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APPLICATION FOR PAYMENT NO. Three To City of St. Anthony (OWNER) Contract Contract for Temporary Granular Activated Carbon System OWNER's Project No. . ENGINEER's Project No. 861908-3 For Work accomplished through the date of September 30, 1988 ITEM CONTRACTOR's Schedule of Values Work Completed Unit Price Quantity Amount Quantity Amount 1. Furnish & Install $ $ $ . Treatment System 124,600.00 Lump Sum 124,600.00 100% 124,600.00 2. Service Fee 108.00 500 Day 54,000.00 69 7,452.00 3. VOC Removal 850.00 80 Pounds 68,000.00 0 --- 4. Extra GAC 25.30 1600 cu/ft 40,480.00 0 --- 5. Remove Equipment 38,650.00 Lump Sum 38,650.00 0 --- TOE $325,730.00 $132,052.0 (Orig. Contracty. C.O. No. 1 C.O. No. 2 Accompanying Documentation: GROSS AMOUNT DUE ....................... $132,052.0 • Invoice No. 960563301 LESS %b RETAINAGE ................... $ None AMOUNT DUE TO DATE ..................... $132,052.00 LESS PREVIOUS PAYMENTS ................ $128,812.00 AMOUNT DUE THIS APPLICATION ......... $ 3.240.00 CONTRACTOR'S Certification: The undersigned CONTRACTOR certifies that (1) all previous progress payments received from OWNER on account of Work done under the Contract referred to above have been applied to discharge in full all obligations of CONTRACTOR incurred in connection with Work covered by prior Applications for Payment numbered 1 through inclusive; and (2) title to all materials and equipment incorporated in said Work or otherwise listed in or covered by this Application for Payment will pass to OWNER at time of payment free and clear of all liens, claims, security interests and encumbrances (except such as covered by Bond acceptable to OWNER). Dated , 19 CONTRACTOR By Payment of the above AMOUNT DUE THIS APPLICATION is recommended. Dated October 12 1988 Rieke C 4roll MAlepAssoc. , Inc. • ' E SEElt By EJCDC No. 1910-8-E(1983 Edition) Prepared by the Engineers'Joint Contract Documents Committee and endorsed by The Associated General Contractors of America.