. ,
Pub 1 i c Horks 31-6-01-01
SECTION A CALCULATION OF SOLID WASTE GRANT
ITEMIZE ALL ELIGIBLE COSTS
TOTAL REQUESTED ESTIMATED DATE OF
ITEM UNIT COST PROJECT COST FROM GRANT DELIVERY OR COMPLETION
(11 (2) (3) (4) (6)
(See Atta hment A)
Admlnlllrallon Not Eligible
Other Indirect
Colts ----, Not Eligible
TOTALS 2,896,382 1.448.191
ICY 010.1 ,... t
.
.
At tach,ent A:
Capi tal Cost Estl.ate
lor Upgrade of Jefferson County Sanitary landfill
to .eet WDOE Mini.u. Functional Standards lor Solid Waste HandlinglWAC 173-104i
FiJe:PTCOsT20
Ite.
Unit
=== :::: === ============ == === == ======== =====;:;:;:;: == === :.:= ::::::::;:;:;: ::: ======= == ==============;: ======= ==.:;: ===========
Unit Total Requested Estl.ated Date 0/
Cost Project Cost Fro. Brant DeUveryor Coopletion
=====;: ::: ==== == == == == == ====:;;;: ==;:;: ==;: === == ::=;;; == == ==;:;: === == ==::;: == == ==== ===::====== == == ::;::: == == ====;: ==;: == ==== == ==;:
Phase 1: Preliminary Landfill leachate Investigations
In/or.ation Search and Agency Input Man-day
Prelillinary On-Site Investigation Man-day
Deterlination of WeJJ Locations Han-day
Develop 4 Monitoring Wells IF
Well Head Surveys Man-day
Hydraulic Conductivity Testing Well
Braund Hater Quality Testing sa.ple
Surface Water Testing sa.ple
Hydrogeology IWater DuaU ty Anal ysi s Man-day
Project Manage.ent l5
360
160
.160
50 '
360
1600
500
400
360
April, 19B7
1 ,BOO
1,0BO
720
50,000
720
6,400
4,000
BOO
5,400
15,000
900
540
360
25,('00
.160
3,200
2,000
400
2,700
7,500
Subtotal
Conti ngenci esllOl)
-- -- - - --- -- - - -- -- - -- - --- - --- ------ -- -- ---- - --- --- - ---.-
142,960
14,296
fB5,920
$81592
--- - - - - - --- - --- - - - ------- -. - -... -- -. ---. ---- --.----.- - -
TDTAl-leacnate Investigation f94,512 $47,256
Phase 2: Engineering Report Preparation September, 19B7
Site Mapping ls 6,000 3,000
Identify Alternatives Man-day 360 2,160 I,OBO
Field Survey and Data Develop.ent lS 15,000 7,500
Alternative Evaluation Man-day 360 10,BOO 5,400
Preli.inary Design Man-day 160 3,600 1,800
Devel.p.ent 0/ Site Monitoring rlan Nan-day 160 3,600 I,BOO
Devel.p.ent of Operating Plan Man-day 36') 5,400 2,700
Preparation of Dralt Rep.rt Man-day 360 7,200 3,600
Agency Revi e. Man-day 160 1,800 900
rroparati.n 0/ Final Rep.rt Man-day 3,0 3,600 I,BOO
Pr.ject "anage.ent ls 12,500 6,250
Subtotal
Contingenciesllm
.......... .------ ...---... ..--......-. ......-..------... --..-....-....-.....
135,630
13,5Bl
f7I ,660
$it 106
.... -....... ..-....- ...... -- ...... -........ ..---..-..-.. ...--.......- -..-....--...-
TDTAl- EngIneering Rep.rt
f7B,B26
139,413
.
.
Attache,nt A:
Capi tal Cost Esti.ate
for Upgrade of Jefferson County Sa,nitary landf i 11
to .'et NODE Hini.u. Functional Standards for Solid Waste HandlinglWAC 173-3041
File:PTCOST20
================::=====================================::::::::::::.::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::==
Ite.
Unit
Unit Total Requested Esli..ted Oate of
Cost Project Cost Fro. Srant Delivery or Co.pletion
=======================================::====;:==::==============::=============::=====::===========================
Phase J: Design and Construction of New Facilities
loperoeable Cap Over E,isting landfill December, 1989
Area Preparation for Capping Acre 1000 15,000 7,500
Foundation Soil, 1.5 It d..p CY 3 90,750 45,375
Botto. Seot"tile SF 0 7B,40B 39,204
I.peroeable Synthetic Cover SF 0 194,030 147,015
Top S..t"tile SF 0 78,40B 39,104
6as Venting Trenches IF 20 70,000 35,000
Cover Soil, 1.0 It deep CY 3 . 60,500 30,150
Topsoi I, 0.5 It d..p CY 12 145,200 72,600
Vegetation Acre 1500 12,500 11,150
---- ---- ---.. -- -- -- ---- ---- -------.. -- -- -------- ---------
Subtotal- I.per.eable Cap 854, 7% 427,39B
lie. Fi 11 Area wi th leachate Control Syste.
Area Pnparation Ac.re 1000 5,000 2,500
Sf te Excavation CY 3 101,667 100,B33
Clay Liner, 1.0 It d..p CY 12 193,600 96,BOO
Batt.. Geotexti Ie SF 0 26,136 13,06B
l.pe"eabl e Synth'ti c Li ner SF I 196,020 9B,010
Top 6eotexli I. SF 0 26,136 13,06B
Drainage layer, 2.0 It d..p CV 7 111,933 56,467
leachate Collection IF 15 30, 000 15,000
Gas Venli ng lS 0 20,000 10,000
Nonitoring W.lIs for N.. Fill Area IF 45 45,000 11,500
-- -- -.. -- --- -.... - ------- -.._- ----..---..- -- -- - - --------- ----
Subtotal- N.. Fi II Area 856,492 418,246
luchat. Stor.g. and Treatoent
On-Sit. l.achat. Storage Facilities lS 50,000 15,000
luchat. Haul Truck Each 80000 80,000 40,000
Hodifiealions to WW1P lS 100,000 50,000
Subtotal- luchat. Facilities 1130,0')0
-----..--..---.....---------------..--..- ---- ------..--..-....- ---
1115,000
Sal.. Ta, (7,91) 1153,361
--..--- ------------....-....- ----- ..-----..---..-- -....--....--..-----....---..
176,661
TDTAl- E,ti..t.d Construction COlt 11,094,650 11,047,3<5
.
.
Attach.,nt 9:
Forecasted Cash Needs by Quar ter
for Upgrad, of Jefferson County Sanitary landfill
to ""t WDOE Nini,uI Functional stand.rds for Solid Wast. H.ndlinglWAC In-3041
fi Ie: PTCDsnO
===============================:::==========================================
Proj,ct
Year Quarter Phase
Projeet
Cost
st.t. shar, County Shore
of Costs of Costs
======================================::=::::::=========::::=:::::::===============
t996 Jon-Nor $9,450 14,725 14,725
Apr-Jun 9,451 4,726 4,72.
Jul-sep 18,902 9,451 9,451
Oct-Dec 18,902 9,451 9,451
1997 Jon-Nor 18,902 9,451 9,451
26,275 13,136 13,138
Apr-Jun 18,902 9,451 9,451
26,275 13,138 13,138
Jul-s.p 26,275 13,138 13,138
Oct-Dee
1988 J.n-Mar ;; 340,381 17'),191 170,191
Apr-Jun 3 340,381 170,191 170,191
Jul-s,p 3 340,381 170,191 170,191
Oct-Dee 3 340,381 170,191 170,191
1989 J.n-Mar 3 340,381 170,191 170,191
Apr-Jun 3 340,381 170,191 \70,191
JuI-s.p ;; 340,381 170,191 170,191
Oct-Dee ;; 340,381 170,191 170,191
-- --......... --- -.... ______.... -_oo- __ __......___ _____...._ _...___ ___.. ___.... __.._..
Total
12,896,392
11,448,191
11,448,191
.
.
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FIGURE 4 .
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S.IAL FUEL USER TAX REPORT .
STATE OF WASHINGTON - DEPAATMl NT OF LICENSING
PRORATE & FUEL TAX DIVISION
READ INSTRUCTIONS ON THE BACI( PACiE. P,O. BOX 9228, OLYMPIA, WA 98504
ATTACH PRE.PRINTED NAME LABEL. OTHERWISE, TYPE OR REPORTJNG PERIOD: L
PR INT NAME: o MONTH OF },,- l';,
o QUARTERLY rn lID lID @]
("X" WHICH QUARTER) .".'
o SEMI.ANNUALL V I]] lID
("X" WHICH HALF)
SPECIAL FUEL TAX LICENSE NO: U ANNUALLY FOR THE YEAR
o NO OPERATIONS DURING PERIOD
INVENTORY COMPUTATllJN: (Gallons)
1, INVENTORY, BEGINNING OF PERIOD (PrevIous report, line 41
PURCHASES AND OTHER RECEIPTS CURING PERIOD :
2.
3, TOTAL GALLONS TO ACCOUNT FOR (Add lines 1 and 21
4, INVENTORY.. END OF PERIOD {PhYsicallnventorvl
5. TOTAL GAllONS USED (SUbtract line 4 from line 3)
NON.TAXABLE USE: (Gallons)
6. AGRICULTURE
7, LOGGING
8. MARINE
9. URBAN TRANSPORTATION ..
10. PUBLIC AGENCY EXEMPT BY STATUTE --- . .' .. I . _.c _, -.' ,I, " - .;.~~..'
11. POWER PUMPING OR POWER TAKE-OFF UNITS , , ./
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12. INDUSTRIAL USE
13, RAilROAD OR ELECTRIC UTILITY "
14, OTHER OFF.HIGHWAY USE ,. ~
IS. TOTAL NON.TAXABLE USE (Sum of Ilnos 6. 14) )
TAXABLE USE (USAGE ON WASHINGTON PUBLIC ROADS): (Gallons)
16. MI LES TRAVELED IN ALL STATES (Including Canada) Seo instru'ttiom. n
17, TOTAL GALLONS OF FUEL USED IN ALL STATES (Including Canada) Sou instructions. -~
~~
AVERAGE MILES PER GALLON (Line 16 divided by line 171 TO TWO DECIMAL PLACES (0,001 c-
~_~O. - 2m
o~
19, MILES TRAVELED ON WASHINGTON PUBLIC ROADS ~'"
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TAX, PENALTY AND INTEREST COMPUTATION 6g
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22. NET TAXABLE GALLONS l&Jbtract IIno 21 from line 20) /" ' /,/' ~I /)
23, TAX DUE (Multiply amount on Iino 22 bV 12 ccntd I
24. PENALTY FOn FILING AFTER 25TH OF MONTH '10%of line 231 /.' I
25. INTEREST FOR FILING AFTER 25TH OF MONTH ""por month of IIno 23. " I '. I
26. TOTAL DUe IAdd 11M, 23.24,25) r ",-I. . I I
, 27, TAX ASSESSMrNTS on cnrorTs FROM PREVIOUS MONTHS .,r ,,;.:' ;:1,:" .
28, ell eDIT Fon WASHINGTON SALES TAX PAID. 5"'1..1:. T"'X NO. "-:,1,.. ..j'!; II,/, " '.,
29. AMOUNT REMITTED (Sum of IInOl20, 27, 281 OR CREDIT DIJE , I
.-
0 CHECK nus BOX IF YOU WIS... HEFUND OF CREDIT ON LINE 29 AT THIS TIME.
I certify under penal tiel of perjury thar thl. report I. true, corruct and complete to the bolt of my knowledge,
I I
SIGNATunE TITLE P"'Tr: Tit&... NO.
rT....41.11~ SN::C. f UI:L USCR TAX REPORT
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SPftrAl FUEL USER TAX REPORT ·
STATE OF WASHINGTON - DEPARTMl NT OF LICENSING
PRORATE & FUEL TAX DIVISION
READ INSTRUCTIONS ON THE BACK PAGE. P.O. BOX 9228, OL Y~PIA, WA 98504
ATTACH PRE-PRINTED NAME LABEL. OTHERWISE, TYPE OR
PRINT NAME:
..........
, ,
REPORTING PERIOD:
o MONTH OF }
o QUARTERLY [l] lID lID I!J
("X" WHICH QUARTER)
o SEMI.ANNUALLY lID lID 19_
("X" WHICH HALF)
U ANNUALLY FOR THE YEAR
o NO OPERATIONS DURING PERIOD
SPECIAL FUEL TAX LICENSE NO:
INVENTORY COMPUTATltlN: (Gallons)
1. INVENTORY, BEGINNING OF PERIOD (Prev/ous roport, line 41
2. PURCHASES AND OTHER RECEIPTS DURING PERIOD
3. TOTAL GALLONS TO ACCOUNT FOR (Add lines 1 and 2)
4. INVENTORY, END OF PERIOD lPhyslcBllnventory)
5. TOTAL GALLONS usee CSubtra;;t line 4 from line 3)
NON.TAXABLE USE: (Gallons)
6. AGAICUL TURE
7. LOGGING
8. MARINE
9. URBAN TRANSPORTATION
10. PUal-IC AGENCY EXEMPT BY STATUTE
1,. POWER PUMPING OR POWER TAKE-OFF UNITS
12. INDUSTRIAL USE
13. RAILROAD OR ELECTRIC UTILITY
14. OTHER OFF.HIGHWAY USE
15. TOTALNON-TAXABLEUSE.CSumoflines6a 14)
TAXABLE USE (USAGE ON WASHINGTON PUBLIC ROADS): (Gallons)
16.
17,
10.
la,
20.
MI LES TRAVELED IN ALL STATES (Including Canada) S(J(1 instruction$.
TOTAL GAl.LONS OF FUEL USED IN ALL STATES (Including Canada) See instructions.
AVERAGe MILES PER GALLON ILine 16 divided bV Une 17) TO TWO DECIMAL. PLACES 10.00)
MILES TRAVELED ON WASHINGTON PUBLIC ROADS
TAXABLE; GALLONS (Line 19 divided by IIno 18)
TAX, PENAL TV AND INTEREST COMPUTATION
, 21.
22.
23,
24.
25.
20.
27.
28.
:>9,
TAX PAID PURCHASES IN WASHINGTON (Gallon.)
NET TAXABLE GALLONS (Subtract line 21 from line 20)
TAX DUE (Multiplv amount on line 22 bV 12 cent.'
PENALTY FOA FILING AFTER 25TH OF MONTH f10%of line 23)
INTEREST FOR FILING AFTER 26TH OF MONTH (,% per month of line 231
TOTAL DUE (Add linflS 23, 24, 261
TAX ASSESSMENTS OR CReDITS FROM PREVIOUS MONTHS
CREDIT FOR WASHINGTON SALESTAX PAID. J SALES TAX NO,
AMOUNT AEMlnEO (Sum of linn 20. 27, 28) OR CREDIT DIJE
I
o CHt:CK THIS BOX IF YOU WISH REFUND OF CREDIT ON LINE 29AT THIS TIME.
r certify under penalties of porjury thllt thl, report I, true, corroct and complote to the ben of my knowlodge.
SlGNA1"Unr.:
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SAtIAL FUEL USER TAX REPORT ·
STATE OF WASHINGTON - DEPARTML NT OF LICENSING
PRORATE & FUEL TAX DIVISION
READ INSTRUCTIONS ON THE BACK PAGE. P.O. BOX 9228, OLYMPIA, WA 98504
SPECIAL FUEL TAX LICENSE NO:
REPORTING PERIOD:
D MONTH OF )
D QUARTERLY rn lID [ID Bl
("X" WHICH QUARTER)
D SEMI-ANNUALLY IJJ lID
("X" WHICH HALF)
U ANNUALLY FOR THE YEAR
D NO OPERATIONS DURING PERIOD 19_
ATTACH PRE-PRINTED NAME LABEL. OTHERWISE, TYPE OR
PRINT NAME:
INVENTORY COMPUTATIUN: (Gallons)
1. INVENTORY, BEGINNING OF PERIOD (Previous report, line 41
2. PURCHASES AND OTHER RECEIPTS DURING PERIOD
3. TOTAL GALLONS TO ACCOUNT FOR (Add lines 1 and 2)
4. INVENTORY. END OF PERIOD (Physical Inventory)
5. TOTAL GALLONS USED (Subtract line 4 from line 3)
NON-TAXABLE USE: (Gallons)
6. AGRICULTURE
7. LOGGI NG
8. MARINE
9. URBAN TRANSPORTATION
10. PUBLIC AGENCY EXEMPT BY STATUTE
1,. POWER PUMPING OR POWER TAKE-OFF UNITS
12. INDUSTRIAL USE
13. RAILROAO OR ELECTRIC UTILITY
14. OTHER OFF.HIGHWAYUSE
15. TOTAL NON.TAXABLE USE (Sumoflinos6-14)
TAXABLE USE (USAGE ON WASHINGTON PUBLIC ROADS): (Gallons)
16,
17.
16,
19.
20,
MILES TRAVELED IN ALL STATES (Including Canadal See instructIons.
TOTAL GALLONS OF FUEL USEO IN ALL STATES (Including Canada) SeD instructions.
AVERAGE MILES PER GALLON (Line 16 divided bV line 17) TO TWO OECIMAL PLACES (0.00)
MILES TRAVELED ON WASHINGTON PUBLIC ROADS
TAXABLE GALLONS (Line 19 divldod bv Iino 18)
TAX, PENALTY AND INTEREST COMPUTATION
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PENALTY FOn FILING AFTER 25TH OF MONTH (10%of IIno 23)
INTEREST FOR FILING AFTER 25TH OF MONTH f1" por m011th 0' line 23)
TOTAL DUE (Add lInes 13,24,261
TAX ASSESSMENTS Oil CREDITS FROM PREVIOUS MONTHS
CREOIT Fon WASHINGTON SALES TAX PAID. I SALEI TAX NO.
AMOUNT nEMITTED (Sum of IlnM 26,27# 28) on CREDIT .DlJE
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o CHeCK THIS BOX IF YOU WISH REFUND OF CnEDIT ON LINE" AT THIS TIME,
I cenlfy under penalti". of perjury that this report I. true, corruct and complete to tho ben of my knowledge,
..GNATUnE
1"1.-4041-111 'Sf're. fur.l. U5fn TAX RFJ"onr
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S.IAL FUEL USER'S TAX REPORT
~,...H 0' """'S"INGTON D(P"'~'MiNT Of ll(fNSINQ
.
FUEL TAX DIVISION
P.O. BOX 9228
OL YMPIA. WASHINGTON 98504
TEl. (20b) 753.6900
,~ 3. ~
'; 1 ~
1 ': r ., .. .~ " .~
SPECIAL FUEL lICENSE NO.
MAILING AODRfSS
'::",;
REPORTING PERIOD.MONTH December
D NO OPERATIONS DURING MONTH
o ~~~~~N~:6~ALH~~OR:EE~P~~~~~~~EI~
D LICENSE IS RETURNED FOR CANCELLATION
NO. OF VEHICLES OPERATED
INTO AND/OR IN WASHINGTON
. .... Ii;'
CITY, STATE, & ZIP
~1~r~1:~:~?Silj1~~gt;-I.
USE SPECIAL fUEL INSTRUCTION SHEET AS A GUIDE WHILE COMPLETING THIS FORM
.','..:~ ';COMI:'UTATION..OI:"TAXABlE'GAlLONS:~':::":' ::';:;,.,/;' c' ''':,;,;: {!~'::);.<'?" ,. '-'. ;'_;~~7,';..li'-,:;:'::" <',i'.;I.'.DIUEL:'\~::t";
(DIESn ONLY'
1. MILES TRAVELED IN ALL STATES (INCLUDING CANADIAN PROVINCES)
376
2, TOTAL GAllONS OF FUel USED IN ALL STATES (INCLUDING CANADIAN PROVINCES)
47
AVERAGE MILES. PER GALLON (LINE 1 DIVIDED BY LINE 2) ROUND TO TWO DECIMAL PLACES (0.00)
B
4. MILES TRAVELED ON WASHINGTON PUBLIC ROADS.
376
TOTAL GALLONS OF FUel USED ON WASHINGTON PUBLIC ROADS (LINE 4 DIVIDED BY LINE 3)
ROUND TO THE NEAREST WHOLE GALLON.
"DEDUCTIONS (USE COMPUTATION SCHEDULES ON REVERSE-SIDE)
47
GALLONS OF FUEL PURCHASED IN WASHINGTON SPECIAL
FUEL TAX PAID OElIVERED INTO VEHICLE FUEL SUPPLY TANKS.
(A) FROM SERVICE STATION, KEYLOCK, OR OTHER FACILITIES
(B) TAX PAID WITHDRAWALS FROM YOUR OWN BULK STORAGE.
o
o
GALLONS OF FUel USED IN MOTOR VEHICLES EXEMPT FROM SPECIAL FUEL TAX. FROM SCHEDULE "A"
o
o
o
B. GALLONS OF FUEL USED TO OPERATE POWER (AjZ~,f:.~~!;~~,~~':~':;~'t~6"1::/:~P~~;i,.uNo~I:C.?r~~ll:~I~.9 OIU. O~ M[ASU~lD BY
~PUMPING UNITS OR POWER TAKE.OFF EQUIPMENT. 18) ON CEMINT MIKIRS "NO lOAD COMPA'TO~ GAU"GI T~U'KS' '~OM SCHEDUlE '.C
TOTAL GALLONS DEDUCTIBLE (ADD LINES 6 THROUGH 8)
no
NET TAXABLE GAllONS
TOTAL GALLONS ON WHICH TAX (OR CREDIT) IS DUE (SUBTRACT LINE 9 FROM LINE 5)
IF LINE 9 IS GREATER THAN LINE 5, INDICATE CREDIT BY PARENTHESES. 47
~.:~~';X",.;~'!j~\l!';rt;:fJ~~}.:'J51t8t\;~l~:Jftl::r~S':I,~y,~,!?t2Jl'!';h:<i;_~::;'vr~;;r.COMPUTATION' OF;..T AX ,DUE ~\':::"t><i~<,~.;};::,.:~:,," - ,',:', '-:':-i!")i ", '-:',~~;~:_\~:iY::';,;':1,\:,,:<i:,~.~{, ,);''''-!';:-:::::-:Ji.iri,,~~t;:{I;..;r::t:l:,
TAX DUE FOR REPORTING PERIOD
TAX DUE (OR CREDIT) ( l; PER GALLON ON GALLONS SHOWN ON LINE 10) iNDICATE CREDIT
BY PARENTHESES. 5 l7
PENALTY FOR FILING AFTER 25TH OF MONTH (10 PERCENT OF LINE 11)
INTEREST FOR FILING AFTER 25TH OF MONTH (\ PERCENT OF liNE II)
TOTAL DUE (OR CREDIT) FOR REPORTING PERIOD (ADD LINES 11 THROUGH 13)
INDICATE CREDIT BY PARENTHESES.
TAX ADJUSTMENT FROM ~R REPORTS
TAX ASSESSMENTS (OR TAX CREDITS) FROM PREVIOUS MONTH(S), INDICATE CREDIT BV PARENTHESES.
NET AMOUNT OF TAX (OR CREDIT) DUE, (LINE 14 AND 15). . INDICATE CREDIT BY PARENTHESES
MAKE REMITTANCE PAYABLE TO STATE TREASURER - (NOTE MAILING INSTRUCTIONS ON REVERSE SIDE).
5 7
~
,;
.-5 ' 7 i
.
~
II
1
-IlIFUNO OF A TAX ('lIDll ON LINE 10 MAY BE ClAIMtD ON THIS R(PORT IN UEU OF rILING A CLAIM FOR REFUND.
D CHECK BOX IF YOU WISH TO APPLY FOR REFUND OF OUTSTANDING TAX CREDIT AT THIS TIME.
SP.AL FUEL USER'S TAX REPORT
STAU Of W"'SHING10N O[""'~IMINT OF 11([NSINC
.
FUEL TAX DIVISION
P.O. BOX 9226
Ot YMPIA. WASHINGTON 98504
TEl. (206) 753.6900
FIRM NAME
.J:::r FET S {;~, eLlUI',"f Y
:.....Cf"T ilf~; (~n..;AY:::.
( t]ci",'ll..lOU~_,
r\(;p r 1 (1 ,\'r_'
,,1
SPECIAL FUEL LICENSE NO.
..? ::. L 3 (,
t ~;'.l ~: ,",
~ G-"
REPORTING PERIOD.MONTH OC tober
D NO OPERATIONS DURING MONTH
D ~l~~~N~t6~AlH~EJEOR~EE~P~~~~~~~~~
D LICENSE IS RETURNED FOR CANCElLATION
NO. OF VEHICLES OPERATED
INTO AND/OR IN WASHINGTON
MAILING ADDRESS
CITY, STATE. & ZIP
SHOW I\.NY (HANCI IN N"'MI,
ADDRUS 011 QWNERSH'P
IINC~ '''ICIO'NG IIf'OIlI
USE SPECIAL FUEL INSTRUCTION SHEET AS A GUIDE WHILE -COMPLETING THIS FORM
~~:'.;,\::l:lIUEL""::.;.;;,-
(DIESEL ONLY)
1. MILES TRAVELED IN ALL STATES (INCLUDING CANADIAN PROVINCES)
GALLONS OF FUel USED TO OPERATE POWER
PUMPING UNITS OR POWER TAKE.OFF EOUIPMENT.
I'"') Oli OIlI'o'UY TRUOS PUMPI/liO PROP"'IiL fUU OilS. OR HI""INO OilS. OR Mt....SURlP 8Y
MnU'NG P('o"(1 "'PPRO'o'tP BY THf DIP! . fROM SCH~OUI( "8
(8) ON CfMHH MlltUS "'NO lO"'O (OMP...."OR C;UB"'Ol UU(K5 . fROM SCHIOUl( "C"
616
77
8
616
77
n
0
0
0
n
77 a
TOTAL GALLONS OF FUel USED IN ALL STATES (INCLUDING CANADIAN PROVINCES)
AVERAGE MILES PER GAllON (LINE 1 DIVIDED BY LINE 2) ROUND TO TWO DECIMAL PLACES (0.00)
MILES TRAVELED ON WASHINGTON PUBLIC ROADS.
TOTAL GALLONS OF FUEL USED ON WASHINGTON PUBLIC ROADS (LINE 4 DIVIDED BY LINE 3)
ROUND TO THE NEAREST WHOLE GALLON.
.-'}:. DEOUCTlONS::(USE:'COMPUTAT,IONSCHEDULES ON REVERSe- SIDE)
GAllONS OF FUel PURCHASED IN WASHINGTON SPECIAL (A) FROM SERVICE STATtON, KEYLOCK, OR OTHER FACILITIES
FUEL TAX PAID DeliVERED INTO VEHICLE FUEl SUPPLY TANKS. (Bl TAX PAID WITHDRAWALS FROM YOUR OWN BULK STORAGE.
GALLONS OF FUel USED IN MOTOR VEHICLES EXEMPT FROM SPECIAL FUEL TAX. FROM SCHEDULE "A"
TOTAL GALLONS DEDUCTIBLE (ADD LINES 6 THROUGH 8)
NET TAXABLE GALLONS
10. TOTAL GALLONS ON WHICH TAX (OR CREDIT) IS DUE (SUBTRACT LINE 9 FROM LINE 5)
IF LINE 9 IS GREATER THAN LINE 5. INDICATE CREDIT BY PARENTHESES.
.~ ~!liil'lllli '".,
. TAX DUE FOR REPORTING PERIOD
TAX DUE (OR CREDIT) (
BY PARENTHESES.
PENALTY FOR FILING AFTER 25TH OF MONTH (10 PERCENT OF LINE 11)
P:>MPIlJ.i'1iOl'/;Ol$T , ' ;QU"iil .W,jIj
.:il:lt~~~~;lll<1r~wr,l#,p
~ PER GALLON ON GALLONS SHOWN ON LINE 10) INDICATE CREDIT
INTEREST fOR FILING AFTER 25TH OF MONTH (1 PERCENT OF liNE 11)
TOTAL DUE (OR CREOlT) FOR REPORTING PERIOD (ADD LINES 11 THROUGH 131
INDICATE CREDIT BY PARENTHESES.
TAX ADJUSTMENT FROM PRIOR REPORTS
TAX ASSESSMENTS (OR TAX CREDITS) FROM PREVIOUS MONTH(S), INDICATE CREDIT BY PARENTHESES,
NET AMOUNT OF TAX (OR CREDIT) DUE, (LINE 14 AND 15). . INDICATE CREDIT BV PARENTHESES.
MAKE REMITTANCE PAYABLE TO STATE TREASURER. (NOTE MAILING INSTRUCTIONS ON REVERSE SIDE).
R 1.7
11 1.7
E
~
..
i
.
"
i
~
ri
..[FUND OF A TAX CRIDIT ON LINE 16 MA'( 81 ClAIMED ON THIS REPORT IN liEU OF fiLING A CLAIM fOR R[FUND
CJ CHECK BOX IF YOU WISH TO APPLV FOR REFUND OF OUTSTANDING TAX CREDIT AT THIS TIME.