#10 - Well 2 PFAS Removal Pay Req 3

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PROJECT PAY FORM PARTIAL PAY ESTIMATE NO. PERIOD OF ESTIMATE TO PROJECT OWNER: CONTRACTOR: 1. Original Contract Amount 2. Net Change Order Sum 3. Revised Contract (1+2) 4. *Work Completed 5. *Stored Materials 6. Subtotal (4+5) 7. Retainage* 8. Previous Payments 9. Amount Due (6-7-8) *Detailed Breakdown Attached START DATE: ON SCHEDULE MILESTONE 1 (EQ. DELIVERED) MILESTONE 2 (MEDIA INSTALL) SUBSTANTIAL COMPLETION:X FINAL COMPLETION: ENGINEER'S CERTIFICATION: DATE CONTRACTOR'S CERTIFICATION:CONTRACTOR DATE APPROVED BY OWNER:CITY OF LAKE ELMO, MINNESOTA DATE DATE BY YES NO The undersigned Contractor certifies that to the best of their knowledge, information and belief the work covered by this payment estimate has been completed in accordance with the contract documents, that all amounts have been paid by the contractor for work for which previous payment estimates was issued and payments received from the owner, and that current payment shown herein is now due. The undersigned certifies that the work has been reviewed and to the best of their knowledge and belief, the quantities shown in this estimate are correct and the work has been performed in accordance with the contract documents. ENGINEER BY 11/18/2024 8/1/2025 REVISED DAYS 256 04/30/2025 ORIGINAL DAYS 5/16/2025 5/30/2025 REMAINING 0 CONTRACT CHANGE ORDER SUMMARY PAY ESTIMATE SUMMARY 3 5/30/20255/9/2025FROM WELL 2 PFAS REMOVAL EQUIPMENT PROJECT NO. 2023.115 CITY OF LAKE ELMO 3880 LAVERNE AVENUE NORTH LAKE ELMO, MN 55042 ATTN: JACK GRIFFIN, CITY ENGINEER AQUEOUS Vets, LLC 16761 CLEAR CREEK ROAD REDDING, CA 96001 ATTN: LINDSIE HABEN, PROJECT/COST ACCOUNTANT CONTRACT TIME TOTALS $0.00 $0.00 $60,526.87 NET CHANGE $0.00 $24,837.305.0% $411,381.81 $0.00 $496,745.98 $660,970.71 $496,745.98 No.Approval Date Amount $660,970.71 Additions Deductions $0.00 FOCUS Engineering, inc. PROJECT PAYMENT FORM