HomeMy WebLinkAboutFY17 Envir Mgt NCEQ Contr 6893 Amend 1K. - r.0.
L n vironmen ral
Quality
June 7. 2017
AMENDMENT NO. 1
AMENDMENT TO CONTRACT NUMBER 6893
BETWEEN
New Hanover County
AND THE
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY
ROY COOPER
C—,
MICHAEL S. REGAN
4,1-1,
Pursuant to the North Carolina General Contract Terms and Conditions (Contractual and Consultant Services) Clause
pertaining to Amendments of Contract No. 6893 the North Carolina Department of Environmental Quality and the
Contractor mutually agree to change the contract ending date from 06/30/2017 to 09/30/2017. This no -cost time
extension is to allow the Contractor to complete the project. Please see attachment A.
THE TOTAL AMOUNT PAYABLE UNDER THIS CONTRACT REMAINS THE SAME.
It is the intent of this amendment to address the provision(s) noted only, and in no way should this amendment be
construed to further modify this contract. All other terms and conditions remain the same. Please indicate acceptance
by your signature below.
New Hanove ounty n_ �� Tommy Kirby, Purchasing Director
j i �v of Vui i)4� u
l0 ta Tf
Return one (1) original- signed documents to the address specified below for execution by the Department:
wanda.andrews @ncdenr.gov
This amendment when fully executed by all parties will be forwarded to the Contractor.
cc: Rob Taylor, DEQ DEACS
Wanda Andrews, DEQ Financial Services Division, Purchasing and Contracts Section
ORIGINAL
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Attachment A Amd 1 no -cost time
DEQ Contract 6893
Form 6100 - DENR Contract Form - revised 8119115 DENR CONTRACT NO:
6893
CONTRACT DENR • ' • (Assigned by Contract Coordinator
DENR Division & Section: DEACS
Address (MSC /Street):
1639 Mall Service Center
City
lRaleigh T21119-1639
Zip
Contract Administrator (TechnIcal expertise):
Phone No: 918 - 707.8139 E-mail address: IMLta Or ncdenr. ov
PURCHASING AND CONTRACTS ONLY
FSD Purchasing Agent:
Date Received:
Requisition No:
PO No:
AMENDMENTNO:
Contract Coordinator Contract Process expertise Rob Taylor
Phone No: 919 -707 -8139 E -mail address: Irob.taylorangdemr.mv
CONTRACT INFORMATION:
Contractor: New Hanover County
Check one of the following:
Minority (51% ovmed)
Contractor Key Contact / PI:: Kim Roane
strewpo Box# 3002 US Highway 421 North
Woman (51% owned)
Handicapped (51% owned)
X None or the above
Cfty/StatelZip: Wilmington, NC 26401
Phone No: 910 798 -4402
E- 11 Address: kroane nhc ov.com
at
Address (Mail Contract for Execution): (University? / N /A)
Address (checks are mailed d different from Contract Execution address):
Name: Kim Roane (910-798440
Name:
StreeUPO Box # 3002 US Highway 421 North
street/PO Box #
city/state2ip: Wilmington, NC 28401
Ci /stat.0p:
Contract Period (Work cannot begin until fully executed contract is in place) Stan Date: 07/01/16 jEnd Date: 06/30/17
DENR Contract Amount complete for initial contract request only): $
Amendment
Amendment Type: No -Cost Tme I Increase
or Decrease
Revised Scope of Work Attached (check one):
No: __J_
JE.ten sion --I— lContmet
Amount
_ Yes _ No _-x— NA
(Required) Explain why amendment is necessary:
New Hanover County grant establishes a Mobile HHW Program and permanent Compost facility.Equipment has been
purchased. Delays in securing a vendor has compelled the county requests a 120 day extension to 9/30/2017 to complete
Time Extension from
7/1117 Time Extension to: 1 9/30/17
Amendment Amount:
$ 1 Revised Contract Total (Initial contract amount plus all amendments): Is
ENCUMBRANCE (Actual or Estimate Per FY):
UNENCUMBRANCE:
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PO Une S Ca: Acct: center
Co: _AU.i' cents.
PO Une a Lo: _A 1: Cents
FY - a Co: AuL Cents
PD Line a Co: Aa Center
PAYMENT SCHEDULE Check one):
Reknburse for agpwetxe expenditures amordng to amount spec'f*d In Scope of Work / a minimum of 10% Wthhelti until DENR accepts Mal work.
Reimburse 9D% of all invoices for allowable expenditures with 10% of each invoice withheld until DENR accepts final work.
Reimburse actual Invoices submitted with a minimum of 10% of DENR Contract amount withheld until DENR acca1ris final work.
A Lump sum payment when DENR accepts contract fulfillment.
Other (Specify):
MANDATORY SIGNATURES:
By signature, I certiN that the above budget information is correct, appropriately budgeted & currently available in the
Division's budget as specified in the Akove encumbrance information.
DIVISION BUDGET OFFICER:
9 _..
Si nature -
at
DIVISION DIRECTOR:
Signature
Date
DEQ Financial
Service Division
1611 MAY 2b A 9,' 42
Purchasing and
Contracts Section
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Attachment A Amid 1 no -cost time
DEQ Contract 6893
Memorandum
To: Allison Phipps, Purchasing Section Chief
From: Joseph Fitzpatrick, Division of Environmental Assistance and Customer Service /2
Date: April 10, 2017 11
Subject: No Cost Time Extension of 120 days for New Hanover County, Contract p 6893
New Hanover County was awarded a community waste reduction and recycling grant (CWRAR) to purchase
equipment to support the establishment of a compost facility. The county is requesting a no cost time extension
to allow for additional time to complete the project and to make best -use of the available state funds supporting
for this recycling effort. The equipment has been ordered but delays in procuring a vendor have significantly
delayed the start date for processing materials for composting at this facility.
Due to the reasons cited above, the county is unable to complete the work before the contract expires on
June 30, 2017 and have requested an extension for this grant through September 30, 2016 (120 day extension).
This will give the county time to complete construction, finish installation, determine volumes of materials
managed, and to complete a final report as required by the staff and the application guidelines. The Division of
Environmental Assistance and Customer Service supports this request and feels that an extension through
September 30, 2017 is justified. I request that this no -cost contract time extension be granted. Please feel free to
contact me Joe Fitzpatrick at 919 - 707 -8121; email; joseph.fitzoatrick @ncdenr.aov if you have any questions or
concerns. I appreciate your assistance in expediting this request.
Attachments
• April 10, 2017 Memorandum from New Hanover County requesting a time extension
• Form 6100
• Request Letter from New Hanover County
• Revised Application with revised Timeline
Attachment A Amd 1 no -cost time
DEQ Contract 6893
Attachment A Amd 1 no -cost time
DEQ Contract 6893
0
c; Y NEW HANOVER COUNTY
o �y DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
z 9 3002 US HIGHWAY 421 NORTH
x
3 ° Wilmington, NC 28401 -9008
Z a2 Telephoner (910) 798 -4400 • Fax (910) 798 -4408
E -Marl Address: isule.yman@nhcgov.com
F'T�eu :NEO`� 1 8
JOE SULEYMAN
Director or Environmental Management
April 7, 2017
Mr. Joseph Fitzpatrick
North Carolina Department of Environmental Quality
Division of Environmental Assistance and Customer Service
1639 Mall Service Center
Raleigh, NC 27699 -1639
RE: CWRAR Grant Extension Request
Mr. Fitzpatrick,
I would like to formally request that the CWRAR grant period for New Hanover County's in- vessel
composting system be extended for an additional one hundred and twenty (120) days. The purpose for
this request is to ensure that adequate data is collected on the system's performance and operational
effectiveness to provide your office with meaningful metrics.
The delay in meeting the original grant timeline is primarily due to procurement - related issues. There
was a delay in getting contract approval once a vendor was selected, and delivery of the composting
equipment is not expected until mid -July, 2017.
Thank you for your time and consideration
Regards, y^
Joe Suleyman
Director
Attachment A Arnd 1 no-cost time
DEQ Contract 6893
Attachment A Amd 1 no -cost time
DEO Contract 6893
NEW HANOVER COUNTY
DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
0,NOVER co �t<
`v
RECYCLING AND
SOLID WASTE
2016 COMMUNITY WASTE REDUCTION AND RECYCLING
GRANT APPLICATION
Household Hazardous Waste (HHW) Mobile Site Expansion
and
Implementation of a new Composting Pilot Program
Attachment A Amid 1 no -cost time
DEQ Contract 6893
New Hanover County — HHW Mobile Site Expansion and New
Composting Pilot Program
Applicant Contact Information:
Kim Roane, Business Officer
New Hanover County Environmental Management Department
3002 U.S. Highway 421 North
Wilmington, NC 28401
Phone: (910) 798 -4402
Fax: (910) 798 -4008
Email: kroane(&nhcgov.com
Federal Tax ID: XX- XXXX324
II. Date of Proposal Submittal: February 2, 2016
III. General Requirements:
CERTIFICATION:
The Director of the New Hanover County Department of Environmental
Management certifies that all NC Solid Waste Disposal Tax Proceeds are
used only for solid waste management purposes within the county. All
Proceeds are used only for recycling collection and processing, landfill
operation and maintenance, Household Hazardous Waste collection, and
Construction and Demolition Debris diversion and recycling. Further,
attached is a written statement from the New Hanover County Chief Financial
Officer certifying the proper use of tax proceeds.
RECYCLING SERVICES AVAILABILITY
New Hanover County (NHC) provides for recycling collection at all key
government buildings. Receptacles for the collection of recyclable materials
are positioned in high - traffic areas at the following locations:
Government Center, all Libraries, Property Management, NHC Parks, Health
Department, Airlie Gardens, Cape Fear Museum, Senior Resource Center,
Animal Control, Juvenile Detention Facility, Old Courthouse, Judicial Building,
Cooperative Extension, Department of Social Services, Register of Deeds,
and Hoggard High School Baseball /Softball fields.
Employees at all locations are encouraged to recycle materials and are, for
example, provided receptacles to separately dispose of recyclable materials
for their regular garbage. Materials collected for recycling include mixed
paper, cardboard, glass, aluminum beverage containers, and plastic
Attachment A Amd 1 no -cost time
DEQ Contract 6893
beverage containers. NHC maintains a contract with a private hauler for the
collection and transportation of the materials to the County's recycling
processing facility.
Additionally, battery collection containers have been placed at the NHC
Government Center, all four (4) NHC public libraries, the NHC Senior Center,
the Fort Fisher Aquarium (State facility), UNCW and at two campuses of the
Cape Fear Community College. These sites are all serviced at no charge by
the NHC Environmental Management Department.
NHC has a program in place for the collection of fluorescent lights and
mercury thermostats from the County's public buildings. These materials are
collected by the NHC Property Management Department until sufficient
quantities are available to be sent to Cleanlites Recycling, Inc., for proper
handling, including recycling and /or disposal. Additionally, the NHC
Environmental Management Department operates a Household Hazardous
Waste (HHW) program for the general public, through which fluorescent bulbs
and mercury thermostats, among other HHW materials, are accepted from
the public at no charge. The mercury- containing materials collected from the
public are sent to either EcoFlo Inc. or Cleanlites Recycling, Inc. for proper
handling, including recycling and /or disposal.
IV. PROJECT DESCRIPTION:
Description and quantities of items to be purchased with grant funds:
A. HHW Mobile Site Expansion Program
The County is seeking to enhance its service delivery through an expansion of the
existing HHW program by providing mobile HHW and E -Waste collection to NHC
residents for whom access to the existing collection facility's location is inconvenient.
Customer Satisfaction Surveys have indicated great community acceptance of this
program, with the only issue being the travel time to reach our primary location
situated at the far western edge of the county.
The current collection and storage site for this program is located at 3002 U.S.
Highway 421 North, Wilmington, NC, in a newly renovated warehouse at the
northeast corner of the department's Recycling, HHW and Administration campus.
The newly renovated warehouse provides a covered, secure facility for processing
and storing collected materials. Hours of operation at this primary facility are
Monday - Friday from 10:00 a.m. — 2:00 p.m., and Saturday from 8:00 a.m. — noon.
Proposed expansion of this program will provide a mobile van with an enclosed
trailer to be taken one (1) day /week to each of three (3) sites in the County:
Wrightsville Beach, Carolina /Kure Beach and Ogden (in the northern portion of the
County) providing improved access to citizens. The hours at each community site
will be 10:00 a.m. — 2:00 p.m., to mirror our primary site's operating hours. The
employee will then transport the sorted materials to the primary HHW facility for final
processing and packaging.
Attachment A Amd 1 no -cost time
DEQ Contract 6893
Our goal with this program expansion is to provide improved access to residents for
whom access to the existing primary HHW collection site is inconvenient. Mobile
collection will increase the amount of collected materials (reducing landfill disposal of
toxic, combustible, corrosive, or reactive materials), improve satisfaction rates for
services offered, expand awareness of the HHW program and reduce the pressure
on the main collection facility during operating hours.
Grant funds will be used to offset a portion of the cost to expand the HHW Program
to include the following:
o Funding to partially cover the cost of the purchase of a high roof mobile
cargo van. Additional funds are being requested from the Mercury Grant
Program for the purchase of this van, and New Hanover County will fund
the remainder of the cost via the Environmental Management Enterprise
Fund.
B. Composting Pilot Program
New Hanover County plans to develop a composting pilot project to provide a
beneficial end -use for the landfill's yard waste and clean wood waste generated from
the Construction & Demolition (C &D) recycling program. A pilot program has been
established in partnership with UNCW, which will supply the pre- consumer food
waste from their cafeteria to provide an important source of nitrogen for the compost
mix. This will assist UNCW in meeting their goal of zero waste.
The NHC landfill currently receives over 4,000 tons of yard waste annually, and
2,000 tons of clean wood waste from the C &D recycling program. Both waste
streams are expected to increase dramatically with the receipt of the City of
Wilmington's yard waste (14,000 tons annually) and full implementation of the
automated C &D recycling system (providing an additional 6,000 tons of wood waste
annually).
Yard waste is currently ground by a contractor and passively composted. This
material is used for erosion control during rainy conditions. Clean wood waste is
ground by a contractor and used to either generate colored mulch or boiler fuel. The
Attachment A Amd 1 no-cost time
DEQ Contract 6893
site does not have any on -site soils suitable for sustaining vegetation, so all topsoils
must be imported from offsite at significant cost.
New Hanover County intends to purchase an invessel composter with loading
conveyors and a vertical mixer, along with associated feed and discharge hoppers,
chutes, and screens to process the material for composting. We will be seeking bids
for the equipment, but have quotes from two vendors, both of which include similar
composting units. The two quotes are nearly identical in price, within $75 of each
bid, with an overall cost of approximately $195,000.
This pilot project is intended to demonstrate that a permitted compost operation can
generate high quality, grade -A organic compost for use as a soil amendment onsite
or for sale to the public.
Permitting applications must be submitted to NCDEQ, in order to implement the
composting project. This permitting is expected to be initiated in February, 2016,
and completed by May 31, 2016. Additionally, a memorandum of understanding
(MOU) will be initiated with UNCW to document respective responsibilities with
regard to the composting process. This MOU process is expected to be completed
and fully executed by May 31, 2016.
The pilot program will be successful if the site is able to consistently generate
compost that meets all state requirements for sale to the public. If successful, the
program can be easily expanded to generate sufficient volumes to reduce the cost of
importing topsoil for cell closure projects and daily cover needs for outside cell
slopes at the landfill.
Example of In- Vessel Composting Equipment
Description of the anticipated life of service for the items or materials to be
purchased with grant funds (estimate how Iona the project will continue to serve
the community):
A. HHW Mobile Site Expansion Program
Attachment A Amd 1 no -cost time
DEQ Contract 6893
The expected service life of the equipment, with proper maintenance, is ten (10)
years, at which time a replacement will be budgeted in order to continue providing
this service to the community on an ongoing basis.
B. Composting Pilot Program
The expected service life of the composting equipment, with proper maintenance, is
ten (10) years. At this point, we anticipate that the program will have significantly
expanded, necessitating larger equipment to increase throughput.
VI. An estimate of the number of households or businesses that will be impacted by
or have access to the recycling services associated with the proposed project:
A. HHW Mobile Site Expansion Program
Current traffic count to the existing facility exceeds 500 visits /month. Many
customers must make a 45- minute round trip to utilize the service due to our remote
location. The implementation of mobile sites at the farthest reaches of the County is
anticipated to increase resident participation in the program while reducing the
volume of residents driving to our primary HHW site. This is important due to the
traffic congestion at the primary site due to the recent addition of a Materials
Recovery Facility (MRF) on the same campus which has increased commercial
vehicle traffic fivefold, creating confusion for customers traveling within the campus
to the HHW facility. Reduction in traffic count to the existing facility, while increasing
overall program participation year- over -year is the goal. We anticipate greater
utilization of our HHW program with the introduction of mobile sites within the
community, reducing the amount of hazardous waste being placed in the garbage to
be picked up by waste haulers and transported to the NHC landfill.
HHW and Electronics recycling services are available to every resident within NHC.
With a current population well over 213,000 — and growing — this program has a
wide reach. Increased diversion of hazardous waste from the landfill is expected to
result in lower operating costs due to efficiencies gained. These savings are passed
on to residents and businesses in the form of reduced fees.
B. Composting Pilot Program
The pilot program's primary goal is to establish a method by which food waste can
be diverted away from landfill disposal. The short-term benefit is directly related to
reduction of UNCW's food waste from the waste stream. Long -term, this program
can benefit schools, hospitals, and grocery stores in achieving their waste reduction
goals.
Attachment A Amd i no -cost time
DEQ Contract 6893
VII. An estimate of the waste reduction impact of the proposed project:
A. HHW Mobile Site Expansion Program
Using current operating practices, the NHC landfill diverts, on average, 240 tons per
year of HHW & E -waste away from disposal. With expansion of the HHW program
to include mobile sites, the diversion goal is an increase of 15 %, for a total goal of 26
tons of diverted HHW and E- waste.
Reducing hazardous waste disposed of in the landfill will reduce long -term liability of
the site, improve leachate quality, and reduce worker exposure to corrosive, toxic,
reactive, and combustible chemicals.
B. Composting Pilot Program
In the pilot phase, it is expected that the waste reduction impact will be 25 tons /week
(1300 tons /year). This includes pre - consumer food waste from UNCW's cafeterias
and vegetative debris and wood waste from the NHC landfill's yard waste and C &D
recycling programs.
VIII. A description of whether the grant project will create anew service, enhance or
expand and existina service. or support an existina recvclina service without
expandina that service:
A. HHW Mobile Site Expansion Program
This grant project will expand as well as enhance an existing service. Our existing
HHW program serves over 500 visitors /month at our primary site. The goal of this
mobile expansion is to increase the utilization by 30% while reducing the number of
visits to our primary HHW site. The efficiencies gained will expand the amount of
waste diverted from landfill disposal from 240 tons per year to an estimated 276 tons
per year. Letters of Support from the Town of Wrightsville Beach and the
Town of Carolina Beach are attached.
B. Composting Pilot Program
This is a new program in New Hanover County. The grant funding will be used to
support the implementation through the partial funding of the purchase of the
composting in- vessel equipment.
IX. SPECIAL REQUIREMENTS:
Attachment A Amd 1 no -cost time
DEQ Contract 6893
Receipt of proceeds from the State of North Carolina's Electronic Management
Fund:
New Hanover County has received Electronics Management Fund distributions in the
past and hopes to continue to receive these funds in the future. One hundred percent
(100 %) of this funding has been used to support our local electronics management
program, only partially covering the cost of labor to process the incoming and outbound
electronics for recycling and disposal. The rising cost of electronics recycling
processing fees local governments in North Carolina are experiencing in FY15 -16
makes it even more essential that we utilize all funding available from the state to
support the increasing cost to manage our program at the local level. New Hanover
County plans to continue to use the funds that will be distributed in February 2016 and
February 2017 to support the cost of labor for the county's local electronic management
program.
X. PROJECT TIMELINE:
A. HHW Mobile Site Expansion Program
• Submit grant request to BOCC for approval: February 1, 2016
• Submit grant application: February 2, 2016
• Establish Interlocal Agreements with the Towns of Carolina Beach and
Wrightsville Beach for collection sites: April, 2016
• Purchase van, trailer and supplies: July- August, 2016
• Employee training: August, 2016
• Begin mobile collections: September, 2016
• Submit final NC DEACS report: September 30, 2017 * **
B. Composting Pilot Program
• Submit grant request to BOCC for approval: February 1, 2016
• Submit grant application: February 2, 2016
• Permitting: February — May, 2016
• Establish Memorandum of Understanding with UNCW — May, 2016
• Issue RFB for Composting Equipment June, 2016
• Purchase Equipment: August — October, 2016
• Begin composting operations: November, 2016
• Submit final NC DEACS report: September 30, 2017 * **
Grant Timeline
• September 26, 2016: Complete purchase of van for HHW program and initiate
mobile collections.
• October 31, 2016: Complete purchase, installation and permitting for composting
equipment and initiate composting pilot program.
Attachment A Amd 1 no-cost time
DEQ Contract 6893
September 30, 2017: Prepare and submit final report to state.
" Revised April, 2017
PROJECT BUDGET
Item
State Grant
NHC Funds
Total
Award —
CWRAR Grant
Caro Van
$15,000
$3,000
$18,000
Composting
$15,000
$180,000
$195,000
Equipment
and
installation
Total
1$30,000
$183,000
$213,000
Attachment A Amd t no -cost time
DEQ Contract 6893
Hewett, Teresa
From: Roane, Kim
Sent: Wednesday, June 07, 2017 4:56 PM
To: Hewett, Teresa
Subject: FW: NC DEQ contract 6983
Attachments: no -cost time.pdf
Hi Teresa,
The state has asked that we return this signed acknowledgement (extending our grant deadline) back to them
immediately. I found an error in the first document she sent this morning, and she has sent a corrected document
(attached). Since she had asked for it back in one day, I called her and let her know that it might take a few days longer
than that for us to get it signed and returned. Wanda said to try to get it to her by next Wednesday.
Let me know if there is anything I can do to help facilitate the signing of the document. I know you like to process these
for the grants, so I have not initiated any process.
Thanks much,
Kim
Kim Roane I Business Officer
Environmental Management - Administration
New Hanover County
3002 U.S. Highway 421 North
Wilmington, NC 28401
(9 10) 798 -4402 p 1 (910) 798 -4408 f
www.nhcgov.com
From: Andrews, Wanda [ mailto :wanda.andrews @ncdenr.gov]
Sent: Wednesday, June 07, 2017 12:25 PM
To: Roane, Kim <KRoane @nhcgov.com>
Subject: RE: NC DEQ contract 6983
Sorry about that. Please use this one and thanks for catching that
From: Roane, Kim (mailto:KRoane @nhcgov.com]
Sent: Wednesday, June 07, 2017 11:18 AM
To: Andrews, Wanda <wanda.andrews @ncdenr.gov>
Subject: FW: NC DEQ contract 6983
Importance: High
Hi Wanda,
The cover page for signature refers to dredging. This is not a dredging project. The attachments are correct in their
description of the project, and the contract number is accurate. How should this be addressed?
Thank you,
Kim
Kim Roane I Business Officer
Environmental Management - Administration
New Hanover County
3002 U.S. Highway 421 North
Wilmington, NC 28401
(910) 798 -4402 p 1 (910) 798 -4408 f
www.nhcqov.com
From: Andrews, Wanda [ mailto :wanda.andrews @ncdenr.gov]
Sent: Wednesday, June 07, 2017 11:12 AM
To: Roane, Kim <KRoane @nhcgov.com>
Subject: NC DEQ contract 6983
Importance: High
Good morning,
Please find attached an amendment for a no -cost time
extension. Please sign it in BLUE INK, scan it in and email it back to me,
today, if at all possible. This is a time sensitive matter.
Thank you for your attention to this matter.
Wanda Andrews
NC Department of Environmental Quality
Financial Services Division, Purchase and Contracts Section
217 West Jones Street, Suite 5422M
Raleigh, NC 27603
Phone: 919 - 707 -8538
Email: wando.andrewsPncdenr.gov
Grant Document Routing
134
Start date: 6/9/17
From: Teresa Hewett, Finance Department (7408)
Signatures required: � I l,f ( k
Tim Burgess, Assistant County Manager 0
Return to Teresa Hewett, Finance Department (7408)
Type(s) of document(s) attached:
1 original — Grant extension amendment
Explanation of document(s):
Attached is a grant extension amendment for Environmental Management's grant to purchase
equipment for the compost facility. The amendment will extend the grant from 6/30/17 to
9/30/17. Please let me know if you have any questions. Thank you.
----------------- or finance department use-------------------------------------- - - - - --
DATE ADDED TO LASERFICHE
PICKED UP BY:
Print Name & Date
Signature