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APPLICATION FOR PAYMENT NO. Twel ve To City of St. Anthony (OWNER) Contractfor Temporary Granular Activated Carbon System - OWNER's Project No. ENGINEER's Project No.861908-3 For Work accomplished through the date of June 30, 1989 CONTRACTOR's Schedule of Values Work Completed ITEM Unit Price Quantity Amount Quantity Amount $ $ $ 1. Furnish & Install Treatment System 124,600.0 Lump Sum 124,600.00 100% 124,600.00 2. Service Fee 108.00 500 Day 54,000.00 342 36,936.00 3. VOC Removal 850.0 80 Pounds 68,000.00 0, --- 4. Extra GAC 25.3 1600 cu/ft 40,480.00 0 --- 5. Remove Equipment 38,650.0 Lump Sum 38,650.00 0 ---. Total (Orig. Contract) $ $ 25,730.00 161,536.00 C.O. No. 1 C.O. No. 2 • Accompanying Documentation: GROSS AMOUNT DUE 161,536. 0 LESS %RETAINAGE ................... $ None Invoice No. 960755801 AMOUNT DUE TO DATE ..................... $ 161,536.00 LESS PREVIOUS PAYMENTS ................ $ 158,296. 0 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 coyTRAAcrolt By Payment of the above AMOUNT DUE THIS APPLICATION is recommended. • Dated July 3 19 89 Riekea roll Allgr Associates, Inc. /00�4�/ _ E GiNEER By EJCDC No. 1910-8-E(1983 Edition)