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Home My WebLink AboutDERR-2024-009268LUST Correspondence Sign-Off Sheet ERRL# Author Subject File Name on Google Drive Enclosures Select Attached Select Specify Special Instructions PM verified site status module in database is current Draft Approval Process Project Manager Section Manager Final Approval Process Section Secretary Author Branch Secretary Administrative Secretary Section Secretary Certified Mail Select SelectEnclosures Included ccs Mailed Select Mailed By 0308-24 Alex Thompson 7000051 OKO PSTE 7000051 OKO PSTE Only No Yes PST Fund Claims Packet dated February 27, 2017 Ill I 07/08/2024 07/17/2024 ~ HT 07/18/2024 L.dL 07/22/2024 ~T ...:E.-~s 07/22/2024 jtJ 07/22/2024 Yes Yes - Yes ~ 07/25/2024 ■ Attach Signed Letter 195 North 1950 West • Salt Lake City, UT Mailing Address: P.O. Box 144840 • Salt Lake City, UT 84114-4840 Telephone (801) 536-4100 • Fax (801) 359-8853 • T.D.D. (801) 536-4284 www.deq.utah.gov Printed on 100% recycled paper State of Utah SPENCER J. COX Governor DEIDRE HENDERSON Lieutenant Governor Department of Environmental Quality Kimberly D. Shelley Executive Director DIVISION OF ENVIRONMENTAL RESPONSE AND REMEDIATION Brent H. Everett Director ERRL-0308-24 July 25, 2024 CERTIFIED MAIL RETURN RECEIPT REQUESTED Doug Slauth 3DP Silver Summit, LLC P.O. Box 681030 Park City, Utah 84068 Re:Petroleum Storage Tank Fund Eligibility 7-Eleven #53603/1833-24022, located at 1815 Canyons Drive, Park City, Utah Facility Identification No. 7000051, Release Site OKO Dear Mr. Slauth: This letter is being sent as a notification that a Petroleum Storage Tank (PST) Eligibility Application has not been submitted to the Division of Environmental Response and Remediation (DERR) for Release Site OKO. The PST Eligibility Application submission is required for your PST Fund eligibility determination regarding this Release Site. In accordance with Utah PST Rule R311-207-2(2), a PST Fund Eligibility Application must be submitted before the responsible party incurs costs for which they intend to seek reimbursement from the PST Fund. A PST Fund Claims Packet is enclosed which includes a PST Fund Eligibility Application. Please submit your completed PST Fund Eligibility Application within 30 days to ensure that the costs you may incur will be eligible for reimbursement to the greatest extent possible. Please note that the DERR may not authorize payments from the PST Fund if the claim is not filed within the time periods specified in Utah Underground Storage Tank (UST) Act Section 19-6-424(1) or if appropriate approvals for work are not timely obtained as specified in Utah UST Act Section 19-6-420. In accordance with Utah PST Rule R311-201-2(1), all PST release management, abatement, investigation, and corrective action work must be performed by a DERR-Certified PST Consultant. In accordance with Utah PST Rule R311-207-3(7), once the responsible party's share of eligible costs has been spent in accordance with Utah UST Act Section 19-6-419, the DERR shall review and approve or disapprove work plans and the corrective action plan and all associated budgets. For costs to be covered by the PST Fund, the DERR must approve all work plans, corrective action plans, and associated budgets before a responsible party initiates any work, except as allowed by Utah UST Act Sections 19-6-420(3) and 19-6-420(6). Facility ID# 7000051 Page 2 If you have any questions, please contact Alex Thompson, the DERR project manager, at (385) 214-2189. Sincerely, Brent H. Everett, Director Division of Environmental Response and Remediation BHE/MAT/stt Enclosure: PST Fund Claims Packet dated February 27, 2017 cc: Phil Bondurant, Ph.D., Director, Summit County Health Department Nathan Brooks, Environmental Health Director, Summit County Health Department t ~ ~ J Petroleum Storage Tank Trust Fund Claim Information Packet February 27, 2017 Department of Environmental Quality Division of Environmental Response and Remediation 195 North 1950 West, 1st Floor P.O. Box 144840 Salt Lake City, Utah 84114-4840 Telephone: (801) 536-4100 Fax: (801) 359-8853 UTAH DEPARTMENT of ENVIRONMENTAL QUALITY ENV I RONMENTA L RESPONSE ,& REMEDI .ATl 1ON TABLE OF CONTENTS Introduction ......................................................................................................................................1 PST Trust Fund Eligibility ...............................................................................................................1 PST Trust Fund Deductible and Coverage ......................................................................................1 Environmental Consultants and Subcontractors ..............................................................................2 Work Plans and Budgets ..................................................................................................................2 PST Trust Fund Reimbursement Documentation ............................................................................3 Third Party Claims ...........................................................................................................................3 Other Information Eligibility Application Work Plan Approval Application and Agreement Standardized Invoice Request for Payment Voucher Proof of Payment Introduction The Division of Environmental Response and Remediation (DERR) established the Petroleum Storage Tank Trust Fund (PST Fund) to help underground storage tank (UST) owners/operators meet U.S. Environmental Protection Agency financial assurance requirements and to help pay the costs of abatement, investigation, and remediation of releases from leaking underground storage tanks (LUSTs). This claim information packet summarizes the procedures and requirements for obtaining PST Fund assistance for the investigation and remediation of releases from PST Fund-covered LUSTs. This claim information packet is not all-inclusive, therefore, one should review the Underground Storage Tank Act 19-6-401 and the Underground Storage Tank Rules R311 for more detailed information. PST Fund Eligibility Known or suspected releases (leaks) from petroleum UST systems (USTs, associated piping, and dispensers) must be reported to the DERR within 24 hours of occurrence. To be eligible for reimbursement from the PST Fund, the UST system must have a valid UST Certificate of Compliance and must be covered by the PST Fund at the time of the release. A “PST Trust Fund Eligibility Application” or claim must be received by the DERR during the period under which the UST system was covered by the PST Fund, or within one year after the UST system was properly closed, or within six months after the end of the period under which the UST was covered by the PST Fund. Following a review of your PST Fund Eligibility Application, the DERR will provide written notification regarding eligibility for reimbursement from the PST Fund. There are time constraints provided by law that may cause an otherwise eligible release to become ineligible. Therefore, it is important to file a PST Trust Fund Eligibility Application promptly. PST Fund Deductible and Coverage Deductible: Releases that occurred and were reported before July 1, 1994 have a $25,000 deductible. Releases that occurred and were reported after July 1, 1994 have a $10,000 deductible. Coverage: For releases reported before May 11, 2010, the PST Fund may reimburse up to $990,000 ($490,000 for non-marketer facilities) of the investigation and remediation costs. For releases reported after May 11, 2010, the PST Fund may reimburse up to $1,990,000 ($990,000 for non-marketer facilities) of the investigation and remediation costs. All costs, including the deductible amount, must be for customary, reasonable, and legitimate work as determined by the DERR. Expenses that are eligible for reimbursement from the PST Fund include costs for vapor abatement, subsurface investigation, soil and groundwater sampling, corrective action, and provision for alternative drinking water supplies. 1 Expenses that are not eligible for reimbursement by the PST Fund include costs to achieve compliance with UST system leak detection requirements, upgrading of an UST system, removal or installation of an UST system, loss of business, and legal fees. If a facility has a current PST Fund-eligible release and a subsequent PST Fund-eligible release occurs at that facility, the PST Fund allowable coverage for the subsequent release will be limited to the amount required to investigate and remediate only the subsequent release. Additional PST Fund monies cannot be obtained for the investigation and remediation of the original release through the coverage of a subsequent release, i.e., the maximum coverages for each release cannot be aggregated. The DERR will determine the coverage based on the magnitude of the subsequent release. In addition, a $10,000 deductible will apply to the subsequent release. Environmental Consultants and Subcontractors Environmental consultants overseeing and directing work at LUST sites must be DERR- Certified UST Consultants in accordance with UST Rule R311-201-2. The Certified UST Consultant must have a current and approved PST Fund Statement of Qualification (SOQ) on file with the DERR in accordance with UST Rule R311-207-3. Consulting firms must update their PST Fund SOQs each year and the SOQs must be approved by the DERR before PST Fund money is expended. Environmental consultants must obtain a minimum of three bids from qualified subcontractors for subcontracted work (drillers, excavation contractors, etc.) in accordance with UST Rule R311-207-4(e). The requirement to obtain three bids for subcontracted work is waived if the subcontracted work is expected to cost, and actually does cost, less than $5,000. Work Plans and Budgets Work Plans and Budgets (WP&B) for work required to investigate and remediate a release must be pre-approved by the DERR and the PST Fund claimant. The claimant and their environmental consultant must complete, sign, and submit a Work Plan Approval Application and Agreement (WPAA&A) form for each WP&B before the work is performed. If the claimant does not want to sign a WPAA&A form for each individual WP&B, the claimant may complete and sign one form that will cover all subsequent work plans with the same environmental consultant. However, the claimant must submit a cover letter with the form to document that this is what they want to do. This authorization will remain in effect until the claimant notifies the DERR otherwise in writing. An approved work plan may be changed and the budget may be exceeded only after obtaining approval from the DERR. Emergency work (work that prevents or abates substantial danger to public health or the environment) can be approved verbally (with a written follow-up submitted within 48 hours requesting an amendment and explaining the need for the change in the scope- of-work and budget). 2 State of Utah SPENCERJ. COX Governor DEIDRE HENDERSON Lieutenant Governor Department of Environmental Quality Kimberly D. Shelley Executive Director DIVISION OF ENVIRONMENTAL RESPONSE AND REMEDIATION Brent H. Everett Director July 25, 2024 ERRL-0308-24 CERTIFIED MAIL RETURN RECEIPT REQUESTED Doug Slauth 3DP Silver Summit, LLC P.O. Box 681030 Park City, Utah 84068 Re: Petroleum Storage Tank Fund Eligibility 7-Eleven#53603/1833-24022, located at 1815 Canyons Drive, Park City, Utah Facility Identification No. 7000051, Release Site OKO Dear Mr. Slauth: This letter is being sent as a notification that a Petroleum Storage Tank (PST) Eligibility Application has not been submitted to the Division of Environmental Response and Remediation (DERR) for Release Site OKO. The PST Eligibility Application submission is required for your PST FUfld eligibility determination regarding this Release Site. In accordance with Utah PST Rule R311-207-2(2), a PST FUfld Eligibility Application must be submitted before the responsible party incurs costs for which they intend to seek reimbursement from the PST Fund. A PST Fund Claims Packet is enclosed which includes a PST FUfld Eligibility Application. Please submit your completed PST FUfld Eligibility Application within 30 days to ensure that the costs you may incur will be eligible for reimbursement to the greatest extent possible. Please note that the DERR may not authorize payments from the PST FUfld if the claim is not filed within the time periods specified in Utah Underground Storage Tank (UST) Act Section 19-6-424(1) or if appropriate approvals for work are not timely obtained as specified in Utah UST Act Section 19-6-420. In accordance with Utah PST Rule R311-201-2(1), all PST release management, abatement, investigation, and corrective action work must be performed by a DERR-Certified PST Consultant. In accordance with Utah PST Rule R311-207-3(7), once the responsible party's share of eligible costs has been spent in accordance with Utah UST Act Section 19-6-419, the DERR shall review and approve or disapprove work plans and the corrective action plan and all associated budgets . For costs to be covered by the PST Fund, the DERR must approve all work plans, corrective action plans, and associated budgets before a responsible party initiates any work, except as allowed by Utah UST Act Sections 19-6-420(3) and 19-6-420(6). 195 North 1950 West• Salt Lake City, UT Mailing Address: P.O. Box 144840 • Salt Lake City, UT 84114-4840 Telephone (801) 536-4100 • Fax (801) 359-8853 • T .D.D. (801) 536-4284 www.deq.utah.gov Printed on 100% recycled paper Facility ID# 7000051 Page2 If you have any questions, please contact Alex Thompson, the DERR project manager, at (385) 214-2189. Sincerely, Brent H. Everett, Director Division of Environmental Response and Remediation BHE/MAT/stt Enclosure: PST Fund Claims Packet dated February 27, 2017 cc: Phil Bondurant, Ph.D., Director, Summit County Health Department Nathan Brooks, Environmental Health Director, Summit County Health Department Petroleum Storage Tank Trust Fund Claim Information Packet UTAH DEPARTMENT ENVIRONMENTAL QUALITY ENVIRONMENTAL RESPONSE & REMEDIATION February 27, 2017 Department of Environmental Quality Division of Environmental Response and Remediation 195 North 1950 West, 1st Floor P.O. Box 144840 Salt Lake City, Utah 84114-4840 Telephone: (801) 536-4100 Fax: (801) 359-8853 TABLE OF CONTENTS Introduction ...................................................................................................................................... 1 PST Trust Fund Eligibility ............................................................................................................... 1 PST Trust Fund Deductible and Coverage ...................................................................................... 1 Environmental Consultants and Subcontractors .............................................................................. 2 Work Plans and Budgets .................................................................................................................. 2 PST Trust Fund Reimbursement Documentation ............................................................................ 3 Third Party Claims ........................................................................................................................... 3 Other Information Eligibility Application Work Plan Approval Application and Agreement Standardized Invoice Request for Payment Voucher Proof of Payment Introduction PST Fund Eligibility PST Fund Deductible and Coverage The Division of Environmental Response and Remediation (DERR) established the Petroleum Storage Tank Trust Fund (PST Fund) to help underground storage tank (UST) owners/operators meet U.S. Environmental Protection Agency financial assurance requirements and to help pay the costs of abatement, investigation, and remediation of releases from leaking underground storage tanks (LUSTs). This claim information packet summarizes the procedures and requirements for obtaining PST Fund assistance for the investigation and remediation of releases from PST Fund-covered LUSTs. This claim information packet is not all-inclusive, therefore, one should review the Underground Storage Tank Act 19-6-401 and the Underground Storage Tank Rules R311 for more detailed information. Known or suspected releases (leaks) from petroleum UST systems (USTs, associated piping, and dispensers) must be reported to the DERR within 24 hours of occurrence. To be eligible for reimbursement from the PST Fund, the UST system must have a valid UST Certificate of Compliance and must be covered by the PST Fund at the time of the release. A "PST Trust Fund Eligibility Application" or claim must be received by the DERR during the period under which the UST system was covered by the PST Fund, or within one year after the UST system was properly closed, or within six months after the end of the period under which the UST was covered by the PST Fund. Following a review of your PST Fund Eligibility Application, the DERR will provide written notification regarding eligibility for reimbursement from the PST Fund. There are time constraints provided by law that may cause an otherwise eligible release to become ineligible. Therefore, it is important to file a PST Trust Fund Eligibility Application promptly. Deductible: Releases that occurred and were reported before July 1, 1994 have a $25,000 deductible. Releases that occurred and were reported after July 1, 1994 have a $10,000 deductible. Coverage: For releases reported before May 11, 2010, the PST Fund may reimburse up to $990,000 ($490,000 for non-marketer facilities) of the investigation and remediation costs. For releases reported after May 11, 2010, the PST Fund may reimburse up to $1,990,000 ($990,000 for non-marketer facilities) of the investigation and remediation costs. All costs, including the deductible amount, must be for customary, reasonable, and legitimate work as determined by the DERR. Expenses that are eligible for reimbursement from the PST Fund include costs for vapor abatement, subsurface investigation, soil and groundwater sampling, corrective action, and provision for alternative drinking water supplies. 1 Environmental Consultants and Subcontractors Work Plans and Budgets Expenses that are not eligible for reimbursement by the PST Fund include costs to achieve compliance with UST system leak detection requirements, upgrading of an UST system, removal or installation of an UST system, loss of business, and legal fees. If a facility has a current PST Fund-eligible release and a subsequent PST Fund-eligible release occurs at that facility, the PST Fund allowable coverage for the subsequent release will be limited to the amount required to investigate and remediate only the subsequent release. Additional PST Fund monies cannot be obtained for the investigation and remediation of the original release through the coverage of a subsequent release, i.e., the maximum coverages for each release cannot be aggregated. The DERR will determine the coverage based on the magnitude of the subsequent release. In addition, a $10,000 deductible will apply to the subsequent release. Environmental consultants overseeing and directing work at LUST sites must be DERR- Certified UST Consultants in accordance with UST Rule R311-201-2. The Certified UST Consultant must have a current and approved PST Fund Statement of Qualification (SOQ) on file with the DERR in accordance with UST Rule R311-207-3. Consulting firms must update their PST Fund SOQs each year and the SOQs must be approved by the DERR before PST Fund money is expended. Environmental consultants must obtain a minimum of three bids from qualified subcontractors for subcontracted work (drillers, excavation contractors, etc.) in accordance with UST Rule R311-207-4(e). The requirement to obtain three bids for subcontracted work is waived if the subcontracted work is expected to cost, and actually does cost, less than $5,000. Work Plans and Budgets (WP&B) for work required to investigate and remediate a release must be pre-approved by the DERR and the PST Fund claimant. The claimant and their environmental consultant must complete, sign, and submit a Work Plan Approval Application and Agreement (WP AA&A) form for each WP&B before the work is performed. If the claimant does not want to sign a WPAA&A form for each individual WP&B, the claimant may complete and sign one form that will cover all subsequent work plans with the same environmental consultant. However, the claimant must submit a cover letter with the form to document that this is what they want to do. This authorization will remain in effect until the claimant notifies the DERR otherwise in writing. An approved work plan may be changed and the budget may be exceeded only after obtaining approval from the DERR. Emergency work (work that prevents or abates substantial danger to public health or the environment) can be approved verbally (with a written follow-up submitted within 48 hours requesting an amendment and explaining the need for the change in the scope- of-work and budget). 2 PST Fund Reimbursement Documentation Third Party Claims Reimbursement amounts are determined by the actual time and material costs expended for the work, up to but not exceeding the approved budget amount for each task. In accordance with UST Rule R311-207-4, all expenses must be documented on a monthly basis and submitted on the "Standardized Invoice" or equivalent. Information from invoices must be compiled on the PST Trust Fund, Request for Payment Voucher. PST Fund reimbursement requests that do not comply with UST Rule R311-207 will be returned to the claimant for correction. The costs for correction of reimbursement requests will not be reimbursable by the PST Fund. Requests for PST Fund reimbursement must be received by the DERR within one year of the date that the work was performed or reimbursement will be denied. The following information is required for PST Fund reimbursement: • Employee name, labor category (e.g., P102-Project Geologist or P104-Field Geologist, etc.), date of work, task or description of work (e.g., groundwater sampling, operation and maintenance, report preparation, etc.), hourly labor rate, and the number of hours spent on each task; • Laboratory analytical costs; • Equipment rental and materials costs; • Utility costs; • Other direct costs; • Invoices from general contractors, subcontractors, and suppliers with a work description and listing of price and quantity of labor, equipment, and materials used; and, • Proof of Payment. If reimbursement is to be made to the PST Fund claimant, proof of payment to the consultant must be provided. If reimbursement is to be made directly to the consultant, then proof of payment to the consultant's subcontractors and suppliers is required. Proof of payment may be in the form of canceled checks, lien waivers, or affidavits from the entity that is owed the money. PST Fund claimants are primarily liable for all costs incurred and should obtain lien releases or lien waivers from the companies, contractors, and subcontractors providing materials or performing services associated with the release. If a third party claim resulting from the release is brought against a PST Fund claimant, or if any action or situation is likely to result in a third party claim, the PST Fund claimant must immediately report it to the Department of Administrative Services, Risk Manager at (801) 538-9560 and to the DERR Project Manager. 3 PST Trust Fund Utah Department of Environmental Quality Division of Environmental Response and Eligibility Application Remediation Petroleum Storage Tank Trust Fund 2/24/17 Were tanks in compliance when leak was detected? □ Yes □ No LUST Release Number: Facility ID Number: Applicant Name (please print) Signature Date Mailing Address City State Zip Telephone ( ) Applicant is a: □ Tank System Owner □ Facility Owner □ Tank System Operator □ Land Owner (Must demonstrate authority to file claim) □ Tank System Owner □ Facility Owner □ Tank System Operator If the tank system owner or □ Land Owner operator, the facility owner, or owner of the land on which the tank system is located is Mailing Address different than the applicant shown above, complete the appropriate spaces in this Telephone portion of the form. Dates of Ownership From To Name of facility where the release occurred: Facility Address: Contact person at the facility: Telephone ( ) Date Release occurred or was discovered: Date release was reported to the DERR: Number of tank systems that contributed to the release at the site (attach additional sheets if needed). Tank Number Tank Volume Product Installation/Closure Date Is this release covered under independent insurance? D Yes (if yes, please submit a copy of your insurance policy) □ No Number of tank systems that were or will be removed during the course of this site cleanup? How was the release confirmed? (Attach a brief summary that includes laboratory analysis, field instrument readings, visual observations, tank tightness test results, etc.) Is there evidence of a previous release? If so, describe how the release was determined. Was the release caused by a third party? If so, explain the circumstances and provide the name, address, and telephone number of the third party and the third party's insurance company. Have you received any reimbursement or offers of reimbursement from a third party or a third party's insurance company? If so, how much and when was it received? Have you signed a release? Utah Code Ann. 19-6-426(7) prohibits responsible parties from doing anything that may prejudice the right of the State to recover from third parties. Petroleum Storage Tank Trust Fund Work Plan Approval Application and Agreement Work Plan No. __________, Amendment No. __________ Facility Name: Address: ------------------- Facility ID No.: ______________ _ Release ID: ______________ ("Release") Owner/Operator, responsible party, or other person seeking PST Trust Fund Reimbursement: __________________________________ ("Claimant") Utah-Certified UST Consultant: _____________________ ("Contractor") In submitting Work Plans __________ and amendments thereto for the above referenced Release _____ for approval, the Claimant and the Contractor collectively, the "Parties," represent and agree to the following: Definitions: "Contractor" means the person identified as such above. "Claimant" means the person identified as such above. "Parties" means Claimant and Contractor. "Division Director" means the Division Director of the Division of Environmental Response and Remediation. "PST Fund" means the Petroleum Storage Tank Trust Fund. "Release" means the release identified above. "State" means the State of Utah including its agencies, officers, employees, volunteers and specifically, the Division of Environmental Response and Remediation (DERR), the Division Director of the Division of Environmental Response and Remediation, and the Petroleum Storage Tank Trust Fund. "Work Plan" means the work plan identified above. 1. 2. The key personnel, for which qualifications are submitted under R311-207-3(c), are: The Claimant acknowledges that the Claimant is required to obtain a payment bond from the Contractor under Section 14-2-1 of the Utah Code. If the Claimant fails to do so, the Claimant is liable to each person who performed labor or services or supplied equipment or materials ("Subcontractors") in the event the Contractor does not pay the subcontractors, even if the Claimant has paid the Contractor (Utah Code Section 14-2-2). The Claimant acknowledges and agrees that the PST Fund will not reimburse the Claimant for such Subcontractors' claims for payment against the Claimant if the PST Fund has already made payment to the Claimant or Contractor. The Claimant understands that the premium paid for a payment bond is reimbursable. Therefore, the Claimant: a. Has required the Contractor to obtain 100 percent payment bond through a United States Treasury-listed bonding company, and attached a copy, or; b. Has obtained other equivalent assurance and waives all claims and remedies against the State if the equivalent assurance does not adequately protect the Claimant. The equivalent assurance is described as follows: 3. The Parties agree that the Contractor shall have no cause of action against the State for payment. The Parties acknowledge and agree that the State is not a party to any contract with the Claimant or the Contractor for reimbursement from the PST Fund in the execution of this Work Plan, except to the extent provided by a contract signed by the Division Director. Instead, the Claimant's reimbursement is governed by the Utah Underground Storage Tank Act and the Utah Underground Storage Tank Rules. The Contractor is entitled to reimbursement solely under his/her contract with the Claimant. 4. The Parties agree that they will use a subcontracting method consistent with the requirements of R311-207. 5. The Parties agree that, as a condition of performing the work under the work plan, the Contractor shall carry the insurance specified in R311-207-3(c)(4). The Contractor represents that the Certificate of Insurance documenting the required insurance is attached or that a current certificate is on file with the Division Director and has been provided to the Claimant. The Parties assume the risk and responsibility of ensuring that the appropriate insurance coverage is in place. 6. The Parties agree that payments from the PST Trust Fund shall be limited to amounts that are customary, legitimate, reasonable and consistent with R311-207. Unless the Parties and the Division Director have entered into a written Pay-for-Performance agreement, the Parties acknowledge that payments will be for actual time and materials expended up to, but not exceeding, the amount of the Division Director approved work plan and Division Director approved change orders, if any. 7. The Parties shall maintain financial and operation records in sufficient detail to document all transactions relating to PST Fund reimbursement for the execution of this work plan. The Parties shall make available for audit and inspection all such records relating to the completion of the work plan and related services, requirements, and expenditures until all audits initiated by State auditors are completed, or for a period of five years from the date of PST Fund reimbursement related to the execution of this work plan. Records which relate to disputes, litigation, or the settlement of claims arising out of the performance of this work plan, or to cost and expenses of this work plan as to which exception has been taken by the Division Director, shall be retained by the Parties until disposition has been made of such disputes, litigation, claims, or exceptions. 8. The Parties certify that there is a contract between the Claimant and the Contractor for the performance of work under the work plan for which approval is sought ("Contract") and incorporate the provisions herein into that Contract. To the extent that the Contract or amendments thereto conflict with any provisions herein, the provisions herein govern. The Parties shall provide the Contract to the Division Director upon request. 9. The Division Director is a third party beneficiary of this Petroleum Storage Tank Trust Fund Work Plan Approval Application and Agreement and may enforce its provisions. 10. This Petroleum Storage Tank Trust Fund Work Plan Approval Application and Agreement does not limit the Division Director's rights and remedies under applicable law. Contractor -------------------------------Signature, Printed Name, and Date Claimant -------------------------------Signature, Printed Name, and Date PROFESSIONAL SERVICES DERR LABOR CATEGORY DERR LABOR CODE TASK HOURS RATE THIS INVOICE TOTAL PREVIOUS TOTAL NEW TOTAL APPROVED BUDGET REMAINING BUDGET SubTotal DIRECT CHARGES DESCRIPTION TASK QUANTITY RATE THIS INVOICE TOTAL PREVIOUS TOTAL NEW TOTAL APPROVED BUDGET REMAINING BUDGET SubTotal OUTSIDE SERVICES DESCRIPTION TASK QUANTITY RATE THIS INVOICE TOTAL PREVIOUS TOTAL NEW TOTAL APPROVED BUDGET REMAINING BUDGET SubTotal BUDGET HISTORY SUMMARY TASK TOTAL TASK BUDGET APPROVED AMOUNT PREVIOUS INVOICES AMOUNT THIS INVOICE TOTAL INVOICE TO DATE TOTAL TASK BUDGET REMAINING %BUDGET REMAINING % OF WORK REMAINING 1 2 3 4 5 6 7 8 WORK PLAN TOTAL STANDARDIZED INVOICE Utah State Petroleum Storage Tank Fund FACILITY ID. #E INVOICE # LOCATION ADDRESS INVOICE DATE LOCATION NAME RELEASE ID. REMIT PAYMENT TO FROM WORK PLAN APPROVED BUDGET INVOICE FOR SERVICES PERFORMED TO DERR WORK PLAN NO.WORK PLAN DESCRIPTION hviled5/ll/12 I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I PETROLEUM STORAGE TANK TRUST FUND REQUEST FOR PAYMENT VOUCHER PAYEE:RELEASE NUMBER:__________________ UTAH DEPT. OF ENVIRONMENTAL QUALITY ADDRESS:FACILITY NUMBER:__________________ DIV. OF ENVIRONMENTAL RESPONSE & REMEDIATION TYPE OF BUSINESS:SITE NAME:____________________________________________________ 195 NORTH 1950 WEST - PO BOX 144840 SOLE PROPRIETOR_____PARTNERSHIP_____CORPORATION_____ SITE LOCATION:_______________________________________________ SALT LAKE CITY, UTAH 84114-4840 PHONE:PHONE NO. (801) 536-4100 DATE WORK PLAN SERVICES RENDERED: DESCRIPTION MUST INCLUDE COPIES OF INVOICES, CHECKS & BACK-UP DOCUMENTATION INVOICE # AMOUNT STATE USE: TOTAL TO REIMBURSE: 7220 480 4731 7220 6137 DERR Project Manager: Date: SUBMITTED BY: BILL TO: I, the undersigned, certify that the above listed items or services were required for and used at this site, that the charges appearing hereon are correct, and that no part of the same has been paid for by the PST Fund. The presentation of a claim based on materially false information is subject to criminal penalties. Utah Code Ann . § 19-6-429. I TOT AL SUBMITTED: $ SIGNATURE OF RESPONSIBLE PARTY DATE SIGNATURE OF CONSULTANT FOR PROJECT DATE I CLAIM# I I LESS DISALLOWED COSTS : NOTE: Signatures of BOTH Responsible Party AND Consultant required for Direct Reimbursement to the Consultant Only one signature required for reimbursement to owner. I PMT# I SUB-TOTAL APPROVED: $ LESS DEDUCTIBLE: $ PROJECT MANAGER DATE ACCOUNTANT DATE DIVISION DIRECTOR DATE $ PST SECTION MANAGER DATE MSC DATE DEQ/FINANCE DATE I FUND AGENCY I LOWORG I APPR SOURCE I PROGRAM I FUNCTION AMOUNT REV DATE: 2/27/17 FINANCIAL CODING I I I I I $ State of Utah OLENE S. WALKER Gove rno r GAYLE F. Mc KEA C HNlE U euteria/11 Governor Department of Environmental Quality ERRL-FORM-LTR Di ann e R. Nie lson , Ph .D. Execu ri ve Direcror DIV IS ION OF E NVIRONMENTAL RES PONSE ANO REMEDIATION Brad T Johnson Direcror To Whom It May Concern: May 27, 2004 Utah Petroleum Storage Tank Rule R311-207-4(d) of the Utah Admin. Code requires that: "for time and material based reimbursement, before receiving payment from the Petroleum Storage Tank Trust Fund, the responsible party must provide proof of past paymen ts for services or construction rendered, in a form acceptable to, or as directed by, the Executive Secretary (UST), u n less the Executive Secretary (UST) has agreed to other arrangements." The Executive Secretary (UST) has determined that in lieu of providing a canceled check, the responsible party may instead provide a copy of the invoice and an affidavit from the contractor (consultant) indicating that the responsible party has executed a promissory note agreeing to pay the full amount of the invoice. The affidavit must be on the attached form and cannot be substantively altered. If the consultant has used subcontractor services, the attached lien waiver mu s t al so be submitted with the affidavit. BTJ/SKA/s rb Enclosures Brad T Johnson , Executive Secretary (UST) Utah Solid and Hazardous Waste Control Board 168 No rth 1950 West • PO Box 144840 • Salt Lake Cit y, UT 84114-4840 • phone (801 ) 536-4100 • fax (801 ) 359-8853 T .D.O . (801) 536-4414 • www.deq.ullll~gov Ulah! Where ideas con11cct • Petroleum Storage Tank Trust Fund AFFIDAVIT: PROOF OF PAYMENT INVOICE # INVOICE DATE AMT. PAID INVOICE # INVOICE DATE AMT. PAID This form should be used when a claimant submits an affidavit from the consultant as proof of payment for costs claimed for reimbursement. See R31 l-207-4(d) Utah Admin. Code Claimant's Name ----------------------------------- Site Name and Address -------------------------------- Facility Identification No. _______________ Release Site _______ _ STATE OF UTAH COUNTY OF ----------- : ss ) ) I, being first duly sworn upon oath and being of lawful age, state that the following invoices relative to the referenced application for reimbursement from the Utah Petroleum Storage Tank Trust Fund have been paid in full through the execution of a promissory note by the claimant. I further state that there is no relationship or affiliation between myself and the claimant. I hereby certify that the foregoing information is correct to the best of knowledge, information, and belief. I understand there are severe civil and/or criminal penalties for any false statement or misrepresentation of a material fact, knowing it to be false, or failing to disclose a material fact with the intent to defraud. Signature: I Date: Print Name: I Title: I Phone: Consultant Company Name: Consultant Company Mailing Address: Subscribed and sworn to before me in the county of ___________ , Utah, this __ day of ________ (month), _____ (year). My commission expires __________ _ Notary Public Signature SUBCONTRACTORS'/MATERIALMENS' LIEN WAIVER For valuable consideration, the receipt and sufficiency whereof is hereby acknowledged, the undersigned Subcontractor/Materialman having performed services or furnished materials for that certain project known as----------------------~ located at _____________________________ _, hereby releases, relinquishes, and waives any and all mechanic's liens, materialman's liens, and all other liens of every nature and kind, and/or the right to file any such lien, against said project for labor, services, equipment, and material supplied and performed through------~ 201 The undersigned certifies that: 1. Full payment, less retainage if any, has been received for all invoices submitted through __________ ~ 201 __ ; and 2. The undersigned has paid all of its subcontractors for work and services performed and all of its materialmen for materials furnished to said date. DATED this ___ day of _________ , 201 Authorized Representative of: Reimbursement amounts are determined by the actual time and material costs expended for the work, up to but not exceeding the approved budget amount for each task. PST Fund Reimbursement Documentation In accordance with UST Rule R311-207-4, all expenses must be documented on a monthly basis and submitted on the “Standardized Invoice” or equivalent. Information from invoices must be compiled on the PST Trust Fund, Request for Payment Voucher. PST Fund reimbursement requests that do not comply with UST Rule R311-207 will be returned to the claimant for correction. The costs for correction of reimbursement requests will not be reimbursable by the PST Fund. Requests for PST Fund reimbursement must be received by the DERR within one year of the date that the work was performed or reimbursement will be denied. The following information is required for PST Fund reimbursement: ● Employee name, labor category (e.g., P102-Project Geologist or P104-Field Geologist, etc.), date of work, task or description of work (e.g., groundwater sampling, operation and maintenance, report preparation, etc.), hourly labor rate, and the number of hours spent on each task; ● Laboratory analytical costs; ● Equipment rental and materials costs; ● Utility costs; ● Other direct costs; ● Invoices from general contractors, subcontractors, and suppliers with a work description and listing of price and quantity of labor, equipment, and materials used; and, ● Proof of Payment. If reimbursement is to be made to the PST Fund claimant, proof of payment to the consultant must be provided. If reimbursement is to be made directly to the consultant, then proof of payment to the consultant’s subcontractors and suppliers is required. Proof of payment may be in the form of canceled checks, lien waivers, or affidavits from the entity that is owed the money. PST Fund claimants are primarily liable for all costs incurred and should obtain lien releases or lien waivers from the companies, contractors, and subcontractors providing materials or performing services associated with the release. Third Party Claims If a third party claim resulting from the release is brought against a PST Fund claimant, or if any action or situation is likely to result in a third party claim, the PST Fund claimant must immediately report it to the Department of Administrative Services, Risk Manager at (801) 538-9560 and to the DERR Project Manager. 3 PST Trust Fund Eligibility Application 2/24/17 Utah Department of Environmental Quality Division of Environmental Response and Remediation Petroleum Storage Tank Trust Fund Were tanks in compliance when leak was detected? Yes No LUST Release Number: Facility ID Number: Applicant Name (please print) Signature Date Mailing Address City State Zip Telephone ( ) Applicant is a: Tank System Owner Facility Owner Tank System Operator Land Owner (Must demonstrate authority to file claim) If the tank system owner or operator, the facility owner, or owner of the land on which the tank system is located is different than the applicant shown above, complete the appropriate spaces in this portion of the form. Tank System Owner Facility Owner Tank System Operator Land Owner Mailing Address Telephone Dates of Ownership From To Name of facility where the release occurred: Facility Address: Contact person at the facility: Telephone ( ) Date Release occurred or was discovered: Date release was reported to the DERR: □ □ □ □ □ □ □ □ □ □ Number of tank systems that contributed to the release at the site (attach additional sheets if needed). Tank Number Tank Volume Product Installation/Closure Date Is this release covered under independent insurance? Yes (if yes, please submit a copy of your insurance policy) No Number of tank systems that were or will be removed during the course of this site cleanup? How was the release confirmed? (Attach a brief summary that includes laboratory analysis, field instrument readings, visual observations, tank tightness test results, etc.) Is there evidence of a previous release? If so, describe how the release was determined. Was the release caused by a third party? If so, explain the circumstances and provide the name, address, and telephone number of the third party and the third party’s insurance company. Have you received any reimbursement or offers of reimbursement from a third party or a third party’s insurance c ompany? If so, how much and when was it received? Have you signed a release? Utah Code Ann. 19-6-426(7) prohibits responsible parties from doing anything that may prejudice the right of the State to recover from third parties. □ □ Petroleum Storage Tank Trust Fund Work Plan Approval Application and Agreement Work Plan No. __________, Amendment No. __________ Facility Name: ____________________________________ Address: _________________________________________ Facility ID No.: ____________________________________ Release ID: _______________________________("Release") Owner/Operator, responsible party, or other person seeking PST Trust Fund Reimbursement: _________________________________________________________________________("Claimant") Utah-Certified UST Consultant: ______________________________________________("Contractor") In submitting Work Plans_______________________ and amendments thereto for the above referenced Release ___________ for approval, the Claimant and the Contractor collectively, the "Parties," represent and agree to the following: Definitions: "Contractor" means the person identified as such above. "Claimant" means the person identified as such above. “Parties” means Claimant and Contractor. "Division Director" means the Division Director of the Division of Environmental Response and Remediation. “PST Fund" means the Petroleum Storage Tank Trust Fund. "Release" means the release identified above. "State" means the State of Utah including its agencies, officers, employees, volunteers and specifically, the Division of Environmental Response and Remediation (DERR), the Division Director of the Division of Environmental Response and Remediation, and the Petroleum Storage Tank Trust Fund. "Work Plan" means the work plan identified above. 1. The key personnel, for which qualifications are submitted under R311-207-3(c), are: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 2. The Claimant acknowledges that the Claimant is required to obtain a payment bond from the Contractor under Section 14-2-1 of the Utah Code. If the Claimant fails to do so, the Claimant is liable to each person who performed labor or services or supplied equipment or materials ("Subcontractors") in the event the Contractor does not pay the subcontractors, even if the Claimant has paid the Contractor (Utah Code Section 14-2-2). The Claimant acknowledges and agrees that the PST Fund will not reimburse the Claimant for such Subcontractors’ claims for payment against the Claimant if the PST Fund has already made payment to the Claimant or Contractor. The Claimant understands that the premium paid for a payment bond is reimbursable. Therefore, the Claimant: a. Has required the Contractor to obtain 100 percent payment bond through a United States Treasury-listed bonding company, and attached a copy, or; b. Has obtained other equivalent assurance and waives all claims and remedies against the State if the equivalent assurance does not adequately protect the Claimant. The equivalent assurance is described as follows: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 3. The Parties agree that the Contractor shall have no cause of action against the State for payment. The Parties acknowledge and agree that the State is not a party to any contract with the Claimant or the Contractor for reimbursement from the PST Fund in the execution of this Work Plan, except to the extent provided by a contract signed by the Division Director. Instead, the Claimant’s reimbursement is governed by the Utah Underground Storage Tank Act and the Utah Underground Storage Tank Rules. The Contractor is entitled to reimbursement solely under his/her contract with the Claimant. 4. The Parties agree that they will use a subcontracting method consistent with the requirements of R311-207. 5. The Parties agree that, as a condition of performing the work under the work plan, the Contractor shall carry the insurance specified in R311-207-3(c)(4). The Contractor represents that the Certificate of Insurance documenting the required insurance is attached or that a current certificate is on file with the Division Director and has been provided to the Claimant. The Parties assume the risk and responsibility of ensuring that the app ropriate insurance coverage is in place. 6. The Parties agree that payments from the PST Trust Fund shall be limited to amounts that are customary, legitimate, reasonable and consistent with R311-207. Unless the Parties and the Division Director have entered into a written Pay-for-Performance agreement, the Parties acknowledge that payments will be for actual time and materials expended up to, but not exceeding, the amount of the Division Director approved work plan and Division Director approved change orders, if any. 7. The Parties shall maintain financial and operation records in sufficient detail to document all transactions relating to PST Fund reimbursement for the execution of this work plan. The Parties shall make available for audit and inspection all such records relating to the completion of the work plan and related services, requirements, and expenditures until all audits initiated by State auditors are completed, or for a period of five years from the date of PST Fund reimbursement related to the execution of this work plan. Records which relate to disputes, litigation, or the settlement of claims arising out of the performance of this work plan, or to cost and expenses of this work plan as to which exception has been taken by the Division Director, shall be retained by the Parties until disposition has been made of such disputes, litigation, claims, or exceptions. 8. The Parties certify that there is a contract between the Claimant and the Contractor for the performance of work under the work plan for which approval is sought ("Contract") and incorporate the provisions herein into that Contract. To the extent that the Contract or amendments thereto conflict with any provisions herein, the provisions herein govern. The Parties shall provide the Contract to the Division Director upon request. 9. The Division Director is a third party beneficiary of this Petroleum Storage Tank Trust Fund Work Plan Approval Application and Agreement and may enforce its provisions. 10. This Petroleum Storage Tank Trust Fund Work Plan Approval Application and Agreement does not limit the Division Director’s rights and remedies under applicable law. Contractor_____________________________________________________________________ Signature, Printed Name, and Date Claimant______________________________________________________________________ Signature, Printed Name, and Date Revised 5/11/12 PROFESSIONAL SERVICES DERR LABOR CATEGORY DERR LABOR CODE TASK HOURS RATE THIS INVOICE TOTAL PREVIOUS TOTAL NEW TOTAL APPROVED BUDGET REMAINING BUDGET SubTotal DIRECT CHARGES DESCRIPTION TASK QUANTITY RATE THIS INVOICE TOTAL PREVIOUS TOTAL NEW TOTAL APPROVED BUDGET REMAINING BUDGET SubTotal OUTSIDE SERVICES DESCRIPTION TASK QUANTITY RATE THIS INVOICE TOTAL PREVIOUS TOTAL NEW TOTAL APPROVED BUDGET REMAINING BUDGET SubTotal BUDGET HISTORY SUMMARY TASK TOTAL TASK BUDGET APPROVED AMOUNT PREVIOUS INVOICES AMOUNT THIS INVOICE TOTAL INVOICE TO DATE TOTAL TASK BUDGET REMAINING %BUDGET REMAINING % OF WORK REMAINING 1 2 3 4 5 6 7 8 WORK PLAN TOTAL STANDARDIZED INVOICE Utah State Petroleum Storage Tank Fund FACILITY ID. # E INVOICE # LOCATION ADDRESS INVOICE DATE LOCATION NAME RELEASE ID. REMIT PAYMENT TO FROM WORK PLAN APPROVED BUDGET INVOICE FOR SERVICES PERFORMED TO DERR WORK PLAN NO. WORK PLAN DESCRIPTION I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I PETROLEUM STORAGE TANK TRUST FUND REQUEST FOR PAYMENT VOUCHER DERR Project Manager: Date: SUBMITTED BY: BILL TO: PAYEE: RELEASE NUMBER:__________________ UTAH DEPT. OF ENVIRONMENTAL QUALITY ADDRESS: FACILITY NUMBER:__________________ DIV. OF ENVIRONMENTAL RESPONSE & REMEDIATION TYPE OF BUSINESS: SITE NAME:____________________________________________________ 195 NORTH 1950 WEST - PO BOX 144840 SOLE PROPRIETOR_____PARTNERSHIP_____CORPORATION_____ SITE LOCATION:_______________________________________________ SALT LAKE CITY, UTAH 84114-4840 PHONE: PHONE NO. (801) 536-4100 DATE WORK PLAN SERVICES RENDERED: DESCRIPTION MUST INCLUDE COPIES OF INVOICES, CHECKS & BACK-UP DOCUMENTATION INVOICE # AMOUNT I, the undersigned, certify that the above listed items or services were required for and used at this site, that the charges appearing hereon are correct, and that no part of the same has been paid for by the PST Fund. The presentation of a claim based on materially false information is subject to criminal penalties. Utah Code Ann. § 19-6-429. TOTAL SUBMITTED: $ SIGNATURE OF RESPONSIBLE PARTY DATE SIGNATURE OF CONSULTANT FOR PROJECT DATE CLAIM # 1 LESS DISALLOWED COSTS: NOTE: Signatures of BOTH Responsible Party AND Consultant required for Direct Reimbursement to the Consultant. Only one signature required for reimbursement to owner. PMT # STATE USE: SUB-TOTAL APPROVED: $ LESS DEDUCTIBLE: $ PROJECT MANAGER DATE ACCOUNTANT DATE DIVISION DIRECTOR DATE TOTAL TO REIMBURSE: $ PST SECTION MANAGER DATE MSC DATE DEQ/FINANCE DATE FUND AGENCY LOW ORG APPR SOURCE PROGRAM FUNCTION AMOUNT REV DATE: 2/27/17 FINANCIAL CODING 7220 480 4731 7220 6137 $ I I I I I I I I I I I I I I I State of Utah O LENE S. WALKER Governo r GAYLE F. Mc KEACHNlE Ueutenant Governor Department of Environmental Quality ERRL-FORM-LTR Dianne R. N ie lson , Ph .D. Executive Direct0r D fVIS ION OF ENVIRONMENTAL RES PONSE AND REMEDIATION Brad T Johnson D irec1or T o Whom It May Concern: May 27, 2004 Utah Petroleum Storage Tank Rule R31 l -207-4(d) of the Utah Admin . Code requires that: "for time and material b ased reimbursement, before receiving payment from the Petroleum Storage Tank Trust Fund, the responsible party must provide proof of past payments for services or construction rendered, in a form acceptable to , or as directed by, the Executive Secretary (UST), unless the Executive Secretary (UST) has agreed to other arrangements." The Executive Secretary (UST) has determined that in lieu of providing a canceled check, th e re sponsible party may instead provide a copy of the invoice and an affidavit from the contractor (consultant) indicating that the responsible party has executed a promissory note agreeing to pay the full amount of the invoice. The affidavit must be on the attached form and cannot be substantively altered . If the cons ultant has used subcontractor services , the attached lien waiver must al so be submitted with the affidavit. BTJ/SK.Nsrb Enclosures Brad T Johnson, Executive Secretary (UST) Utah Solid and Hazardous Waste Control Board J 68 N orth 1950 West • PO Box 144840 • S al t Lake City, UT 841 14-4840 • phone (80 I) 536-4 100 • fax (80 I) 359-8853 T .D.D. (80 1) 536-4414 • www.deq.utah.gov Ulah! Where ideas con ncct .. Petroleum Storage Tank Trust Fund AFFIDAVIT: PROOF OF PAYMENT This form should be used when a claimant submits an affidavit from the consultant as proof of payment for costs claimed for reimbursement. See R311-207-4(d) Utah Admin. Code Claimant’s Name ______________________________________________________________________ Site Name and Address _________________________________________________________________ _________________________________________________________________ Facility Identification No. __________________________________ Release Site___________________ STATE OF UTAH ) : ss COUNTY OF ______________________ ) I, being first duly sworn upon oath and being of lawful age, state that the following invoices relative to the referenced application for reimbursement from the Utah Petroleum Storage Tank Trust Fund have been paid in full through the execution of a promissory note by the claimant. INVOICE # INVOICE DATE AMT. PAID INVOICE # INVOICE DATE AMT. PAID I further state that there is no relationship or affiliation between myself and the claimant. I hereby certify that the foregoing information is correct to the best of knowledge, information, and belief. I understand there are severe civil and/or criminal penalties for any false statement or misrepresentation of a material fact, knowing it to be false, or failing to disclose a material fact with the intent to defraud. Signature: Date: Print Name: Title: Phone: Consultant Company Name: Consultant Company Mailing Address: Subscribed and sworn to before me in the county of _______________________, Utah, this _____ day of _________________(month), __________(year). My commission expires ________________________. ______________________________________________ Notary Public Signature I I I SUBCONTRACTORS’/MATERIALMENS’ LIEN WAIVER For valuable consideration, the receipt and sufficiency whereof is hereby acknowledged, the undersigned Subcontractor/Materialman having performed services or furnished materials for that certain project known as ___________________________________________________, located at ___________________________________________________________________, hereby releases, relinquishes, and waives any and all mechanic’s liens, materialman’s liens, and all other liens of every nature and kind, and/or the right to file any such lien, against said project for labor, services, equipment, and material supplied and performed through ________________, 201____. The undersigned certifies that: 1. Full payment, less retainage if any, has been received for all invoices submitted through ___________________________, 201____; and 2. The undersigned has paid all of its subcontractors for work and services performed and all of its materialmen for materials furnished to said date. DATED this _______ day of _______________________, 201____. ___________________________________ Authorized Representative of: ___________________________________ ru ~ a-m □ a-m a- □ □ □ □ □ a- ru r-'I □ ru □ I"'- U.S. Postal Service™ CERTIFIED MAIL® RECEIPT Domestic Mail Only --•1••. . ..... . ., .... .., .. . . 0 FF I C I AL u s E Certified Mail Fee $ Extra Services & Fees (check box. odd "'8 as appropriate/ 0 Return Receipt (hardcopy) $ 0 Return Receipt (electronic) $ Postmark 0 Certified Mail Restricted Dellvely $ Here D Adult Signature Required $ □ Adult Signature Restricted Dellvely $ 3DP Silver Summit LLC ATTN: Doug Slauth PO Box 681030 ------------------------------ Park City, UT 84068 ------------------------------ PS Form 3800, April 201 5 PS N 7530-02-000-9047 See Reve rse for ln struct10ns Certified Mail service provides the following benefits: • A receipt (this portion of the Certified Mail labeQ . for an electronic return receipt, see a retail • A unique identifier for your mailpiece . associate for assistance._To receive a duplicate ■ Electronic verification of delivery or attempted return receipt for no add1t1onal fee, present this delivery. 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If you don't need a postmark on1his Certified Mail receipt, detach the barcoded portion of this label, affix it to the mailplece , apply appropriate postage, and deposit the mailpiece . IMPORTANT: Save this receipt for your records. PS Form 3800, Aprll 2015 (Reverse) PSN 7530-02-000-9047