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Home My WebLink AboutExhibit C"EXHIBIT C" FLORIDA DEPARTMENT OF ENVIRONMENTAL PROTECTION CONTRACTOR DESIGNATION Florida Department of Environmental Protection Bob Martinez Center 2600 Blair Stone Road Tallahassee, Florida 32399-2400 Charlie Crist Governor Jeff Kottkarnp Lt. Governor Michael W. Sole Secretary Bureau of Petroleum Storage Systems - Petroleum Cleanup Preapproval Program CONTRACTOR DESIGNATION FORM & REAL PROPERTY OWNER/RESPONSIBLE PARTY AFFIDAVIT • This Contractor Designation supersedes all previous designations for this site made by the Real Property Owner or Responsible Party whose signature appears below. • Please read this entire four -page form carefully a nd c omplete a 11 a pplicable p ortions, i t c ontains important information regarding the cleanup of your site. • Please Print or Type all required information (except for the signature block in Part 6). • This request will not be processed without the completed Owner/RP Affidavit in Part 6. • If you prefer not to designate a specific contractor, you may request that the Department select the cleanup contractor in Part 4 of this form. 1. The Florida Department of Environmental Protection (Department) is required by statute to preapprove the scope of work and cost for the cleanup of a petroleum contaminated site if state funds will be used to pay for that cleanup [Section 376.30711(1)(b), Florida Statutes (F.S.)]. 2. The current Real Property Owner or Responsible Party for the cleanup must use this form to designate a contractor that meets certain criteria (Sections 376.30711(2)(b)-(c), F.S.) for the Department to work with on their site. In addition, if the Department should coordinate its actions with your representative, you can use this form to designate such an alternative contact. 3. If the current Real Property Owner is not the person responsible for completing the cleanup, then the • Responsible Party should complete this form and submit it along with a copy of the legal agreement between them and the current Real Property Owner that details their cleanup responsibility. Responsible party agreements with former Real Property Owners will not be accepted without a signed letter from the current Real Property Owner which indicates that they either concur with the responsible party agreement or do not object to the Responsible Party (identified in Part 3 of this form) selecting the contractor. 4. Please fill out this form completely and carefully. The form will be rejected if there is any omission, error or correction (including "white -out") in any of the required information, including the notary portion of the form. This will delay the cleanup of your site. 5. The current Real Property Owner or Responsible Party may designate a contractor or request a change to a new contractor at any time by submitting a completed Contractor Designation Form (CDF). However, changes in contractor designation are limited to no more than two (2) in any 12-month period. Changes in contractor d esignation m ay a iso c reate a d elay I n t he c leanup o f y our s ite. A !so, t he current Real Property Owner or Responsible Party will be liable for payment for any work that the new contractor must perform in order to assume the site cleanup if the Department previously paid for such work. If a new contractor is designated, then any work in progress will be completed by the contractor to whom the work was awarded through the end of the current Work Order unless that contractor is being replaced for documented poor performance or it voluntarily agrees (in writing) to forgo the remaining work. A new designation does not take effect until the completed CDF is accepted and approved by the Department. BUREAU OF PETROLFUff SYSTEMS "More Protection, Less Process" CDFMARW2A6i12flO7 MCT.doc www.dep.state.11.us/waste/categories/pcp/default.htm PETROLEUM CLEANUP SECTION ONE Page 1 of 4 MCT.doc Bureau of Petroleum Storage Systems - Petroleum Cleanup Preapproval Program CONTRACTOR DESIGNATION FORM & REAL PROPERTY OWNER/RESPONSIBLE PARTY AFFIDAVIT 6. Designating a contractor means that you are responsible for its actions. Pursuant to Section 2.h. of the Petroleum Cleanup Preapproval Program work order issued by the Department, your contractor is required to pay all subcontractors and vendors within 7 days of receipt of payment from the Department that includes their costs for non -final invoices and prior to submittal of the final invoice for each work order (unless there is a written agreement between the contractor and subcontractor/vendor to the contrary). To protect their financial interests, subcontractors and vendors may file a lien against your property that can be exercised in the event t he c ontractor d oes n of p ay t hem i n f ull. Accordingly, you should take steps to insure that your contractor pays all of its subcontractors a nd v endors. F urthermore, it is a dvised t hat y ou r equest t hat y our contractor demonstrate that they are financially solvent and that they have an acceptable performance record with respect to successful completion of cleanup projects and payments to subcontractors and vendors. 7. Pursuant to Florida -Law, it isunlawful.: for.. a. site_owner-or operator, or his _or_her.designee, to receive .any remuneration, in cash or in kind, directly or indirectly, from a rehabilitation contractor performing site cleanup activities..." under the preapproval program (Section 376.30711(6) F.S.). It is also unlawful for any contractor to offer any remuneration in cash or in kind, either directly or indirectly, to a site owner, operator or their designee. This prohibition includes payment of any program deductible by a contractor. See Section 7.13 of the BPSS Standard Operating Procedures Manual. 8. Please retum the form with original signatures (copies cannot be accepted) to Petroleum Cleanup Section One, Mail Station 4540, in the Bureau of Petroleum Storage Systems at t he letterhead a ddress. I f you choose not to designate a cleanup contractor, you may ask the Department to select one for you in Part 4.e. below. If you have any questions, please call Leila Shuffler at (850) 245-8839. Thank you for your cooperation. Part 1. FDEP Facility Name and. Identification # (required): a. Name of Facility/Site: Shamrock / Supreme Service Station b. FDEP Facility Identification #: 138732522 Part 2. Real Property Identification and Current Ownership Verification (required): This information must match that listed in the applicable County Property Appraiser's Office. While the real property owner listed here may be the same as that listed in Part 3, the actual designation of the cleanup contractor occurs only by the entity listed in Parts 3 and 6 of this form. a. Real Property Street Address of Record: 6200 NW 17th Avenue, Miami, Florida 33150 b. Parcel # or Property Identification # of Record: 01-3115-005-3291 c. Legal Property Description of Record (may attach legible copy): LIBERTY CITY PB 7-79 LOT 21 & LOTS 22 & 23 LESS E10FT & LOT 24 LESS S10FT OF LOTS 23 & 24 FOR R/W BLK 12 LOT SIZE 13924 SO FT OR 22744-3044 1004 3 d. Name of Current Real Property Owner(s) of Record: City of Miami Asset Management e. If There is Any Reason Why the Property Appraiser's Records May Not Be Accurate, Provide an Explanation and Attach Documentation: MS PETROLEUM CLEMJP SECTION 0fE "More Protection, Less Process" www.dep.stateflus/waste/categoriestocnidefault.htm Page 2 of 4 Bureau of Petroleum Storage Systems - Petroleum Cleanup Preapproval Program CONTRACTOR DESIGNATION FORM & REAL PROPERTY OWNER/RESPONSIBLE PARTY AFFIDAVIT Part 3. Entity Designating the Preapproval Program Cleanup Contractor (required): a. Name of the Entity Designating the Preapproval Cleanup Contractor (if business, include name/title of representative):Model Citv Communitv Revitalization District Trust b. (Check One): Current Real Property Owner Or X Responsible Party c. Mailing Address and Telephone # of the Entity Designating the Contractor: 4800 NW 12th Avenue, Miami, Florida 33142 Phone (305) 635-2301 Part 4. Preapproval Program Cleanup Contractor Designation (required): Please check one of the options below. You may request that the Department select the cleanup contractor_ (State) or you may designate a specific cleanup contractor (Owner/RP). Complete section a through d below. only if Owner/RP designated contractor. (Check One) State Designated Contractor Or X Owner/RP Designated Contractor a. Designated Contractor Name: Cherokee Enterprises, Inc. b. Designated Contractor Mailing Address: 144T4 Commerce Way, Miami Lakes, Florida 33016 c. Contact Person for Designated Contractor: Gabino Cuevas, P.E. d. Telephone # for Contact Person: (305) 828-3353 e. E-Mail address for Contact Person: cicfa.cherokeecorp.com Part 5. Alternate Contact Designation for Current Real Property Owner or Responsible Party (optional): Use this section to designate an alternative point of contact to act on behalf of the entity named in Part 3.a. This person will serve as your representative regarding the cleanup of this site and receive all further notices on your behalf. Do not list the contact person for the contractor. If you do not wish to designate an alternate point of contact, then leave this part blank. a. Alternate Contact Name: b. Alternate Contact Address and Telephone #: Phone ( ) c. Relationship of Alternate Contact to Current Real Property Owner or Responsible Party: Part 6. Real Property OwneriResponsible Party Affidavit (required) This affidavit must be completed and signed by the current real property owner or responsible party in the presence of a notary public when designating a contractor for the Petroleum Cleanup Preapproval Program. The signature of the current real property owner or responsible party shall be notarized as set forth below. No work will be authorized on your site until this form is accepted by the Department. By signing below you are certifying that you have read and understand all of the information on all four pages of this form and that all of the information listed above is true and correct to the best of your knowledge. The name in Part 6.a. must match that listed in Part 3.a. MCT.doc "More Protection, Less Process" www.dep.state.flus/wastelcategories/pepidefault.htm Page 3 of 4 CDFAfdavit-013107 Bureau of Petroleum Storage Systems - Petroleum Cleanup Preapproval Program CONTRACTOR DESIGNATION FORM & REAL PROPERTY OWNER/RESPONSIBLE PARTY AFFIDAVIT a. 1, ELAINE H. BLACK am the PRESIDENT/CEO of (name of person appearing) (title of person appearing) LIBERTY CITY TRUST, f/k/n/a MODEL CITY COMMUNITY and hereby certify: (name ofXdafirklpteXiptinigrNA responsible party listed in Part 3.a.) b. That the Contractor Designated in Part 4 of this form is authorized to perform work in the Petroleum Cleanup Preapproval Program on the real property identified in Parts 1 and 2 of this form. c. That the contractor has not offered any remuneration in cash or in kind directly or indirectly in exchange for designatingthem as.my,contractor. d. That I have not solicited or accepted remuneration in cash or in kind directly or indirectly from the contractor in exchange for designating them as my contractor. e. That I acknowledge that soliciting or accepting remuneration in cash or in kind directly or indirectly in exchange for designation of a contractor is prohibited pursuant to Section 376.30711(6), F.S., and may result the loss of eligibility for State funded petroleum contamination cleanup assistance at this site. f. That the person appearing is authorized to make thestatements set forth in this affidavit. (Signature of the`Own'er, RP or authorized representative listed above) ---------------- Notarization of Signature of Real Property Owner or Responsible Party (required) ------------ State of FLORIDA County/Parish of DADE Swom to and subscribed before me by ELAINE H. BLACK this 9 day of MARCH 20 07, Personally known ** Produced Identification ( ) Type of ID: (if produced identification) - — My Commission Expires (notary's signature) Notary Public, State of FIB ORI DA MCT.doc 74471 Commission Number (if applicable) DE) 208299 IRIS M. HUDSON I r. COMMISSION800208299 EXPIRcS:'July 11, 2007 ... ••fM, Notary adt Undemtratr "More Protection, Less Process" www.dep.state.11. us/wasie%ateeories/pcp/default.htm Page 4 of 4 CDFAfdavil-013107 Contractor Designation Form Checklist Information Taken From CDF: Facility ID: 138732522 Date Received :03/26/07 Signature Date : 03/09/07 Site Name: Shamrock/Supreme Service Station Site Address :6200 NW 17th Ave Owner Name: City of Miami Asset Management Contractor :Cherokee Enterprises Inc Information from DEP: ORACLE/PCT Score:10 With in Funding Range? NO Site Eligible? YES Site Address:Same Does it match the CDF7 YES Owner Name:Federal Deposit Insurance Corp Does it Match the CDF? NO Site Manager: Kong T OCULUS: Previous CDF?. YES contractor:Cherokee Enterprises, Inc Date signed:02/07/07 Valid? NO Previous Owner/RP? NO Name & Date Contacted: RP agreement provided? Eligible for Preapproval? YES Reason: PAC SITE Valid CDF? YES Notes:Model City Community Revitalization District Trust submitted CDF as RP, owner letter in file. Property owner confirmed in property records. Reviewer: Ashley Olcott Date: Monday, April 02, 2007 Discharge Information 1ST DISCHARGE DISCHARGE DATE: 03/13/1987 PROGRAM: EDI ELIGIBLE: ELIGIBLE ELIGIBILITY. DATE: 08/03/1987 FUNDING CAP: DEDUCTIBLE AMOUNT: DEDUCTIBLE PAID: *COMBINED WITH: CLEAN UP INFO: ACTIVE CLEAN UP STATUS: SA TOTAL SPENT TO DATE: FCFS BUDTRACK TOTAL CDF HOLDING FOR: DEDUCTIBLE ❑ LCAR 0 *SITE MANAGERS - Please refer to and follow the guidance memos from Lewis Cornman dated 5/30/01 regarding NFA orders for eligible discharges not determined to be an actual discharge (SOP Appendix C-10) and rescission of PCT discharge report for non eligible discharges (SOP Appendix C-11). Linert? Oi'iv .1ciw nLIn ;✓fl ,iia,ization rut February 12, 2007 Leila Shuffler Florida Department of Environmental Protection MailStop 4540 Bob Martinez Center 2600 Blair Stone Road Tallahassee, Florida 32399-2400 co FF13 1 5 20i7 ( b Re: Facility/Site: Shamrock/Supreme Service Station FDEP Facility Identification: 138732522 Property: 6200 NW 17 Avenue, Miami, Florida 33150 Dear Ms. Shuffler: Enclosed as instructed is the Contractor Designation Form 8.7 Real Property Affidavit for real property address 6200 NW 17th Avenue, Miami, Florida. We have selected Cherokee Enterprises, Inc. as the designated contractor to oversee the cleanup process for the above -referenced property. Should you have any questions, please do not hesitate to contact me at (305 635- 2301 ext. 371. Iris Hudson - Finance Manager Liberty City Trust cc: Cherokee Enterprises, Inc. Encls. Miller Dawkins Pool Complex •4800 NW 12th Avenue • Miami, Florida 33127 • Phone: 305.635.2301 • Fax: 305.634.2774 Email: info@LibertyCityTrust.org • Website: www.LibertyCityTrust.org Flonda Department of Environmental Protection Bob Martinez Center 2600 Blair Stone Road Tallahassee, Florida 32399-2400 Charlie Crist Governor Jeff Kottkamp Lt. Governor Michael W. Sole Secretary Bureau of Petroleum Storage Systems - Petroleum Cleanup Preapproval Program CONTRACTOR DESIGNATION FORM & REAL PROPERTY OWNER/RESPONSIBLE PARTY AFFIDAVIT • This Contractor Designation supersedes all previous designations for this site made by the Real Property Owner or Responsible Party whose signature appears below. • Please read this entire four -page form carefully a nd c omplete a II a pplicable p ortions, i t c ontains important information regarding the cleanup of your site. • Please Print or Type all required information (except for the signature block in Part 6). • This request will not be processed without the completed Owner/RP Affidavit in Part 6. • If you prefer not to designate a specific contractor, you may request that the Department select the cleanup contractor in Part 4 of this form. 1. The Florida Department of Environmental Protection (Department) is required by statute to preapprove the scope of work and cost for the cleanup of a petroleum contaminated site if state funds will. be used to pay for that cleanup [Section 376.30711(1)(b), Florida Statutes (F.S.)]. 2. The current Real Property Owner or Responsible Party for the cleanup must use this form to designate a contractor that meets certain criteria (Sections 376.30711(2)(b)-(c), F.S.) for the Department to work with on their site. In addition, if the Department should coordinate its actions with your representative, you can use this form to designate such an alternative contact. 3. If the current Real Property Owner is not the person responsible for completing the cleanup, then the Responsible Party should complete this form and submit it along with a copy of the legal agreement between them and the current Real Property Owner that details their cleanup responsibility. Responsible party agreements with former Real Property Owners will not be accepted without a signed letter from the current Real Property Owner which indicates that they either concur with the responsible party agreement or do not object to the Responsible Party (identified in Part 3 of this form) selecting the contractor. 4. Please fill out this form completely and carefully. The form will be rejected if there is any omission, error or correction (including "white -out") in any of the required information, including the notary portion of the form. This will delay the cleanup of your site. 5. The current Real Property Owner or Responsible Party may designate a contractor or request a change to a new contractor at any time by submitting a completed Contractor Designation Form (CDF). However, changes in contractor designation are limited to no more than two •(2) in any 12-month period. Changes in contractor d esignation m ay a Iso c reate a d elay in the cleanup o f your s ite. A iso, t he current Real Property Owner or Responsible Party will be liable for payment for any work that the new contractor must perform in order to assume the site cleanup if the Department previously paid for such work. If a new contractor is designated, then any work in progress will be completed by the contractor to whom the work was awarded through the end of the current Work Order unless that contractor is being replaced for documented poor performance or it voluntarily agrees (in writing) to forgo the remaining work. A new designation does not take effect until the completed CDF is accepted and approved by the Department. MCT. doc "More Protection, Less Process" www.dep.statell.us/waste/categories/pcp/default.htrn Page 1 of 4 CDFAfdavit-013107 Bureau of Petroleum Storage Systems - Petroleum Cleanup Preapproval Program CONTRACTOR DESIGNATION FORM & REAL PROPERTY OWNER/RESPONSIBLE PARTY AFFIDAVIT 6. Designating a contractor means that you are responsible for its actions. Pursuant to Section 2.h. of the Petroleum Cleanup Preapproval Program work order issued by the Department, your contractor is required to pay all subcontractors and vendors within 7 days of receipt of payment from the Department that includes their costs for non -final invoices and prior to submittal of the final invoice for each work order (unless there is a written agreement between the contractor and subcontractor/vendor to the contrary). To protect their financial interests, subcontractors and vendors may file a lien against your property that can be exercised in the event t he c ontractor d oes n of p ay t hem i n full. Accordingly, you should take steps to insure that your contractor pays all of its subcontractors a nd v endors. F urthermore, it is a dvised t hat'you r equest t hat y our contractor demonstrate that they are financially solvent and that they have an acceptable .performance record with respect to successful completion of cleanup projects and payments to subcontractors and vendors. 7. Pursuant to Florida Law, it is unlawful for a site owner or operator, or his or her designee, to receive any remuneration, in cash -or in -kind, -directly or -indirectly, from -a rehabilitation contractorperforming site cleanup activities..." under the.preapproval program (Section 376.30711(6) F.S.). It is also unlawful for any contractor to offer any remuneration in cash or in kind, either directly or indirectly, to a site owner, operator or their designee. This prohibition includes payment of any program deductible by a contractor. See Section 7.13 of the BPSS Standard Operating Procedures Manual. 8. Please return the form with original signatures (copies cannot be accepted) to Petroleum Cleanup Section One, Mail Station 4540, in the Bureau of Petroleum Storage Systems at t he I etterhead address. I f y ou choose not to designate a cleanup contractor, you may ask the Department to select one for you in Part 4.e. below. If you have any questions, please call Leila Shuffler at (850) 245-8839. Thank you for your cooperation. Part 1. FDEP Facility Name and Identification # (required): a. Name of Facility/Site: Shamrock / Supreme Service Station b. FDEP Facility Identification #: 138732522 Part 2. Real Property Identification and Current Ownership Verification (required): This information must match that listed in the applicable County Property Appraiser's Office. While the real property owner listed here may be the same as that listed in Part 3, the actual designation of the cleanup contractor occurs only by the entity listed in Parts 3 and 6 of this form. a. Real Property Street Address of Record: 6200 NW 17th Avenue, Miami, Florida 33150 b. Parcel # or Property Identification #•of Record: 01-3115-005-3291 c. Legal Property Description of Record (may attach legible copy): LIBERTY CITY PB 7-79 LOT 21 & LOTS 22 & 23 LESS E10FT & LOT 24 LESS S10FT OF LOTS 23 & 24 FOR R/W BLK 12 LOT SIZE 13924 SQ FT OR 22744-3044 1004 3 d. Name of Current Real Property Owner(s) of Record: City of Miami Asset Management e. If There is Any Reason Why the Property Appraiser's Records May Not Be Accurate, Provide an Explanation and Attach Documentation: MCT.doc "More Protection, Less Process" wi+w. dep.stare.fl. us/wastelcateeories/pcp/default. him Page 2 of 4 • CDFAfdavit-0/3 / 07 Bureau of Petroleum Storage Systems - Petroleum Cleanup Preapproval Program CONTRACTOR DESIGNATION FORM & REAL PROPERTY OWNER/RESPONSIBLE PARTY AFFIDAVIT Part 3. Entity Designating the Preapproval Program Cleanup Contractor (required): a. Name of the Entity Designating the Preapproval Cleanup Contractor (if business, include name/title of representative)':Model City Community Revitalization District Trust b. (Check One): Current Real Property Owner Or X Responsible Party c. Mailing Address and Telephone # of the Entity Designating the Contractor: 4800 NW 12th Avenue, Miami, Florida 33142 Phone (305) 635-2301 Part 4. Preapproval Program Cleanup Contractor Designation (required): Please check one of the options below. You may request that the Department select the cleanup contractor (State) or you may designate a specific cleanup contractor (Owner/RP). Complete section a through d below only if Owner/RP designated contractor. (Check One) State Designated Contractor Or X Owner/RP Designated Contractor a. Designated Contractor Name: Cherokee Enterprises, Inc. b. Designated Contractor Mailing Address: 14474 Commerce Way, Miami Lakes, Florida 33016 c. Contact Person for Designated Contractor: Gabino Cuevas, P.E. d. Telephone # for Contact Person: (305) 828-3353 e. E-Mail address for Contact Person: gcecherokeecorp.com Part 5. Alternate Contact Designation for Current Real Property Owner or Responsible Party (optional): Use this section to designate an alternative point of contact to act on behalf of the entity named in Part 3.a. This person will serve as your representative regarding the cleanup of this site and receive all further notices on your behalf. Do not list the contact person for the contractor. If you do, not wish to designate an alternate point of contact, then leave this part blank. a. Alternate Contact Name: b. Alternate Contact Address and Telephone #: Phone ( c. Relationship of Alternate Contact to Current Real Property Owner or Responsible Party: Part 6. Real Property Owner/Responsible Party Affidavit (required) This affidavit must be completed and signed by the current real property owner or responsible party in the presence of a notary public when designating a contractor for the Petroleum Cleanup Preapproval Program. The signature of the current real property owner or responsible party shall be notarized as set forth below. No work will be authorized on your site until this form is accepted by the Department. By signing below you are certifying that you have read and understand all of the information on aft four pages of this form and that all of the information listed above is true and correct to the best of your knowledge. The name in Part 6.a. must match that listed in Part 3,a. MCT.doc "More Protection, Less Process" www.dep.statellus/waste/catezories/pcn/default.hon Page 3 of 4 CDFAfdavit-013107 Bureau of Petroleum Storage Systems - Petroleum Cleanup Preapproval Program CONTRACTOR DESIGNATION FORM & REAL PROPERTY OWNER/RESPONSIBLE PARTY AFFIDAVIT a. 1, Apo P. am the (name of person appearing) pp-�� (title ui person appearing) 6/T Of f11 / ee'O'V/l'W(G ?l�W �i4iI / and hereby certify: (narne of real property owner or responsible party listed in Part 3.a.) b. That the Contractor Designated in Part 4 of this form is authorized to perform work in the Petroleum Cleanup Preapproval Program on the real property identified in Parts 1 and 2 of this form. c. That the contractor has not offered any remuneration in cash or in kind directly or indirectly in exchange for designating them as my contractor. of d. That I have not solicited or accepted remuneration in cash or in kind directly or indirectly from the contractor in exchange for designating them as my contractor. e. That I acknowledge that soliciting or accepting remuneration in cash or in kind directly or indirectly in exchange for designation of a contractor is prohibited pursuant to Section 376.30711(6), F.S., and may result the loss of eligibility for State funded petroleum contamination cleanup assistance at this site. f. That the person appearing is authorized to make the statements set forth in this affidavit. State of (Signal `e Owner`; - or authorized representative listed above) Notarization of Signature of Real Property Owner or Responsible Party (required) /`� County/Parish of Sworn to and subscribed before me by 6✓ don 'Si"'u this Personally known Produced Identification f jType of ID: (if produced identification) du.. (notary's signature) Notary Public, State of MCT.doc ® day of ��_� 20 CJ7" My Commission Expires ?+///, ` "4 IRIS M. HUDSON RITOMMISOMIDD32084e83p1 EXPIRES: July11, 2007 Bonded Thai Notary Public tinderdtats 'cable) �.w "More Protection, Less.Process" www.dep.staie.17.us/wastelcategories/pcp/default. him Page 4 of 4 IRIS M. HUDSON 'Y MY COMMISSION 8 DD 208299 '� ,. �!� * EXPIRES: July 11, 2007 7� iJf h BondedThru Notary Public Underwatats CDFAfdavit-013107