7C, Final Draft of I&I Report - Laserfiche WebLink

Home Browse Search

Appendix 0: Surcharge Credit Verification Form Complete this form and its attachments to assure MCES that the community has spent the surcharge equivalent on applicable projects, approved by MCES, during the calendar year 2007 or 2008. To receive payment, send the completed form to: Mail: Assistant Manager, Engineering Planning 390 N. Robert Street SI. Paul, MN 55101 Fax: Attn: Assistant Manager, Engineering Planning (651) 602-1030 Community: ARDEN ttl L.-l-? Calendar Year in which Work was Performed: '2-00~ - 2.001- Was the work pre-approved by MCES? 0 Yes (Attach MCES letter) ~ No a) Public Facility Work: Attach a detailed breakdown of actual expenditures for the municipal system III program. Include only amounts actually paid during the calendar year. MCES may request additional documentation to verify expenditures. Include the percent of each projects costs that are related to 1/1 mitigation: Summary of Costs: -::r. ~ 1 S-rU.OY) AAlw MST6"f< 8A:tJ 111<\1'<..'-( sew e~ -relA~"\SINb I I2X:f'Ale . ~kL.) "-lA,~l-toL6 lJ,jspecn~> ANt> b) Private Property Work: Attach a detailed list itemizing the locations and repairs made on private properties within municipal borders. Summarize the type of repairs and applicable costs using the list below: Sump pump disconnections: $150 per dwelling = $ Foundation drain disconnections: $3,000 per building = $ Rain leader disconnections: $100 per single family dwelling = $ Rain leader disconnections: $3,000 per commercial dwelling = $ Service lateral repairs: $5,000 per repair = $ Describe Other Work: . '2. qo Total claimed for U10b -l.Q?1- (calendar year):: $ II'Ll ?9J . -- City or Township OfflclalfTItle: l-I ~ I , ~h \'J'\ ,HoC<.e"r Date Signed: :, \ l.S-j 01) Phone #: l1AIL'L uJo<1KS f)it2VTOR- 051- 7'1:), - TffL/7 Amount Eligible: $ MCES USE ONLY Form: ILVerification_200S Last update: 6/12/07 19