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HomeMy WebLinkAboutWWP273831i) AB - 1784 Transportation Systems Division requested approval of Addendum 03-16 to lease
agreement LAG-13-005 with Landing Gear Works, LLC, for an increase of 2,020 sq. ft. of office
space and 1,474 sq- ft. of storage space in the 295 E Perimeter Rd. building, for a net revenue
increase of $9,175.06 per year. Refer to Transportation (Aviation) Committee.
j) AB - 1785 Transportation Systems Division submitted 10C-01-54 (Formerly CAG-13-149, WO
#54.15), Airport Pressure Reducing Valve Installation, with Forma Construction Company; and
requested acceptance of the project and approval of the final pay estimate in the amount of
$13,085.92. Council Concur.
k) AB -1783 Utility Systems Division submitted CAG-15 149, Cascade Interceptor Rehabilitation
Phase 11, with Insituform Technologies, LLC; and requested acceptance of the project and
release of the retainage in the amount of $66,077 02 after 60 days, subject to the receipt of
all required authorizations Council Concur.
1) AB - 1787 Utility Systems Division recommended adoption of the 2016 King County Surface
Water Design Manual with City amendments Refer to Planning & Development Committee.
MOVED BY CORMAN, SECONDED BY PAVONE, COUNCIL CONCUR TO APPROVE
THE CONSENT AGENDA, AS PRESENTED, CARRIED
UNFINISHED BUSINESS
a) Committee of the Whole: Council President Corman stated that consensus appeared to be
reached regarding the adoption of legislation regarding source of income discrimination
MOVED BY CORMAN, SECONDED BY MCIRVIN, COUNCIL ADOPT THE EMERGENCY
VERSION OF THE SOURCE OF INCOME DISCRIMINATION ORDINANCE DRAFTED BY
THE CITY ATTORNEY AS AMENDED TO ONLY INCLUDE SECTION 8 HOUSING
CHOICE VOUCHERS.'
Council discussion ensued regarding the other forms of income included in the ordinance
such as social security disability and pensions, child support payments, and unemployment
benefits among others. It was determined that only Section 8 Housing Choice Vouchers be
included in the emergency ordinance
*ROLL CALL: ALL AYES. MOTION CARRIED.
MOVED BY PRINCE, SECONDED BY CORMAN, COUNCIL REFER THE DISCUSSION
ON OTHER SOURCES OF INCOME DISCRIMINATION TO THE ADMINISTRATION TO
BE PRESENTED AT A FUTURE COMMITTEE OF THE WHOLE MEETING. CARRIED.
ADDED LEGISLATION
Ordinance for first reoding and advancement to second and final reoding:
a) Ordinance No. 5828: An ordinance was read amending Title VI (Police Regulations) of the
Renton Municipal Code, by adopting a new Chapter 6-32, entitled Fair Housing Regulations,
temporarily prohibiting property owners and property managers from discriminating against
tenants or potential tenants on the basis of participation in a Section 8 Housing Choice
Program, establishing penalties and an appeal process, and declaring an emergency and
immediate need for this ordinance to take effect upon passage.
November 7, 2016 REGULAR COUNCIL MEETING MINUTES
CITY COUNCIL REGULAR MEETING — November 7, 2016
SUBJECT/TITLE: Project Acceptance: Cascade Interceptor Rehabilitation Phase II
CAG-15-149
RECOMMENDED ACTION: Council Concur
DEPARTMENT: PW/Utility Systems Division
STAFF CONTACT: John Hobson
EXT.: 7279
The original contract amount was $752,904.32 and the final amount is $761,624.61, an increase
of $8,720.29. The minor cost increase was due to additional time and materials to rehabilitate
the project's 20 manholes that had larger diameters than the plans and specifications indicated.
SUMMARY OF ACTION:
The project was awarded on August 10, 2015. Construction began on July 18, 2016, and was
completed on October 5, 2016.
This rehabilitation project utilized Cured -in -Place Pipe (CIPP) technology. Insituform
Technologies, LLC was the company awarded the contract. The next vacancy in their
construction schedule was December 2015. To accomplish the work, Soos Creek Water and
Sewer District would be required to reroute some of their sewage flows to a different
interceptor. However, the other interceptor does not have the capacity to accept the additional
sewage flows and the stormwater infiltration that occurs during the winter months. Therefore,
the start of construction was rescheduled for summer 2016 to take advantage of the dry
weather.
Eighty percent of the sewage that flows through the Cascade Interceptor comes from Soos Creek
Water and Sewer District. As part of an interlocal agreement, Soos Creek Water and Sewer
District will reimburse the City of Renton for 80% of the construction costs ($609,299.69).
A. Notice of Completion of Public Works Contract
Accept the project and release the retainage in the amount of $66,077.02 after 60 days, subject to
the receipt of all required authorizations.
H:\File Sys\WWP - WasteWater\WWP-27-03831 Cascade Interceptor Rehabilitation Phase II\Pay Estimates\agenda bill Central
Renton Interceptor Reline & Upsize.docx\JDHtp
SF, SCATf7
r, Original
�El Revised #
't rNtl9 a,
NOTICE OF COMPLETION OF PUBLIC WORKS CONTRACT
Date: Contractor's UBI Number: 601880220
Name & Mailing Address of Public Agency Department Use Only
City of Renton Assigned to:
1055 S Gradv Wav
Renton, WA 98057 Date Assigned:
UBI Number: 177000094
Notice is lrerebt' Qiven relative to the completion of contract or project described below
Project Name
Contract Number
Job Order Contracting
Cascade Interceptor Rehabilitation Phase II
Cag-15-149
❑ Yes V No
Description of Work Done/Include Jobsite Address(es)
Cured -in -Place Pipe (CIPP) of approximately 605 ft of 14" diameter, 265 ft of 18" diameter, 962 ft of 21" diameter and
2,935 ft of 24" diameter concrete sewer mains and rehabilitation of 20 concrete manholes in the Tiffany Park
neighborhood of Renton, Washington
�{
Federally funded transportation project? El Yes S No (if yes, provide Contract Bond Statement below)
Contractor's Name
E-mail Address
Affidavit 1D*
Insituform Technologies, LLC
Ipsoles470@insituform.com
1671645
Contractor Address
Telephone #
17988 Edison Ave, Chesterfield, MO 63005
1636-530-8000
If Retainage is not withheld, please select one of the following and List Surety's Name & Bond Number.
❑ Retainage Bond ❑ Contract/Payment bond (valid for federall} funded transportation projects)
Name:
I Bond Number:
Date Contract Awarded
Date Work Commenced
Date Work Completed
Date Work Accepted
August 10, 2015
July 18, 2016
October 5, 2016
Were Subcontracters used on this project? If so, please complete Addendum A. Wyes ❑ No
Affidavit ID* - No L&I release will be granted until all affidavits are listed.
Contract Amount
Additions ( + )
Reductions (- )
Sub -Total
Sales Tax Rate 9.5
(If various rates apply, please send a breakdown)
Sales Tax Amount
687,583.85
7.963.74
$ 695,547.59
66077.02
TOTAL S 761,624.61
:vv t c: i nese two totals must ae
Liquidated Damages $
Amount Disbursed $ 726,847.22
Amount Retained $ 34,777.39
TOTAL $ 761,624.61
Note: The Disbursing Officer must submit this completed notice immediately after acceptance of the work done under this contract.
NO PAYMENT SHALL BE MADE FROM RETAINED FUNDS until receipt of all release certificates.
Submitting Form: Please submit the completed form by email to all three agencies below.
Contact Name: Natalie Wissbrod Title: Accounting Assistant
Email Address: nwissbrod@rentonwa.gov Phone Number: 425-430-6919
to
Department of Revenue Washington State mEmployment are Dgrxvn o} p � Security
Public Works Section Department
Labor & Industries Registration, In ui
TRO(360) 704-5650 Contract Release Standards 8 Coordination
PWC@dor.wa.gov (855) 545-8163, option # 4 Unit
ContractRelease@LNI.WA. GOV (360) 902-9450
REV 31 0020e (10/26/15) F215-038-00010-2014 publicworks@esd.wa.gov
Addendum A: Please List all Subcontractors and Sub -tiers Belo%i
This addendum can be submitted in other formats.
Provide knox%n affidavits at this time. No L&I release i%ill he granted until all affidavits are listed.
Subcontractor's Name: UBI Number: (Required) Affida%it HY
Advanced Government Services. Inc 602304323 672039
Maverick Pump Services 603265774 671826
C-More Pipe Services Co 601854387 674291
For tax assistance or to request this document in an alternate format, please call 1-800-647-7706. Teletype (TTY) users may use the
Washington Relay Service by calling 711.
REV 31 0020e Addendum (10/26/15) F215-038-000 10-2014
DATE: I `� ✓,__Z -I �. l `p
COUNCILCITY 'R MEETING —November1
SUBJECT/TITLE: Project Acceptance: Cascade Interceptor Rehabilitation Phase II
CAG-15-149
RECOMMENDED ACTION: Council Concur
DEPARTMENT: PW/Utility Systems Division
STAFF CONTACT: John Hobson
EXT.: 7279
SUMMARY:FISCAL IMPACT
The original contract amount was $752,904.32 and the final amount is $761,624.61, an increase
of $8,720.29. The minor cost increase was due to additional time and materials to rehabilitate
the project's 20 manholes that had larger diameters than the plans and specifications indicated.
SUMMARY OF ACTION:
The project was awarded on August 10, 2015. Construction began on July 18, 2016, and was
completed on October 5, 2016.
This rehabilitation project utilized Cured -in -Place Pipe (CIPP) technology. Insituform
Technologies, LLC was the company awarded the contract. The next vacancy in their
construction schedule was December 2015. To accomplish the work, Soos Creek Water and
Sewer District would be required to reroute some of their sewage flows to a different
interceptor. However, the other interceptor does not have the capacity to accept the additional
sewage flows and the stormwater infiltration that occurs during the winter months. Therefore,
the start of construction was rescheduled for summer 2016 to take advantage of the dry
weather.
Eighty percent of the sewage that flows through the Cascade Interceptor comes from Soos Creek
Water and Sewer District. As part of an interlocal agreement, Soos Creek Water and Sewer
District will reimburse the City of Renton for 80% of the construction costs ($609,299.69).
A. Notice of Completion of Public Works Contract
Accept the project and release the retainage in the amount of $66,077.02 after 60 days, subject to
the receipt of all required authorizations.
H:\File Sys\WWP - WasteWater\WWP-27-03831 Cascade Interceptor Rehabilitation Phase II\Pay Estimates\agenda bill Central
Renton Interceptor Reline & Upsize.docx\JDHtp
t
ITA
LYI Original
S
Y; ❑ Revised #
?hl 1*69 a`
NOTICE OF COMPLETION OF PUBLIC WORKS CONTRACT
Date: Contractor's UBI Number: 601880220
Name & Mailing Address of Public Agency Department Use Only
City of Renton Assigned to:
1055 S Gradv Wav
Renton, WA 98057 Date Assigned:
UBI Number: 177000094
Notice is hereby eiven relative to the comnletion of contract or nroiect described below
Project Name
Contract Number
Job Order Contracting
Cascade Interceptor Rehabilitation Phase II
Cag-15-149
❑ Yes V No
Description of Work Done/Include Jobsite Address(es)
Cured -in -Place Pipe (CIPP) of approximately 605 ft of 14" diameter, 265 ft of 18" diameter, 962 ft of 21" diameter and
2,935 ft of 24" diameter concrete sewer mains and rehabilitation of 20 concrete manholes in the Tiffany Park
neighborhood of Renton, Washington
Federally funded transportation project? ❑ Yes SK No (if yes, provide Contract Bond Statement below)
Contractor's Name
E-mail Address
Affidavit ID*
Insituform Technologies, LLC
ipsoles470@insituform.com
1676375
Contractor Address
Telephone ##
17988 Edison Ave, Chesterfield, MO 63005
636-530-8000
If Retainage is not withheld, please select one of the following and List Surety's Name & Bond Number.
❑ Retainage Bond ❑ Contract/Payment bond (valid for federally funded transportation projects)
Name:
I Bond Number:
Date Contract Awarded
Date Work Commenced
Date Work Completed
Date Work Accepted
August 10, 2015
July 18, 2016
October 5, 2016
Were Subcontracters used on this project? If so, please complete Addendum A. Yes ❑ No
Affidavit ID* - No L&I release will be granted until all affidavits are listed.
Contract Amount
Additions ( + )
Reductions (- )
Sub -Total
Sales Tax Rate 9.5
(If various rates apply, please send a breakdown)
Sales Tax Amount
TOTAL
$ 687,583.85
$ 7,963.74
$ 695, 547.59
$ 66077.02
$ 761.624.61
jvviC: ttrese two totats must ne
Liquidated Damages $
Amount Disbursed $ 726,847.22
Amount Retained $ 34,777.39
TOTAL $ 761,624.61
Note: The Disbursing Officer must submit this completed notice immediately after acceptance of the work done under this contract.
NO PAYMENT SHALL BE MADE FROM RETAINED FUNDS until receipt of all release certificates.
Submitting Form: Please submit the completed form by email to all three agencies below.
Contact Name: Natalie wissbrod
Email Address: nwissbrod@rentonwa.gov
Department of Revenue Washington staw DeparMwnt of
CPublic Works Section Labor & Industries
(360) 704-5650 Contract Release
PWC@dor.wa.gov (855) 545-8163, option # 4
ContractRelease@LNI. WA.GOV
Title: Accounting Assistant
Phone Number: 425-430-6919
Employment Security
Departrnent
Registration, Inquiry,
Standards & Coordination
Unit
(360)902-9450
publicworks@esd.wa.gov
REV 31 0020e (10/26/15) F215-038-000 10-2014
Addendum A: Please List all Subcontractors and Sub -tiers Belo"
This addendum can be submitted in other formats.
Provide kno,.Nn affidavits at this time. No LSI release %gill be granted until all affidavits are listed.
Subcontractor's Name: UBI Number: (Required) Affidavit lDx
Advanced Government Services, Inc 602304323 672039
Maverick Pump Services 603265774 671826
C-More Pipe Services Co. 601854387 674291
For tax assistance or to request this document in an alternate format. please call 1-800-647-7706. Teletype (TTY) users may use the
Washington Relay Service by calling 711.
REV 31 0020e Addendum (10/26/15) F215-038-000 10-2014
State of Washington
Department of Labor & Industries
Prevailing Wage Section - Telephone 360-902-5335
PO Box 44540, Olympia, WA 98504-4540
Affidavit of Wages Paid
Project Detail -.Project Dashboard
Document 10/26/2016 Intent 724502 Affidavit 676375 Affidavit Approved
Received Date Id Id Status on
10/27/2016
Your Company Information
Name
Address
WA UBI no.
Contractor Registration no.
Industrial Insurance Account Id
Email Address
Fi led By
Project Information
Awarding agency:
Awarding agency contact:
Awarding agency contact phone number:
Project Details
Project name
INSITUFORM TECHNOLOGIES
LLC
17988 EDISON AVE
CHESTERFIELD,MO,63005
601880220
INSITTL883CW
fiili:L7�il
psoles470@insituform.com
Soles,Paul
RENTON, CITY OF
1055 S GRADY WAY RENTON,
WA - 98055
John Hobson
425-430-7279
Cascade Interceptor
Rehabilitation Phse II
County where work was performed King
City where work was performed Renton
Job site address/directions:
Prime contractor name INSITUFORM TECHNOLOGIES
LLC
Prime contractor registration no.
INSIT-FL883CW
Contract no.
CAG-15-149
Prime contractor Phone Number
636-530-8000
Prime contractor Intent form Id# for this project
724502
Dollar amount of your contract:
$ 761,624.61
Bid due date
8/4/2015
Contract award date
9/4/2015
Intent filed date
10/5/2015
Job start date:MM-DD-YYYY
10/26/2015
Date work completed:MM-DD-YYYY
8/20/2016
Project Completion
Did your subcontractors perform all work on this No
project?
Did your company hire any subcontractors? Yes
Did your company have employees perform work Yes
on this project?
Did this project utilize American Recovery and No
Reinvestment Act (ARRA) funds?
Specifically, did this project utilize any No
weatherization or energy efficiency upgrade funds
(ARRA or otherwise)?
Company Owner Information
How many owner/operators performed work on 0
the project that own 30% or more of the
company?
No company owner added.
Affidavit Subcontractor(s)
Company Name UBI License#
C-MORE PIPE SERVICES CO 601854387 CMOREPS023CZ
ADVANCED GOVERNMENT SVCS INC 602304323 ADVANGS9720Z
MAVERICK PUMP SERVICES LLC 603265774 MAVERPS8781-5
Journeylevel Wages
County Trade Occupation Wages
King Laborers - Pipe Layer
Underground
Sewer Et Water
Apprentice Wages
Public Notes
o Show/Hide Existing Notes
No note exists
43.46
Fringes
Workers Hours
5 945.50
A.
State of Washington
Department of Labor & Industries
Prevailing Wage Section - Telephone 360-902-5335
PO Box 44540, Olympia, WA 98504-4540
Affidavit of Wages Paid
Project Detail - Project Dashboard
Document 10/18/2016 Intent 738011 Affidavit 674291 Affidavit Approved on
Received Date Id Id Status 10/19/2016
Your Company Information
Name C-MORE PIPE SERVICES
CO
Address 9350 RICKREALL RD
RICKREALL,OR,97371
WA UBI no. 601854387
Contractor Registration no. CMOREPS023CZ
Industrial Insurance Account Id
Email Address brenda@cmorepipe.com
Filed By McCoy,Viola
Project Information
Awarding agency: RENTON, CITY OF
1055 S GRADY WAY
RENTON, WA - 98055
Awarding agency contact: John Hobson
Awarding agency contact phone number: 425-430-7279
Project Details
Project name Cascade Interceptor
Rehabilitation Phse 11
County where work was performed King
City where work was performed Renton
Job site address/directions:
Prime contractor name INSITUFORM
TECHNOLOGIES LLC
Prime contractor registration no. INSITTL883CW
Contract no. CAG-15-149
Prime contractor Phone Number 636-530-8000
Prime contractor Intent form Id# for this project 724502
Dollar amount of your contract: $ 90,836.77
Bid due date 8/4/2015
Contract award date 9/4/2015
Intent filed date 12/ 16/2015
Job start date:MM-DD-YYYY 1 /11 /2016
Date work completed: MM-DD-YYYY 9/16/2016
Project Completion
Did your subcontractors perform all work on this project? No
Did your company hire any subcontractors? No
Did your company have employees perform work on this Yes
project?
Did this project utilize American Recovery and Reinvestment Act No
(ARRA) funds?
Specifically, did this project utilize any weatherization or No
energy efficiency upgrade funds (ARRA or otherwise)?
Company Owner Information
How many owner/operators performed work on the project that 0
own 30% or more of the company?
No company owner added.
Affidavit Subcontractor(s)
No subcontractor is selected for this affidavit.
Journeylevel Wages
County Trade
Occupation Wages
King
Inspection/Cleaning/Sealing
Cleaner 31.45
Of Sewer Et Water Systems
Operator,
By Remote Control
Foamer
Operator
King
Inspection/Cleaning/Sealing
Tv Truck 20.45
Of Sewer Et Water Systems
Operator
By Remote Control
King
Inspection/Cleaning/Sealing
Head Operator 24.91
Of Sewer Et Water Systems
By Remote Control
King
Inspection/Cleaning/Seating
Technician 19.33
Of Sewer Et Water Systems
By Remote Control
Apprentice Wages
Public Notes
o Show/Hide Existing Notes
No note exists
Fringes
Workers Hours
1 23.00
1 23.00
1 213.75
1 213.75
State of Washington
Department of Labor & Industries
Prevailing Wage Section - Telephone 360-902-5335
PO Box 44540, Olympia, WA 98504-4540
Affidavit of Wages Paid
Project Detail - Project Dashboard
Document 10/7/2016 Intent 774926 Affidavit 671826 Affidavit Approved
Received Date Id Id Status on
10/7/2016
Your Company Information
Name MAVERICK PUMP SERVICES
LLC
Address 9791 TITAN PARK CIRCLE
LITTLETON, CO, 80125
WA UBI no. 603265774
Contractor Registration no. MAVERPS8781-5
Industrial Insurance Account Id 26344100
Email Address beckiCmavpump.com
Fi led By Moessner, Becki
Project Information
Awarding agency: RENTON, CITY OF
1055 S GRADY WAY
RENTON, WA - 98055
Awarding agency contact: John Hobson
Awarding agency contact phone number: 425-430-7279
Project Details
Project name Cascade Interceptor
Rehabilitation Phse II
County where work was performed
King
City where work was performed
Renton
Job site address/directions:
Prime contractor name
INSITUFORM
TECHNOLOGIES LLC
Prime contractor registration no.
INSITTL883CW
Contract no.
CAG-15-149
Prime contractor Phone Number
636-530-8000
Prime contractor Intent form Id# for this project
724502
Dollar amount of your contract:
$ 169,000.00
Bid due date
8/4/2015
Contract award date
9/4/2015
Intent filed date
7/14/2016
Job start date:MM-DD-YYYY
7/21 /2016
Date work completed:MM-DD-YYYY
8/31 /2016
Project Completion
Did your subcontractors perform all work on this
No
project?
Did your company hire any subcontractors?
No
Did your company have employees perform work on
Yes
this project?
Did this project utilize American Recovery and
No
Reinvestment Act (ARRA) funds?
Specifically, did this project utilize any
No
weatherization or energy efficiency upgrade funds
(ARRA or otherwise)?
Company Owner Information
How many owner/operators performed work on the
0
project that own 30% or more of the company?
No company owner added.
Affidavit Subcontractor(s)
No subcontractor is selected for this affidavit.
Journeylevel Wages
County Trade Occupation Wages
King Laborers - General Laborer 32.37
Underground Ft Topman
Sewer Et Water
Apprentice Wages
Public Notes
c Show/Hide Existing Notes
No note exists
Fringes # #
Workers Hours
10.30 3 495.25
State of Washington
Department of Labor & Industries
Prevailing Wage Section - Telephone 360-902-5335
PO Box 44540, Olympia, WA 98504-4540
Affidavit of Wages Paid
Project Detail -.Project Dashboard
Document 10/7/2016 Intent 782210 Affidavit 672039 Affidavit Approved
Received Date Id Id Status on
10/10/2016
Your Company Information
Name
Address
WA UBI no.
Contractor Registration no.
ADVANCED GOVERNMENT SVCS INC
8644 PACIFIC AVE
TACOMA, W A, 98444
602304323
ADVANGS972OZ
Industrial Insurance Account Id 07045100
Email Address shearring@advancedgovernmentservicesinc.com
Filed By HEARRING,Suzanne
Project Information
Awarding agency: RENTON, CITY OF
1055 S GRADY WAY RENTON, WA - 98055
Awarding agency contact: John Hobson
Awarding agency contact phone 425-430-7279
number:
Project Details
Project name Cascade Interceptor Rehabilitation Phse 11
County where work was King
performed
City where work was performed Renton
Job site address/directions:
Prime contractor name INSITUFORM TECHNOLOGIES LLC
Prime contractor registration no. INSITTL883CW
Contract no.
CAG-15-149
Prime contractor Phone Number 636-530-8000
Prime contractor Intent form Id# 724502
for this project
Dollar amount of your contract: $ 6,145.50
Bid due date 8/4/2015
Contract award date 9/4/2015
Intent filed date 8/15/2016
Job start date:MM-DD-YYYY 8/9/2016
Date work completed:MM-DD- 9/8/2016
YYYY
Project Completion
Did your subcontractors perform No
all work on this project?
Did your company hire any No
subcontractors?
Did your company have Yes
employees perform work on this
project?
Did this project utilize American No
Recovery and Reinvestment Act
(ARRA) funds?
Specifically, did this project No
utilize any weatherization or
energy efficiency upgrade funds
(ARRA or otherwise)?
Company Owner Information
How many owner/operators
performed work on the project
that own 30% or more of the
company?
No company owner added.
Affidavit Subcontractor(s)
E
No subcontractor is selected for this affidavit.
Journeylevel Wages
County Trade Occupation
King Flaggers Journey Level
Apprentice Wages
Public Notes
- Show/Hide Existing Notes
No note exists
Wages Fringes Workers Hours
25.17 11.00 2 96.25
WN2016 . r about:blank
State of Washington
Department of Labor & Industries
Prevailing Wage Section - Telephone 360-902-5335
PO Box 44540, Olympia, WA 98504-4540
Statement of Intent to Pay Prevailing Wage
Project Detail - Project Dashboard
Document Received Date:
12/16/2015
Company Details
Company Name:
Address:
Contractor Registration No.
WA UBI Number
Phone Number
Industrial Insurance Account ID
Email Address
Fi led By
Prime Contractor
Company Name
Contractor Registration No.
WA UBI Number
Phone Number
Project Information
Awarding Agency
about blank
Intent ID: Affidavit ID: Status: Approved On
738011 12/18/2015
C-MORE PIPE SERVICES CO
9350 RICKREALL RD
RICKREALL, OR, 97371
CMOREPS023CZ
601854387
503-623-1319
brenda@cmorepipe.com
McCoy, Viola
INSITUFORM TECHNOLOGIES LLC
INSITTL883CW
601880220
636-530-8000
RENTON, CITY OF
1 /3
8r'312016"
about.blank
1055 S GRADY WAY RENTON, WA - 98055
Awarding Agency Contact
Awarding Agency Contact Phone Number
Contract Number
Project Name
Contract Amount
Bid due date
Award Date
Project Site Address or Directions
Payment Details
Check Number:
Transaction Id:
John Hobson
425-430-7279
CAG-15-149
Cascade Interceptor Rehabilitation Phse
11
$752, 904.32
8/4/2015
9/4/2015
105047511
Intent Details
Expected project start date: (MM-DD-YYYY) 1 /11 /2016
In what county (or counties) will the work be King
performed?
In what city (or nearest city) will the work be Renton
performed?
What is the estimated contract amount? OR is this $90,836.77
a time and materials estimate?
Will this project utilize American Recovery and No
Reinvestment Act (ARRA) funds?
Specifically, will this project utilize any No
weatherization or energy efficiency upgrade funds
(ARRA or otherwise)?
Does your company intend to hire ANY No
subcontractors?
Does your company intend to hire subcontractors No
to perform ALL work?
Will your company have employees perform work Yes
on this project?
about blank
2/3
8,73/201E . aboAblank
Do you intend to use any apprentices? (Apprentices No
are considered employees.)
How many owner/operators performing work on 0
the project own 30% or more of the company?
Hiring Contractor
Company Name
Contractor Registration No.
WA UBI Number
Journey Level Wages
INSITUFORM TECHNOLOGIES LLC
INSITTL883CW
601880220
County
Trade
Occupation
Wage Fringe
Workers
King
Inspection/Cleaning/Sealing Of
Cleaner Operator, Foamer
$31.49 1
Sewer Et Water Systems By
Operator
Remote Control
King
Inspection/Cleaning/Sealing Of
Tv Truck Operator
$20.45 1
Sewer Et Water Systems By
Remote Control
King
Inspection/Cleaning/Seating Of
Head Operator
$24.91 1
Sewer Et Water Systems By
Remote Control
King
Inspection/Cleaning/Sealing Of
Technician
$19.33 1
Sewer Et Water Systems By
Remote Control
Public Notes
- Show/Hide Existing Notes
No note exists
about:blank 313
K'2016,s
about:blank
State of Washington
Department of Labor & Industries
Prevailing Wage Section - Telephone 360-902-5335
PO Box 44540, Olympia, WA 98504-4540
Statement of Intent to Pay Prevailing Wage
Project Detail - Project Dashboard
Document Received Date:
7/14/2016
Company Details
Company Name:
Address:
Contractor Registration No.
WA UBI Number
Phone Number
Industrial Insurance Account ID
Email Address
Filed By
Prime Contractor
Company Name
Contractor Registration No.
WA UBI Number
Phone Number
Project Information
Awarding Agency
about:blank
Intent ID: Affidavit ID: Status: Approved On
774926 7/21/2016
MAVERICK PUMP SERVICES LLC
9791 TITAN PARK CIRCLE
LITTLETON, CO, 80125
MAVERPS8781-5
603265774
303-981-8349
26344100
becki@mavpump.com
Moessner, Becki
INSITUFORM TECHNOLOGIES LLC
INSITTL883CW
601880220
636-530-8000
RENTON, CITY OF
1/3
§/2,�016
about: bl ank
1055 S GRADY WAY RENTON, WA - 98055
Awarding Agency Contact
Awarding Agency Contact Phone Number
Contract Number
Project Name
Contract Amount
Bid due date
Award Date
Project Site Address or Directions
Payment Details
Check Number:
Transaction Id:
John Hobson
425-430-7279
CAG-15-149
Cascade Interceptor Rehabilitation Phse
11
$752,904.32
8/4/2015
9/4/2015
105323518
Intent Details
Expected project start date: (MM-DD-YYYY) 7/18/2016
In what county (or counties) will the work be King
performed?
In what city (or nearest city) will the work be Renton
performed?
What is the estimated contract amount? OR is this $169,000.00
a time and materials estimate?
Will this project utilize American Recovery and No
Reinvestment Act (ARRA) funds?
Specifically, will this project utilize any No
weatherization or energy efficiency upgrade funds
(ARRA or otherwise)?
Does your company intend to hire ANY No
subcontractors?
Does your company intend to hire subcontractors No
to perform ALL work?
Will your company have employees perform work Yes
on this project?
about: bl ank
2J3
TW-,'2016. r about:blank
Do you intend to use any apprentices? (Apprentices No
are considered employees.)
How many owner/operators performing work on 0
the project own 30% or more of the company?
Hiring Contractor
Company Name
Contractor Registration No.
WA UBI Number
Journey Level Wages
INSITUFORM TECHNOLOGIES LLC
INSITTL883CW
601880220
County Trade Occupation
King Laborers - Underground Sewer General Laborer Ft Topman
iL Water
Public Notes
- Show/Hide Existing Notes
No note exists
Wage Fringe
Workers
$32.37 $10.30 3
about:blank 3/3
-, It
State of Washington
Department of Labor & Industries
Prevailing Wage Section - Telephone 360-902-5335
PO Box 44540, Olympia, WA 98504-4540
Statement of Intent to Pay Prevailing Wage
Project Detail - Project Dashboard
Document Received Date:
8/15/2016
Company Details
Company Name:
Ad d re ss:
Contractor Registration No.
WA UBI Number
Phone Number
Industrial Insurance Account ID
Email Address
Fi led By
Prime Contractor
Company Name
Contractor Registration No.
WA UBI Number
Phone Number
Project Information
Intent ID: Affidavit ID: 672039 Status: Approved On
782210 8/22/2016
ADVANCED GOVERNMENT SVCS INC
8644 PACIFIC AVE
TACOMA, WA, 98444
ADVANGS972OZ
602304323
253-531-9782
07045100
shearring@advancedgovernmentservicesinc.com
HEARRING, Suzanne
INSITUFORM TECHNOLOGIES LLC
INSITTL883CW
601880220
636-530-8000
Awarding Agency
Awarding Agency Contact
Awarding Agency Contact Phone Number
Contract Number
Project Name
Contract Amount
Bid due date
Award Date
Project Site Address or Directions
Payment Details
Check Number:
Transaction Id:
RENTON, CITY OF
1055 S GRADY WAY RENTON, WA - 98055
John Hobson
425-430-7279
CAG-15-149
Cascade Interceptor Rehabilitation Phse
11
$752, 904.32
8/4/2015
9/4/2015
105368692
Intent Details
Expected project start date: (MM-DD-YYYY) 8/9/2016
In what county (or counties) will the work King
be performed?
In what city (or nearest city) will the work Renton
be performed?
What is the estimated contract amount? OR Time and materials
is this a time and materials estimate?
Will this project utilize American Recovery No
and Reinvestment Act (ARRA) funds?
Specifically, will this project utilize any No
weatherization or energy efficiency
upgrade funds (ARRA or otherwise)?
Does your company intend to hire ANY No
subcontractors?
Does your company intend to hire No
subcontractors to perform ALL work?
Will your company have employees perform Yes
work on this project?
Do you intend to use any apprentices?
(Apprentices are considered employees.)
How many owner/operators performing
work on the project own 30% or more of
the company?
Hiring Contractor
Company Name
Contractor Registration No.
WA UBI Number
Journey Level Wages
County Trade
King Flaggers
King Laborers
Public Notes
- Show/Hide Existing- Notes
No note exists
M
X
INSITUFORM TECHNOLOGIES LLC
INS ITTL883C W
601880220
Occupation
Journey Level
Traffic Control Supervisor
Wage Fringe Workers
$25.17 $11.00 1
$27.68 $11.00 1
8/23/2016
aboAblank
State of Washington
Department of Labor & Industries
Prevailing Wage Section - Telephone 360-902-5335
PO Box 44540, Olympia, WA 98504-4540
Statement of Intent to Pay Prevailing Wage
Project Detail - Project Dashboard
Document Received Date:
10/5/2015
Company Details
Company Name:
Address:
Contractor Registration No.
WA UBI Number
Phone Number
Industrial Insurance Account ID
Email Address
Filed By
Prime Contractor
Company Name
Contractor Registration No.
WA UBI Number
Phone Number
Project Information
Intent ID: Affidavit ID: Status: Approved On
724502 10/13/2015
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD, MO, 63005
INSITTL883CW
601880220
636-530-8000
88268501
psoles470@insituform.com
Soles, Paul
INSITUFORM TECHNOLOGIES LLC
INSITTL883CW
601880220
636-530-8000
about, bl ank
113
8/23/2016
Awarding Agency
Awarding Agency Contact
Awarding Agency Contact Phone Number
Contract Number
Project Name
Contract Amount
Bid due date
Award Date
Project Site Address or Directions
Payment Details
Check Number:
Transaction Id:
Intent Details
aboLftlank
RENTON, CITY OF
1055 S GRADY WAY RENTON, WA - 98055
John Hobson
425-430-7279
CAG-15-149
Cascade Interceptor Rehabilitation Phse
11
$7521904. 32
8/4/2015
9/4/2015
104953250
Expected project start date: (MM-DD-YYYY) 10/26/2015
In what county (or counties) will the work be King
performed?
In what city (or nearest city) will the work be Renton
performed?
What is the estimated contract amount? OR is this $752,904.32
a time and materials estimate?
Will this project utilize American Recovery and No
Reinvestment Act (ARRA) funds?
Specifically, will this project utilize any No
weatherization or energy efficiency upgrade funds
(ARRA or otherwise)?
Does your company intend to hire ANY Yes
subcontractors?
Does your company intend to hire subcontractors No
to perform ALL work?
Will your company have employees perform work Yes
about blank 2/3
8/2.3/2016 aboulliank
on this project?
Do you intend to use any apprentices? (Apprentices No
are considered employees.)
How many owner/operators performing work on 0
the project own 30% or more of the company?
Journey Level Wages
County Trade Occupation
King Laborers - Underground Sewer Pipe Layer
8 Water
Public Notes
- Show/Hide Existinp, Notes
No note exists
Wage Fringe
Wo rkers
$43.46 5
abm t:bl ank 313
G.More Pipe Services
PO Box 69
Rickreall. OR 97371
Phone/Fax: 503-623-1319
Insituform Technologies
19165 SW 1 19th Ave.
Tualatin, OR 97062
Attn: Jerry Zimmerman
INVOICE
INVOICE #: 16-1434MH
DATE: September 9, 2016
Job
Date of Service
Due Date
# 1434 — City of Renton
8/8/16 — 9/1 /16
10/9%16
Qty.
Description
Unit Price
Total
1
Mobilization/Demobilization of Manhole Rehab
Truck/Trailer
$2,000 Trip
$2.000.00
7
Labor & Equipment to Spray Seal Interior of MH
with 1/2" Cementitious Mortar for 11-20' MH Depth
$3,838/Ea.
$26.866.00
5
Labor & Equipment to Spray Seal Interior of MH
with 11Y Cementitious Mortar for 21-30' MH Depth
$5.0701/ 1Ea.
$30,420.00
Payments shall be made within 30 days following the date of the invoice. A late
charge of 1 12 percent per month will be assessed on unpaid balances over 60
days.
Subtotal
$59.286.00
Sales Tax
NA
Total
$59,286.00
Make all checks payable to C-More Pipe Services
THANK YOU FOR YOUR BUSINESS!
C-,.IMo.#•e Pipe Services
PO Box 69
Rickreall, OR 97371
Phone/Fax: 503-623-1319
Insituform Technologies
19165 SW 119`' Ave.
Tualatin. OR 97062
Attn: Jerry Zimmerman
INVOICE
INVOICE #: 16-1434MH-1
DATE: September 22. 2016
Job
Date of Service
Due Date
# 1434 — City of Renton
88 16 — 9 1 16
10 9'16
Ot .
Description
Unit Price
Total
4
Labor & Equipment to Spray Seal Interior of MH
with 112' Cementitious Mortar for 0-10' MH Depth
$2,216'Ea.
$8.864.00
3
Labor & Equipment to Spray Seal Interior of MH
with 112" Cementitious Mortar for 11-20' MH Depth
$3,838/Ea.
$11.514.00
1
Labor & Equipment to Spray Seal Interior of MH
with 11i' Cementitious Mortar for 21-30' MH Depth
$5.070%Ea.
$5.070.00
Payments shall be made within 30 days following the date of the invoice. A late
charge of 1 ,z percent per month will be assessed on unpaid balances over 60
days.
Subtotal
$25.448.00
Sales Tax
NA
Total
$25,448.00
Make all checks payable to C-More Pipe Services
THANK YOU FOR YOUR BUSINESS!
Clore Pipe Services
PO Box 69
Rickreall. OR 97371
Phone/Fax: 503-623-1319
Insituform Technologies
19165 SW 1191h Ave.
Tualatin. OR 97062
Attn: Jerry Zimmerman
INVOICE
INVOICE #: 16-1434MH-CO
DATE: September 9. 2016
Job
Date of Service
Due Date
# 1434 — City of Renton
88 16 — 9 1 16
10 9 16
Ot .
Description
Unit Price
Total
25
Material Costs — AV100 Grout
$18.50'Gal
$462.50
20
Material Costs — Strong Plug
$10.50/Gal
$105.00
1
Water Meter Rental Fees
LS
$76.50
Payments shall be made within 30 days following the date of the invoice. A late
charge of 1 1,2 percent per month will be assessed on unpaid balances over 60
days.
Subtotal
$644.00
Sales Tax
NA
Total
$644.00
Make all checks payable to C-More Pipe Services
THANK YOU FOR YOUR BUSINESS!
C-,More Pipe Services
PO Box 69
Rickreall, OR 97371
Phone; Fax: 503-623-1319
Insituform Technologies
19165 SW 1 19`' Ave.
Tualatin, OR 97062
Attn: Jerry Zimmerman
INVOICE
INVOICE #: 16-1434MH-COl
DATE: September 22, 2016
Job Date of Service Due Date
# 1434 — City of Renton 8'8 16 — 9'1'16 101916
of .
Description
Unit Price
Total
35
Material Costs — AV100 Grout
$18.50/Gal
$647.50
16
Material Costs — Strong Plug
$10.50/Gal
$168.00
Payments shall be made within 30 days following the date of the invoice. A late
charge of 1 ' 2 percent per month will be assessed on unpaid balances over 60
days
Subtotal
$815.50
Sales Tax
NA
Total
$815.50
Make all checks payable to C-More Pipe Services
THANK YOU FOR YOUR BUSINESS!
Job #: NM l f
C-More Pipe Manhole Inspection Report Report # : I
CLIENT:y. s .''� w�c rm CITY:
MH NO: 2 ` �f j MH LOCATION:DEPTH: DIAMETER: mr471,
DATE INSPECTED: I - I I t:' COMPLETED: POST INSPECT:
MH TYPE: STORM/ EWER + X PRE -CAST —BRICK WET -WELL STORM CONE
POUR -IN -PLACE CINDERBLOCK
WATER TABLE: (LO EDIUM/HIGH WEATHER: CLEAWRA �RCASTIGAS METER READING:
CONDPTION OF MANHOLE: KEY CODES
LID & FRAME: POOR FAIR GOOD, ^LEAKING (Y/N) SS = STRONG SEAL
CS = CHEMICAL SEAL
ORB LlCONE/FLAT TOP: ►VIP = MORTAR PATCH
CRA
—POOR _FAIR GOOD, LEAKING (Y/Adf = PIN HOLE T
RISER: __POOR FAIR —GOOD, _LEAKING 1) -PICK HOLE
= LADDFjR STEP '�•�'I 3
BENCH:
—POOR FAIR
_ GOOD,
_LEAKING `S/N)
CHANNEL:
—POOR FAIR
_ GOOD,
_LEAKING (YIN)
STEPS: # —POOR I( FAIR GOOD, —LEAKING (YIN)
PIPE INVERT IN: SIZE4,L, I (TOP TO BOTTOM)
PIPE INVERT OUT: SIZEI
MH LID COVER: 2-HOLE 16 HOLE OTHER k, , p
Pre -Inspection Notes:
T!, . A. ✓ a w1r
Repair/Rehab Notes:
SUPPLIES USED:
AA' - W-' — tQ 2AI -^
TRAFFIC CONTROL NEEDED: Yes No
If yes —see back
Street
Mark North (N)
with arrow line
kcAK
f
Down Stream
t
I
F
SING RISER
RAIN
GUARD:
RIESR
BENCH
H
Updated 4/16
PO Box 69, RickreaU, OR 9 73 71 * (503) 623-1319 Offke/Fax
Job #: MH 113q th,1�
C-More Pipe Manhole Inspection Report Report # :
CLIENT: L+Ls+++. CITY: �ov� L✓
MH NO: 2 77 MH LOCATION: `% + r,L,j �.K I.w'( DEPTH: 7L 4V DIAMETER: [
DATE INSPECTED: `�" 1 COMPLETED: �' / �� POST INSPECT:
MH TYPE: STORM/ EWER ) PRE -CAST _`BRICK _ WET -WELL STORM CONE
POUR -IN -PLACE CINDERBLOCK
WATER TABLE: LOW/Nr(1�D�U1�/HIGH WEATHER: CI,F,AR/RAIN/OVE_Ci4T GAS METER READING:
CONDTTION OF MANHOLE:
LID & FRAME:
_POOR _FAIR
_ GOOD,
_LEAKING (Y/N)
CORBEL/CONE/FLAT TOP:
_POOR _FAIR
_ GOOD,
_LEAKING (YIN)
RISER:
_POOR _FAIR
— GOOD,
_LEAKING (Y/N)
BENCH:
POOR
FAIR
GOOD,
LEAKING (YIN)
CHANNEL:
POOR
FAIR
GOOD,
LEAKING (YIN)
STEPS: #A—
_POOR _FAIR
_ GOOD,
_LEAKING (YIN)
PIPE INVERT IN:
SIZE 21
1
1 1
(TOP TO BOTTOM)
PIPE INVERT OUT: SIZE A
MH LID COVER: 2-HOLE 16 HOLE OTHER J. I�•
Repair/Rehab Notes: x
SUPPLIES USED: S— Z Cr
+ a, ,
"4�aj S""Street
TRAFFIC CONTROL NEEDED: Yes No Mark North (N)
If yea —gee back with arrow line
STRONG SEAL
Sf
CCHEMICAL
SEAL
M
MORTA PATCH
^=
CRA \\
PPIN
LPPIC HO E
Ii
AT1r1FR TRP
R SER
.4
RBEL
RAIN
GUARD:
RISER
CHAN
BENCH
Updated 4/ 16
PO Box 69, RickreaI4 OR 97371 * (503) 623-1319 Office/Fax
A
Job #: MH
C-More Pipe Manhole Inspection Report
Report # :
CLIENT: j �- CITY:. �� ✓I. c.S
3 LOCATION: 1 'dG q k; 0,-J
L S DEPTH: A DIAMETER: 37 2—
MH NO: 3r -
DATE INSPECTED: V _ I O `- I (o COMPLETED: '6 — / &/
POST INSPECT:
MH TYPE: STORM EWER PRE -CAST —BRICK WET -WELL STORM CONE
POUR -IN -PLACE CINDERBLOCK
--t
WATER TABLE: LOW i Eb U /HIGH WEATHER: CLEAR/RAI
—
/OVERCAST
M JRJUA
MG: 2�
Y
CONDITION OF MANHOLE:
SS = S
DES
BONGS L
�1
LID & FRAME: POOR �IR _ GOOD, —LEAKING (Y"
—
CS = C
JEMICAL SEAL
MP =
ORTAR TCH
�r
CORBEL CO /FLAT TOP:
R AIR GOOD, (YA
^^^^^
C
— _ —LEAKING
PH = P
N HOLE
RISER: — AlR &/N)
PK = F.
CK I IOL
_/POOR _GOOD, —LEAKING
LS = L
DDER S EP
BENCH: `POOR _FAIR GOOD, —LEAKING (Yfxd
-�
CHANNEL: -- POOR /FAIR_ GOOD, _LEAKING (Y/K
STEPS: #_' V —POOR )CFAIR — GOOD, —LEAKING (Y/N)
PIPE INVERT IN: SIZE 2� lZ (TOP TO BOTTOM) ;
PIPE INVERT OUT: SIZE 24 1
MH LID COVER: 2-HOLE 16 HOLE
Repair/Rehab Notes:
SUPPLIES USED:
`2 -'ems
TRAFFIC CONTROL NEEDED: Yes No
If yes —wee back
r
Street
Mark North (N)
with arrow line
RAIN
GUARD:
_,7 2
tv v o
4
RISER
BENCH
7 `J
tt
i
Down Stream
Updated 4/ ] 6
PO Box 69, Rickreak OR 9 73 71 - (503) 623-1319 Office/Fax
L
S
C)
C-More Pipe Manhole Inspection Report Rcp rt#H 1 3y Pt
CLn CITY:.
MH NO: 2Tj_ MH LOCATION: L 0DEPTH: 11 1 DIAMETER: ;S
DATE INSPECTED: - l l — C & COMPLETED: POST INSPECT:
MH TYPE: STOR S WUi� X PRE -CAST
BRICK WET -WELL STORM CONE
POUR -IN -PLACE CINDERBLOCK
WATER TABLE: LOW/MERI&/`HIGH WEATHER: 16LEARJ1WN/OVERCAST
GAS METER READING: .Z. C% ['
CONDTTION OF MANHOLE:
LID & FRAME: POOR AIR
GOOD,
//
(N/N)
KEY CODES
SS = STRONG SEAL
—
—
_LEAKING
CS = CHEMICAL SEAL
CORBEL/CONE/FLAT TOP:
MP = MORTAR PATCH
POOR /FAIR
GOOD,
(,YtN)
I = CRACK
_LEAKING
PH = PIN HOLE
RISER: POOR -FAIR
GOOD,
(�Y/N)
PK = PICK HOLE
—
—
_LEAKING
=LADDF-WSTEP`j
BENCH: _POOR _FAIR
— GOOD,
_LEAKING (Y11N)
S 3 6,
CHANNEL: `FAIR
GOOD,
(Y[Yd
v'ty t- ? Z ••
_POOR
FAIR
—
—LEAKING
i RING RISER
STEPS: # ; ti _POOR
— GOOD,
—LEAKING (Y/N)
I
+-
PIPE INVERT IN: SIZE 2����II(TOP TO BOTTOM)
PIPE INVERT OUT: SIZE 2 41
MH LID COVER: 2-HOLE 16 HOLE OTHER 1
SUPPLIES USED:
2-10
TRAFFIC CONTROL NEEDED: Yes No
If yes —see back
Street
Mark North (N)
with arrow line
x
RAIN
/ GUARD:
4 --
RISER
2 y1-1—' I BENCH
k
Down Stream
Updated 4/ 16
PO Box 69, RickreaI4 OR 9 73 71 * (503) 623-1319 Of Ice/Fax
Job #: MH m i4
C-More Pipe Manhole Inspection Report
Report
CLIENT: TVn4 �*J"'
CITY:- ke-A 'F44.- =t
MH NO: 2,1 MH LOCATION: S:^ S t e�-446(- AV DDEPTH: DIAMETER: 7
DATE INSPECTED:
COMPLETED: t r (6 - G POST INSPECT:
MH TYPE: STORM EW PRE -CAST BRICK WET -WELL STORM CONE
POUR -IN -PLACE CINDERBLOCK
J
WATER TABLE: LOW . EDI iHIGH WEATHER: CLEAR/RA /OVERCAS GAS METER READING:
CONDITION OF MANHOLE:
KEY CODES
SS = STRONG SEAL
LID & FRAME: POOR —FAIR
_ GOOD, _LEAKING (Y/N)
CS = CHEMICAL SEAL
CORBEL/CONE/FLAT TOP:
MP = MORTAR PATCH
nnnnn —
GOOD, (Y/N)
_POOR _FAIR
— _LEAKING
P = PIN HOLE
RISER: POOR ' FAIR
— —
— GOOD, _LEAKING (Y/N)
P = PICK HOLE
L = LADDE EP
BENCH: POOR _FAIR
_ GOOD, _LEAKING (Y/N)
CHANNEL: _POOR _FAIR
_>,/G60D, _LEAKING (Y/N)
STEPS: # —POOR FAIR
GOOD, _LEAKING (Y/N)
RING RISER�—
PIPE INVERT IN: SIZE I I
(TOP TO BOTTOM)
PIPE INVERT OUT: SIZE 24 �
MH LID COVER: 2-HOLE 16 HOLE __>!!�_OTHER_t�
Pre -Inspection Notes:
Repair/Rehab Notes: x
SUPPLIES USED:
TRAFFIC CONTROL NEEDED: Yes No
uy"ee back
Street
Mark North (N)
with arrow line
Updated 4/ 16
PO Box 69, R1Ckrea14 OR 9 73 71 * (503) 623-1319 Ofj°Ice/Fax
RAIN
_ � f `—•----�-. GUARD:
RISER
L \
BENCH
5 `5
Down Strea G ~✓
L �z
Job #: MH
C-More Ripe Manhole Inspection Report Report # : IV-,
CLIENT: �_ yy�, c ,+�+ CITY:• _
MH NO: MH LOCATION: DEPTH: r1 k DIAMETER:'`_
DATE INSPECTED: qS _ 12-16 COMPLETED: ` 2- POST INSPECT:
MH TYPE: STOR S E X PRE -CAST __ BRICK _ WET -WELL STORM CONE
POUR -IN -PLACE CINDERBLOCK
WATER TABLE: LOW EDIU ~ IGII WEATHER. EA IN/OVERCAST GAS METER READING: 201
CONDITION OF MANHOLE -
LID & FRAME: _POOR FAIR
GOOD,
_LEAKING (Y/N)
CORBEL/CONE L�TO/FAIR
_ GOOD,
_LEAKING Id)
RISER: POOR _.FAIR
—GOOD,
_LEAKING W N)
BENCH: __POOR FAIR
_ GOOD,
_LEAKING Vl1)
CHANNEL: _POOR `FAIR
GOOD,
_LEAKING (yx
STEPS: #-I�- _POOR /FAIR
_ GOOD,
_LEAKING (YIN)
PIPE INVERT IN: S17,E 241 1
1 1
(TOP TO BOTTOM)
PIPE INVERT OUT: SIZE 22 A
MH LID COVER: 2-HOLE 16 HOLE _MOTHER f J,,c 4:
Repair/Rehab Notes: x
KEY CODES
SS = STRONG SEAL
CS - CHEMICAL SEAL
= MORTAR PATCH
PI6F = NOLE
PICK
=LVIDtIR S Ey '3�7
��
T, L?
RI
0 ) CO BEL
RAIN
f� r� � � GUARD:
lei off FA 'dg MA
SUPPLIES USED: � % S42 1 \
0;'S4'' /1ZS- Zf� ct
R4
V
Street
TRAFFIC CONTROL NEEDED: Yes No
Mark North (N) C
If yes —see back with arrow line
Down Stream
Updated 4i 16
PO Box 69, Rkkreall, OR 97371 * (503) 623-1319 Ofjice/Fax
4
RISER
BENCH
Job #: MH I SYY IIIi
C-More Pipe Manhole Inspection Report Report # : -7
CLIENT: :Zv y r'-m CITY: "w" 4,"
MH NO: Z ly 3 MH LOCATION: g �r I
4 �F,- +tit / 4wy �C DEPTH: DIAMETER: ?
DATE INSPECTED: 9 -/ 7-16 COMPLETED: POST INSPECT:
MH TYPE: STORM/ E '1C PRE -CAST _ BRICK WET -WELL STORM CONE
POUR -IN -PLACE CINDERBLOCK
WATER TABLE: LOW/) HIGH WEATHER CL A AIN/OVERCAST GAS METER READING: Z�0, jn
CONDITION OF MANHOLE:
CODE
STRO
L
LID & FRAME: POOR FAIR
—
__ GOOD,
_LEAKING (Y/N)
CH I
1=CRA
AL SEAL
MORT
R PATCH
QC�ORRBECON AT TO
K
_P OR AIR
__GOOD,
_LEAKING (YIN)
PH
- PIN H
LE
RISER: POOR V( AIR
GOOD,
(Y/N)
P
-PICK I OLE
—
_LEAKING
LS
LADD
R STEP
BENCH: —POOR Y'FAIR
_ GOOD,
_I•EAKING (Y/N)
CHANNEL: _POOR _ kgA1R
_ GOOD,
_LEAKING (Y/N)
RING RISER
STEPS: # —POOR ) AIR
— GOOD,
_LEAKING (Y/N)
PIPE INVERT IN: SIZE jq $
(TOP TO BOTTOM)
CORBE
PIPE INVERT OUT: SIZE 2k
♦
MH LID COVER: 2-HOLE
j r,,
16 HOLE O'I'HER\-A
Repair/Rehab Notes:
� L
SUPPLIES USEED:L ;
p
Street
TRAFFIC CONTROL NEEDED: Yes No Mark North (N)
If yes —see back with arrow line
Updated 4/16
PO Box 69, Rickreall, OR 9 73 71 * (503) 623-1319 Office/Fax
A
'j
VW
CHANNEL
Down Stream
RAIN
GUAI
IS
Job #: MH I`q 3-4 i l
C-Afore Pipe Manhole Inspection Report Report #: �
CLIENT: L +1 j c� r onn CITY:. _ ems t ►n j r �.
MH NO;6 2S )_ MH LOCATION: DEPTH: ' Z 7 _DIAMETER:_ z,_
DATE INSPECTED: COMPLETED: POST INSPECT:
MH TYPE: STO EW�� XPRE-CAST ___ BRICK WET -WELL STORM CONE
_ POUR -IN -PLACE CINDERBLOCK
WATER TABLE: LOV EDIU 1/HIGH WEATHER: �LEARI IN/OVERCAST GAS METER READING:
CONDITION OF MANHOLE: KEY CODES
LID & FRAME: POOR FAIR— GOOD, _LEAKING (Y/N) SS = STRONG SEAL
CS = CHEMICAL SEAL
CORBE CONE LAT TOP:
—POOR _FAIR _ GOOD,
_LEAKING (YIN)
RISER: POOR FAIR GOOD,
LEAKING (Y/N) `
BENCH: _POOR _ FAIR GOOD,
-- -LEAKING (YIN)
CHANNEL: _POOR —FAIR GOOD,
_LEAKING (Y/N)
STEPS: # -7 POOR FAIR GOOD,
LEAKING (Y/N)
PIPE INVERT IN: SIZE1O.61--6 1�j I 1__
(TOP TO BOTTOM)
PIPE INVERT OUT: SIZE
MH LID COVER: 2-HOLE 1C16 HOLE
OTHER
Pre-Imnertinn Note -a!
y n- e1,+Jw.w x ✓,e d•j cQh//S//k� �,L L'1 v1 i raw w�+a✓
Q 'ti!'#f Ali
.(Si.o►.�C'f'{ �li �'
Repair/Rehab Notes: k
t
P,Ae ✓ !ti'� Wit. l� tl _ ' r �c.t Ewa
SUPPLIES USED:
l l J Street
TRAFFIC CONTROL NEEDED: Yes No Mark North (N)
If yes —see back with arrow line
g3
IS
Down Stream
Updated 4/ 16
PO Box 69, Rtckreall; OR 97371 * (503) 623-1319 OJj`icdFax
fi
Job #: MR /Y-r*A
C bore Pipe Manhole Inspection Report I report 9 :
�I
CLIENT: 5 CITY; - l tom: t. ; t L ✓'L
MM NO: 21 3Q_ MI-1 LOCATION: (k, �• ,�- n :Q� � .1 MH DFffH: FT LIN DIAMETER:
DATE INSPECTED: Z `3 I COMPLETED: `i POST INSPECT:
IAY:Id. TY PE S FOR EWE _ PRE -CAST _ BRICK WET -WELL __ STORM CONE
POUR -IN -PLACE CINDERBLOCK
WATER TABLE: &Z-WTUDIUMAUGH WEATHER: C EA AIN/OVERCAS'T GAS METER READING: '
CONDITION OF MANHOLE:
LID & FRAME: POOR _FAIR X GOOD, _LEAKING (Y/idf
CORBEL: --POOR )CFAIR
—GOOD,
_LEAKING (Y/Di�r-
[USER: _POOR FAIR
_ GOOD,
_LEAKING OYN)
BENCH: _POOR YFAIR
_ GOOD,
LEAKING MI)
CHANNEL: POOR FAIR
VOOD,
LEAKING (YfXr
STEPS: #�_ ___-POOR AIR
^ GOOD,
_LEAKING (Y/N)
PIPE INVERT IN: SIZE a�, 1 9'>l (TOP TO BOTTOM)
PIPE INVERT OUT: SIZE 9*1
MII LID COVER: 2-HOLE
16 HOLE
V OTHER
DROP: Al Li --INSIDE, SIZE JVAOUTSIDE, SIZE
RAIN GUARD: RECOMMENDED _)t NONE
NOTESIRECOMIIENDATIONS (see back for additional information)
Al it Qi v B S. rew� te'k:4 4I } ��' ~ Y Ei��►s otwi;f
TRAFFIC CONTROL NEEDED: Y N Street
HEY CODES
SS = STRONG SEAL
CS = CHEMICAL SEAL
MP = MORTAR PATCH
PIN I
PICK
STEP
RING RISER
/0l4
X I I ! �"R R
11 "g
q
VIEW
LOCATION:
Mark North A
with arrow line Z
GMore Pipe Service, 9350 R&kreaU Rd, RickreW4 OR 97371 * (503) 623-1319 0ffkeJFav
4 --
BENCH
f
Job #: MR !-/A
C bare Pipe Manhole Inspection Report Report
CLrEraT: Y,`I jt _ - — CITY: 0-0-,,4 P1
11IN NO: Z MIi LOCATION: W l i ig ( C , MH DEPTH: _LL FT jIN DIAMETER:
DATE INSPECTED: � u / COMPLETED: __ POST INSPECT: _
,"AH T'I!PE: STO ER K PRE -CAST _ BRICK WET -WELL STORM CONE
POUR -IN -PLACE CINDERBLOCK
WATER TABLE:/�ONEDIUM/HIGH WEATHER:OV RCAS ME
CLEAR/RAI GAS TER REA-DING:
CONDITION OF MANHOLE: KEY CODES
LID & FRAME: _POOR _FAIR /GOOD, _LEAKING SS = STRONG SEAL
CORBEL: NPOOR _FAIR
_ GOOD,
LEAKING (Y/VI
RISER: _POOR FAIR
GOOD,
_LEAKING6NN)
BENCH: Y POOR _FAIR _
GOOD,
_LFAKING (VN)
CHANNEL: _POOR FAIR
_ GOOD,
___LEAKING (Yxf
STEPS: # f t3 _POOR FAIR
_ GOOD,
,LEAKING (YlXf
PIPE INVERT IN: SIZE Zvi 11I_—_j1__
(TOP TO BOTTOM)
PIPE INVERT OUT: SIZE 7-1-11
MH LED COVER: 2-HOLE 16 HOLE OTHER LIE
DROP: � INSIDE, SIZE IVAOUTSIDE, SIZE
RAIN GUARD: RECOMMENDED NONE
NOTEWRECOMMENDATIONS (see back for additional information)
i 3 5."�- 5 - At 5.2 c
TRAFFIC CONTROL NEEDED: Yes Q
:.00ATION:
Street
Mark North (N)
with arrow line
CS = CHEMICAL SEAL
CMvre Plpe Service, 9350 RkkeeaU Rd, Mckreal4 OR 9 73 71 * (503) 623-1319 Office/Fax
Job #: M11 N.Pi
C-More .,ft* Manhole hupecdon report I Report ff : _�
L _
CLIENT: CITY•
IyIH NO: 2-'614 MII LOCATION: _ I (, Qc-) 1H DEPTH: FT IN DIAMETER:
LATE INSPECTED: COMPLETED:3 r i POST INSPECT: -- -
IvHI TYPE: STORM/ EVI+ PRE -CAST BRICK WET -WELL STORM CONE
POUR-IN-PLACECINDERBLOCK
WATER TABLE: (IOWNED1UM/HIGH WEATHER CLEA
CONDITION OF MANHOLE:
LID & FRAME: _POOR
_FFAIR
— GOOD, _LEAKING
(YIN)
C BEL: j C-Or"--POOR
n FAIR
^ GOOD, _LEAKING
)
0
RISER: _POOR
V FAIR
_ GOOD, _LEAKING1)
BENCH: -POOR
'_FAIR
, GOOD, _LEAKING
(Y/N)
CHANNEL:
Y
__POOR
'FAIR
GOOD, __LEAKING
(YIN)
STEPS: # _POOR
_FAI,,R
_ GOOD, _LEAKING
(YIN)
PIPE INVERT IN: SIZE ?L-f I f I I (TOP TO BOTTOM)
PIPE INVERT OUT: SIZE 2,q
MH LID COVER: 2-HOLE
DROP: IVA INSIDE, SIZE
16HOLE OTHER_ _t_/1. tl
AloUTSIDE, SIZE
RAIN GUARD: RECOMMENDED NONE
NOTES/RECOM-MENDATIONS (see back for additional Information)
TRAFFIC CONTROL NEEDED: Ye Ni Street
—
LOCATION:
Itobc Mark North (M
J with arrow line
iv
C-More Pipe Service, 9350 Ricky eall RiL, Rkkre4g OR 9 73 71 * (503) 623-1319 Offlce/Fax
= STRO G SEAL
= CHEM CAL SEAL
= MOR"
R PATCH
' = CRA
K
= PIN H
E
= PICK H
LE
= LADDE
STEP
-7
RING RISER
-f
BENCH
I
Job #: MH /y 3 j
C-More .ire Manhole Inspection Report Report
CLI�+'NT: .`� , w� CrrX: �04'Ji o- GV k- — ----
Ipy1CH NO: 27 CC MH LOCATION: +�0 t 7:jE.X JL, 51 DEPTH: MH 21 FT 2- IN DIAMETER: 7 2
DATE INSPECTED: I �? COMPLETED: _ G/ , �_ , POST INSPECT: —
'& %74P TStPE: STORM/EWER RE -CAST _ BRICK WET -WELL STORM CONE
_ POUR -IN -PLACE CINDERBLOCK p
NVATER TABLE OW EDIUM/HIGH WEATHER: CLEAR/ IR =VERCAST GAS METER READING:
CONDITION OF MANHOLE: KEY CODES
LID &. FRAME: _POOR FAIR >C GOOD, _LEAKING (Y/N) SS = STRONG SEAL
CS = CH EAL
CORBELi-5 VPOOR .-.__FAIR -_ __ GOOD, _LEAKING 6?N) P = MORT PAC I
= CR
RISER: x POOR _FAIR _GOOD, _LEAKING i'/N) P = PIN HO
P = PICK H E
BENCH: POOR _FAIR _ GOOD, _LEAKING CON) L = LADDE STEP
CHANNEL: _POOR 'y FAIR ` GOOD, _LEAKING (Y N)RING RISER
STEPS: # I _ _POOR �C FAIR _ GOOD, _LEAKING &N)
T1'
SA
INVERT IN: SIZE Zf ll1-5 'b ("TOP TO BOTTOM)
PIPE INVERT OUT: SIZE 2-41_
MH LID COVER: 2-HOLE 16 HOLE OTHER
DROP: INSIDE, SIZE OUTSIDE, SIZE I I SS
RAIN GUARD: RECOMMENDED -eZ NONE
l�c'.?J.+.� �nJ•r.5 �a� c'�,�i � /" v'� yv1Ot.-,'t..IrGC
<kf*-d eL.L ii�Sa�iXl t.,LC'G . 4n.-.-fi,
,, ,',, s bdv- o +-v-6 - ;11 6"j`
A
IA S Z tk
TI�xAO+�q x,,Y Ate- S
FFIC cONTR L NEEDED: Yea i o7 Street
LOCATION:
p ( '3
Mark North (N)
1bC� -ha2.� N4L9 with arrow line 2 4
C-Md�e Plpe Service, 93SO Rkkreafl P.d, Rkkreak OR 97371 * (503) 623-13I9 Oj, eelFax
-75
RBEL
S 5 --�
SS
HANTIT�L
2 BENCH
9�
INSITUFORM TECHNOLOGIES
19165 SW 119th St.
lnsituform-
Tualatin, OR 97062
Please Remit Payment to:
Insituform Technologies, Inc.
Box 674060
BEVA Compass
4400 AMON CARTER BLVD Ste 110
FT Worth, TX 76155
Noteif you are overnighting a check via fedex or ups - ITI has a physical address for the check to go.
MONTHLY / WEEKLY REVENUE PRODUCTION
REPORT
JOB Name: Renton. Wa_Cascade Interceptor
Project Manager: Roberto Rizo
JOB Number 202221
Superintendent #1: David Stambaugh
Att John D. Hobston
Field Engineer Jerry Zimmerman
Previous Production Production This Month
tad
DHcrtptldn
Est -at"
_ -.-
Unit ar
-- ►rice Rer Unll Contract ►rk.
or
F.
bet.uw
__„_
R...... Prpdue.d
1
M bihz.hon
1 x/
LS $ 16.850.00
0.80
$ 13.48000
TrARic l'alnol
1.�10
LS $ 5.430.00
0.90
$ 4,867.00
3
Pre-N+IallatxlO Cltani and Inspection
i.'BJ.,x)
LF S 13.873.60
4781.00
f 17.67360
4
In mll 14" CEPP
605,on
LF S 29.645.00
545.00
$ 26.705.00
5
InslAl118"CEPP
265.00
LF f 41.340.00
23t1.00
S 37.128,00
6
hnta1121"CIPP
979.00
1.F S 100.93700
gel 00
S 90.743,00
7
In.ull 24"C1PP
-1 lxt
Lk S 404,29625
2641.00
S 363.797.75
8
R-utc Suk Scorer Tap,:
00
EA S 140.00
200
$ 140.00
9
Post hi'mlhnon Ilss i-i
4 "`:I Ixl
LF S 2.392.00
000
S
10
Sewn kiH R h b 0' 10 10'
1 tx1
1.11 S 7.5e0.00
000
$
11
Sewn MH Rehab I1'to 29
I11.Ix1
F:5 S 3S,e00.D0
Co
S
12
Sewn hIH Rdmb 21' to 30' Deep
Iq
F a S 29.400.00
-
Insitutorm Work Totals
I s 667,583.85
S 550.754.35
Chanoe Orden -- Work Done by Insltulorm
PAGE:
1
DATE:
ESTIMATE #:
1
INVOICE #:
1
JOB #:
202221
BILLING PERIOD:
7/25/2016 to &25=16
FEDERAL10:
13-3032158
DAY INDINO :
Is Job Complete 7:
NO
Pay Est 21
Job To Date
Ins[sll.d %c8=1I of
Rwanw rroducw
0uanla
Total
16.850.00
100%
I
S 5,430.00
100%
47UGo
S 1387360
100%
%2. 10 I S 99o96.3C 1 911% 1
m co
6 00 i9.100.00 - .
Chanj
a Orders Plus Allowable Mark U .- Work Done by Sub Contractors:
C01
MH Rehab Coel De/eronc. D b 10 DOW
4
EA
$ 37557
S 1.302.2e
0.0
I S
4.0
$ 111121
4.0
S 1,102,21
111%
CO2
MH R.rup Cnt Dxlr.r1t. 17'b20' Deep
10
EA
S 30186
S 7.Ot8.60
0.0
$
10.0
S 7.Of e.60
10.0
S 3.018.60
100%
CO3
MH R.hall Cost DOveoce 21'to 30'Deep
6
EA
$ 198. 90
S 1,19340
0.0
s
6,0
s 1, 193.40
6.0
$ 1.19340
100%
204
M.lerul Cost
t
LS
s 1.70762
S 1 707.62
0.0
S
1.0
S 1 707.62
t.0
S 10707.62
100-1.
COS
AdoNOMI Mooflual- For Un.apeclw Material Overage
1
LS
$ 2.340 W
2.34U.00
0.0
S
1.0
s 2 340 00
t.0
f 2,340.00
100
Chan - Sub Contractor Total.
S 9.761.e0
f
S 2 761.90
f .,let..
100 %
Total Eutaw ►ravlou. Period Toilet 4rr1.d Cunt P.rbd Toah flamed To Dan
Total of roved Work S 597.3a5.75 $ 550.754.35 S 144,850.70 S 095605.05 1 100%
AMOUNT DUE s ,a.$5070
CURRENT ESTIMATE
Job Status Comments: Sample reports are In route and will be delivered via postal mail no later than Wednesday, September 28, 2016. Final video report and media package are to be
delivered via FedEx on Friday September 23 2016,
Sub -Contractor Work Comments:
Insituform Project Management Approval by: '.001141111"TAijdFr Progress Payment Approval by:
tobMo J. R1zo Ham.
503.486,6274 Tim.
20150910 Date
INSITUFORM TECHNOLOGIES
19165 SW 119th St
V 1,nit�m, Tualatin OR 97062
I Please Remit Payment to:
Insituform Technologies, Inc.
Box 674060
BEVA Compass
4400 AMON CARTER BLVD Ste 110
FT Worth, TX 76155
Note, If you are overnighhng a check via fedex or ups - ITI has a physical address for the check to go.
MONTHLY / WEEKLY REVENUE PRODUCTION REPORT
JOB Name: Renton, Wa_Cascade Interceptor Project Manager Roberto Rizo
JOB Number: 202221 Superintendent 01 David Stambaugh
Att John D. Hobson Field Engineer Jerry Zimmerman
Previous Production Production This Month
61tl Description Estimated 1.unitol Price Per Unit Contract Pnce No. of Inslalteo Revenue Protlucetl
S
1.
luaatl_'1"CIPP
9'9,00
LE f 10D,837.00
962.10
S 99,096.30
luwdl 24"CUT
2,935,00
LE S 404.296,25
:935.00
b 404,296.25
8
Reuulare Side Sewer Taps2
0U
EA f 140.00
200
140A0
9
post Installation Im ctiou
4'84.00
LF' S 2.392.00
4767 10
S 2,793.55
10
+ewer MH Rehab 0' to 10'
400
FA S 7.580 DO
s P_
S 7,S80.00
11
Sewer MH Rehab 1I'to 20'
10.00
EA f 35,800,00
36.800.00
1'
Sewer MH Rdtab 2I' to 10'Deep
6 00
E.a S 2940000
o DC
_ 29 400 00
S 687
PAGE:
1
DATE:
ESTIMATE #:
3 - Final
INVOICE #:
1
JOB #:
202221
BILLING PERIOD:
v2sr20teto8.25r2016
FEDERAL ID:
13-3032158
DAY ENDIND :
W297016
Is Job Complete 7:
YES
Pay Eat at
Job To Date
Inatelietl
_ .._
Revenue Prodtl
uce
'e Compl of
_
962.10
1 $ 99.096 30
98%
2935.00
$ 404,296.25
10D%
2.00
$ 140.00
100%
4767,10
f 2,39355
100%
4.00
$ 7,58000
t00%
10A0
S 35,8D0.00
10D%
6,00
$ 2/40/017
110%
$ 685.76s.69
t6ox
Change Orders Plus Allowable ark Up - Work Dons b Sub Contractors:
C7i '.IF Remo Cost DMannca __ 976190 S 9.76190 M00 S 9,761.90 - 9761.90 0%
Chen es • Sub contractor Totals f 9.761.90 f $ 9,761.90 S 9.761.90 1 100%
Total Earned Pre us Period Total Earned Current Period Totni Earned To Date
Total of Approved Work S 691.345.75 $ 682.415.69 1 1 1 1 S 13.131.90 $ 695.547.59 100%
AMOUNT DUE
CURRENT ESTIMATE f 13.131.80
Job Status Comments Sample reports are in route and will be delivered via postal mail no later than Wednesday. September 28 2016. Final video report and media package are to be
delivered via FedEx on Friday, September 23. 2016.
Sub -Contractor Work Comments:
Insituform Project Management Approval by:
�Z&
Fi6berr!57 Rtzo
503.486 6274
20150910
Progress Payment Approval by:
None.
Tilde
Dab
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30, 1997
Public reponing burden for this collection of information is estimated to average 16 minutes per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and revievnng the collection of mfonnation. Send comments regarding this burden estimate or any other aspect of this collection
of informationincluding suggestions for reducing this burden. to Department of Defense. Washington Headquarters Services, Directorate for Information Operations and Reports. 1215
eHerson Davis Highway, Suite 1204. Anington. VA 22202-4302and to the Office of Management and Budget. Paperwork Reduction Project (1215-0149) Washington. DC 20503
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1 PAYROLL NUMBER
YROLL PAYMENT DATE (YYMMDD)
F
3. CONTRACT NUMBER
4 DATE (YYMMDD)
52
16/09/30
1 16/09/30
I, Stephanie Forrest Payroll Specialist do hereby state
IName of signatory party) (Tree)
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II Conbacto orsubccniractarl
on the CAG-15-149 , that during the payroll period commencing on the 18 day of
(Bu(Jding or work)
September 201 6 and ending the 24 day of September 201 6 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat 948, 63 Stat 108, 72 Stat 967, 76 Stat 357, 40 U.S.0 276c), and described below
Federal, Fica, State and Local tax. 401K, Loan re -payment, Insurance, garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete: that the
age rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training. United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees.
except as noted in Section 4 (C) below
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
-Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract.
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5.REMARKS
6. NAME (Last, First, Middle Initial)
TITLE
8 SIGNATURE -
Forrest, Forrest, Stephanie
Payroll Specialist
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal 0Cution.
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
DD FORM 879, MAR 95 (EG) PREVIOUS EDITON MAY BE USED
R07371 Aegion Corporation 9/29/2016 7:34:18
Certified Payroll Register Page - 33
Pay Period Ending Date 9/24/2016
INSITUFORM TECHNOLOGIES LLC Pro ect and Location 202221 Period Number 5
17988 EDISON AVE RE�TON - WA- CAG-15-149
CHESTERFIELD MO 63005 CASCADE INTERCEPTOR -PHASE II
4784'x 14,18,21,24' CIPP
WA
St SMS SDep FMS FDep Sex EEO Union ....................... Craft......................... Step.........................
Social Security No Ethnic Cat ....... Regular . . ..... ....... Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
NO WORK PERFORMED
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30. 1997
Public reporting burden for tins collection of information is estimated to average 15 minutes per response, including the time for revie inng instructions, searching existing data sources.
gathering and maintaining the data needed and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection
of informationincluding suggestions for reducing this burden. to Department of Defense. Washington Headquarters Services. Directorate for Information Operations and Reports. 1215
Jefferson Davis Highway. Suite 1204, Arlington. VA 22202-4302and to the Office of Management and Budget, Paperwork Reduction Protect (1215-0149) Washington, DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1. PAYROLL NUMBER
2 PAYROLL PAYMENT DATE (YYMMDD)
3. CONTRACT NUMBER
4 DATE (YYMMDD)
53
16/10/07
1 16/10/07
I, Stephanie Forrest Payroll Specialist do hereby state
(Name of signatory party) (Title)
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Contractor or subcontractor)
on the CAG-15-149 ; that during the payroll period commencing on the 25 day of
(Building or work)
September 201 6 and ending the 1 day of October 201 6 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Connector a subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations. Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat. 948. 63 Stat. 108, 72 Stat. 967, 76 Stat. 357: 40 U.S.C. 276c). and described below:
Federal. Fica, State and Local tax, 401 K, Loan re -payment, Insurance, garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete, that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
W1-Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5.REMARKS
8. NAME (Last. First, Middle Initial)
TITLE
8 SIG NATUR
Forrest, Stephanie
T Payroll Specialist
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
DID FORM 879, MAR 95 (EG) PREVIOUS EDITON MAY BE USED
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Protect and Location 202221
RENTON - WA- CAG-15-149
CASCADE INTERCEPTOR-PHASEII
4784'x 14,18,21,24" CIPP
WA
St SMS SDep FMS FDep Sex EEO Union ....................... Craft ......................... Step .........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ........... Check Detail .......
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
— NO WORK PERFORMED-------J
10/5/2016 7:39:41
Page - 33
Pay Period Ending Date 10/1/2016
Period Number 1
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per response. including the time for reviewing instructions. searching existing data sources,
gathering and maintaining the data needed and completing and reviewing the collection of information Send comments regarding this burden estimate or any other aspect of this collection
of information. Including suggestions for reducing this burden. to Department of Defense Washington Headquarters Services Directorate for Information Operations and Reports. 1215
Jefferson Davis Highway Sure 1204. Arington. VA 22202-4302. and to the Office of Management and Budget. Paperwork Reduction Protect (1215-0149) Washington. DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
PAYROLL NUMBER
r7AYROLL PAYMENT DATE (YYMMDD)
3. CONTRACT NUMBER
4 DATE;YYMMDD
51
16/09/23
1 16/09/23
I. Stephanie Forrest Payroll Specialist do hereby state
(Na— of signatory party -if-
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (contactor a subcontractor,
on the CAG-15-149 that during the payroll period commencing on the 11 day of
(8uildmg or work)
September 201 6 and ending the 17 day of September 201 6 all persons employed
on said protect have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations. Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat 948, 63 Stat. 108 72 Stat 967 76 Stat 357, 40 U.S.C. 276c), and described below.
Federal. Fica. State and Local tax 401 K. Loan re -payment. Insurance. garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete, that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract. that the classifications set forth therein for each laborer or mechanic conform with the work performed
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training. United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS. OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll. payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
-Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll. an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5 REMARKS
6 NAME (Last. First. Middle Initial)
TITLE
8 SIGN UR
Forrest, Stephanie
TPayroll Specialist
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or trim( rosecutr
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
UU I-VNM ot/ i, MAN y5 (tzu) PREVIOUS EDITON MAY BE USED
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Pro11'ect and Location 202221
RENTON - WA- CAG-15-149
CASCADE INTERCEPTOR -PHASE II
4784'x 14,18,21,24" CIPP
WA
9/22/2016 7:36:03
Page - 41
Pay Period Ending Date 9/17/2016
Period Number 4
St SMS SDep FMS FDep Sex EEO Union ....................... Craft......................... Step.........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
I
[ NO WORK PERFORMED _ l
V
^ ,4 y. .
Form QSS-347
CERTIFIED PAYROLL
Page 1 of I
Contractor:
Insituforrn Technologies LLC
Subcontractor: I/
Advanced Government Services Inc
8644 Pacific Ave
Tacoma, WA 98444-6471
Project or Contract No: CAG-15-149 Cascade Interc
Cost Acct. or Other No: CAG-15-149 Cascade Interc
Tax ID No: 20-0053479
Payroll No: 5
For Week Ending: 09/10/2016
Project and Insituform Technologies LLC.2O2221 Cascade Interceptor PI2-Renton
Location: Renton
Name. Address, and
Social Security Number
of Employee
#
Ex
Work
Classification/
Apprentice Rate
OT
or
ST
Day and Date
Total
Hours
Rate
of Pay
Fringe
Ben.
Gross
Amount
Weekly Deduction Totals
Net
Wages
09104
09,05
09,06
0907
0908
09,09
09/10
FICA
State
Other
Total
Ded.
Su
Mo
Tu
We
T,
Fr
Sa
Plan 5
Week
With-
Holding
Local
Tax
Tax
Check
No.
Hours Worked Each Day
Cash $
Class
Ded.
Michael M Johnson
xxx-xx-0541
Journeyman Flagger
O
0
0
0
0
0
0
0
0
000
77 00
74261,
000
8 15
4896
693 69
S
0
0
O
0
C
25 17
000
176 19
84 CO
000
-100 00
21530
Myron D Trov`er
xxx-xx.4619
0
Journeyman Fiagger
O
-
0
0
0
.,
0
_
0
0 00
62 50
906 24
69 33
0 00
21 79
126 12
78C 1:
S
0
0
7 5
0
0
7 5
25 17
0 00
' 88 78
35 00
coo
000
21534
0
S
O
S
0
S
O
S
0
S
0
S
wA&
Date 09/16/2016
I. L Fredrick
(Name of Signatory Party)
PR/AR Manager
(Title)
do hereby state
(1) That I pay or supervise the payment of the persons employed by
Advanced Government Services Inc on the project
Insituform Technologies LLC:202221 Cas that during the payroll period commencing
on the 04 day of September 2016 and ending the 10 day of September
2016 all persons employed on said protect have been paid the full weekly wages earned
that no rebates have been or will be made either directly or indirectly to or on behalf of said
Advanced Government Services Inc from the
tContractor or Subcontractor)
full weekly wages earned by any person and that no deductions have been made either
directly or indirectly from the full wages earned by any person other than permissible
deductions as defined in Regulations Part 3 (29 CFR Subtitle A). issued by the Secretary
of Labor under the Copeland Act. as amended (48 Stat 948, 63 Stat 108 72 Stat 967
76 Stat 357 40 U S C 276c), and described below
Aflac/Colornal Life
Court Ordered Garn/Support
Wa Workers Comp
(2) That any payrolls otherwise under this contract required to be submitted for the
above period are correct and complete that the wage rates for laborers or mechanics
contained therein are not less than the applicable wage rates contained in any wage
determination incorporated into the contract that the classifications set forth therein for
each laborer or mechanic conform with the work he performed.
(3) That any apprentices employed in the above period are duly registered in a bona
fide apprenticeship program registered with a State apprenticeship agency recognized by
the Bureau of Apprenticeship and Training, United States Department of Labor or if no
such recognized agency exists in a State are registered with the Bureau of Apprenticeship
and Training. United States Department of Labor
i4) That
ia1 WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS. OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed in
the above referenced payroll, payments of fringe benefits as listed in the contract
have been or will be made to the appropriate programs for the benefit of such
employees. except as noted in Section 4(c) below
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
-Each laborer or mechanic listed in the above referenced payroll has been paid
as indicated on the payroll. an amount not less than the sum of the applicable
basic hourly wage rate plus the amount of the required fringe benefits as listed
in the contract. except as noted in Section 4(c) below
(c) EXCEPTIONS
EXCEPTION (CRAFT)
EXPLANATION
REMARKS
The prevailing wages have been paid in accordance with the pre -filed Statement of Intent
to Pay Prevailing Wages on file with the public agency (RCW 39 12 070) S11 00 fringe.
per hour worked is deposited to 'The Contractors Plan Administrators" for "Qualified
Medical Insurance and/or 401K Retirement Plan"
NAME AND TITLE
L Fredrick
PR/AR Manager
SIGNATURE
/i
THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT
THE CONTRACTOR OR SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION
SEE SECTION 1001 OF TITLE 18 AND SECTION 231 OF TITLE 31 OF THE UNITED
STATES CODE
Form OSS-348
Monthly Employment Utilization Report U.S. Department of Labor
Employment Standards Administration - Office of Federal Contract Compliance Programs
This report is required by Executive Order 11246, Sec 203 Failure to report can result in contracts
being cancelled terminated or suspended in whole or in part and the conlractoi may be oeclared
ineligible for further Government contracts of federally assisted construction contracts
1. Covered Area (SMSA or EA)
2 Employers LD No.
20-0053479
0M8 No. 1215-01633
3 Current Goals
Minority 6.5
Female 6.9
4 Reporting Period
From 08/01/2016
To 08/31/2016
Name and Location of Contractor
Advanced Government Services Inc
8644 Pacific Ave
Tacoma, WA 98444-6471
Project and Location
Insituform Technologies LLC:202221 Cascade
Interceptor PH2-Renton
Renton
Federal Funding Agency
5
CONSTRUCTION
TRADE
Classifications
6 TOTAL FEDERAL
& NON-FEDERAL
CONSTRUCTION
WORK
HOURS
s
Total
Number of
Employees
to
Total Number of
Minority Employees
6a
Total All
Employees
By Trade
6b
Black
(Not of
Hispanic Origin)
6c
Hispanic
6d
Asian or
Pacific
Islander
6e
American
Indian or
Nalive American
7
A4uionty
Percentage
8
Female
Percentage
M
F
M
I F
M
F
M
F
M
F
M
F
M
F
Flagger
Journey Worker
40.5
41.25
205
0
0
0
0
0
0
0
25,08%
50.46%
2
2
1
0
Apprentice
0
0
0
0
0
0
0
0
0
0
0
0
-
0
0
Trainee
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Sub -Total
81.75
20.5
0
0
0
4
1
Journey Worker
Apprentice
Trainee
Sub -Total
Journey Worker
Apprentice
Trainee
Sub -Total
Journey Worker
Apprentice
Trainee
Sub -Total
Journey Worker
Apprentice
Trainee
Sub -Total
Total Journey Worker
40.5
41 25
20.5
0
0
0
0
0
0
0
25.08%
50.460"o
2
2
1
0
Total Apprentice
o
0
0
0
0
0
0
0
0
0
0
0
0
0
Total Trainee
0
0
0
b
0
0
0
0
0
C
0
0
0
0
Grand Total
81.75
20.5
0
0
0
4
1
11. Company Official's Signature and Title
12. Telephone Number
Q (Include area code)
rtt- /j f - t
13. Date Signed I Page
531-9782 j
1 of 1
Form CC-257
BUREAU OF LABOR AND INDUSTRIES
WAGE AND HOUR DIVISION
PRIME CONTRACTOR ❑ SUBCONTRACTOR 29
PAYROLL NO. �
PAYROLLICERTIFIED STATEMENT FORM WH-38
FOR USE IN COMPLYING WITH ORS 279C.845'
FINAL PAYROLL ❑
Business Name (OBA): ' _&10ve_ pLpe—, serv," ,e C73. Phone: CCB Registration Number:
Pro ect Name: [,( p Project Number: Type of Work:
Street Address: , _5�?
Mailing Address 0 P30 x �'�}I
Project Location:
Project County:
Date Pay Period Began:
lcp Date Pay Period Ended:
4
THIS SECTION FOR PRIME CONTRACTORS ONLY
THIS SECTION FOR SUBCONTRACTORS ONLY
Public Contracting Agency Name:
( )
Date Contract Specifications First Advertised for Bid:
Contract Amount:
Subcontract Amount:
Prime Contractor Business Name (DBA): _S
Prime Contractor Phone: ( ) A✓t
Prime Contractor's CCB Registration Number.
Date You Be an Work on the Project:
1
2
3 DAY AND DATE
4
5
6
7
8
9
1( 0)
11
NAME, ADDRESS AND
EMPLOYEE'S
IDENTIFICATION
NUMBER
CLASSIFICATION
(INCLUDE GROUP p
AND APPRENTICESHIP
STEP IF APPLICABLE)
5
'�
r
VV
r
1
TOTAL
HOURS
HOURLY
BASE
RATE
HOURLY
FRINGE
BENEFIT
AMOUNTS
PAID AS
WAGES TO
EMPLOYEE
GROSS
AMOUNT
EARNED (see
directions)
ITEMIZED
DEDUCTIONS
FICA, FED,
STATE, ETC.
NET WAGES
PAID
HOURLY FRINGE
BENEFITS PAID
TO BENEFIT
PARTY, PLAN,
FUND, OR
PROGRAM
NAME OF BENEFIT
PARTY, PLAN,
FUND, OR
PROGRAM
^
t
i�
HOURS
WORKED
EACH
DAY
r�E U1S
n�+nmtxdtit.
i �d
t�xY-
OT
j
•5
2
1 W
��.
��
1012.22
ST
3
`�
$
`�
3�
�I
u�
GYz-
Iecl�n;cto
°T
5
1
5
2.
(o
,Ca
1-74
ST
$
55
OT
ST
OT
ST
OT
ST
'Although this form has not been officially approved by the U.S. Department of Labor, it is designed to meet the requirements of both the state PWR law and the federal Davis -Bacon Act.
VVH-38(Rev. 06114)
THIS FORM CONTINUED ON REVERSE
CERTIFIED STATEMENT
Date: 2Z T
�
6t�i��il J r
Ivl
I, rr`���.{.Q.F�t{YE��v J{0 LjOfXa=��S
In addition to completing sections (1) - (3), if your project is subject to the federal
Davis -Bacon Act requirements, complete the following section as well:
(NAME OF SIGNATORY PARTY) (TITLE)
do hereby state:
(1) That I pay or supervise the payment of1he persons employed by:
lK -no rare Pt4&, E-Z"Is C6
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS OR
PROGRAMS
❑ - In addition to the basic hourly wage rates paid to each laborer or mechanic
listed in the above referenced payroll, payments of fringe benefits as listed in
the contract have been or will be made to appropriate programs for the benefit
of such employees, except as noted in Section 4(c) below.
(C011r-T%TO SUBC TRAC,��f� �R SURETY)
on the �� .P.�ntlP/1. ►U?�tN.�hat during the payroll period
(B ILDIN OR WORK)
commencing on the day of . i� O , and ending the10 day
��'rn (MONTH) (YEAR)
f oall persons employed on said project have been paid the
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
(MON ) (YEAR)
full weekly wages earned, that no rebates have been g�will be made either directly or
indirectly to or on behalf of said C—{YlUlrf' 1 ixe SC✓V'LPS_
(CONTRACTOR, SUBC NTRACTOR OR SURETY)
from the full weekly wages earned by any person, and that no deductions have been
❑ - Each laborer or mechanic listed in the above referenced payroll has been paid,
as indicated on the payroll, an amount not less than the sum of the applicable
basic hourly wage rate plus the amount of the required fringe benefits as listed
in the contract, except as noted in Section 4(c) below.
made either directly or indirectly from the full wages earned by any person, other than
permissible deductions as specified in ORS 652.610, and as defined in Regulations, Part
(c) EXCEPTIONS:
3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as
amended (48 Stat. 948, 63 Stat. 108, 72 Stat. 967; 76 Stat. 357; 40 U.S.C. 276c), and
EXCEPTION (CRAFT) EXPLANATION
described below:
(2) That any payrolls otherwise under this contract required to be submitted for the above
period are correct and complete; that the wage rates for workers contained therein are
not less than the applicable wage rates contained in any wage determination
incorporated into the contract, that the classifications set forth therein for each worker
conform with work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide
apprenticeship program registered with a state apprenticeship agency recognized by the
REMARKS:
Bureau of Apprenticeship and Training, United States Department of Labor, or if no such
recognized agency exists in a state, are registered with the Bureau of Apprenticeship
and Training, United States Department of Labor.
NAME AND TITLE SIGNATURE
I HAVE READ THIS CERTIFIED STATEMENT, KNOW THE CONTENTS THEREOF
AND IT IS TRUE TO MY KNOWLEDGE:
1 p
►re{Zc{yZ 0�� �IJLG{,°iy�r4(VP 11)(;,5
THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY
SUBJECT THE CONTRACTOR OR SUBCONTRACTOR TO CIVIL OR CRIMINAL
PROSECUTION. SEE SECTION 1001 OF TITLE 18 AND SECTION 231 OF TITLE 31
(NAME AND TITLE)
e-A
jb
OF THE UNITED STATES CODE.
(GNAT R AND DATE
FILE THIS FORM WITH THE PUBLIC AGENCY ASSOCIATED WITH THE PROJECT
NOTE TO CONTRACTORS: YOU MUST ATTACH COPIES OF THIS FORM TO EACH OF YOUR PAYROLL SUBMISSIONS ON THIS PROJECT.
INSTRUCTIONS AND ADDITIONAL FORMS ARE AVAILABLE ON OUR WEBSITE: WWW.OREGON.GOV/BOLT.
BUREAU OF LABOR AND INDUSTRIES
WAGE AND HOUR DMSION
PRIME CONTRACTOR ❑ SUBCONTRACTOR
PAYROLL NO. ri
PAYROLUCERTIFIED STATEMENT FORM WH-38
FOR USE IN COMPLYING WITH ORS 279C.845'
FINAL PAYROLL -
Business Name (DBA): ' _ fYLr Y-e— PLPe-- se-i v," % Phone: (� ?�) (dZ3 -l3 Lu CCB Registration Number. l Z_'I t= X?CD
Project Name: G ( Project Number: Type of Work: %
Street Address: ?�_q� '-
Mailing Address:
Project Location:
Project County:
Date Pay Period Began: r Date Pay Period Ended: --)
THIS SECTION FOR PRIME CONTRACTORS ONLY
THIS SECTION FOR SUBCONTRACTORS ONLY
Public Contracting Agency Name:
Phone: ( )
Date Contract Specifications First Advertised for Bid:
Contract Amount:
Subcontract Amount:
Prime Contractor Business Name (DBA): ��c �( �l
Prime Contractor Phone: ( )
Prime Contractor's CCB Registration Number:
Date You Began Work on the Pro ect.
1
2
3 DATE
4
5
6
7
8
9
10
11
NAME, ADDRESS AND
EMPLOYEE'S
IDENTIFICATION
NUMBER
CLASSIFICATION
(INCLUDE GROUP #
AND APPRENTICESHIP
STEP IF APPLICABLE(
!�"1
—
I
VDAAY `^AN,D
Y
'
r
S
TOTAL
HOURS
HOURLY
BASE
RATE
HOURLY
FRINGE
BENEFIT
AMOUNTS
PAID AS
WAGES TO
EMPLOYEE
GROSS
AMOUNT
EARNED (see
directions)
ITEMIZED
DEDUCTIONS
FICA, FED,
STATE, ETC.
NET WAGES
PAID
HOURLY FRINGE
BENEFITS PAID
TO BENEFIT
PARTY, PLAN,
FUND, OR
PROGRAM
NAME OF BENEFIT
PARTY, PLAN,
FUND, OR
PROGRAM
�,,
I
I�
HOURS
WORKED
EACH
DAY
�eia
OT
�
Z
3
C%u�b
OT
I i5
-2—
3
f
ST
OT
ST
OT
ST
OT
I
ST
'Although this form has not been officially approved by the U.S. Department of Labor, it is designed to meet the requirements of both the state PWR law and the federal Davis -Bacon Act.
WH-38 (Rev. 06114)
THIS FORM CONTINUED ON REVERSE
Date:
cAlZ3lI�0 I
I, ,'�9'�ttLt tit �C q . jl,f` ctn {Ycx � P Cpe '� cyis
(NAME OF SIGNATORY PARTY) (TITLE)
do hereby state:
(1) That I pay or supervise the payment ofthe p rsons employed by:
J)A
�r ONT TOR, SUBC, TRACTOR OR SURETY)
on the P till�.� �pPJA� , that during the payroll period
(BUILDING OR WORK
commencing commencing on the day oftl� and ending the L-1 day
(MO TH) (YEAR)
all persons employed on said project have been paid the
(MONTH) (YEAR)
full weekly wages earned, that no rebates have been will be made either directly or
indirectly to or on behalf of said (2--i"we j. ,zt° �C'+'✓+GPI
(CONTRACTOR, SUBC NTRACTOR OR SURETY)
from the full weekly wages earned by any person, and that no deductions have been
made either directly or indirectly from the full wages earned by any person, other than
permissible deductions as specified in ORS 652.610, and as defined in Regulations, Part
3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as
amended (48 Stat. 948, 63 Stat. 108, 72 Stat. 967; 76 Stat. 357: 40 U.S.C. 276c), and
described below J, � t ; bS" (C���
(2) That any payrolls otherwise under this contract required to be submitted for the above
period are correct and complete; that the wage rates for workers contained therein are
not less than the applicable wage rates contained in any wage determination
incorporated into the contract, that the classifications set forth therein for each worker
conform with work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide
apprenticeship program registered with a state apprenticeship agency recognized by the
Bureau of Apprenticeship and Training, United States Department of Labor, or if no such
recognized agency exists in a state, are registered with the Bureau of Apprenticeship
and Training, United States Department of Labor.
I HAVE READ THIS CERTIFIED STATEMENT, KNOW THE CONTENTS THEREOF
AND IT IS TRUE TO MY KNOWLEDGE
13fe_vt,:�Q Mc�CaN . kcc n~ yet : } VP GAS
(NAME AND TITLE)
1 -f-A ac e , �r '7tit - q 12Zc ► �0
TU
TATEME
In addition to completing sections (1) - (3), if your project is subject to the federal
Davis -Bacon Act requirements, complete the following section as well:
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS OR
PROGRAMS
❑ - In addition to the basic hourly wage rates paid to each laborer or mechanic
listed in the above referenced payroll, payments of fringe benefits as listed in
the contract have been or will be made to appropriate programs for the benefit
of such employees, except as noted in Section 4(c) below-
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
❑ - Each laborer or mechanic listed in the above referenced payroll has been paid,
as indicated on the payroll, an amount not less than the sum of the applicable
basic hourly wage rate plus the amount of the required fringe benefits as listed
in the contract, except as noted in Section 4(c) below.
(c) EXCEPTIONS:
EXCEPTION (CRAFT) EXPLANATION
REMARKS:
NAME AND TITLE SIGNATURE
THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY
SUBJECT THE CONTRACTOR OR SUBCONTRACTOR TO CIVIL OR CRIMINAL
PROSECUTION. SEE SECTION 1001 OF TITLE 18 AND SECTION 231 OF TITLE 31
OF THE UNITED STATES CODE.
FILE THIS FORM WITH THE PUBLIC AGENCY ASSOCIATED WITH THE PROJECT
NOTE TO CONTRACTORS: YOU MUST ATTACH COPIES OF THIS FORM TO EACH OF YOUR PAYROLL SUBMISSIONS ON THIS PROJECT.
INSTRUCTIONS AND ADDITIONAL FORMS ARE AVAILABLE ON OUR WEBSITE: WWW.OREGON.GOVIBOLI.
NCH-38 (Rev.
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30 1997
Public reporting burden for this collection of information 6 estimated to average 16 minutes per response including the time for reviewing instructions searching existing data sources.
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection
of information including suggestions for reducing this burden. to Department of Defense. Washington Headquarters Services. Directorate for Information Operations and Reports 1215
Jefferson Davis Highway Suite 1204. Arlington. VA 22202-4302. and to the Office of Management and Budget. Paperwork Reduction Protect 0215-0149) Washington. DC 20503
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
4. PAYROLL NUMBER
AYROLL PAYMENT DATE (YYMMDDi
r
3 CONTRACT NUMBER
4 DATE iYYMMDD
45
16/08/12
16/08/12
Stephanie Forrest Payroll Specialist do hereby state
(Name of signatory parry) 17 rtlei
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Contractor or subcontractor;
on the CAG-15-149 that during the payroll period commencing on the 31 day of
(Building or work)
July 201 6 and ending the 6 day of August 201 6 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or Indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations. Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act. as amended
(48 Stat 948, 63 Stat 108. 72 Stat 967, 76 Stat 357. 40 U.S.C. 276c). and described below:
Federal. Fica. State and Local tax. 401K. Loan re -payment. Insurance. garnishments
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete: that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform with the work performed
(3) That any apprentices employed in the above period are duly registered In a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training. United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training. United States Department of Labor.
(4) That
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted In Section 4 (C) below
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll. an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5 REMARKS
6 NAME (Last First Middle Initial)
TITLE
8 SIGNATURE
Forrest, Stephanie
TPayroll Specialist
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or cnmi osecutr
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
UU t-UKM D/y, MHK y5 (t:u) PREVIOUS EDITON MAY BE USED
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Pro ect and Location 202221
RATON - WA- CAG-15-149
CASCADE INTERCEPTOR-PHASEII
4784'x 14,18,21,24" CIPP
WA
8/10/2016 12:13:32
Page - 38
Pay Period Ending Date 8/6/2016
Period Number 2
St SMS SDep
FMS FDep Sex
EEO Union .......................
Craft .........................
Step .........................
Social Security No
Ethnic Cat
....... Regular ..............
Overtime ......
Other
Total
Job
......... Check Detail ..........
Name/Address
Work Date Hours Rate
Hours Rate
Hours
Hours
Amount
Description Amount
MO S
S M
008 1971 For HBU 1971 Accrual
PIPL Pipelayer
default
XXX-XX-5785
White
Shane M Ayers
SA 8/6/2016
12.00 65.190
9.00
21.00
1,564.56
Payment Number:04927276
1575 Fircrest Ct SE
Pipelayer
12.00
9.00
21.00
1,564.56
Gross Pay
3,595.47
Salem OR 97306
OR Departmen
326.67
United States
FED W/H Tax
689.05
FICA W/H
223.54
Medicare W/H
52.28
Garnish %
575.98
Total Deduct
1,867.52
Net Pay
1,727.95
Hrs This Chk
65.00
Subtotal for Payment Number:04927276
12.00
9.00
21.00
1,564.56
Shane M Ayers
12.00
9.00
21.00
1,564.56
MO S S 1 M 008 1971 For HBU 1971 Accrual PIPL Pipelayer
XXX-XX-0002 White
Adam Eugene Clary SA 8/6/2016 12.00 65.190
1768 Pine Street Pipelayer 12.00
Silverton OR 97381
United States
Subtotal for Payment Number:04927281 12.00
Adam Eugene Clary 12.00
default
9.00
21.00
1,564.56
Payment
Number:04927281
9.00
21.00
1,564.56
Gross Pay
3,501.94
OR Departmen
316.42
FED W/H Tax
812.71
FICA W/H
217.12
Medicare W/H
50.78
Chd Sup $/%
98.08
Total Deduct
1,495,11
Net Pay
2,006.83
Hrs This Chk
61.00
9.00
21.00
1,564.56
9.00
21.00
1,564.56
R07371 Aegion Corporation 8/10/2016 12:13:32
Certified Payroll Register Page - 39
Pay Period Ending Date 8/6/2016
INSITUFORM TECHNOLOGIES LLC Pro'ect and Location 202221 Period Number 2
17988 EDISON AVE RNTON - WA- CAG-15-149
CHESTERFIELD MO 63005 CASCADL1 NT1 RC24"EPTOR-PHASE II
WA
St SMS SDep FMS FDep Sex EEO Union .................... Craft .................... Step ..................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
MO S S 1 M 007 1971 For HSU 1971 Accrual
XXX-XX-0687 White
Brian Mitchell Hille SA 8/6/2016
3150 SW 108th Ave Pipelayer
Beaverton OR 97005
United States
Subtotal for Payment Number: 04927285
Brian Mitchell Hille
MO M M M 008 1971 For HBU 1971 Accrual
XXX-XX-8053 White
Brennon Christopher Pratt SA 8/6/2016
1634 SE Jonathan Avenue Pipelayer
Dallas OR 97338
United States
Subtotal for Payment Number:04927269
Brannon Christopher Pratt
PIPL Pipelayer
default
12.00 65.190
9.00
21.00
1,564.56
Payment Number:04927285
12.00
9.00
21.00
1,564.56
Gross Pay 3,605.88
OR Departmen 327.49
FED W/H Tax 844.03
FICA W/H 224.06
Medicare W/H 52.40
Total Deduct 1,447.98
Net Pay 2,157.90
Hrs This Chk 63.00
12.00
9.00
21.00
1,564.56
12.00
9.00
21.00
1,564.56
PIPL Pipelayer
default
12.00 65.190
9.00
21.00
1,564.56
Payment Number:04927289
12.00
9.00
21.00
1,564.56
Gross Pay 3,495.78
OR Deparlmen 286.83
FED W/H Tax 682.50
FICA W/H 216.74
Medicare W/H 50.69
Total Deduct 1,236.76
Net Pay 2,259.02
Hrs This Chk 61.00
12.00
9.00
21.00
1, 564.56
12.00
9.00
21.00
1,564.56
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Project and Location 202221
RENTON - WA- CAG-15-149
CASCA11NTt21 RCEPT DI`_OR-PHASE II
WA
8/10/2016 12:13 32
Page - 40
Pay Period Ending Date 8/6/2016
Period Number 2
St SMS SDep FMS FDep Sex EEO Union .................... Craft .................... Step ..................
Social Security No Ethnic Cat ....... Regular ....... I ...... Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
RENTON - WA- CAG-15-149 48.00 36.00 84.00 6,258.24
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30, 1997
Public reporting burden for this collection of information is estimated to average 15 minutes per response Including the time for reviewing instructionssearching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden. to Department of Defense. Washington Headquarters Services. Directorate for Information Operations and Reports. 1215
Jefferson Davis Highway. Suite 1204. Arlington. VA 22202-4302. and to the Office of Management and Budget. Paperwork Reduction Project (1215-0149) Washington. DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES, RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1 PAYROLL NUMBER
PAYROLL PAYMENT DATE (YYMMDD)
3. CONTRACT NUMBER
4 DATE (YYMMDDI
50
F16/09/16
1 16/09/16
Stephanie Forrest Payroll Specialist do hereby state
(Name of signatory party) , Tire,
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Contractor or subcontractor,
on the CAG-15-149 that during the payroll period commencing on the 4 day of
(Building or w010
September 201 6 and ending the 10 day of September 201 6 all persons employed
on said project have been paid the full weekly wages earned. that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subcontractor)
and that no deductions have been made either directly or indirectly from the full wages eamed by any person, other than permissible
deductions as defined in Regulations. Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat 948. 63 Stat. 108, 72 Stat. 967. 76 Stat. 357, 40 U. S. C. 276c), and described below.
Federal. Fica. State and Local tax. 401 K, Loan re -payment. Insurance. garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete, that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract. that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training. United States Department of Labor
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract.
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5 REMARKS
6 NAME (Last First Middle Initial)
TIT-E
8 SIGNATUR
Forrest, Stephanie
TPayroll Specialist
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or cnmtina ro ti
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
UU FUKM d/9. MAK 9b (E(i) PREVIOUS EDITON MAY BE USED
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Pro'ect and Location 202221
RE�TON - WA- CAG-15-149
CASCADE INTERCEPTOR-PHASEII
4784'x 14,18,21,24" CIPP
WA
9/15/2016 7:3934
Page - 39
Pay Period Ending Date 9/10/2016
Period Number 3
St SMS SDep FMS FDep Sex EEO Union ....................... Craft......................... Step.........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
NO WORK PERFORMED —
Form QSS-347 CERTIFIED PAYROLL Page 1 of 1
Contractor: ❑
Insituform Technoloqies LLC
Subcontractor: IV71
Advanced Government Services Inc
8644 Pacific Ave
Tacoma, WA 98444-6471
Project or Contract No: CAG-15-149 Cascade Interc
Cost Acct. or Other No: CAG-15-149 Cascade Interc
Tax ID No: 20-0053479
Payroll No: 4
For Week Ending: 09/03/2016
Project and Insituform Technologies LLC:202221 Cascade Interceptor PI2-Renton
Location: Renton
Name, Address, and
Social Security Number
of Employee
#
Ex
Work
Classification/
Apprentice Rate
OT
or
ST
Day and Date
Total
Hours
Rate
of Pay
Fringe
Ben.
Gross
Amount
We ly Deduction Totals
Net
Wages
9
08/28
08/29
08/30
08/31
09/01
09/02
09/03
FICA
State
Other
Total
Ded.
Su
Mo
Tu
I we
I Th
Fr
Sa
Plan $
Week
With-
Holding
Local
Tax
Tax
Check
No.
Hours Worked Each Day
Cash $
Class
Ded.
No Work Performed.
O
s
0
s
0
S
0
S
�S
0
0
s
0
S
0
S
Date 09/09/2016
I, L Fredrick PR/AR Manager
(Name of Signatory Party) (Title)
do hereby state:
(1) That I pay or supervise the payment of the persons employed by
Advanced Government Services Inc on the project
Insituform Technologies LLC:202221 Cas that during the payroll period commencing
on the 28 day of August 2016 and ending the 03 day of September
2016 , all persons employed on said project have been paid the full weekly wages earned,
that no rebates have been or will be made either directly or indirectly to or on behalf of said
Advanced Government Services Inc from the
(Contractor or Subcontractor)
full weekly wages earned by any person and that no deductions have been made either
directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary
of Labor under the Copeland Act, as amended (48 Stat 948, 63 Stat. 108, 72 Stat 967,
76 Stat. 357, 40 U.S.C. 276c), and described below:
Aflac/Colonial Life
Court Ordered Garn/Support
Wa Workers Comp
(2) That any payrolls otherwise under this contract required to be submitted for the
above period are correct and complete, that the wage rates for laborers or mechanics
contained therein are not less than the applicable wage rates contained in any wage
determination incorporated into the contract; that the classifications set forth therein for
each laborer or mechanic conform with the work he performed.
(3) That any apprentices employed in the above period are duly registered in a bona
fide apprenticeship program registered with a State apprenticeship agency recognized by
the Bureau of Apprenticeship and Training, United States Department of Labor, or if no
such recognized agency exists in a State, are registered with the Bureau of Apprenticeship
and Training, United States Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed in
the above referenced payroll, payments of fringe benefits as listed in the contract
have been or will be made to the appropriate programs for the benefit of such
employees, except as noted in Section 4(c) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
-Each laborer or mechanic listed in the above referenced payroll has been paid,
as indicated on the payroll, an amount not less than the sum of the applicable
basic hourly wage rate plus the amount of the required fringe benefits as listed
in the contract, except as noted in Section 4(c) below.
(c) EXCEPTIONS
EXCEPTION (CRAFT)
EXPLANATION
REMARKS
The prevailing wages have been paid in accordance with the pre -filed Statement of Intent
to Pay Prevailing Wages on file with the public agency. (RCW 39.12.070) $11.00 fringe,
per hour worked, is deposited to "The Contractors Plan Administrators" for "Qualified
Medical Insurance and/or 401 K Retirement Plan".
NAME AND TITLE
L Fredrick
PR/AR Manager
SIGNATURE
/
THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT
THE CONTRACTOR OR SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION.
SEE SECTION 1001 OF TITLE 18 AND SECTION 231 OF TITLE 31 OF THE UNITED
STATES CODE.
Form OSS-348
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30. 1997
Public reporting oumen for this collection of information is estimated to average 16 minutes per response. including the time for reviewing instructions. searching existing data sources.
gathering and maintaining the data needed, and completing and reviewing the collection of information Send comments regarding this burden estimate or any other aspect of this collection
of information. including suggestions for reducing this burden. to Department of Defense Washington Headquarters Services. Directorate for Information Operations and Reports 1215
deflerson Davis Highway Suite 12D4, Arlington VA 22202-4302. and to the Office of Management and Budget. Paperwork Reduction Project (1215-0149) Washington. DC 20503
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
'i PAYROLL NUMBER
AYROLL PAYMENT DATE (YYMMDD)
F
3 CONTRACT NUMBER
� DATE YYMPdDD
49
16/09/09
16/09/09
Stephanie Forrest Payroll Specialist do hereby state
(Name of signatory partyi
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Contractor or subcontractor,
on the CAG-15-149 i that during the payroll penod commencing on the 28 day of
!Building or work)
August 201 6 and ending the 3 day of September 201 6 all persons employed
or, said project have been paid the fuli weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person other than permissible
deductions as defined in Regulations. Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat. 948, 63 Stat 108, 72 Stat 967. 76 Stat. 357: 40 U.S C. 276c). and described below
Federal, Fica, State and Local tax, 401 K. Loan re -payment. Insurance. garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete, that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract that the classifications set forth therein for each laborer or mechanic conform with the work performed
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training. United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training. United States Department of Labor
(4) That
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5 REMARKS
6 NAME (Last First Middle Initial)
TITLE
8 SIGN U`)-.N\
Forrest, Stephanie
Payroll Specialist
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or cri final o ecu
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code
UU I-UKM bl/ j. MAK Vb (Eu) PREVIOUS EDITON MAY BE USED
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Pro'ect and Location 202221
RE TON - WA- CAG-15-149
CASCADE INTERCEPTOR-PHASEII
4784'x 14,18,21,24" CIPP
WA
St SMS SDep FMS FDep Sex EEO Union ....................... Craft ......................... Step .........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ......... .
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
[ ------NO WORK PERFORMED --
;t
9/B/2016 7:43:06
Page - 39
Pay Period Ending Date 9/3/2016
Period Number 2
f
z,5Lz L (
BUREAU OF LABOR AND INDUSTRIES PAYROLLICERTIFIED STATEMENT FORM WH-38
WAGE AND HOUR DIVISION c FOR USE IN COMPLYING WITH ORS 279C.845-
PRIME CONTRACTOR ❑ SUBCONTRACTOR PAYROLL NO. J FINAL PAYROLL \
Business Name (DBA): ''_� _•� tMOV-e- ptq� -)� SeW, c -, % . : C• Phone: ( ,) 4'Z-�i"I� l�� CCB Registration Number. (Z" 0qL-)
Project Name Dt QWVA Project Number: TypeofWok
Street Address: 3 ; �a�L ?c .
Mailing Address: P c,Z1vect-LE, Or'— { ��.�
Project Location:
Project County:
Date Pay Period Began: Date Pay Period Ended:
THIS SECTION FOR PRIME CONTRACTORS ONLY
ITHIS
SECTION FOR SUBCONTRACTORS ONLY
Public Contracting Agency Name:
Phone: ( )
Date Contract Specifications First Advertised for Bid:
Contract Amount:
Subcontract Amount:
Prime Contractor Business Name (DBA) Z(�l5[�yt 1M TeG�n .
Prime Contractor Phone: ( )
Prime Contractor's CCB Registration Number:
Date You Began Work on the Pro ect:
1
2
3 DAY AND DATE
4
5
6
7
8
9
10
11
NAME, ADDRESS AND
EMPLOYEE'S
IDENTIFICATION
NUMBER
CLASSIFICATION
(INCLUDE GROUP #
AND APPRENTICESHIP
STEP IF APPLICABLE)
m
rj�
V V
�,'
(YZ
C j
TOTAL
HOURS
HOURLY
BASE
RATE
HOURLY
FRINGE
BENEFIT
AMOUNTS
PAID AS
WAGESTO
EMPLOYEE
GROSS
AMOUNT
EARNED (see
directions)
ITEMIZED
DEDUCTIONS
FICA, FED,
STATE, ETC.
NET WAGES
PAID
BENEFITS TSRPA DE
TO BENEFIT
PARTY, PLAN,
FUND, OR
PROGRAM
NAME OF BENEFIT
PARTY, PLAN,
FUND, OR
PROGRAM
Z'
HOURS WORKED EACH DAY
V_aAA—
T`r� 1.bi2_
A,"l'D✓
OT
X„�'�-;
ST
b
iu
`rc�
ty
OT
STJA
OT
ST
OT
ST
OT
ST
'Although this form has not been officially approved by the U.S. Department of Labor, it is designed to meet the requirements of both the state PWR law and the federal Davis -Bacon Act.
WH-38 (Rev. 08114)
THIS FORM CONTINUED ON REVERSE
for
CERTIFIED STATEMENT
Date: [rd ( ("::'
In addition to completing sections (1) - (3), if your project is subject to the federal
rz. LL� I
L I: Xti'� �t �'I L`� ✓tf - � [l rt [4'c�>ti:; Vic) C�i'.r�`�'i U`YLS
Davis -Bacon Act requirements, complete the following section as well:
,
(NAME OF SIGNATORY PARTY) (TITLE)
(4) That:
do hereby state:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS OR
(1) That I pay or sue the payment of the persons employed by:
T-myrif E42c� C6
PROGRAMS
❑ - In addition to the basic hourly wage rates paid to each laborer or mechanic
listed in the above referenced payroll, payments of fringe benefits as listed in
the contract have been or will be made to appropriate programs for the benefit
(CONTRACTOR, SUBCONTRACTOR OR SURETY)
on the ; that during the payroll period
(BUILDING OR WORK)
commencing on the day of ` and ending the = r day
of such employees, except as noted in Section 4(c) below.
(MONTH) (YEAR)
of all persons employed on said project have been paid the
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
(MONTH) (YEAR)
full weekly wages earned, that no rebates have been will be made either directly or
indirectly to or on behalf of said C-VYl(afU' 1 LiIE-SC'ry'Lxs
❑ - Each laborer or mechanic listed in the above referenced payroll has been paid,
as indicated on the payroll, an amount not less than the sum of the applicable
(CONTRACTOR, SUBCONTRACTOR OR SURETY)
basic hourly wage rate plus the amount of the required fringe benefits as listed
from the full weekly wages earned by any person, and that no deductions have been
in the contract, except as noted in Section 4(c) below.
made either directly or indirectly from the full wages earned by any person, other than
permissible deductions as specified in ORS 652.610, and as defined in Regulations, Part
(c) EXCEPTIONS:
3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as
amended (48 Stat. 948, 63 Stat. 108, 72 Stat. 967; 76 Stat. 357, 40 U.S.C. 276c), and
EXCEPTION (CRAFT) EXPLANATION
described below. _ �--
V / 1
i I `c t,�i
(2) That any payrolls otherwise under this contract required to be submitted for the above
period are correct and complete; that the wage rates for workers contained therein are
not less than the applicable wage rates contained in any wage determination
incorporated into the contract; that the classifications set forth therein for each worker
conform with work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide
apprenticeship program registered with a state apprenticeship agency recognized by the
REMARKS:
Bureau of Apprenticeship and Training, United States Department of Labor, or if no such
recognized agency exists in a state, are registered with the Bureau of Apprenticeship
and Training, United States Department of Labor.
NAME AND TITLE SIGNATURE
I HAVE READ THIS CERTIFIED STATEMENT, KNOW THE CONTENTS THEREOF
AND IT IS TRUE TO MY KNOWLEDGE. \'`D
f� t� Ntt: — kzzlgf Yc'�U v J
THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY
SUBJECT THE CONTRACTOR OR SUBCONTRACTOR TO CIVIL OR CRIMINAL
PROSECUTION. SEE SECTION 1001 OF TITLE 18 AND SECTION 231 OF TITLE 31
( ME AND TITLE)
OF THE UNITED STATES CODE.
S NATU AND DATE
FILE THIS FORM WITH THE PUBLIC AGENCY ASSOCIATED WITH THE PROJECT
NOTE TO CONTRACTORS: YOU MUST ATTACH COPIES OF THIS FORM TO EACH OF YOUR PAYROLL SUBMISSIONS ON THIS PROJECT.
INSTRUCTIONS AND ADDITIONAL FORMS ARE AVAILABLE ON OUR WEBSITE: WWW.OREGON.GOV/BOLT.
wrt-:sss (rtev. UW14)
0.9Z7_l
BUREAU OF LABOR AND INDUSTRIES
WAGE AND HOUR DIVISION
PRIME CONTRACTOR ❑ SUBCONTRACTOR 29
PAYROLL NO.
PAYROLUCERTIFIED STATEMENT FORM WH-38
FOR USE IN COMPLYING WITH ORS 279C.845'
FINAL PAYROLL ❑
Business Name (DBA): _.�1DY'eG P�rG `��►'�/�c e�� U. Phone: (' ) U=Z,?j-11icl CCB Registration Number: 12 C>e{C?
Project Name: Ci( Pro ect Number: T e of Work:
Street Address: _�
Mailing Address:C
c �t'ctL[, ►=
Project Location:
Project County:
Date Pay Period Be an: Date Pay Period Ended:
THIS SECTIONTOR PRIME CONTRACTORS ONLY
THIS SECTION FOR SUBCONTRACTORS ONLY
Public Contracting Agency Name
( )
Date Contract Specifications First Advertised for Bid:
Contract Amount:
Subcontract Amount
Prime Contractor Business Name (DBA):c�
Prime Contractor Phone: ( ) w1
Prime Contractor's CCB Registration Number.
Date You Began Work on the Pro ect:
1
2
3 DAY AND DATE
4
5
6
7
8
9
10
11
NAME , ADDRESS AND
EMPLOYEE'S
IDENTIFICATION
NUMBER
CLASSIFICATION
(INCLUDE GROUP 0
AND APPRENTICESHIP
STEP IF APPLICABLE)
n�}
M
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(/ �
V 4
i
1
(�
i
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TOTAL
HOURS
HOURLY
BASE
RATE
HOURLY
FRINGE
BENEFIT
AMOUNTS
PAID AS
WAGESTO
EMPLOYEE
GROSS
AMOUNT
EARNED (see
directions)
ITEMIZED
DEDUCTIONS
FICA, FED,
STATE, ETC.
NET WAGES
PAID
HOURLY FRINGE
BENEFITS PAID
TO BENEFIT
PARTY, PLAN.
FUND, OR
PROGRAM
NAME OF BENEFIT
PARTY, PLAN,
FUND, OR
PROGRAM
,
Q
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10
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'Although this form has not been officially approved by the U.S. Department of Labor, it is designed to meet the requirements of both the state PWR law and the federal Davis -Bacon Act.
VIM-38 (Rev. W14)
THIS FORM CONTINUED ON REVERSE
Date:
(NAME OF SIGNATORY PARTY) (TITLE)
do hereby state:
(1) That I pay or supervise the payment of the pgrsons employed to
(COj4T_RACTOR, S 5CO TRACTOR OR SURETY)
l on the P 113, r that during the payroll period
(BUILDING OR WORK)
commencing on the �_ day of7Di
(L, and ending the day
(MONT ) (YEAR)
of all persons employed on said project have been paid the
(MONT (YEAR)
full weekly wages earned, that no rebates have been QLwill be I made either directly or
indirectly to or on behalf of said C—{'Ylt � L'Qf See—y+CPS
(CONTRACTOR, SUBCONTRACTOR OR SURETY)
from the full weekly wages earned by any person, and that no deductions have been
made either directly or indirectly from the full wages earned by any person, other than
permissible deductions as specified in ORS 652.610, and as defined in Regulations, Part
3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as
amended (48 Stat. 948, 63 Stat. 108, 72 Stat. 967; 76 Stat. 357; 40 U.S.C. 276c), and
described below EAL
(2) That any payrolls otherwise under this contract required to be submitted for the above
period are correct and complete; that the wage rates for workers contained therein are
not less than the applicable wage rates contained in any wage determination
incorporated into the contract; that the classifications set forth therein for each worker
conform with work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide
apprenticeship program registered with a state apprenticeship agency recognized by the
Bureau of Apprenticeship and Training, United States Department of Labor, or if no such
recognized agency exists in a state, are registered with the Bureau of Apprenticeship
and Training, United States Department of Labor.
I HAVE READ THIS CERTIFIED STATEMENT, KNOW THE CONTENTS THEREOF
AND IT IS TRUE TO MY KNOWLEDGE:
1,R vet't
AND
t MELE) O L t`1
AND DATE
In addition to completing sections (1) - (3), if your project is subject to the federal
Davis -Bacon Act requirements, complete the following section as well:
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS OR
PROGRAMS
❑ - In addition to the basic hourly wage rates paid to each laborer or mechanic
listed in the above referenced payroll, payments of fringe benefits as listed in
the contract have been or will be made to appropriate programs for the benefit
of such employees, except as noted in Section 4(c) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
❑ - Each laborer or mechanic listed in the above referenced payroll has been paid,
as indicated on the payroll, an amount not less than the sum of the applicable
basic hourly wage rate plus the amount of the required fringe benefits as listed
in the contract, except as noted in Section 4(c) below.
(c) EXCEPTIONS:
EXCEPTION (CRAFT) EXPLANATION
REMARKS:
NAME AND TITLE SIGNATURE
THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY
SUBJECT THE CONTRACTOR OR SUBCONTRACTOR TO CIVIL OR CRIMINAL
PROSECUTION. SEE SECTION 1001 OF TITLE 18 AND SECTION 231 OF TITLE 31
OF THE UNITED STATES CODE.
FILE THIS FORM WITH THE PUBLIC AGENCY ASSOCIATED WITH THE PROJECT
NOTE TO CONTRACTORS: YOU MUST ATTACH COPIES OF THIS FORM TO EACH OF YOUR PAYROLL SUBMISSIONS ON THIS PROJECT.
INSTRUCTIONS AND ADDITIONAL FORMS ARE AVAILABLE ON OUR WEBSITE: WWW.OREGON.GOV/BOLT.
WH-38 (Rev. 06/14)
Z13ZZL(
BUREAU OF LABOR AND INDUSTRIES
WAGE AND HOUR DIVISION
PRIME CONTRACTOR ❑ SUBCONTRACTOR
PAYROLL NO. l
PAYROLUCERTIFIED STATEMENT FORM WH-38
FOR USE IN COMPLYING WITH ORS 279C.845'
FINAL PAYROLL ❑
Business Name (DBA): ' _r1-'Wye. Pi4Z Phone: CCB Registration Number: (ZZ040
Project Name:' . , fU j Project Number: Type of Work:
Street Address: n�.
Mailing Address. X (`�
Project Location:
Project County:
Date Pay Period Began:
IP Date Pay Period Ended:
THIS SECTION FOR PRIME
CONTRACTORS ONLY
THIS SECTION FOR SUBCONTRACTORS ONLY
Public Contracting Agency Name:
Phone: ( )
Date Contract Specifications First Advertised for Bid:
Contract Amount_
Subcontract Amount:
Prime Contractor Business Name (DBA): __-
Prime Contractor Phone: ( BLS
) wt
Prime Contractor's CCB Registration Number:
Date You Began Work on the Pro ect:
1
2
3 DAY AND DATE
4
5
6
7
8
9
10
11
NAME, ADDRESS AND
EMPLOYEE'S
IDENTIFICATION
NUMBER
CLASSIFICATION
[INCLUDE GROUP #
AND APPRENTICESHIP
STEP IF APPLICABLE)
S
�
1 n'�
y r
`
�.
,�
TOTAL
HOURS
HOURLY
BASE
RATE
HOURLY
FRINGE
BENEFIT
AMOUNTS
PAID AS
WAGESTO
EMPLOYEE
GROSS
AMOUNT
EARNED (see
directions)
ITEMIZED
DEDUCTIONS
FICA, FED,
STATE, ETC.
NET WAGES
PAID
HOURLY FRINGE
BENEFITS PAID
TO BENEFIT
PARTY, PLAN,
FUND, OR
PROGRAM
NAME OF BENEFIT
PARTY, PLAN,
FUND, OR
PROGRAM
{
(.l
8
HOURS WORKED EACH DAY
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'Although this form has not been officially approved by the U.S. Department of Labor, it is designed to meet the requirements of both the state PWR law and the federal Davis -Bacon Act.
wH-38(Rev. 06114)
THIS FORM CONTINUED ON REVERSE
CERTIFIED STATEMENT
Date:
In addition to completing sections (1) - (3), if your project is subject to the federal
C�CNyy�� II Aaki /
Davis -Bacon Act requirements, complete the following section as well:
(NAME OF SIGNATORY PARTY) (TITLE)
(4) That:
do hereby state:
(1) That I pay or supervise the payment of the pgfsons employed by:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS OR
PROGRAMS
❑ - In addition to the basic hourly wage rates paid to each laborer or mechanic
listed in the above referenced payroll, payments of fringe benefits as listed in
the contract have been or will be made to appropriate programs for the benefit
0ITRACTiaR, SU CO TRAC OR SURETY)
on the A A that during the payroll period
UILD G OR WORK
commencing on the _LL-r_ day of zuao_ and ending theme day
of such employees, except as noted in Section 4(c) below.
(MONT ) (YEAR)
Of 2 0 (0, all persons employed on said project have been paid the
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
(MONT ) (YEAR)
full weekly wages earned, that no rebates have been g,Lwill be made either directly or
indirectly to or on behalf of said C—h'1 *e, 1or-, SC'Y✓-(pS
(CONTRACTOR, SUBCONTRACTOR OR SURETY)
❑ - Each laborer or mechanic listed in the above referenced payroll has been paid,
as indicated on the payroll, an amount not less than the sum of the applicable
basic hourly wage rate plus the amount of the required fringe benefits as listed
from the full weekly wages earned by any person, and that no deductions have been
in the contract, except as noted in Section 4(c) below.
made either directly or indirectly from the full wages earned by any person, other than
permissible deductions as specified in ORS 652.610, and as defined in Regulations, Part
(c) EXCEPTIONS:
3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as
amended (48 Stat. 948, 63 Stat. 108. 72 Stat. 967: 76 Stat. 357: 40 U.S.C. 276c), and
EXCEPTION (CRAFT) EXPLANATION
described below: PW 7 Svc►
T
(2) That any payrolls otherwise under this contract required to be submitted for the above
period are correct and complete; that the wage rates for workers contained therein are
not less than the applicable wage rates contained in any wage determination
incorporated into the contract; that the classifications set forth therein for each worker
conform with work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide
apprenticeship program registered with a state apprenticeship agency recognized by the
REMARKS:
Bureau of Apprenticeship and Training, United States Department of Labor, or if no such
recognized agency exists in a state, are registered with the Bureau of Apprenticeship
and Training, United States Department of Labor.
NAME AND TITLE SIGNATURE
I HAVE READ THIS CERTIFIED STATEMENT, KNOW THE CONTENTS THEREOF
AND IT IS TRUE TO MY KNOWLEDGE:
1,4ctb — A ta- 6-e,0 VP ""YLS
THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY
SUBJECT THE CONTRACTOR OR SUBCONTRACTOR TO CIVIL OR CRIMINAL
PROSECUTION. SEE SECTION 1001 OF TITLE 18 AND SECTION 231 OF TITLE 31
(NAME AND TITLE)
OF THE UNITED STATES CODE.
S NATU ND DATE
FILE THIS FORM WITH THE PUBLIC AGENCY ASSOCIATED WITH THE PROJECT
NOTE TO CONTRACTORS: YOU MUST ATTACH COPIES OF THIS FORM TO EACH OF YOUR PAYROLL SUBMISSIONS ON THIS PROJECT.
INSTRUCTIONS AND ADDITIONAL FORMS ARE AVAILABLE ON OUR WEBSITE: WWW.OREGON.GOV/BOLT.
wH-36 (Rev. 06/14)
20 2Z z a
BUREAU OF LABOR AND INDUSTRIES
WAGE AND HOUR DIVISION
PRIME CONTRACTOR ❑ SUBCONTRACTOR ES
PAYROLL NO. 6
PAYROLLICERTIFIED STATEMENT FORM WH-38
FOR USE IN COMPLYING WITH ORS 279C,845"
FINAL PAYROLL ❑
Business Name(DBA): _r'V1iJvPc��z Se'.h/�c.e"� ..C:. Phone (�3-1�) CCB Registration Number. IZ_-70q ?
Project Name: )(tit k Project Number. T e of Work: Lc_
Street Address: 3_ d;
�c:� �x C>< t
Mailing Address: U 13 (
Project Location:
Project County:
Date Pay Period Began: YL( Date Pay Period Ended:
THIS SECTION FOR PRIME CONTRACTORS ONLY
THIS SECTION FOR SUBCONTRACTORS ONLY
Public Contracting Agency Name:
Phone: ( )
Date Contract Specifications First Advertised for Bid:
Contract Amount:
Subcontract Amount:
Prime Contractor Business Name (DBA):—lSli-t,riT✓Vt.��`PG(,l ttJ e S
Prime Contractor Phone: ( ) v
Prime Contractor's CCB Registration Number:
Date You Began Work on the Pro ect:
1
Z
3 DAY AND DATE
4
5
6
7
8
9
10
11
NAME, ADDRESS AND
EMPLOYEE'S
IDENTIFICATION
NUMBER
CLASSIFICATION
(INCLUDE GROUP #
AND APPRENTICESHIP
STEP IF APPLICABLE(
��
1
1 n.
V `r
IP..1
TOTAL
HOURS
HOURLY
BASE
RATE
HOURLY
FRINGE
BENEFIT
AMOUNTS
PAID AS
WAGESTO
EMPLOYEE
GROSS
AMOUNT
EARNED (see
tlirectltlnsI
ITEMIZED
DEDUCTIONS
FICA, FED,
STATE, ETC.
NET WAGES
PAID
-��7�P`
HOURLY FRINGE
BENEFITS PAID
TO BENEFIT
PARTY, PLAN,
FUND, OR
PROGRAM
NAME OF BENEFIT
PARTY, PLAN,
FUND, OR
PROGRAM
(
/
_
��'
i
.^
-�
HOURS WORKED EACH DAY
�M
Mona
L7p�
Pu LYlV
OT
(ol.g3
ST
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rr tJI.�J
OT
//Oz/
OT
ST
OT
ST
OT
ST
'Although this form has not been officially approved by the U.S. Department of Labor, it is designed to meet the requirements of bath the state PWR law and the federal Davis -Bacon Act.
WH-38 (Rev. W14)
THIS FORM CONTINUED ON REVERSE
Date: � [A ( ( co
"5-",&t MeC -Po-*'��L
(NAME OF SIGNATORY PARTY)
do hereby state:
(1) That I pay or supervise the payment of the
CERTIFIED STATEMENT
In addition to completing sections (1) - (3), if your project is subject to the federal
Davis -Bacon Act requirements, complete the following section as well:
v' i� C`� L'r>•S
(TITLI=) (4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS OR
sons employed by. PROGRAMS
'- ( ONT�`CTOR, SUBCONTRACTOR OR SURETY)
on the [ �ln�%Lr�tt S fit i�h that during the payroll period
UILDING OR WORK)
commencing on the __ day of and ending the 1J day
'(MONT ) (YEAR)
of Wit all persons employed on said project have been paid the
(MO TH) (Y
full weekly wages earned, that no rebates have been;;_will be made either directly or
indirectly to or on behalf of said iL—P Lye— WLc)", s ►'_y-u—S.
(CONTRACTOR, SUBCONTRACTOR OR SURETY)
from the full weekly wages earned by any person, and that no deductions have been
made either directly or indirectly from the full wages earned by any person, other than
permissible deductions as specified in ORS 552.610, and as defined in Regulations, Part
3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as
amended (48 Stat. 948, 63 Stat. 108, 72 Stat. 967: 76 Stat. 357: 40 U.S.C. 276c), and
described below:n�
(2) That any payrolls otherwise under this contract required to be submitted for the above
period are correct and complete; that the wage rates for workers contained therein are
not less than the applicable wage rates contained in any wage determination
incorporated into the contract; that the classifications set forth therein for each worker
conform with work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide
apprenticeship program registered with a state apprenticeship agency recognized by the
Bureau of Apprenticeship and Training, United States Department of Labor, or if no such
recognized agency exists in a state, are registered with the Bureau of Apprenticeship
and Training, United States Department of Labor.
I HAVE READ THIS CERTIFIED STATEMENT, KNOW THE CONTENTS THEREOF
AND IT IS TRUE TO MY KNOWLEDGE
(NAME AND TITLE)
(SIGN RE A ATE)
❑ - In addition to the basic hourly wage rates paid to each laborer or mechanic
listed in the above referenced payroll, payments of fringe benefits as listed in
the contract have been or will be made to appropriate programs for the benefit
of such employees, except as noted in Section 4(c) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
❑ - Each laborer or mechanic listed in the above referenced payroll has been paid,
as indicated on the payroll, an amount not less than the sum of the applicable
basic hourly wage rate plus the amount of the required fringe benefits as listed
in the contract, except as noted in Section 4(c) below.
(c) EXCEPTIONS:
EXCEPTION (CRAFT) EXPLANATION
REMARKS:
NAME AND TITLE SIGNATURE
THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY
SUBJECT THE CONTRACTOR OR SUBCONTRACTOR TO CIVIL OR CRIMINAL
PROSECUTION. SEE SECTION 1001 OF TITLE 18 AND SECTION 231 OF TITLE 31
OF THE UNITED STATES CODE.
FILE THIS FORM WITH THE PUBLIC AGENCY ASSOCIATED WITH THE PROJECT
NOTE TO CONTRACTORS: YOU MUST ATTACH COPIES OF THIS FORM TO EACH OF YOUR PAYROLL SUBMISSIONS ON THIS PROJECT.
INSTRUCTIONS AND ADDITIONAL FORMS ARE AVAILABLE ON OUR WEBSITE: WWW.OREGON.GOV/BOLI.
WH-38 (Rev. 06/14)
?z-
U.S. Department of Labor PAYROLL iND,
Wage and Hour Division (For Contractor's Optional Use; See Instructions at www.dol.gov/whd/forms/wh3471nstr.htm)
U.S. W;rtie and Hour l)ieiaun
Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. Rev. Dec. 2008
NAME OF CONTRACTOR OR SUBCONTRACTOR ® ADDRESS 9791 Titan Park Circle ! OMB No.: 1235-0006
Maverick Pump Services, LLC Littleton, CO 80125 Expires: 01/31/2015
PAYROLL NO. FOR WEEK ENDING PROJECT AND LOCATION i PROJECT OR CONTRACT NO.
7 - final 09/03/2016 Cascade Interceptor Rehabilitation Phase II CAG-15-149
Renton, WA
(1) -
NAME AND INDIVIDUAL IDENTIFYING NUMBER
(e.g.. LAST FOUR DIGITS OF SOCIAL SECURITY
NUMBER OF WORKER
(2)
o
F
0 i
ry
i i �
(3)
WORK
CLASSIFICATION
(4) DAY AND DATE
(5)
TOTAL
HOURS
I (6)
RATE
OF PAY
(7)
GROSS
AMOUNT
EARNED
18)
DEDUCTIONS
(9)
NET
WAGES
PAID
FOR WEEK
o
w[K/2N
kn„n
Tuc
WA
Thu
Fri
Sat
N
o
8/29
8130
8,31
9/I
9/2
9/3
FICA
WITH-
HOLDING
TAX
mtdirvc
OTHER
TOTAL
DEDUCTIONS
HOURS
WORKED EACH
DAY
Miguel Mata
1701 Garden Oaks Dr, Irving, TX 75061
xXx-xx-2276
3
Laborer
Sewer & Water
General Laborer
o 100
4.00
sin
200
00
000
000
] g.0(
bG,
lad'�!i
$141.57
$250.43
$33.11
$425.11
1CI �L+
s 0.00
a,on
8.e0
sw
0ua
ow0a,
24.0(
33.65 10.30
Miguel Mijares
1914 Dory Lane Irving, TX 75061
xxx-xx-0216
p
Laborer
Sewer & Water
General Laborer
o toe
4.00
3.00
200
000
0.00
0.00
18_0(
''-IY_
-] 7'
$ 3ry
$141.57
S174.49
$33.11
S349.17
s 0.00
11.00
a.w
wu
uoe
0
0.w
24.0
33.65 1030
0
s
0
6
0
T.-
Reg - 33.65 + fringe 10.30 = $43.95
OT - $60.78
DOT - $77.60
0
s
0
s
While completion of Form WH-347 is optional, it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R. §§ 3.3. 5.5(a). The Copeland Act
(40 U.S.C. § 3145) contractors and subcontractors performing work on Federally financed or assisted construction contracts to'Yurrish weekly a statement with respect to the wages paid each employee dunng the preceding week.' U.S. Department of Labor (DOL) regulations at
29 C.F.R. § 5.5(a)(3)(ii) require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction pro)ect, accompanied by a signed "Statement of Compliance' indicating that the payrolls are correct and complete and that each laborer
or mechanic has been paid not less then the proper Davis -Bacon prevailing wage rate for the work performed. DOL and federal contracting agencies receiving this information review the Information to datermine that employees have received legally required wages and fringe benefits.
Public Burden Statement
We estimate that is will lake an average of 55 minutes to complete this collection, including time for reviewing Instructions, searching exlsfing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have
any comments regarding these estimates or any other aspect of this collection, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of Labor. Room S3502. 200 Constitution Avenue. N.W.
Washington. D.C. 20210
i3
'41
(over)
Date 9/6/16
Becki Moessner office manager
(Name of Signatory Party) (Title)
do hereby state:
(1) That I pay or supervise the payment of the persons employed by
Maverick Pump Services, LLC on the
(Contractor or Subcontractor)
Renton Cascade Interceptor Rehab Phase II , that during the payroll period commencing on the
(Building or Work)
28th day of August 2016 , and ending the 3rd day of September 2016
all persons employed on said project have been paid the full weekly wages earned, that no rebates have
been or will be made either directly or indirectly to or on behalf of said
Maverick Pump Services, LLC
(Contractor or Subcontractor)
from the full
weekly wages earned by any person and that no deductions have been made either directly or indirectly
from the full wages earned by any person, other than permissible deductions as defined in Regulations. Part
3 (29 C.F.R. Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat. 948.
63 Start. 108, 72 Stat. 967, 76 Stat. 357. 40 U.S.C. § 3145), and described below
loan repayment
(2) That any payrolls otherwise under this contract required to be submitted for the above period are
correct and complete, that the wage rates for laborers or mechanics contained therein are not less than the
applicable wage rates contained in any wage determination incorporated into the contract, that the classifications
set forth therein for each laborer or mechanic conform with the work he performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship
program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and
Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered
with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
— in addition to the basic hourly wage rates paid to each laborer or mechanic listed in
the above referenced payroll, payments of fringe benefits as listed in the contract
have been or will be made to appropriate programs for the benefit of such employees.
except as noted in section 4(c) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
m — Each laborer or mechanic listed in the above referenced payroll has been paid
as indicated on the payroll, an amount not less than the sum of the applicable
basic hourly wage rate plus the amount of the required fringe benefits as listed
in the contract, except as noted in section 4(c) below-
(c) EXCEPTIONS
EXCEPTION (CRAFT) EXPLANATION
REMARKS
NAME AND TITLE SI UR
Becki Moessner
office manager
THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SU JECT THE NTRACTOR OR
SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION. SEE SECTION 1001 OF TITLE AND SECTION 231 OF TITLE
31 OF THE UNITED STATES CODE.
U.S. Department of Labor PAYROLL
Wage and Hour Division (For Contractor's Optional Use; See Instructions at www.dol-goviwhd/forms/wh347instr.htm)
Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number.
Air
aWND
U.S. Wage and Hour t)11%4aicm
Rev. Dec. 2008
NAME OF CONTRACTOR Q OR SUBCONTRACTOR ® ADDRESS 9791 Titan Park Circle OMB No.: 1235-0008
Maverick Pump Services, LLC Littleton, CO 80125 Expires: 01/31/2015
PAYROLL NO. FOR WEEK ENDING PROJECT AND LOCATION PROJECT OR CONTRACT NO.
4 - revised 09/03/2016 Trimble Road Trunk
Santa Clara, CA 190794
(1)
(2)
(3)
(4) DAY AND DATE
(5)
(6)
(7)
(9)
(B)
DEDUCTIONS
0 Sun
rtua
I Tuc
I Wut
Thu
Fri
Saltjo
NAME AND INDIVIDUAL IDENTIFYING NUMBER
a
o
o
GROSS
NET
WAGES
WITH-
(e.g., LAST FOUR DIGITS OF SOCIAL SECURITY
I
WORK
� tv2x
o
xn9
s/JU
s!JI
9/1
9/2
9/3
TOTAL
RATE
AMOUNT
HOLDING
mcdicarc
TOTAL
PAID
HOURS
WORKED
EACH
DAY
NUMBER OF WORKER
i 3
CLASSIFICATION
HOURS
OF PAY
EARNED
H r lu
FICA
TAX
OTHER
DEDUCTIONS
FOR WEEK
Carlos Mata
Laborer Group 1
0 ,za,
400
400
400
nao
u,0o
0m
34,0(
2512 W 4th Irving, TX 75060
0
J�
$277.07
$4R6.17
$G4.80
$828A4
l�
xxx-xx-1100
s o 0o
s oo
s 0o
s oo
1,..
x oo
o o0
38.0(
29.29 22.20
Miguel Mata
Laborer Group 1
0 0.0o
0.00
0.00
0.00
000
0.00
ono
$66.14
1701 Garden Oaks Dr, Irving, TX 75061
3
s 0.00
0.U0
0.00
rI o
0.00
e00
0.00
29.29 22.20
xxx-xx-2276
Carlos Miguel Davila
Laborer Group 1
0 cot,
400
4.u0
400
400
000
0oo
28.0
u h•Iu
29
2802 N Pioneer Rd #130. Irving 75061
0
'
$237.45
$477.36
$55.53
$770.34
s 0.0n
x.00
8.00
e.0o
Boo
1.00
0.00
35.0(
29.29 22.20
xxx-xx-0121
Ever Ruiz
Laborer Group 1
0 000
0.00
0.00
0.00
000
ago
Ono
$66.14
$308.94
1701 Garden Oaks Dr, Irving, TX 75061
0
$19.15
$21.52
$4.47
$45.14
$263.80
s 0,00
Don
0.0o
000
ew
ono
0o0
6.00
29,29 22.20
xxx-xx-6845
0
TT
0
s
Basic - 29.29. Fringe - $22.20
0
Total Hourly - $51.49
OT - $66.14 DOT - $80.78
s
0
s
While completion of Form WH-347 is optional, it is mandatory for covered contractors and subconlractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R. §§ 3.3. 5.5(a). The Copeland Act
(40 U.S.C. § 3145) contractors and subcontractors performing work on Federally financed or assisted construction contracts to "furnish weekly a statement with respect to the wages paid each employee during the preceding week." U.S. Department of Labor (DOL) regulations at
29 C.F.R. § 5.5(a)(3)(ii) require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction projecl, accompanied by a signed "Statement of Compkance" indicating that the payrolls are correct and complete and that each laborer
or mechanic has been paid not less than the proper Davis -Bacon prevailing wage rate for the work performed. DOL and federal contracting agencies receiving this information review the information to determine that employees have received legally required wages and fringe benefits.
Public Burden Statement
We estimate that is will take an average of 55 minutes to complete this collection, including time for reviewing instructionssearching existing data sources, gathering and maintaining the data needed and completing and reviewing the collection of information. If you have
any comments regarding these estimates or any other aspect of this collection, including suggestions for reducing this burden, send them to the Administrator. Wage and Hour Division. U.S. Department of Labor. Room S3502, 200 Constitution Avenue. N.W.
Washington, D.C. 20210
om
.y i
(over)
Date 9/6/ 16
Becki Moessner office manager
(Name of Signatory Party) (Title)
do hereby state.
(1) That I pay or supervise the payment of the persons employed by
Maverick Pump Services, LLC on the
(Contractor or Subcontractor)
Trimble Road Trunk that during the payroll period commencing on the
(Building or Work)
28th day of Auguest 2016 and ending the 3rd day of September 2016
all persons employed on said project have been paid the full weekly wages earned. that no rebates have
been or will be made either directly or indirectly to or on behalf of said
Maverick Pump Services, LLC
(Contractor or Subcontractor)
from the full
weekly wages earned by any person and that no deductions have been made either directly or indirectly
from the full wages earned by any person, other than permissible deductions as defined in Regulations, Part
3 (29 C.F.R. Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat. 948,
63 Start. 108, 72 Stat. 967, 76 Stat. 357, 40 U.S.C. § 3145), and described below:
loan repayment
(2) That any payrolls otherwise under this contract required to be submitted for the above period are
correct and complete', that the wage rates for laborers or mechanics contained therein are not less than the
applicable wage rates contained in any wage determination incorporated into the contract, that the classifications
set forth therein for each laborer or mechanic conform with the work he performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship
program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and
Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered
with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS. FUNDS, OR PROGRAMS
— in addition to the basic hourly wage rates paid to each laborer or mechanic listed in
the above referenced payroll, payments of fringe benefits as listed in the contract
have been or will be made to appropriate programs for the benefit of such employees,
except as noted in section 4(c) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
m — Each laborer or mechanic listed in the above referenced payroll has been paid,
as indicated on the payroll, an amount not less than the sum of the applicable
basic hourly wage rate plus the amount of the required fringe benefits as listed
in the contract, except as noted in section 4(c) below.
(c) EXCEPTIONS
EXCEPTION (CRAFT)
EXPLANATION
REMARKS
reU-e�
�19 !cc nclU-cue
12-
NAME AND TITLE
Becki Moessner
office manager
I ATU E
THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE CQ4TRACTOR OR
SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION. SEE SECTION 1001 OF TITLE 1 AND SECTION 231 OF TITLE
31 OF THE UNITED STATES CODE.
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30, 1997
Pubk reporting burden for this collection of information is estimated to average 16 minutes per response, including the time for reviewing instructions. searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden, to Department of Defense. Washington Headquarters Services, Directorate for Information Operations and Reports. 1215
Jefferson Davis Highway. Suite 1204, Arlington, VA 22202-4302, and to the Office of Management and Budget Paperwork Reduction Project (1215-0149) Washington, DC 20503
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1. PAYROLL NUMBER
YROLL PAYMENT DATE (YYMMDD)
F
3 CONTRACT NUMBER
4 DATE (YYMMDD)
47
16/08/26
1 16/08/26
I. Stephanie Forrest Payroll Specialist do hereby state
(Name of signatory parry) %F tie;
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Contractor or subcontractor)
on the CAG 15-149 , that during the payroll period commencing on the 14 day of
(Buildrng or work)
August 201 6 and ending the 20 day of August 201 6 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat. 948. 63 Stat. 108, 72 Stat 967, 76 Stat. 357; 40 U.S.C. 276c), and described below:
Federal, Fica, State and Local tax. 401 K. Loan re -payment.. Insurance. garnishments
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete, that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5.REMARKS
6. NAME (Last, First, Middle Initial)
TITLE
8. SIGNATURE
Forrest, Stephanie
TPayroll Specialist
I )
1)
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or crimindl r e io
See Section 1007 of Title 18 and Section 231 of Title 31 of the United States Code.
DD FORM 879, MAR 95 (EG) PREVIOUS EDITON MAY BE USED
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Pro act and Location 202221
RE�TON - WA- CAG-15-149
CASCADE INTERCEPTOR-PHASEII
4784'x 14,18.21,24" CIPP
WA
8/25/2016 7:39:47
Page - 42
Pay Period Ending Date 8/20/2016
Period Number 4
St SMS SDep
FMS FDep Sex
EEO Union .......................
Craft.........................
Step.........................
Social Security No
Ethnic Cat
.....
I . Regular ..............
Overtime
......
Other
Total
Job
........... Check Detail ..........
Name/Address
Work Date
Hours Rate
Hours
Rate
Hours
Hours
Amount
Description Amount
MO S
S M
008 1971 For HBU 1971 Accrual
PIPL Pipelayer
default
XXX-XX-5785
White
Shane M Ayers
MO 8/15/2016
8.00 41.890
4.00
65.190
12.00
595.88
Payment Number:04929200
1575 Fircrest Ct SE
TU 8/16/2016
8.00 41.890
2.00
65.190
10.00
465.50
Gross Pay
4,901.26
Salem OR 97306
WE 8/17/2016
1.00
1.00
86.92
OR Departmen
456.01
United States
WE 8/17/2016
8.00 41.890
4.00
65.190
12.00
595.88
FED W/H Tax
1,084.31
TH 8/18/2016
2.00
2.00
173.84
FICA W/H
304.54
TH 8/18/2016
8.00 41.890
4.00
65.190
12.00
595.88
Medicare W/H
71.23
FIR 8/19/2016
2.00
2.00
173.84
Net Pay
2,985.17
FIR 8/19/2016
8.00 41.890
4.00
65.190
12.00
595.88
Hrs This Chk
83.00
SA 8/20/2016
8.00
8.00
695.36
SA 8/20/2016
12.00
65.190
12.00
782.28
Subtotal for Payment Number:04929200
40.00
30.00
13.00
83.00
4.761.26
Shane M Ayers
40.00
30.00
13.00
83.00
4,761.26
MO S
S 1 M 006 1971 For HBU 1971 Accrual
PIPL Pipelayer
default
XXX-XX-0002
White
Adam Eugene Clary
MO 8/15/2016
8.00
42.000
4.00
65.190
12.00
596.76
Payment
Number:04929204
1768 Pine Street
TU 8/16/2016
8.00
42.000
2.00
65.190
10.00
466.38
Gross Pay
4,905.66
Silverton OR 97381
WE 8/17/2016
1.00
1.00
86.92
OR Departmen
455.38
United States
WE 8/17/2016
8.00
42.000
4.00
65.190
12.00
596,76
FED W/H Tax
1,262.14
TH 6/18/2016
2.00
2.00
173.84
FICA W/H
304.15
TH 8/16/2016
8.00
42.000
4.00
65.190
12.00
596.76
Medicare W/H
71.13
FIR 8/19/2016
2.00
2.00
173.84
Chd Sup $/%
98.08
FIR 8/19/2016
8.00
42.000
4.00
65.190
12.00
596.76
Net Pay
2,714.78
SA 8/20/2016
8.00
8.00
695.36
Hrs. This Chk
83.00
SA 8/20/2016
12.00
65.190
12.00
782.28
Subtotal for Payment Number:04929204
40.00
30.00
13.00
83.00
4,765,66
Adam Eugene Clary
40.00
30.00
13.00
83.00
4,765.66
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Pro'ect and Location 202221
RETON - WA- CAG-15-149
4784'x 14 18,21 24" CIPP
CASCADL INTERCEPTOR -PHASE II
WA
8/25/2016 7:39:47
Page - 43
Pay Period Ending Date 8/20/2016
Period Number 4
St SMS SDep
FMS FDep Sex EEO Union ....................
Craft ....................
Step
..................
Social Security No
Ethnic Cat .......
Regular ..............
Overtime ......
Other
Total
Job
........... Check Detail ..........
Name/Address Work Date
Hours Rate
Hours Rate
Hours
Hours
Amount
Description Amount
MO M
M 5 M 008 1971 For HBU 1971 Accrual
PIPL Pipelayer
default
XXX-XX-3029
Black or African Ame
Thomas Juan Dunn
MO 8/15/2016
8.00 37.380
4.00 65.190
12.00
559.80
Payment Number:04929208
P.O. Box 52
TU 8/16/2016
8.00 37,380
2.00 65.190
10.00
429.42
Gross Pay
4,680.86
Smartville CA 95977
WE 8/17/2016
1.00
1.00
86.92
CA Departmen
355.23
United States
WE 8/17/2016
8.00 37.380
4.00 65.190
12.00
559.80
CA -SDI
41.34
TH 8/18/2016
2.00
2.00
173.84
FED W/H Tax
1,024.97
TH 8/18/2016
8.00 37.380
4.00 65.190
12.00
559.80
FICA W/H
284.82
FR 8/19/2016
2.00
2.00
173.84
Medicare W/H
66.61
FR 8/19/2016
8.00 37.380
4.00 65.190
12.00
559.80
MEDICAL
80.31
SA 8/20/2016
8.00
8.00
695.36
DENTAL
5.99
SA 8/20/2016
12.00 65.190
12.00
782.28
VISION
.69
Pipelayer
40.00
30.00
13.00
83.00
4,580.86
OP SP LIFE
1.83
Net Pay
2,819.07
Hrs This Chk
83.00
Subtotal for Payment Number:04929208
40.00
30.00
13.00
83.00
4,580.86
Thomas Juan Dunn
40.00
30.00
13.00
83.00
4,580.86
MO S
S 1 M 007 1971 For HBU 1971 Accrual
PIPL Pipelayer
default
XXX-XX-0687
White
Brian Mitchell Hills
MO 8/15/2016
8.00
42.080
4.00
65.190
12.00
597.40
Payment
Number:04929209
3150 SW 108th Ave
TU 8/16/2016
8.00
42.080
2.00
65.190
10.00
467.02
Gross Pay
3,411.22
Beaverton OR 97005
WE 8/17/2016
1.00
1.00
86.92
OR Departmen
308.49
United States
WE 8/17/2016
8.00
42.080
4.00
65.190
12.00
597.40
FED W/H Tax
790.29
TH 8/18/2016
2.00
2.00
173.84
FICA W/H
212.16
TH 8/18/2016
8.00
42.080
4.00
65.190
12.00
597.40
Medicare W/H
49.62
FR 8/19/2016
2.00
2.00
173.84
Total Deduct
1,360.56
FR 8/19/2016
8.00
42.080
4.00
65.190
12.00
597.40
Net Pay
2,050.66
Pipelayer
40.00
18.00
5.00
63.00
3,291.22
Hrs This Chk
63.00
Subtotal for Payment Number:04929209
40.00
18.00
5.00
63.00
3,291.22
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Pro'ect and Location 202221
RE�TON - WA- CAG-15-149
CASC1 NTI=RCEPT ADI`OR-PHASE II
WA
8/25/2016 7.39:47
Page - 44
Pay Period Ending Date 8/20/2016
Period Number 4
St SMS SDep FMS FDep Sex EEO Union .................... Craft .................... Step ..................
Social Security No Ethnic Cat ..... I . Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
Brian Mitchell Hille 40.00 18.00 5.00 63.00 3,291.22
MO M M
M 008 1971 For HBU 1971 Accrual PIPL
Pipelayer
default
XXX-XX-8053 White
Brennon Christopher Pratt
MO 8/15/2016
8.00
42.160
4.00
65.190
12.00
598.04
Payment
Number:04929215
1634 SE Jonathan Avenue
TU B/16/2016
8.00
42.160
2.00
65.190
10.00
467.66
Gross Pay
4,912.06
Dallas OR 97338
WE 8/17/2016
1.00
1.00
86.92
OR Departmen
416.54
United Stales
WE 8/17/2016
8.00
42.160
4.00
65.190
12.00
598.04
FED W/H Tax
1,093.89
TH 8/18/2016
2.00
2.00
173.84
FICA W/H
304.55
TH 8/18/2016
8.00
42.160
4.00
65.190
12.00
598.04
Medicare W/H
71.23
FR 8/1912016
2.00
2.00
173.84
Total Deduct
1,886.21
FR 8/19/2016
8.00
42.160
4.00
65.190
12.00
598.04
Net Pay
3,025.85
SA 8/20/2016
8.00
8.00
695.36
Hrs This Chk
83.00
SA 8/20/2016
12.00
65.190
12.00
782.28
Subtotal for Payment Numbev 04929215
40.00
30.00
13.00
83.00
4,772.06
Brennon Christopher Pratt
40.00
30.00
13.00
83.00
4,772.06
RENTON - WA- CAG-15-149 200.00 138.00 57.00 395.00 22,171.06
U.S. Department of Labor PAYROLL
Wage and Hour Division (For Contractor's Optional Use; See Instructions at www.dol.gov/whd/forms/wh347instr.htm)
Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number.
aNNO
Hi
Rev. Dec. 200A
NAME OF CONTRACTOR OR SUBCONTRACTOR ®
ADDRESS 9791 Titan Park Circle
OMB No.: 1235-000E
Maverick Pump Services, LLC
Littleton, CO 80125
Expires: 01/31/2015
PAYROLL NO. FOR WEEK ENDING
PROJECT AND LOCATION
PROJECT OR CONTRACT NO.
5 08/20/2016
Cascade Interceptor Rehabilitation Phase II
Renton, WA
C
AG-15-149
(1)
(2)
(3)
(4) DAY AND DATE
(5)
(6)
(7)
(9)
Sun
M..
Tuc
wc
Thu
Fri
Sat
g o
r
v,
I
DEDUCTIONS
NAME AND INDIVIDUAL IDENTIFYING NUMBER
a
O
GROSS
NET
WAGES
WITH-
e. LAST FOUR DIGITS OF SOCIAL SECURITY
( 9••
`S �
WORK
0
o
ri/la
Srl,
fi/le
8'17
tlrl i
R/19
8i20
TOTAL
RATE
AMOUNT
HOLDING
mcdwc
TOTAL
PAID
HOURS
WORKED EACH DAY
NUMBER OF WORKER
9
CLASSIFICATION
HOUR
OF PAY
EARNED
FICA
TAX
OTHER
DEDUCTIONS
FOR WEEK
Miguel Mata
Laborer
o
0.00
000
000
000
noo
nor,
low
10.0(
$60.78
$607.80
1701 Garden Oaks Or, Irving, TX 75061
3
Sewer & Water
$37.68
$0.00
$8.81
$40.49
$561.31
xxx-xx-2276
General Laborer
s
nno
0.00
000
ear
o.uu
or,.
a-
33,65 10.30
Miguel Mijares
Laborer
0
'Di,
om
000
Orin
000
am
uro
1914 Dory Lane Irving, TX 75061
0
Sewer & Water
$156.07
$285.50
$36.50
S250.00
S728.07
s
u00
sm
600
moo
eW
moo
0.00
35.0
33.65 10,30
xxx-xx-0216
General Laborer
0
s
0
s
0
s
0
s
Reg - 33.65 + fringe 10.30 = $43.95
0
OT - $60.78
s
DOT - $77.60
0
T-F
While completion of Form WH-347 is optional. it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R. §§ 3.3 5.5(a). The Copeland Act
(40 U.S.C. § 3145) contractors and subcontractors performing work on Federally financed or assisted construction contracts to 'Yurnish weekly a statement with respect to the wages paid each employee during the preceding week." U.S. Department of Labor (DOL) regulations at
29 C.F.R. § 5.5(a)(3)(6) require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project. accompanied by a signed "Statement of Compliance" indicating that the payrolls are correct and complete and that each laborer
or mechanic has been paid not less than the proper Davis -Bacon prevailing wage rate for the work performed, DOL and federal contracting agencies receiving this information review the information to determine that employees have received legally required wages and fringe benefits.
Public Burden Statement
We estimate that is will take an average of 55 minutes to complete this collection, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have
any comments regarding these estimates or any other aspect of this collection, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S3502, 200 Constitution Avenue, N.W.
Washington, D.C. 20210
(over)
Date 8/22/2016
1. Becki Moessner office manager
(Name of Signatory Party)
do hereby state:
(Title)
(1) That I pay or supervise the payment of the persons employed by
Maverick Pump Services, LLC on the
(Contractor or Subcontractor)
Renton Cascade Interceptor Rehab Phase II , that during the payroll period commencing on the
(Building or Work)
14th cby of August 2016 and ending the 20th day of August 2016
all persons employed on said pro)ect have been paid the full weekly wages earned, that no rebates have
been or will be made either directly or indirectly to or on behalf of said
Maverick Pump Services, LLC
(Contractor or Subcontractor)
from the full
weekly wages earned by any person and that no deductions have been made either directly or indirectly
from the full wages earned by any person, other than permissible deductions as defined in Regulations, Part
3 (29 C.F.R. Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat. 948,
63 Start. 108, 72 Stat. 96T, 76 Stat. 357. 40 U.S.0 § 3145). and described below
loan repayment
(2) That any payrolls otherwise under this contract required to be submitted for the above period are
correct and complete, that the wage rates for laborers or mechanics contained therein are not less than the
applicable wage rates contained in any wage determination incorporated into the contract. that the classifications
set forth therein for each laborer or mechanic conform with the work he performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship
program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and
Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered
with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
— In addition to the basic hourly wage rates paid to each laborer or mechanic listed in
the above referenced payroll, payments of fringe benefits as listed in the contract
have been or will be made to appropriate programs for the benefit of such employees,
except as noted in section 4(c) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
m — Each laborer or mechanic listed in the above referenced payroll has been paid
as indicated on the payroll, an amount not less than the sum of the applicable
basic hourly wage rate plus the amount of the required fringe benefits as listed
in the contract, except as noted in section 4(c) below.
(c) EXCEPTIONS
EXCEPTION (CRAFT) EXPLANATION
REMARKS
NAME AND TITLE SI UR
Becki Moessner
office manager
THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMEN S MAY BJEC THE CONTR TOR OR
SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION. SEE SECTION 1001 OF TITLE 18 AN ECTION 231 OF TITLE
31 OF THE UNITED STATES CODE.
U.S. Department of Labor
Wage and Hour Division
PAYROLL
(For Contractor's Optional Use; See Instructions at www.dol.gov/whd/forms/wh347instr.htm)
Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number.
4NNO
Rev. Dec. 2008
NAME OF CONTRACTOR OR SUBCONTRACTOR ® ADDRESS 9791 Titan Park Circle OMB No.: 1235-0008
Maverick Pump Services, LLC Littleton, CO 80125 Expires: 01/31/2015
PAYROLL NO. FOR WEEK ENDING
4 08/13/2016
PROJECT AND LOCATION
Cascade Interceptor Rehabilitation Phase II
Renton, WA
PROJECT OR CONTRACT NO.
CAG-15-149
(1)
NAME AND INDIVIDUAL IDENTIFYING NUMBER
e. LAST FOUR DIGITS OF SOCIAL SECURITY
( 9.•
NUMBER OF WORKER
(2)
2.
62
o
g a
O
sE
i � �
(3)
WORK
CLASSIFICATION
(4) DAY AND DATE
(5)
TOTAL
HOURSI
(6)
RATE
OF PAY
(7)
GROSS
AMOUNT
EARNED
(8)
DEDUCTIONS
(9)
NET
WAGES
PAID
FOR WEEK
1�
w Sun
re
Mun
I
Tuc
I
Wcd
I
The
Fri
Sal
o
� 8/7
o
8B
8/9
8'IU
8/i l
K, 12
8/13
FICA
WITH-
HOLDING
TAX
mcdicurc
OTHER
TOTAL
DEDUCTIONS
HOURS
WORKED EACH DAY
Carlos Mata
2512 W 4th Irving, TX 75060
xxx-xx-1100
0
Laborer
Sewer & Water
General Laborer
0 000
$60.78
s 6ca
33.65 10.30
Miguel Mijares
1914 Dory Lane Irving, TX 75061
xxx-xx-0216
0
Laborer
Sewer & Water
General Laborer
o 000
2.rxl
300
oae
Dal
nor
126o
17.0(
$60.78
$2,483.61
$153.9X
$280.46
$36.01
$250.00
$720.45
$1,763.16
a 000
tw
sui
1100
33.(1l
33.65 103u
0
0
s
0
s
0
s
Reg - 33.65 + fringe 10.30 = $43.95
OT - $60.78
DOT - $77.60
0
11
s
s
7T
—T
While completion of Form WH-347 is optional, it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R. §§ 3.3, 5.5(s). The Copeland Act
(40 U.S.C. § 3145) contractors and subcontractors performing work on Federally financed or assisted construction contracts to'Yurnish weekly a statement with respect to the wages paid each employee during the preceding week." U.S. Department of Labor (DOL) regulations at
29 C.F.R. § 5.5(a)(3)(ii) require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project, accompanied by a signed "Statement of Compliance" indicating that the payrolls are correct and complete and that each laborer
or mechanic has been paid not less than the proper Davis -Bacon prevailing wage rate for the work performed. DOL and federal contracting agencies receiving this information review the information to determine that employees have received legally required wages and fringe benefits.
Public Burden Statement
We estimate that is will take an average of 55 minutes to complete this collection, including time for reviewing instructions, searching existing data sources. gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have
any comments regarding these estimates or any other aspect of this collection, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S3502. 200 Constitution Avenue, N.W.
Washington, D.C. 20210
(over)
Date 8/15/2016
Becki Moessner
(Name of Signatory Party)
do hereby state
office manager
(1) That I pay or supervise the payment of the persons employed by
Maverick Pump Services, LLC
(Contractor or Subcontractor)
Renton Cascade Interceptor Rehab Phase II
(Title)
on the
that during the payroll period commencing on the
(Building or Work)
7th clay of August 2016 , and ending the 13th day of August 2016
all persons employed on said project have been paid the full weekly wages earned that no rebates have
been or will be made either directly or indirectly to or on behalf of said
Maverick Pump Services, LLC
(Contractor or Subcontractor)
from the full
weekly wages earned by any person and that no deductions have been made either directly or indirectly
from the full wages earned by any person, other than permissible deductions as defined in Regulations, Part
3 (29 C.F.R. Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat. 948,
63 Start. 108, 72 Stat. 967, 76 Stat. 357, 40 U.S.C. § 3145), and described below:
loan repayment
(2) That any payrolls otherwise under this contract required to be submitted for the above period are
correct and complete: that the wage rates for laborers or mechanics contained therein are not less than the
applicable wage rates contained in any wage determination incorporated into the contract, that the classifications
set forth therein for each laborer or mechanic conform with the work he performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship
program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and
Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered
with the Bureau of Apprenticeship and Training. United States Department of Labor.
(4) That
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
— in addition to the basic hourly wage rates paid to each laborer or mechanic listed in
the above referenced payroll, payments of fringe benefits as listed in the contract
have been or will be made to appropriate programs for the benefit of such employees,
except as noted in section 4(c) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
m — Each laborer or mechanic listed in the above referenced payroll has been paid,
as indicated on the payroll, an amount not less than the sum of the applicable
basic hourly wage rate plus the amount of the required fringe benefits as listed
in the contract, except as noted in section 4(c) below.
(c) EXCEPTIONS
EXCEPTION (CRAFT)
EXPLANATION
REMARKS
NAME AND TITLE
Becki Moessner
office manager
s U
THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATt6rNTS MAY SUB CT THE C TRACTOR OR
SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION. SEE SECTION 1001 OF TITLE 1 AND SECTION 231 OF TITLE
31 OF THE UNITED STATES CODE.
u
FormOSS-347 CERTIFIED PAYROLL Page 1 of 1
Contractor:
Insttuform Technologies LLC
Subcontractor: V
Advanced Government Services Inc
8644 Pacific Ave
Tacoma- WA 98444-6471
Project or Contract No: CAG-15-149 Cascade Interc
Cost Acct. or Other No: CAG-15-149 Cascade Interc
Tax ID No: 20-0053479
Payroll No: 2
For Week Ending: 08/20/2016
Project and Insituform Technologies LLCi202221 Cascade Interceptor PH2-Renton
Location: Renton
Name, Address, and
Social Security Number
of Employee
#
Ex
Work
Classification/
Apprentice Rate
RT
-
OT
ST
Day and Date
Total
Hours
Rate
of Pay
Fringe
Ben.
Gross
Amount
Weekly Deduction Totals
Net
Wages
08%14
08%15
08 16
1 08'17
08118
1 0819
O8120
FICA
State
Other
Total
Ded.
Su
fro
Tu
We
rn
Fr
Sa
Plan S
Week
With-
Holding
Local
Tax
Tax
Check
No.
Hours Worked Each Day
Cash S
Class
Ded.
Brandy N Eaves -Stone
xxx-xx-4937
0
Journeyman Flagger
RT
0
0
0
0
0
0
C 1
000
38 50
t 054 28
80 55
D:r
18 35
251 OC
OT
0
0
0
0
0
0
0
0
000
000
17619
15'-
a
TO 00
213Ct
ST
35
0
0
0
0
0
0
35
5034
James E Gilbert
xxx-xx-9554
Journeyman Flagger
RT
0
0
0
0
0
0
7
0
000
3850
1283 39
98 1?
4-
697 48
585 91
OT
o
0
0
0
0
0
0
0
000
000
176 19
131 OJ
56 84
ST
3 5
0
0
0
D
o
0
3 5
50 34
RT
OT
ST
RT
OT
ST
j
i
RT
OT
ST
RT
OT
ST
RT
OT
ST
RT
OT
ST
Date
08126/2016
L Fredrick
PR/AR Manager
(Name of Signatory Party) (Title)
do hereby state
(1) That I pay or supervise the payment of the persons employed by
Advanced Government Services Inc on the project
Insituform Technologies LLC:202221 Cas that during the payroll period commencing
on the 14 day of August 2016 and ending the 20 day of August
2016 . all persons employed on said project have been paid the full weekly wages earned.
that no rebates have been or will be made either directly or indirectly to or on behalf of said
Advanced Government Services Inc from the
(Contractor or Subcontractor)
full weekly wages earned by any person and that no deductions have been made either
directly or indirectly from the full wages earned by any person other than permissible
deductions as defined in Regulations. Part 3 t29 CFR Subtitle A), issued by the Secretary
of Labor under the Copeland Act. as amended (48 Stat 948. 63 Stat 108 72 Stat 967
76 Stat 357 40 U S C 276c). and described below
Aflac/Colonial Life
Court Ordered Garn/Support
Wa Workers Comp
(2) That any payrolls otherwise under this contract required to be submitted for the
above period are correct and complete, that the wage rates for laborers or mechanics
contained therein are not less than the applicable wage rates contained in any wage
determination incorporated into the contract that the classifications set forth therein for
each laborer or mechanic conform with the work he performed
(3) That any apprentices employed in the above period are duly registered in a bona
fide apprenticeship program registered with a State apprenticeship agency recognized by
the Bureau of Apprenticeship and Training United States Department of Labor, or if no
such recognized agency exists in a State, are registered with the Bureau of Apprenticeship
and Training. United States Department of Labor
(4) That
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed in
the above referenced payroll, payments of fringe benefits as listed in the contract
have been or will be made to the appropriate programs for the benefit of such
employees except as noted in Section 4(c) below
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
-Each laborer or mechanic listed in the above referenced payroll has been paid.
as indicated on the payroll. an amount not less than the sum of the applicable
bask hourly wage rate plus the amount of the required fringe benefits as listed
in the contract except as noted in Section 4(c) below
(c) EXCEPTIONS
EXCEPTION (CRAFT)
EXPLANATION
REMARKS
The prevailing wages have been paid in accordance with the pre -filed Statement of Intent
to Pay Prevailing Wages on file with the public agency (RCW 39 12 070) S11 00 fringe
per hour worked is deposited to "The Contractors Plan Administrators" for "Qualified
Medical Insurance and/or 401 K Retirement Plan"
NAME AND TITLE
L Fredrick
PR/AR Manager
SIGNATURE
THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT
THE CONTRACTOR OR SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION
SEE SECTION 1001 OF TITLE 18 AND SECTION 231 OF TITLE 31 OF THE UNITED
STATES CODE
Form OSS-348
Form Approved
STATEMENT OF COMPLIANCE 202221
Orate No 1215-0149
Expires Jun 30. 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per response, including the time for reviewing instructions. searching existing data sources.
gathering and maintaining the data heeded, and Completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden. to Department of Defense. Washington Headquarters Services. Directorate for Information Operations and Reports. 1215
Jefferson Davis Highway, Suite 1204, Arlington. VA 22202-4302, and to the Office of Management and Budget. Paperwork Reduction Project (1215-0149) Washington, DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1. PAYROLL NUMBER
2 PAYROLL PAYMENT DATE (YYMMDD)
3. CONTRACT NUMBER
4. DATE (YYMMDD)
48
1 16/09/02
1 16/09/02
I, Stephanie Forrest Payroll Specialist do hereby state
(Name of signatory party) (Trtle)
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Contractor or Subcontractor)
on the CAG-15-149 that during the payroll period commencing on the 21 day of
(Building or work)
August 201 6 and ending the 27 day of August 201 6 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat. 948, 63 Stat. 108, 72 Stat. 967, 76 Stat. 35T, 40 U.S. C. 276c), and described below:
Federal, Fitts, State and Local tax, 401 K, Loan re -payment, Insurance, garnishments
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
-Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5.REMARKS
6 NAME (Last, First, Middle Initial)
TITLE
8. SIGNATURE,/
Forrest, Stephanie
TPayroll Specialist
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or cnm I e ti
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
DD FORM 879, MAR 95 (EG) PREVIOUS EDITON MAY BE USED
If
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Pro''ect and Location 202221
RENTON - WA- CAG-15-149
CASCADE INTERCEPTOR -PHASE II
4784'x 14,18,21,24" CIPP
WA
8/31/2016 1150:00
Page - 40
Pay Period Ending Date 812712016
Period Number 1
St SMS SDep
FMS FDep Sex
EEO Union ....................... Craft .........................
Step .........................
Social Security No
Ethnic Cat
....... Regular .............. Overtime ......
Other
Total
Job
........... Check Detail .........
.
Name/Address
Work Date Hours Rate Hours Rate
Hours
Hours
Amount
Description Amount
MO S
S M
008 1971 For HBU 1971 Accrual PIPL Pipelayer
default
XXX-XX-5785
White
Shane M Ayers
SU 8/21/2016
6.00
6.00
521.52
Payment Number: 04930856
1575 Fircrest Ct SE
Pipelayer
6.00
6.00
521.52
Gross Pay
2,463.60
Salem OR 97306
OR Departmen
204.96
United States
FED W/H Tax
370.87
FICA W/H
153.09
Medicare W/H
35.80
Net Pay
1,698.88
Hrs This Chk
39.50
Subtotal for Payment
Number:04930856
6.00
6.O0
521.52
Shane M Ayers
6.00
6.00
521.52
MO S S 1 M 008 1971 For HBU 1971 Accrual
XXX-XX-0002 White
Adam Eugene Clary SU 8/21/2016
1768 Pine Street Pipelayer
Silverton OR 97381
United States
PIPL Pipelayer default
6.00 6.00 521.52 Payment
Number:04930860
6.00 6.00 521.52 Gross Pay
2,465.80
OR Departmen
194.26
FED W/H Tax
497.24
FICA W/H
147.26
Medicare W/H
34.44
Chd Sup $/%
98.08
Other order$
311.55
MEDICAL
88.88
DENTAL
5.46
VISION
.74
OP EE LIFE
2.54
OP CH LIFE
.69
Short Term D
4.81
Net Pay
1,079.85
Hrs This Chk
39.50
M
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
ProJ'ecI and Location 202221
RENTON - WA- CAG-15-149
4784'x 14 18.21 24" CIPP
CASCADt INTtRCEPTOR-PHASE II
WA
8/31 /2016 13.50:00
Page - 41
Pay Period Ending Date 8/27/2016
Period Number 1
St SMS SDep FMS FDep Sex EEO Union .................... Craft .................... Step ..................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
Subtotal for Payment Number:04930860 6.00 6.00 521.52
Adam Eugene Clary 6.00 6.00 521.52
MO M M 5 M 008 1971 For HBU 1971 Accrual PIPL Pipelayer
XXX-XX-3029 Black or African Ame
Thomas Juan Dunn SU 8/21/2016
P.O. Box 52 Pipelayer
Smartville CA 95977
United States
Subtotal for Payment Number: 04930863
Thomas Juan Dunn
MO M M
XXX-XX-8053 White
Brennon Christopher Pratt
1634 SE Jonathan Avenue
Dallas OR 97338
F United States
M 008 1971 For HBU 1971 Accrual
SU 8/21/2016
Installation Technician
TECH Installation Technic
default
6.00
6.00
521.52
Payment
Number: 04930863
6.00
6.00
521.52
Gross Pay
2,373.40
CA Departmen
119.18
CA -SDI
20.58
FED W/H Tax
402.85
FICA W/H
141.75
Medicare W/H
33.15
MEDICAL
80.31
DENTAL
5.99
VISION
.69
OP SP LIFE
1.83
Net Pay
1,567.07
Hrs This Chk
39.50
6.00
6.00
521.52
6.00
6.00
521.52
default
6.00 6.00
6.00 6.00
521.52 Payment Number:04930868
521.52 Gross Pay
2,469.00
OR Departmen
194.41
FED W/H Tax
413.50
FICA W/H
153.08
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
ProJ'ect and Location 202221
RE TON - WA-CAG-15-149
CASCA1 TREPT DI=N�COR-PHASE II
WA
St SMS SDep FMS FDep Sex EEO Union .................... Craft.................... Step..................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount
Subtotal for Payment Number:04930868 6.00 6.00 521.52
Brennon Christopher Pratt 6.00 6.00 521.52
RENTON - WA- CAG-15-149 24.00 24.00 2,086.08
8/31 /2016 13, 50.00
Page - 42
Pay Period Ending Date 8/27/2016
Period Number 1
........ I . Check Detail ..........
Description Amount
Medicare W/H
35.80
Total Deduct
796.79
Net Pay
1,672.21
Hrs This Chk
39.50
U.S. Department of Labor PAYROLL
Wage and Hour Division (For Contractor's Optional Use; See Instructions at www.dol.gov/whd/forms/wh347instr.htm)
Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number.
MHO JF
U.S. Wales and Hour l)iviFlon
Rev. Dec. 2008
NAME OF CONTRACTOR OR SUBCONTRACTOR ®
ADDRESS 9791 Titan Park Circle
OMB No.: 1235-000E
Maverick Pump Services, LLC
Littleton, CO 80125
Expires: 01/31/2015
PAYROLL NO, FOR WEEK ENDING
PROJECT AND LOCATION
PROJECT OR CONTRACT NO.
6 08/27/2016
Cascade Interceptor Rehabilitation Phase II
AG-15-149
C
Renton, WA
(1)
(2)
(3)
(4) DAY AND DATE
(5)
(6)
(7)
(9)
o
H
DEDUCTIONS
Sun
.Mug
7uc
Wed
Thu
Fri
Sat
NAME AND INDIVIDUAL IDENTIFYING NUMBER
F
n
o
GROSS
NET
WAGES
WITH
(e.g., LAST FOUR DIGITS OF SOCIAL SECURITY
ry
WORK
r-
o
„/21
w22
8/23
V24
8/25
x^6
8/27
TOTAL
RATE
AMOUNT
HOLDING
medicare.
TOTAL
PAID
HOURS WORKED EACH
DAY
NUMBER) OF WORKER
i
CLASSIFICATION
HOURS
OF PAY
EARNED
FICA
TAX
OTHER
DEDUCTIONS
FOR WEEK
Miguel Mata
Laborer
o
r.,00
0.00
0.00
000
400
200
,00u
22.0(
moo.?j
��'
$�p�'
r
v—►
1701 Garden Oaks Dr, Irving, TX 75061
3
Sewer & Water
.187.26
$285.02
$43.80
$516.08
xxx-xx-2276
General Laborer
s
0a,
N.00
7.00
500
800
Srx,
om
36.0(
33.65 10.30
Miguel Mijares
Laborer
o
e.o0
e1x1
euo
0,„,
401)
ux,
I—
22.0(
�,
3G2$.2'8
L -1
1914 Dory Lane Irving, TX 75061
0
Sewer & Water
$187.26
$360.96
$43.79
$250.00
$842.01
6
o.u0
Nor)
zoo
sca
N00
9W
6.w
36.0
33.65 W30
xxx-xx-0216
General Laborer
0
s
0
s
0
s
0I
I
sl
I
Reg - 33.65 + fringe 10.30 = $43.95
0
OT - $60.78
DOT - $77.60
s
0
s
While completion of Form WH-347 is optional, it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R. §§ 3.3, 5.5(a). The Copeland Act
(40 U.S.C. § 3145) contractors and subcontractors performing work on Federally financed or assisted construction contracts to "furnish weekly a statement with respect to the wages paid each employee dunng the preceding week." U.S. Department of Labor (DOL) regulations at
29 C.F.R. § 5.5(a)(3)(ii) require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project, accompanied by a signed "Statement of Compliance" indicating that the payrolls are correct and complete and that each laborer
or mechanic has been paid not less than the proper Davis -Bacon prevailing wage rate for the work performed. DOL and federal contracting agencies receiving this information review the information to determine that employees have received legally required wages and fringe benefits.
Public Burden Statement
We estimate that is will take an average of 55 minutes to complete this collection, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed. and completing and reviewing the collection of information. If you have
any comments regarding these estimates or any other aspect of this collection, Including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Divislon, U.S. Department of Labor, Room 53502, 200 Constitution Avenue, N.W.
Washington. D.C. 20210
(over)
Date 8/29/2016
Becki Moessner
(Name of Signatory Party)
do hereby state.
office manager
(Title)
(1) That I pay or supervise the payment of the persons employed by
Maverick Pump Services, LLC on the
(Contractor or Subcontractor)
Renton Cascade Interceptor Rehab Phase II ; that during the payroll period commencing on the
(Building or Work)
21 st day of August 2016 and ending the 27th day of August 2016
all persons employed on said project have been paid the full weekly wages earned, that no rebates have
been or will be made either directly or indirectly to or on behalf of said
Maverick Pump Services, LLC
(Contractor or Subcontractor)
from the full
weekly wages earned by any person and that no deductions have been made either directly or indirectly
from the full wages earned by any person, other than permissible deductions as defined in Regulations. Part
3 (29 C.F.R. Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat. 948,
63 Start. 108, 72 Stat. 967: 76 Stat. 357, 40 U.S.C. § 3145), and described below.
loan repayment
(2) That any payrolls otherwise under this contract required to be submitted for the above period are
correct and complete. that the wage rates for laborers or mechanics contained therein are not less than the
applicable wage rates contained in any wage determination incorporated into the contract, that the classifications
set forth therein for each laborer or mechanic conform with the work he performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship
program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and
Training. United States Department of Labor.. or if no such recognized agency exists in a State. are registered
with the Bureau of Apprenticeship and Training. United States Department of Labor.
(4) That
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
— in addition to the basic hourly wage rates paid to each laborer or mechanic listed in
the above referenced payroll. payments of fringe benefits as listed in the contract
have been or will be made to appropriate programs for the benefit of such employees,
except as noted in section 4(c) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
m — Each laborer or mechanic listed in the above referenced payroll has been paidr
as indicated on the payroll, an amount not less than the sum of the applicable
basic hourly wage rate plus the amount of the required fringe benefits as listed
in the contract, except as noted in section 4(c) below.
(c) EXCEPTIONS
EXCEPTION (CRAFT) EXPLANATION
REMARKS
NAME AND TITLE 1 ATU E
Becki Moessner
office manager
P2—�
THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE MENTS MAYS JECT THE QNTRACTOR OR
SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION. SEE SECTION 1001 OF TITLE AND SECTION 231 OF TITLE
31 OF THE UNITED STATES CODE.
FJ
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30. 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per response, including the time for reviewing instructionssearching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden, to Department of Defense, Washington Headquarters Services. Directorate for Information Operations and Reports, 1215
Jefferson Davis Highway, Suite 1204. Arlington, VA 22202-4302. and to the Office of Management and Budget. Paperwork Reduction Project (12150149) Washington. DC 20503,
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1. PAYROLL NUMBER
AYROLL PAYMENT DATE (YYMMDD)
F
3. CONTRACT NUMBER
4 DATE (YYMMDD)
46
16/08/19
1 16/08/19
I. Stephanie Forrest Payroll Specialist do hereby state
(Name of signatory patty) (Title)
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (contractor or subcortracton
on the CAG-15-149 , that during the payroll period commencing on the 7 day of
(Building or, work)
Auoust 201 6 ,and ending the 13 day of August 201 6 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or Will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor, or subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat. 948, 63 Stat. 108, 72 Stat. 967, 76 Stat. 357, 40 U.S. C. 276C), and described below:
Federal, Fica, State and Local tax, 401 K, Loan re -payment, Insurance, garnishments
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete, that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract; that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
-Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
i
k
5 REMARKS
6. NAME (Last, First, Middle Initial)
TITLE
B. SIGNATUR
Forrest, Stephanie
TPayroll Specialist
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or c i ro n-
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
UU t-UKM d(V, MAK 9b (L(i) PREVIOUS EDITON MAY BE USED.
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Pro'ect and Location 202221
RE�TON - WA- CAG-15-149
CASCADE INTERCEPTOR -PHASE II
4784'x 14,18,21,24" CIPP
WA
8/17/2016 15:01:34
Page - 45
Pay Period Ending Date 8/13/2016
Period Number 3
St SMS SDep
FMS FDep Sex EEO Union .......................
Craft .........................
Step .........................
Social Security No
Ethnic Cat .......
Regular ..............
Overtime ......
Other
Total
Job
........... Check Detail ..........
Name/Address Work Date
Hours Rate
Hours Rate
Hours
Hours
Amount
Description Amount
MO S
S M 008 1971 For HBU 1971 Accrual
PIPL Pipelayer
default
XXX-XX-5785
White
Shane M Ayers
MO 8/8/2016
8.00 41.890
4.00 65.190
2.50
14.50
813.18
Payment Number:04928373
1575 Fircrest Ct SE
TU 8/9/2016
8.00 41.890
4.00 65.190
1.00
13.00
682.80
Gross Pay
4,991.64
Salem OR 97306
WE 8/10/2016
8.00 41.890
4.00 65.190
12.00
595.88
OR Departmen
464.93
United States
TH 8/11/2016
8.00 41.890
4.00 65.190
12.00
595.88
FED W/H Tax
1,114.06
FR 8/12/2016
8.00 41.890
2.00 65.190
10.00
465.50
FICA W/H
310.13
SA 8/13/2016
11.00
11.00
956.12
Medicare W/H
72.53
SA 8/13/2016
12.00 65.190
12.00
782.28
Garnish %
296.97
Pipelayer
40.00
30.00
14.50
84.50
4,891.64
Net Pay
2,733.02
Hrs This Chk
84.50
Subtotal for Payment Number:04928373
40.00
30.00
14.50
84.50
4,891.64
Shane M Ayers
40.00
30.00
14,50
84.50
4,891.64
MO S
S 1 M 008 1971 For HBU 1971 Accrual
PIPL Pipelayer
default
XXX-XX-0002
White
Adam Eugene Clary
MO 8/8/2016
8.00
42.000
4.00
65.190
2.50
14.50
814.06
Payment
Number:04928377
1768 Pine Street
TU 8/9/2016
8.00
42.000
4.00
65.190
1.00
13.00
683.68
Gross Pay
4,996.04
Silverton OR 97381
WE 8/10/2016
8.00
42.000
4.00
65.190
12.00
596.76
OR Departmen
464.33
United States
TH 8/11/2016
8.00
42.000
4.00
65.190
12.00
596.76
FED W/H Tax
1,291.97
FR 8/12/2016
8.00
42.000
2.00
65.190
10.00
466.38
FICA W/H
309.76
SA 8/13/2016
11.00
11.00
956.12
Medicare W/H
72.44
SA 8/13/2016
12.00
65.190
1200.
782.28
Chd Sup $/%
98.08
Pipelayer
40.00
30.00
14.50
84.50
4,896.04
Net Pay
2,759.46
Hrs This Chk
84.50
Subtotal for Payment Number:04928377
40.00
30.00
14.50
84.50
4,896.04
Adam Eugene Clary
40.00
30.00
14.50
84.50
4.896.04
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Pro'ecI and Location 202221
RE�TON - WA- CAG-15-149
4784'x 14 18,21 24" CIPP
CASCADE` INTERCEPTOR -PHASE II
WA
8/17/2016 15:01:34
Page - 46
Pay Period Ending Date 8/13/2016
Period Number 3
St SMS SDep FMS FDep Sex EEO
Union ....................
Craft ....................
Step ..................
Social Security No Ethnic Cat
.......
Regular ..............
Overtime
......
Other
Total
Job
........... Check Detail ..........
Name/Address
Work Date
Hours Rate
Hours
Rate
Hours
Hours
Amount
Description Amount
MO M M 5 M 008
1971 For HBU 1971 Accrual
PIPL Pipelayer
default
XXX-XX-3029 Black or African Ame
Thomas Juan Dunn
MO 8/8/2016
8.00 37.380
4.00
65.190
2.50
14,50
777.10
Payment Number:04928380
P.O. Box 52
TU 8/9/2016
8.00 37.380
4.00
65.190
1.00
13.00
646.72
Gross Pay
4,711.24
Smartville CA 95977
WE 8/10/2016
8.00 37.380
4.00
65.190
12.00
559.80
CA Departmen
358.34
United States
TH 8/11/2016
8.00 37.380
4.00
65.190
12.00
559.80
CA -SDI
41.62
FR 8/12/2016
8.00 37.380
2.00
65.190
10.00
429.42
FED W/H Tax
1,033.92
SA 8/13/2016
11.00
11.00
956.12
FICA W/H
286.71
SA 8/13/2016
12.00
65,190
12.00
782.28
Medicare W/H
67.06
Pipelayer
40.00
30.00
14.50
84.50
4,711.24
MEDICAL
80,31
DENTAL
5.99
VISION
.69
OP SP LIFE
1.83
Total Deduct
1,876.47
Net Pay
2,834.77
Hrs This Chk
84.50
Subtotal for Payment Number04928380 40.00
Thomas Juan Dunn 40.00
MO S S
1 M 007 1971 For HBU 1971 Accrual
XXX-XX-0687
White
Brian Mitchell Hille
MO 8/8/2016
8.00
42.080
3150 SW 108th Ave
TU 8/9/2016
8.00
42,080
Beaverton OR 97005
WE 8/10/2016
8.00
42.080
United States
TH 8/11/2016
8.00
42.080
FIR 8/12/2016
8.00
42.080
SA 8/13/2016
SA 8/13/2016
Pipelayer
40.00
30.00 14.50 84.50 4,711.24
30.00 14.50 84.50 4.711.24
PIPL Pipelayer
default
4.00
65.190
2.50
14.50
814.70
Payment Number
04928381
4.00
65.190
1.00
13.00
684.32
Gross Pay
4,999.24
4.00
65.190
12.00
597.40
OR Departmen
465.69
4.00
65.190
12.00
597.40
FED W/H Tax
1,296.49
2.00
65.190
10.00
467.02
FICA W/H
310.60
11.00
11.00
956.12
Medicare W/H
72.64
12.00
65.190
12.00
782.28
Total Deduct
2.145.42
30.00
14.50
84.50
4,899.24
Net Pay
2,853.82
Hrs This Chk
84.50
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Pro1'ect and Location 202221
RENTON - WA- CAG-15-149
CASCA1 TREPT DLNtCOR-PHASE II
WA
St SMS SDep FMS FDep Sex EEO Union .................... Craft ....................
Step ..................
Social Security No Ethnic Cat ....... Regular .............. Overtime ......
Other
Total
Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate
Hours
Hours
Amount Description Amount
Subtotal for Payment Number 04928381 40.00 30.00
14.50
84.50
4,899.24
Brian Mitchell Hille 40.00 30.00
14.50
84.50
4,899.24
MO M M
XXX-XX-8053 White
Brennon Christopher Pratt
1634 SE Jonathan Avenue
Dallas OR 97338
United States
M 008 1971 For HBU 1971 Accrual
MO 8/8/2016
8.00
42.160
TU 8/9/2016
8.00
42.160
WE 8/10/2016
8.00
42.160
TH 8/11/2016
8.00
42.160
FIR 8/12/2016
8.00
42.160
SA 8/13/2016
SA 8/13/2016
Pipelayer
40.00
Subtotal for Payment Number:04928385 40.00
Brennon Christopher Pratt 40.00
8/17/2016 15 01:34
Page - 47
Pay Period Ending Date 8/13/2016
Period Number 3
PIPL Pipelayer
default
4.00
65.190
2.50
14.50
815.34
Payment
Number: 04928385
4.00
65.190
1.00
13.00
684.96
Gross Pay
5,002.44
4.00
65.190
12.00
598.04
OR Departmen
427.26
4.00
65.190
12.00
598.04
FED W/H Tax
1,123.72
2.00
65.190
10.00
467.66
FICA W/H
310.15
11.00
11.00
956.12
Medicare W/H
72.53
12.00
65.190
12.00
782.28
Total Deduct
1,933.66
30.00
14.50
84.50
4,902.44
Net Pay
3,068.78
Hrs This Chk
84.50
30.00
14.50
84.50
4,902.44
30.00
14.50
84.50
4,902.44
RENTON - WA- CAG-15-149 200.00 150.00 72.50 422.50 24,300.60
•4
U.S. Department of Labor PAYROLL
Wage and Hour Division (For Contractor's Optional Use; See Instructions at www.dot.govlwhdlformslwh347instr.htm)
Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number.
U.S. Wage auJ Hour Divi,ion
Rev. Dec. 2008
NAME OF CONTRACTOR OR SUBCONTRACTOR ®
ADDRESS 9791 Titan Park Circle
OMB No.: 1235-000E
Maverick Pump Services, LLC
Littleton, CO 80125
Expires: 01/31/2015
PAYROLL NO. FOR WEEK ENDING
PROJECT AND LOCATION
PROJECT OR CONTRACT NO.
3 08/06/2016
Cascade Interceptor Rehabilitation Phase II
Renton, WA
CAG-15-149
(1)
(2)
(3)
(4) DAY AND DATE
(5)
(6)
(7)
(9)
(9)
Sun
Mvn
Tuc
w,d
Thu
Fri
Sat
I
So
1�
w
DEDUCTIONS
NAME AND INDIVIDUAL IDENTIFYING NUMBER
d
o .
GROSS
NET
WAGES
WITH-
(e.g., LAST FOUR DIGITS OF SOCIAL SECURITY
SS
WORK
o
131
8/1
8/2
8/3
8/4
i/5
Ii/6
TOTAL
RATE
AMOUNT
HOLDING
mcllc rc
TOTAL
PAID
HOURS
WORKED EACH
DAY
NUMBER) OF WORKER
i g
CLASSIFICATION
HOURS
OF PAY
EARNED
FICA
TAX
OTHER
DEDUCTIONS
FOR WEEK
Carlos Mata
Laborer
o
ow
2512 W 4th Irving, TX 75060
Sewer & Water
s
ow
33.65 10.30
xxx-xx-1100
0
General Laborer
Miguel Mijares
Laborer
o
orxi
150
aw
orio
otio
eno
rtoo
18.5(
(00.
1845 .8'
I7`9 8
1914 Dory Lane Irving, TX 75061
0
Sewer & Water
�%
1
$114.44
$184.79
$26.77
$250.00
S576A0
1�•
s
o.w
s.ou
6.50
o0o
000
o,00
ow
14.5
33,65 10,30
xxx-xx-0216
General Laborer
0
s
0
6
0
s
0
s
Reg - 33.65 + fringe 10.30 = $43.95
a
OT - $60.78
s
DOT - $77.60
0
-11117
4Nvle completion of Form WH347 is optional, it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R. §§ 3.3. 5.5(a). The Copeland Act
(40 U.S.C. § 3145) contractors and subcontractors performing work on Federally financed or assisted construction contracts to 'furnish weekly a statement with respect to the wages paid each employee during the preceding week." U.S. Department of Labor (DOL) regulations at
29 C.F.R. § 5.5(a)(3)(ii) require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project, accompanied by a signed "Statement of Compliance" indicating that the payrolls are correct and complete and that each laborer
or mechanic has been paid not less than the proper Davis -Bacon prevailing wage rate for the work performed. DOL and federal contracting agencies receiving this information review the Information to determine that employees have received legally required wages and fringe benefits.
Public Burden Statement
We estimate that is will take an average of 55 minutes to complete this collection, Including time for reviewing instructions, searching existing data sources, gathering and maintaining the date needed, and completing and reviewing the collection of information. If you have
any comments regarding these estimates or any other aspect of this collection, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division. U.S. Department of Labor, Room S3502. 200 Constitution Avenue, N.W.
Washington, D.C. 20210
(over)
Date 8/8/2016
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
Becki Moessner office manager
m — Each laborer or mechanic listed in the above referenced payroll has been paid,
(Name of Signatory Party) (Title)
as indicated on the payroll, an amount not less than the sum of the applicable
do hereby state:
basic hourly wage rate plus the amount of the required fringe benefits as listed
in the contract, except as noted in section 4(c) below.
(1) That I pay or supervise the payment of the persons employed by
(c) EXCEPTIONS
Maverick Pump Services, LLC on the
(Contractor or Subcontractor)
EXCEPTION (CRAFT) EXPLANATION
Renton Cascade Interceptor Rehab Phase 11 , that during the payroll period commencing on the
(Building or Work)
30th clay of July 2016 , and ending the 6th day of August 2016
all persons employed on said project have been paid the full weekly wages earned, that no rebates have
been or will be made either directly or indirectly to or on behalf of said
Maverick Pump Services, LLC
from the full
(Contractor or Subcontractor)
weekly wages earned by any person and that no deductions have been made either directly or indirectly
from the full wages earned by any person, other than permissible deductions as defined in Regulations, Part
3 (29 C.F.R. Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat. 948,
63 Start. 108, 72 Stat. 967: 76 Stat. 357, 40 U.S.C. § 3145), and described below:
loan repayment
REMARKS
(2) That any payrolls otherwise under this contract required to be submitted for the above period are
correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the
applicable wage rates contained in any wage determination incorporated into the contract, that the classifications
set forth therein for each laborer or mechanic conform with the work he performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship
program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and
Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered
with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
NAME AND TITLE SI NAT
El
Becki Moessner
— in addition to the basic hourly wage rates paid to each laborer or mechanic listed in
office manager
the above referenced payroll, payments of fringe benefits as listed In the contract
THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT E CONTRAC OR OR
have been or will be made to appropriate programs for the benefit of such employees,
SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION. SEE SECTION 1001 OF TI LE 18 AND S TION 231 OF TITLE
except as noted in section 4(c) below.
OF THE UNITED STATES CODE.
U.S. Department of Labor PAYROLL
Wage and Hour Division (For Contractor's Optional Use; See Instructions at www.dol.gov/whd/forms/wh3471nstr.htm)
Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number.
aWND
U.S. Wage and Hour Dhision
Rev Ikec 9nnA
NAME OF CONTRACTOR OR SUBCONTRACTOR ®
Maverick Pump Services, LLC
ADDRESS 9791 Titan Park Circle
Littleton, CO 80125
OMB No.: 1235-OOOE
Expires: 01/31/2015
PAYROLL NO. FOR WEEK ENDING
2 07/30/2016
PROJECT AND LOCATION
Cascade Interceptor Rehabilitation Phase II
Renton, WA
PROJECT OR CONTRACT NO.
CAG-15-149
(�)
NAME AND INDIVIDUAL IDENTIFYING NUMBER
(e.g., LAST FOUR DIGITS OF SOCIAL SECURITY
NUMBER OF WORKER
(2)
z
a
o
i
(3)
WORK
CLASSIFICATION
IA
O
(4)DAY ANDDATE
(5)
TOTAL
HOURSOF
(6)
RATE
PAY
(7)
GROSS
AMOUNT
EARNED
2109 y .93
(6)
DEDUCTIONS
(8)
NET
WAGES
PAID
FOR WEEK
sun
Man
Tuc
wed
Thu
Fri
Sat
7/24
723
726
7/27
7/28
7/29
7/30
FICA
WITH-
HOLDING
TAX
medicare
OTHER
TOTAL
DEDUCTIONS
HOURS
WORKED
EACH
DAY
Carlos Mata
2512 W 4th Irving, TX 75060
xxx-xx-1100
0
Laborer
Sewer & Water
General Laborer
o
0.00
5.50
3.00
0.50
3.00
3.00
0.00
15.0(
AA
$167.09
$312.16
$39.08
$S 1 R.33
21-Ap, (A
a
0.00
s.00
size
s.00
sea
e.0o
0.00
40.0(
33.65 10.30
Miguel Mijares
1914 Dory Lane Irving, TX 75061
xxx-xx-0216
0
Laborer
Sewer & Water
General Laborer
o
0.00
7.00
4.00
0.50
4.00
3.00
3.2s
21,7-
$172.29
$324.74
$40.29
$250.00
$787.32
19q 1.51
6
0.00
ail
8.00
zoo
soo
too
0.00
32,0
33.65 10 3l1
0
6
0
6
0
[4-1-1
0
a
Reg - 33.65 + fringe 10.30 = $43.95
OT - $60.78
DOT - $77.60
0
a
0
a
While completion of Form WH347 is optional, it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R. §§ 3.3. 5.5(a). The Copeland Act
(40 U.S.C. § 3145) contractors and subcontractors performing work on Federally financed or assisted construction contracts to "furnish weekly a statement with respect to the wages paid each employee dung the preceding week." U.S. Department of Labor (DOL) regulations at
29 C.F.R. § 5.5(e)(3)(II) require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project, accompanied by a signed "Statement of Compliance" Indicating that the payrolls are correct and complete and that each laborer
or mechanic has been paid not less than the proper Davis -Bacon prevailing wage rate for the work performed. DOL and federal contracting agencies receiving this Information review the Information to determine that employees have received legally required wages and fringe benefits.
Public Burden Statement
We estimate that is will take an average of 55 minutes to complete this collection, Inducing time for reviewing instructions, searching existing data sources, gathering and maintaining the data neededand completing and reviewing the collection of information. If you have
any comments regarding these estimates or any other aspect of this collection, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S3502, 200 Constitution Avenue, N.W.
Washington, D.C. 20210
(over)
Date 8/1/2016
Becki Moessner
office manager
(Name of Signatory Party) (Title)
do hereby state.
(1) That I pay or supervise the payment of the persons employed by
Maverick Pump Services, LLC on the
(Contractor or Subcontractor)
Renton Cascade Interceptor Rehab Phase 11 , that during the payroll period commencing on the
(Building or Work)
24th day of July 2016 , and ending the 30th day of July 2016
all persons employed on said project have been paid the full weekly wages earned, that no rebates have
been or will be made either directly or indirectly to or on behalf of said
Maverick Pump Services, LLC
(Contractor or Subcontractor)
from the full
weekly wages earned by any person and that no deductions have been made either directly or indirectly
from the full wages earned by any person, other than permissible deductions as defined in Regulations, Part
3 (29 C.F.R. Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat. 948.
63 Start. 108, 72 Stat. 967: 76 Stat. 357. 40 U.S.C. § 3145), and described below:
loan repayment
(2) That any payrolls otherwise under this contract required to be submitted for the above period are
correct and complete, that the wage rates for laborers or mechanics contained therein are not less than the
applicable wage rates contained in any wage determination incorporated into the contract, that the classifications
set forth therein for each laborer or mechanic conform with the work he performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship
program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and
Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered
with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
El - in addition to the basic hourly wage rates paid to each laborer or mechanic listed in
the above referenced payroll. payments of fringe benefits as listed in the contract
have been or will be made to appropriate programs for the benefit of such employees,
except as noted in section 4(c) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
m — Each laborer or mechanic listed in the above referenced payroll has been paid.
as indicated on the payroll, an amount not less than the sum of the applicable
basic hourly wage rate plus the amount of the required fringe benefits as listed
in the contract, except as noted in section 4(c) below.
(c) EXCEPTIONS
EXCEPTION (CRAFT) EXPLANATION
REMARKS
NAME AND TITLE S TU
Becki Moessner
office manager
)wo Ux
THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STAT91MIENTS MAY SUBJECT TH C TRACTOR OR
SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION, SEE SECTION 1001 OF TITLE 18.-AND SECTION 231 OF TITLE
31 OF THE UNITED STATES CODE.
U.S. Department of Labor PAYROLL
Wage and Hour Division 4NN0
(For Contractor's Optional Use; See Instructions at www.dol.gov/whd/forms/wh347instr.htm)
L.S. Wage and Hour Dhiaun
Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. Rev. Dec. 200E
NAME OF CONTRACTOR OR SUBCONTRACTOR ®
Maverick Pump Services, LLC
ADDRESS 9791 Titan Park Circle OMB No.: 1235-OOOE
Littleton, CO 80125 Expires: 01/31/2015
PAYROLL NO. FOR WEEK ENDING
1 07/23/2016
PROJECT AND LOCATION
Cascade Interceptor Rehabilitation Phase it
Renton, WA
PROJECT OR CONTRACT NO.
CAG-15-149
(1)
NAME AND INDIVIDUAL IDENTIFYING NUMBER
(e.g., LAST FOUR DIGITS OF SOCIAL SECURITY
NUMBER OF WORKER
(2)
2 �
0
u_ g
O
ia
(3)
WORK
CLASSIFICATION
1�
m
o
r
o
(4) DAY AND DATE
(5)
TOTAL
HOURS
(6)
RATE
OF PAY
(7)
GROSS
AMOUNT
EARNED
DEDUCTIONS
(9)
NET
WAGES
PAID
FOR WEEK
Sun
mve
Tuc
wcd
Thu
Fri
Sat
7/17
7;1N
7/19
7l2U
7R1
74?
7�:3
FICA
WITH-
HOLDING
TAX
mcdicnrr
OTHER
TOTAL
DEDUCTIONS
HOURS
WORKED EACH
DAY
Carlos Mata
2512 W 4th Irving, TX 75060
xxx-xx-1100
0
Laborer
Sewer & Water
General Laborer
o
0.00
oso
ergo
uoo
s,so
sao
tiro
22.5(
w0
7'
1993. o5
$117.37
$ I91.87
$27.45
$336.69
�5J�0•
s
grog
a.w
grin
o00
,uo
Nrq
o.o0
11.0(
33.0 10.30
Miguel Mijares
1914 Dory Lane Irving, TX 75061
xxx-xx-0216
0
Laborer
Sewer & Water
General Laborer
o
Ito
1
aoa
arxi
eix,
—
err,
inns
100
$60.78
$607.80
$37.68
$25.16
$8.81
$71.65
$536.15
IS
0-
0.00
000
0.00
0,00
0.00
0.00
33.65 1030
0
s
0
s
0
s
0
S
Reg - 33.65 + fringe 10.30 = $43.95
OT - $60.78
DOT - $77.60
0
s
0
6
While completion of Form M-347 is optional, it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained In 29 C.F.R. §§ 3.3, 5.5(a). The Copeland Act
(40 U.S.C. § 3145) contractors and subcontractors performing work on Federally financed or assisted construction contracts to'lumish weekly a statement with respect to the wages paid each employee during the preceding week." U.S. Department of Labor (DOL) regulations at
29 C.F.R. § 5.5(a)(3)(Ii) require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project. accompanied by a Signed "Statement of Compliance" indicating that the payrolls are correct and complete and that each laborer
or mechanic has been paid not less than the proper Davis -Bacon prevailing wage rate for the work performed. DOL and federal contracting agencies receiving INS information review the information to determine that employees have received legally required wages and fringe benefits.
Public Burden Statement
We estimate that is will take an average of 55 minutes to complete this collection, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have
any comments regarding these estimates or any other aspect of this collection, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S3502, 200 Constitution Avenue, N.W.
Washington, D.C. 20210
0
(over)
Date 7/25/16
Becki Moessner
office manager
(Name of Signatory Party) (Title)
do hereby state:
(1) That I pay or supervise the payment of the persons employed by
Maverick Pump Services, LLC on the
(Contractor or Subcontractor)
Renton Cascade Interceptor Rehab Phase II that during the payroll period commencing on the
(Building or Work)
17th clay of July 2016 , and ending the 23rd day of July 2016
all persons employed on said pro)ect have been paid the full weekly wages earned, that no rebates have
been or will be made either directly or indirectly to or on behalf of said
Maverick Pump Services, LLC
(Contractor or Subcontractor)
from the full
weekly wages earned by any person and that no deductions have been made either directly or indirectly
from the full wages earned by any person, other than permissible deductions as defined in Regulations. Part
3 (29 C.F.R. Subtitle A), issued by the Secretary of Labor under the Copeland Act. as amended (48 Stat. 948.
63 Start. 108, 72 Stat. 96T 76 Stat. 357, 40 U.S.C. § 3145), and described below.
loan repayment
(2) That any payrolls otherwise under this contract required to be submitted for the above period are
correct and complete, that the wage rates for laborers or mechanics contained therein are not less than the
applicable wage rates contained in any wage determination incorporated into the contract, that the classifications
set forth therein for each laborer or mechanic conform with the work he performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship
program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and
Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered
with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
— in addition to the basic hourly wage rates paid to each laborer or mechanic listed in
the above referenced payroll, payments of fringe benefits as listed in the contract
have been or will be made to appropriate programs for the benefit of such employees,
except as noted in section 4(c) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
m — Each laborer or mechanic listed in the above referenced payroll has been paid,
as indicated on the payroll, an amount not less than the sum of the applicable
basic hourly wage rate plus the amount of the required fringe benefits as listed
in the contract. except as noted in section 4(c) below.
(c) EXCEPTIONS
BUREAU OF LABOR AND INDUSTRIES
WAGE AND HOUR DMSION
PRIME CONTRACTOR ❑ SI IFlr.nNTDGCT(1D DQ
PAYROLLICERTIFIED STATEMENT FORM WH-38
FOR USE IN COMPLYING WITH ORS 279C.845'
----- - —. Fr 1 RVLL nv. FINAL PAYROLL U
Business Name (DBA): _.� Vj,j yt - P ��w, -:, �-, ,
Li'' Phone: (' '�) 4''L3-t?>i.e-1 CCB Registration Number: (ZZv?0
Project Name Or ae Project Number: Type of Work:
Street Address: Project Location:
Mailing Address. 7 + Project County:
I � Yf'cLi) C)r,-z oj-
Date Pay Period Began: Date Pay Period Ended: ?
THIS SECTION FR PF1IME CONTRACTORS ONLY THIS SECTION FOR SUBCONTRACTORS ONLY
Public Contracting Agency Name:
Phone: ( )
Date Contract Specifications First Advertised for Bid:
Contract Amount:
2 3 DAY AND DATE 4
Subcontract Amount
Prime Contractor Business Name (DBA):
Prime Contractor Phone: ( )
Prime Contractor's CCB Registration Number:
Date You Be an Work on the Pro ect.
5 6 7 8 g �p 11
NAME , ADDRESS AND
EMPLOYEE'S
IDENTIFICATION
NUMBER
CLASSIFICATION
(INCLUDE GROUP #
AND APPRENTICESHIP
STEP IF APPLICABLE)
S
��
,r
V
t rl
�j
TOTAL
HOURS
HOURLY
BASE
RATE
HOURLY
FRINGE
BENEFIT
AMOUNTS
PAID AS
WAGES TO
EMPLOYEE
GROSS
AMOUNT
EARNED (see
directions)
ITEMIZED
DEDUCTIONS
FICA, FED,
STATE, ETC.
NET WAGES
PAID
BENEFITS TSURLY RIN DE
TO BENEFIT
PARTY, PLAN,
FUND, OR
PROGRAM
NAME OF BENEFIT
PARTY, PLAN,
FUND, OR
PROGRAM
�y�.
41t
HOURS WORKED EACH DAY
UaAA-
(�Ov�LP,�'t•Z.a.vto
AWE ITI/j . DY•--
I V
OT
�5'la8
2'7.3'8
33o.5b
--
ST
20.
S�oN �wSi
JtM A.LI.S, D E_
U tlnGLfST
OT
S
OT
ST
OT
ST
OT
ST
IT
I
'Although this form has not been officially approved by the U.S. Department of Labor, it is designed to meet the requirements of both the state PWR law and the federal Davis -Bacon Act.
WH-38 (Rev. 06114)
THIS FORM CONTINUED ON REVERSE
Date:
1, ► t MCCi-M'ail &v�L
(NAME OF SIGNATORY PARTY)
do hereby state.
(1) That I pay or supervise the payment of1he
C -m cre Lye,_
CEK I IrIEU 5 I A I I=MLN I
In addition to completing sections (1) - (3), if your project is subject to the federal
Davis -Bacon Act requirements, complete the following section as well:
u' i� Cpi',t�c�`�t L�
(TITLE) (4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS OR
sons employed. by. PROGRAMS
(CONTRACTOR, SUBCONTRACTOR OR SURETY)
on the that during the payroll period
(BUILDING R WORD �
commencing on the day of and ending they day
(MONTH)1 (YEAR)
of. �. all persons employed on said project have been paid the
(MONTH) (YEAR)
full weekly wages earned, that no rebates have been,DLwill be made either directly or
indirectly to or on behalf of said eiMl��" SC'r tf .Lp SSC'r �/ [yp S
(CONTRACTOR, SUBCONTRACTOR OR SURETY)
from the full weekly wages earned by any person, and that no deductions have been
made either directly or indirectly from the full wages earned by any person, other than
permissible deductions as specified in ORS 652.610, and as defined in Regulations, Part
3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as
amended (48 Stat. 948, 63 Stat. 108, 72 Stat. 967; 76 Stat. 357; 40 U.S.C. 276c), and
described below: V X]1 1 . 5VJ_1 1 VU &I-1V _
(2) That any payrolls otherwise under this contract required to be submitted for the above
period are correct and complete; that the wage rates for workers contained therein are
not less than the applicable wage rates contained in any wage determination
incorporated into the contract, that the classifications set forth therein for each worker
conform with work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide
apprenticeship program registered with a state apprenticeship agency recognized by the
Bureau of Apprenticeship and Training, United States Department of Labor, or if no such
recognized agency exists in a state, are registered with the Bureau of Apprenticeship
and Training, United States Department of Labor.
I HAVE READ THIS CERTIFIED STATEMENT, KNOW THE CONTENTS THEREOF
AND IT IS TRUE TO MY KNOWLEDGE:
LAME AND TITLE)
❑ - In addition to the basic hourly wage rates paid to each laborer or mechanic
listed in the above referenced payroll, payments of fringe benefits as listed in
the contract have been or will be made to appropriate programs for the benefit
of such employees, except as noted in Section 4(c) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
❑ - Each laborer or mechanic listed in the above referenced payroll has been paid,
as indicated on the payroll, an amount not less than the sum of the applicable
basic hourly wage rate plus the amount of the required fringe benefits as listed
in the contract, except as noted in Section 4(c) below.
(c) EXCEPTIONS:
EXCEPTION EXCEPTION (CRAFT)EXPLANATION
REMARKS:
NAME AND TITLE SIGNATURE
THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY
SUBJECT THE CONTRACTOR OR SUBCONTRACTOR TO CIVIL OR CRIMINAL
PROSECUTION. SEE SECTION 1001 OF TITLE 18 AND SECTION 231 OF TITLE 31
OF THE UNITED STATES CODE.
FILE THIS FORM WITH THE PUBLIC AGENCY ASSOCIATED WITH THE PROJECT
NOTE TO CONTRACTORS: YOU MUST ATTACH COPIES OF THIS FORM TO EACH OF YOUR PAYROLL SUBMISSIONS ON THIS PROJECT.
INSTRUCTIONS AND ADDITIONAL FORMS ARE AVAILABLE ON OUR WEBSITE: WWW.OREGON.GOV/BOLI.
WH-3s
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per response, including the time for reviewing instructionssearching existing data sources.
gathering and maintaining the data needed and completing and reviewing the collection of information Send comments regarding this burden estimate or any other aspect of this collection
of information including suggestions for reducing this burden. to Department of Defense Washington Headquarters Services. Directorate for Information Operations and Reports, 1215
Jefferson Davis Highway Suite 1204. Arington. VA 22202-4302 and to the Office of Management and Budget. Paperwon, Reduction Protect 11215-0149) Washington. DC 20503
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1. PAYROLL NUMBER
2 PAYROLL PAYMENT DATE (YYMMDD)
3 CONTRACT NUMBER
4 DATE (YYMMDD)
44
1 16/08/05
16/08/05
Stephanie Forrest Payroll Specialist do hereby state
(Name of signatory party) :Tine
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Contractor or subrontraoror)
on the CAG-15-149 that during the payroll period commencing on the 24 day of
(Building or work)
July 201 6 and ending the 30 day of July 201 6 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act as amended
(46 Stat 948 63 Stat 108 72 Stat 967. 76 Stat 357. 40 U S.C. 276c), and described below:
Federal. Fica, State and Local tax, 401K Loan re -payment. Insurance. garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete:. that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract: that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State. are registered with the Bureau of Apprenticeship and Training. United States Department of Labor.
(4) That
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS. FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
-Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
i
5 REMARKS`
6. NAME (Last First. Middle Initial)
TITLE
8. SIGNP,tUPE ,
Forrest, Stephanie
Payroll Specialist
T
� l(p
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or c n pros On.
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code
DD FORM 879. MAR 95 (EG) PREVIOUS EDITON MAY BE USED
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Pro'ect and Location 202221
RE�TON - WA- CAG-15-149
CASCADE INTERCEPTOR -PHASE II
�A 4'x 14,18,21,24" CIPP
St SMS SDep FMS FDep Sex EEO Union ....................... Craft......................... Step.........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
NO WORK PERFORMED_
8/3/2016 8:34:14
Page - 37
Pay Period Ending Date 7/30/2016
Period Number 1
Vo
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30. 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per response, including the time for reviewing instructionssearching existing data sources.
gathering and maintaining the data needed. and completing and revievng the collection of information Send comments regarding this burden estimate or any other aspect of this collection
of information. including suggestions for reducing this burden. to Department of Defense Washington Headquarters Services . Directorate for Information Operations and Reports. 1215
Jefferson Davis Highway Suite 1204. Arington VA 22202-4302 and to the Office of Management and Budget. Paperwork Reduction Protect 02150149� Washington. DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1 PAYROLL NUMBER
2 PAYROLL PAYMENT DATE (YYMMDD)
3 CONTRACT NUMBER
4 DATE !YYMMDDI
43
1 16/07/29
1 16/07/29
I. Stephanie Forrest Payroll Specialist do hereby state
(Name o'srgnatory party, (TRlei
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (contractor or subcontractorl
on the CAG-15-149 that during the payroll period commencing on the 17 day of
(8m1dmg or work.)
July 201 6 and ending the 23 day of July 201 6 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations. Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat 948, 63 Stat 108, 72 Stat 967 76 Stat 357, 40 U. S. C 276c). and described below.
Federal. Fica. State and Local tax. 401 K. Loan re -payment. Insurance. garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete, that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State. are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll. payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5 REMARKS
6. NAME (Last. First. Middle Initial)
77LE
8 SIGNATU
Forrest, Stephanie
TPayroll Specialist
10
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or cn pros ub6 .
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
DD FORM 879, MAR 95 (EG) PREVIOUS EDITON MAY BE USED
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Pro'ect and Location 202221
RETON - WA- CAG-15-149
CASCADE INTERCEPTOR-PHASEII
4784'x 14,18,21,24" CIPP
WA
7/27/2016 13:55:54
Page - 35
Pay Period Ending Date 7/23/2016
Period Number 5
St SMS SDep FMS FDep Sex EEO Union ....................... Craft ......................... Step .........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
NO WORK PERFORMED
00
0,-4k
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30, 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per response, including the time for reviewing instructions. searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden. to Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports, 1215
Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302, and to the Office of Management and Budget. Paperwork Reduction Project (1215-0149) Washington. DC 20503
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER-
1 PAYROLL NUMBER
2 PAYROLL PAYMENT DATE (YYMMDD)
3. CONTRACT NUMBER
4 DATE (YYMMDD)
41
1 16/07/15
1 16/07/15
I, Stephanie Forrest Payroll Specialist do hereby state
(Na— of signatory party) (Title)
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Contactor or subconbacror)
on the CAG-15-149 that during the payroll period commencing on the 3 day of
(Building o, work)
July 201 6 and ending the 9 day of July 201 6 all persons employed
on said project have been paid the full weekly wages earned. that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(contractor or subcontac"
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat. 948, 63 Stat. 108, 72 Stat. 967, 76 Stat. 357. 40 U.S.C. 276c), and described below:
Federal, Fica, State and Local tax, 401K, Loan re -payment, Insurance, garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete, that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform With the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
-Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5.REMARKS
6. NAME (Last, First, Middle Initial)
TITLE
8. SIGN U
Forrest, Stephanie
TPayroll Specialist
1 12)
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or crilbioal DAeC&Ill
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
DID FORM 879, MAR 95 (EG) PREVIOUS EDITON MAY BE USED.
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Pro ect and Location 202221
RE�TON - WA- CAG-15-149
CASCADE INTERCEPTOR -PHASE II
4784'x 14,18,21,24" CIPP
WA
7/15/2016 10:08:19
Page - 36
Pay Period Ending Date 7/9/2016
Period Number 3
St SMS SDep FMS FDep Sex EEO Union ....................... Craft......................... Step.........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job I .. I ..... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
-------- NO WORK PERFORMED ---------- J
U
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30, 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per response. including the time for reviewing instructionssearching existmg data sources.
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection
of information. including suggestions for reducing this burden. to Department of Defense. Washington Headquarters Services. Directorate for information Operations and Reports, 1215
Jefferson Davis Highway Suite 1204, Arlington VA 22202-4302, and to the Office of Management and Budget, Paperwork Reduction Protect (1215-0149) Washington, DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER,
1 PAYROLL NUMBER
AYROLL PAYMENT DATE (YYMMDD)
F
3. CONTRACT NUMBER
4 DATE (YYMMDD)
42
16/07/22
1 16/07/22
I, Stephanie Forrest Payroll Specialist do hereby state
(Name of signatory party) (Title)
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Contractor or subconaacror)
on the CAG-15-149 that during the payroll period commencing on the 10 day of
(B.ddmg or works
July 201 6 and ending the 16 day of July 201 6 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat. 948, 63 Stat. 108, 72 Stat. 967, 76 Stat. 357. 40 U.S.C. 276c), and described below:
Federal, Fica. State and Local tax. 401 K, Loan re -payment, Insurance, garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete, that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5.REMARKS
6. NAME (Last, First, Middle Initial)
TITLE
8 SIGNAT
Forrest, Stephanie
TPayroll Specialist
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or c in l pr a n.
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
DD FORM 879. MAR 95 (EG) PREVIOUS EDITON MAY BE USED.
R07371 Aegion Corporation 7/20/2016 13 22:37
Certified Payroll Register Page - 39
Pay Period Ending Date 7/16/2016
INSITUFORM TECHNOLOGIES LLC Pro''ect and Location 202221 Period Number 4
17988 EDISON AVE RENTON - WA- CAG-15-149
CHESTERFIELD MO 63005 CASCADE INTERCEPTOR -PHASE II
WA4'x 14,18,21,24" CIPP
St SMS SDep FMS FDep Sex EEO Union ....................... Craft ......................... Step .........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
NO WORK PERFORMED
A
a
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No. 1215-0149
Expires Jun 30, 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden, to Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports, 1215
Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302, and to the Office of Management and Budget, Paperwork Reduction Protect (1215-0149) Washington, DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1. PAYROLL NUMBER
2. PAYROLL PAYMENT DATE (YYMMDD)
3. CONTRACT NUMBER
4. DATE (YYMMDD)
38
1 16/06/24
1 16/06/24
I, Stephanie Forrest Payroll Specialist do hereby state
(Name of signatory party) (Ttfe)
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Contractor or subcontractor)
on the CAG-15-149 that during the payroll period commencing on the 12 day of
(Building or work)
June 201 6 ,and ending the 18 day of June 201 6 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat. 948, 63 Stat. 108, 72 Stat. 967, 76 Stat. 357, 40 U.S.C. 276c), and described below:
Federal, Fica, State and Local tax, 401 K, Loan re -payment, Insurance, garnishments
NO WORK
(2) That any payrolls otherwise under this Contract required to be submitted for the above period are correct and complete, that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the Contract; that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
-Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5.REMARKS
6. NAME (Last, First, Middle Initial)
7. TITLE
8. SIGNATUR
Forrest, Stephanie
Payroll Specialist
I
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil o?crKtnavprosecutton.
See Section 1001 of Title 16 and Section 231 of Title 31 of the United States Code.
DID FORM 879, MAR 95 (EG) PREVIOUS EDITON MAY BE USED.
10
R07371 Aegion Corporation 6/22/2016 14:14:28
Certified Payroll Register Page - 31
Pay Period Ending Date 6/18/2016
INSITUFORM TECHNOLOGIES LLC Prot1ect and Location 202221 Period Number 4
17988 EDISON AVE RENTON - WA- CAG-15-149
CHESTERFIELD MO 63005 CASCADE INTERCEPTOR -PHASE II
4784'x 14,18,21,24" CIPP
WA
St SMS SDep FMS FDep Sex EEO Union ....................... Craft ......................... Step .........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
NO WORK PERFORMED
a
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30. 1997
Public reporting burden for tins collection of information is estimated to average 16 minutes per responseincluding the time for reviewing instructions. searching ewstmg data sources.
gathering and maintaining the data needed and completing and reweaving the collection of information Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden, to Department of Defense. Washington Headquarters Services, Directorate for Information Operations and Reports 1215
Jefferson Davis Highway, Suite 1204. Arington VA 22202-4302 and to the Office of Management and Budget. Paperwork Reduction Protect (1215-0149) Washington DC 20503
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1 PAYROLL NUMBER
PAYROLL PAYMENT DATE (YYMMDDi
3. CONTRACT NUMBER
4 DATE (YYMMDD)
40
16/07/08
1 16/07/08
Stephanie Forrest Payroll Specialist do hereby state
(Name o'stgnarory party ,Td)e
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Con"crar or subcontractor
on the CAG-15-149 that during the payroll period commencing on the 26 day of
iButldmg o1 work)
June 201 6 and ending the 2 day of July 201 6 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(contractor or subcontractoo
and that no deductions have been made either directly or indirectly from the full wages earned by any person other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A). issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat 948. 63 Stat 108 72 Stat 967. 76 Stat, 357. 40 U.S C 276c), and described below
Federal, Fica. State and Local tax. 401K. Loan re -payment. Insurance. garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract: that the classifications set forth therein for each laborer or mechanic conform with the work performed
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training. United States Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees.
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
557 -Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5 REMARKS
6 NAME (Last. First. Middle Initial)
TITLE
8 SIGN.ATU
Forrest, Stephanie
T Payroll Specialist
� 6 1
L/�
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or chmina%pios
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code
DID FORM 879, MAR 95 (EG) PREVIOUS EDITON MAY BE USED
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Pro'ect and Location 202221
RE�TON - WA- CAG-15-149
CASCADE INTERCEPTOR-PHASEII
4784'x 14,18,21,24" CIPP
WA
7/6/2016 11:48:40
Page - 40
Pay Period Ending Date 7/2/2016
Period Number 2
St SMS SDep FMS FDep Sex EEO Union ....................... Craft......................... Step.........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
NO WORK PERFORMED--------
i.
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30. 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per response, mctutlmg the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection
of information. including suggestions for reducing this burden. to Department of Defense, Washington Headquarlers services, Directorate for Information Operations and Reports. 1215
Jefferson Davis Highway. Suite 1204. Arlington, VA 22202-4302, and to the Office of Management and Budget, Paperwork Reduction Project (1215.0149) Washington, DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1. PAYROLL NUMBER
2 PAYROLL PAYMENT DATE (YYMMDD)
3. CONTRACT NUMBER
4 DATE (YYMMDD)
37
1 16/06/17
1 16/06/17
I, Stephanie Forrest Payroll Specialist do hereby state
(Name of signatory parry) (Title)
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Contractor or subcontractor;
on the CAG-15-149 that during the payroll period commencing on the 5 day of
(Building or work)
June 201 6 and ending the 11 day of June 2016 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat. 948, 63 Stat. 108, 72 Stat. 967; 76 Stat. 357, 40 U.S.C. 276c), and described below:
Federal, Fica, State and Local tax, 401 K, Loan re -payment, Insurance, garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete, that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract; that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
-Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5.REMARKS
6. NAME (Last, First, Middle Initial)
TITLE
8. SIGNATURE '
Forrest, Stephanie
T Payroll Specialist
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or c r e ion.
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
DD FORM 879, MAR 95 (EG) PREVIOUS EDITON MAY BE USED.
r
R07371 Aegion Corporation 6/15/2016 13:31:04
Certified Payroll Register Page - 42
Pay Period Ending Date 6/11/2016
INSITUFORM TECHNOLOGIES LLC Pro act and Location 202221 Period Number 3
17988 EDISON AVE RE�TON - WA- CAG-15-149
CHESTERFIELD MO 63005 CASCADE INTERCEPTOR -PHASE II
4784'x 14,18,21,24" CIPP
WA
St SMS SDep FMS FDep Sex EEO Union ....................... Craft......................... Step.........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
NO WORK PERFORMED
f
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30. 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per response including the time for reviewing instructionssearching existing data sources
gathering and maintaining the data neededand completing and reviewing the collection of information Send comments regarding this burden estimate or any other aspen of this collection
of informationincluding suggestions for reducing this burtlen. to Department of Defense Washington Headquarters services. Directorate for Information Operations and Reports. 1215
Jefferson Davis Highway Suite 1204, Arlington VA 22202-4302 and 10 the Office of Management and Budget. Paperwork Reduction Protect 02150149) Washington DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
,, PAYROLL NUMBER
PAYROLL PAYMENT DATE !YYMMDD.
T
3 CONTRACT NUMBER
4 DATE (YYMMDDi
39
16/07/01
16/07/01
Stephanie Forrest Payroll Specialist do hereby state
(Name of signatory party) (Teel
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Contractor or subcontractor)
on the CAG-15-149 that during the payroll period commencing on the 19 day of
(Building or work)
June 201 6 and ending the 25 day of June 201 6 all persons employed
on said project have been paid the full weekly wages earned that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations. Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat 948. 63 Stat. 108, 72 Stat. 967: 76 Stat. 357. 40 U.S.C. 276c). and described below
Federal. Fica. State and Local tax, 401 K. Loan re -payment. Insurance. garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete: that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract. that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor. or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That.
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract.
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5 REMARKS
6. NAME (Last. First, Middle Initial)
-.'LE
8 SIGNATU
Forrest, Stephanie
TPayroll Specialist
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or crimi ecution
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code
Liu rvftivi Ofti. IvItNM aD (tu) PREVIOUS EDITON MAY BE USED
a
R07371 Aegion Corporation 6/29/2016 13:05:09
Certified Payroll Register Page - 33
Pay Period Ending Date 6/25/2016
INSITUFORM TECHNOLOGIES LLC Pro'ect and Location 202221 Period Number 1
17988 EDISON AVE RE�TON - WA- CAG-15-149
CHESTERFIELD MO 63005 CASCADE INTERCEPTOR -PHASE II
4784'x 14,18,21.24" CIPP
WA
St SMS SDep FMS FDep Sex EEO Union ....................... Craft ......................... Step .........................
Social Security No Ethnic Cat ... I ... Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
NO WORK PERFORMED
1
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30. 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per response, including the time for reviewing instructions. searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection
of information. including suggestions for reducing this burden, to Department of Defense, Washington Headquarters Services. Directorate for Information Operations and Reports, 1215
Jefferson Davis Highway, Sutle 1204, Arlington. VA 22202-4302. and to the Office of Management and Budget. Paperwork Reduction Project (12150149) Washington. DC 20503,
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER-
1. PAYROLL NUMBER
2. PAYROLL PAYMENT DATE (YYMMDD)
3. CONTRACT NUMBER
4. DATE (YYMMDD)
36
1 16/06/10
1 16/06/10
I, Stephanie Forrest Payroll Specialist do hereby state
(Name of signatory party) (Title)
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Contractor Or subMnraGtor)
on the CAG-15-149 , that during the payroll period commencing on the 29 day of
(Building or work)
May 201 6 and ending the 4 day of June 2016 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subcontrdCrori
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat. 948. 63 Stat. 108, 72 Stat. 967, 76 Stat. 357, 40 U.S.C. 276c), and described below:
Federal, Fica, State and Local tax, 401K, Loan re -payment, Insurance, garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duty registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
-Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
s
5.REMARKS
6. NAME (Last. First, Middle Initial)
7. TITLE
8. SIGNATURE
Forrest, Stephanie
Payroll Specialist
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or crimin'2Lcution.
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
UU 1-UKM bf!:i, MAK !:l5 (L(3) PREVIOUS EDITON MAY BE USED.
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Pr'
J'ect and Location 202221
RENTON - WA- CAG-15-149
CASCADE INTERCEPTOR -PHASE II
WA4'x 14,18,21,24" CIPP
6/8/2016 13:44:23
Page - 49
Pay Period Ending Date 6/4/2016
Period Number 2
St SMS SDep FMS FDep Sex EEO Union ....................... Craft ......................... Step .........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ......... .
Name/Address _ Work Dale Hours Rate Hours Rate Hours Hours Amount Description Amount
----- NO WORK PERFORMED __-]
ri
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per responseincluding the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data neededand completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden, to Department of Defense. Washington Headquarters Services. Directorate for Information Operations and Reports. 1215
Jefferson Davis Highway, Suite 1204. Arlington. VA 22202-4302. and to the Office of Management and Budget, Paperwork Reduction Project (1215-0149) Washington, DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1 PAYROLL NUMBER
2 PAYROLL PAYMENT DATE (YYMMDD)
3 CONTRACT NUMBER
4. DATE (YYMMDD)
34
1 16/05/27
1 16/05/27
I, Stephanie Forrest Payroll Administrator do hereby state
(Name of signatory parry) (Tme)
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Contractor or subcontractor)
on the CAG-15-149 that during the payroll period commencing on the 15 day of
(Budding or work)
May 201 6 and ending the 21 day of May 201 6 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor a, subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat. 948, 63 Stat. 108, 72 Stat. 967, 76 Stat. 357, 40 U.S.C. 276c), and described below:
Federal, Fica, State and Local tax, 401 K, Loan re -payment, Insurance, garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete, that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
-Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5.REMARKS
6. NAME (Last, First. Middle Initial)
TITLE
8. SIGNATURE
Forrest, Stephanie
Tpayroll Administrator
i
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or crimmalpr6secution.
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
DD FORM 879, MAR 95 (EG) PREVIOUS EDITON MAY BE USED
R07371 Aegion Corporation 5/25/2016 13:41:40
Certified Payroll Register Page - 43
Pay Period Ending Date 5/21/2016
INSITUFORM TECHNOLOGIES LLC Project and Location 202221 Period Number 4
17988 EDISON AVE RENTON - WA- CAG-15-149
CHESTERFIELD MO 63005 CASCADE INTERCEPTOR -PHASE II
4754'x 14,18,21,24" CIPP
WA
St SMS SDep FMS FDep Sex EEO Union ....................... Craft......................... Step.........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
NO WORK PERFORMED
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per response, including the time for reviewing instructions, searching existing data sources.
gathering and maintaining the data needed. and completing and reviewing the collection of information. Send comments regarding Nis burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden. to Department of Defense, Washington Headquarters Services. Directorate for Information Operations and Reports, 1215
Jefferson Davis Highway, Suite 1204. Arlington. VA 22202-4302and to the Office of Management and Budget. Paperwork Reduction Protect (1215-0149) Washington, DC 20503
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1 PAYROLL NUMBER
2 PAYROLL PAYMENT DATE (YYMMDD)
3 CONTRACT NUMBER
4 DATE (YYMMDD)
35
1 16/06/03
1 16/06/03
I, Stephanie Forrest Payroll Administrator do hereby state
(Name of signatory party) (Tt)el
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (contractor or sabcontrdotorl
on the CAG-15-149 that during the payroll period commencing on the 22 day of
(Building or work)
May 201 6 and ending the 28 day of May 201 6 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insitufonm Technologies, LLC from the full weekly wages earned by any person
(Contactor or subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat. 948. 63 Stat. 108. 72 Stat. 967: 76 Stat. 357, 40 U.S.C. 276c), and described below:
Federal, Fica, State and Local tax. 401 K, Loan re -payment, Insurance, garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete, that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered With the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
-Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5 REMARKS
6. NAME (Last, First, Middle Initial)
8. SIGNATURE
17TITLE
Forrest, Stephanie
Payroll Administrator
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal ion.
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code. -
DID FORM 879, MAR 95 (EG) PREVIOUS EDITON MAY BE USED.
R07371 Aegion Corporation 6/1/2016 15:33:58
Certified Payroll Register Page - 48
Pay Period Ending Date 5/28/2016
INSITUFORM TECHNOLOGIES LLC Prot1ect and Location 202221 Period Number 1
17988 EDISON AVE RENTON - WA- CAG-15-149
CHESTERFIELD MO 63005 CASCADE INTERCEPTOR -PHASE II
�A 4'x 14,18,21,24" CIPP
St SMS SDep FMS FDep Sex EEO Union ....................... Craft ......................... Step .........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
-- NO WORK PERFORMED -----
•
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30. 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per responseincluding the time for reviewmg instructionssearching existing data sources.
gathenng and maintaining the data neededand completing and reviewing the collection of information Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden, to Department of Defense. Washington Headquarters Services, Directorate for Information Operations and Reports. 1215
Jefferson Davis Highway. Suite 1204. Arlington. VA 22202-4302and to the Office of Management and Budget Paperwork Reduction Project (1215-0149) Washington DC 20503
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1 PAYROLL NUMBER
AYROLL PAYMENT DATE (YYMMDDI
F
3 CONTRACT NUMBER
4 DATE (YYMMDD)
33
16/05/20
1 16/05/20
Stephanie Forrest Payroll Administrator do hereby state
(Name or s,gnatory panyi (Title,
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Contractor or subcontractor)
on the CAG-15-149 that during the payroll period commencing on the 8 day of
(Budding or work)
May 201 6 and ending the 14 day of May 201 6 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or Indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subcontractor,
and that no deductions have been made either directly or Indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat. 948. 63 Stat 108 72 Stat 967: 76 Stat, 357: 40 U.S C 276c). and described below.
Federal. Fica State and Local tax. 401 K. Loan re -payment. Insurance. garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete, that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform with the work performed
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees.
except as noted in Section 4 (C) below_
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
-Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll. an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5 REMARKS
6 NAME (Last. First. Middle Initial)
TITLE
8. SIGNATURE
Forrest, Stephanie
Tpayroll Administrator
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal prosecution
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
UU FURM 879. MAR 95 (EG) PREVIOUS EDITON MAY BE USED
i
R07371 Aegion Corporation 5/18/2016 14:58:35
Certified Payroll Register Page - 43
Pay Period Ending Date 5/14/2016
INSITUFORM TECHNOLOGIES LLC Pro ect and Location 202221 Period Number 3
17988 EDISON AVE RE�TON - WA- CAG-15-149
CHESTERFIELD MO 63005 CASCADE INTERCEPTOR -PHASE II
4784'x 14,18,21,24" CIPP
WA
St SMS SDep FMS FDep Sex EEO Union ....................... Craft......................... Step.........................
Social Security No Ethnic Cat ... I ... Regular .............. Overtime ...... Other Total Job .......... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
— NO WORK PERFORMED ----
4
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30. 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per response. including the time for reviewing instructions searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information send comments regarding this burden estimate or any other aspect of this collection
of mformatmnincluding suggestions for reducing this burden. to Department of Defense. Washington Headquarters services. Directorate for information Operations and Reports. 1215
Jefferson Davis Highway Suite 1204. Arlington. VA 22202A302 and to the Office of Management and Budget, Paperwork Reduction Project 0215-0149) Washington. DC 20503
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1 PAYROLL NUMBER
2 PAYROLL PAYMENT DATE (YYMMDDj
3. CONTRACT NUMBER
< DATE (YYMMDDi
32
1 16/05/13
116/05113
Stephanie Forrest Payroll Administrator do hereby state
)Name of signatory party, ,Tbe
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Contractor or subcontractor,
on the CAG-15-149 that during the payroll period commencing on the 1 day of
(Building or work)
May 201 6 and ending the 7 day of May 201 6 all persons employed
on said pro)ect have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
/Contractor or subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act. as amended
(48 Stat. 948. 63 Stat. 108, 72 Stat 967. 76 Stat 357. 40 U.S.C. 276c), and described below:
Federal. Fica. State and Local tax. 401 K Loan re -payment. Insurance. garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete: that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract: that the classifications set forth therein for each laborer or mechanic conform with the work performed
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training. United States Department of Labor, or if no such recognized
agency exists in a State. are registered with the Bureau of Apprenticeship and Training. United States Department of Labor
(4) That
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract.
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5 REMARKS
B NAME (Last, First. Middle Initial)
- TITLE
8 SIGNATURE
Forrest, Stephanie
Payroll Administrator
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or cnYninal pro`secbfion.
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code
DD FORM 879, MAR 95 (EG) PREVIOUS EDITON MAY BE USED.
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63006
St SMS SDep FMS FDep Sex
Social Security No Ethnic Cat
Name/Address
Aegion Corporation
Certified Payroll Register
Pro'ect and Location 202221
RRTON - WA- CAG-15-149
CASCADE INTERCEPTOR -PHASE II
4A84'x 14,18,21,24" CIPP
5/11/2016 13:11:15
Page - 46
Pay Period Ending Date 5/7/2016
Period Number 2
EEO Union ....................... Craft......................... Step.........................
....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
NO WORK PERFORMED---------
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30 1997
Public reporting burden forthls colleclion of information is estimated to average 16 minutes per response. including the time for reviewing instructions. searching existing data sources.
gathering and maintaining the data needed and completing and reviewing the colleclion of information. Send comments regarding this burden estimate or any other aspect of this coliechon
of informationincluding suggestions for reducing this burden to Department of Defense Washington Headquarters Services, Directorate for Information Operations and Reports, 1215
Jefferson Davis Highway Suite 1204. Arlington. VA 22202-4302. and to the Office of Management and Budget Paperwork Reduction Project (12150149) Washington. DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1 PAYROLL NUMBER
2 PAYROLL PAYMENT DATE (YYMMDDj
3 CONTRACT NUMBER
4 DATE. iYYMMDD':
30
1 16/04/29
1 16104/29
Stephanie Forrest Payroll Administrator do hereby state
(Name of signatory parry) (iibe
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II iContractor or subcontractor
on the CAG-15-149 that during the payroll period commencing on the 17 day of
fBurldrng or work'
April 201 6 and ending the 23 day of April 201 6 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Confracta or subcontractor
and that no deductions have been made either directly or indirectly from the full wages earned by any person other than permissible
deductions as defined In Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(46 Stat 948. 63 Stat. 108, 72 Stat. 967: 76 Stat 357. 40 U.S C 276c). and described below:
Federal. Fica. State and Local tax. 401 K. Loan re -payment. Insurance. garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete: that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered In a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training. United States Department of Labor, or if no such recognized
agency exists in a State. are registered with the Bureau of Apprenticeship and Training. United States Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees.
except as noted in Section 4 (C) below
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
XX Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract.
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5 REMARKS
6 NAME (Last. First, Middle Initial
TITLE
8 SIGNATU EForrest,
Stephanie
Tayroll Administrator
I I � )
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal pro n.
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code
UU FUKM 6/9, MAR 95 (E (3) PREVIOUS EDITON MAY BE USED
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Pro1'ect and Location 202221
RE4TON - WA- CAG-15-149
CASCADE INTERCEPTOR -PHASE II
4764'x 14,18,21,24" CIPP
WA
4/27/2016 12:29:20
Page - 47
Pay Period Ending Date 4/23/2016
Period Number 5
St SMS SDep FMS FDep Sex EEO Union ....................... Craft ......................... Step .........................
Social Security No Ethnic Cat ..... I . Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
F NO WORK PERFORMED -----
a
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 7215-0149
Expires Jun 30. 1997
Public reporting burden for this collection of )nformation is estimated to average 16 minutes per response including the time for reviewing instructions. searching existing data sources.
gathering and maintaining the data neededand completing and reviewing the collection of information Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden, to Department of Defense Washington Headquarters Services. Directorate for Information Operations and Reports, 1215
Jefferson Davis Highway. Suite 1204. Arlington VA 22202-4302 and to the Office of Management and Budge: Paperwork Reduction Protect (1215-01491 Washington. DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1 PAYROLL NUMBER
T7AYROLL PAYMENT DATE (YYMMDD�
3 CONTRACT NUMBER
4 DATE (YYMMDD)
31
16/05/06
1 16/05/06
1, Stephanie Forrest Payroll Administrator do hereby state
(Name of Signatory party, Witte
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Contractor or sub —tractor)
on the CAG-15-149 that during the payroll period commencing on the 24 day of
(Budding or work'
April 201 6 and ending the 30 day of April 201 6 all persons employed
on said project have been paid the full weekly wages earned. that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A). issued by the Secretary of Labor under the Copeland Act. as amended
(46 Stat 948, 63 Stat. 108 72 Stat 967 76 Stat. 357: 40 U. S. C. 276c). and described below
Federal, Fica. State and Local tax. 401K. Loan re -payment. Insurance. garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete: that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform with the work performed
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training. United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll. payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5 REMARKS
6 NAME (Last. First, Middle Initial)
TITLE
8 SIGNATForrest,
Stephanie
Tayroll Administrator
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or crimin p , e ion.
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code
UU rUKM Y9/y, MAK yb (t(3) PREVIOUS EDITON MAY BE USED
R07371 Aegion Corporation 5/4/2016 7 40 09
Certified Payroll Register Page - 46
Pay Period Ending Date 4/30/2016
INSITUFORM TECHNOLOGIES LLC Pro ect and Location 202221 Period Number 1
17988 EDISON AVE RMON - WA- CAG-15-149
CHESTERFIELD MO63005 CASCADE INTERCEPTOR -PHASE II
4784'x 14,18,21,24" CIPP
WA
St SMS SDep FMS FDep Sex EEO Union ....................... Craft ......................... Step .........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job .......... Check Detail ......... .
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
NO WORK PERFORMED
s
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30. 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per responseincluding the time for reviewing instructions searcfnng existing data sources.
gathering and maintaining the data needed and completing and reviewing the couenion of information. Send comments regarding this burden estimate or any other aspect of this collection
of informationincluding suggestions for reducing this burden. to Department of Defense. Washington Headquarters Services. Directorate for Information Operations and Reports, 1215
Jefferson Davis Highway. Suite 1204. Arlington. VA 22202-4302and to the Office of Management and Budget. Paperwork Reduction Project (1215-0149) Washington. DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1 PAYROLL NUMBER
2. PAYROLL PAYMENT DATE (YYMMDD)
3 CONTRACT NUMBER
c ;
DATE YYMMDD.
28
16/04/16
16/04/15
I. Stephanie Forrest Payroll Administrator do hereby state
(Name of signatory party) , Tiber
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Contractor or subcontractor)
on the CAG-15-149 that during the payroll period commencing on the 3 day of
(Building or work)
April 201 6 and ending the 9 day of April 201 6 all persons employed
on said protect have been paid the full weekly wages earned. that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
fContractor or subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person. other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat 948 63 Stat 108, 72 Stat. 967: 76 Stat 357, 40 U. S.C. 276c), and described below
Federal. Fica, State and Local tax, 401 K. Loan re -payment. Insurance. garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete. that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor. or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That.
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS. OR PROGRAMS
In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5.REMARKS
6. NAME (Last, First, Middle Initial)
7 TITLE
8 SIGNATURE
Forrest, Stephanie
Payroll Administrator
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal PFOSeo
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
Liu rvr-'rvl of V, IVI/AM yD (tv) PREVIOUS EDITON MAY BE USED
R07371 Aegion Corporation 4/13/2016 13:15:45
Certified Payroll Register Page - 44
Pay Period Ending Date 4/9/2016
INSITUFORM TECHNOLOGIES LLC Pro1'ect and Location 202221 Period Number 3
17988 EDISON AVE RENTON - WA- CAG-15-149
CHESTERFIELD MO 63005 CASCADE INTERCEPTOR -PHASE II
WA4'x 14,18,21,24" CIPP
St SMS SDep FMS FDep Sex EEO Union ....................... Craft ......................... Step .........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job .... I ...... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
— NO WORK PERFORMED
1
a
At
Form Approved
STATEMENT OF COMPLIANCE 202221
once No 1215-0149
Expires Jun 30. 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per responseincluding the time for reviewing instructionssearching existing data sources.
gathering and maintaining the data neededand completing and reviewing the collection of information Send comments regarding this burden estimate or any other aspect of this collection
of information. including suggestions for reducing this burden to Department of Defense Washington Headquarters Services. Directorate for Information Operations and Reports. 1215
Jefferson Davis Highway Suite 1204. Arington VA 22202-4302 and to the Office of Management and Budget. Paperwori, Reduction Project (1215-0149) Washington. DC 20503,
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1 PAYROLL NUMBER
AYROLL PAYMENT DATE (YYMMDD)
r
3 CONTRACT NUMBER
4 DATE (YYMMDD
29
16/04/22
1 16/04/22
I, Stephanie Forrest Payroll Administrator do hereby state
(Name of signatory party) 7,1re.
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Contractor or subcontractor)
on the CAG-15-149 that during the payroll period commencing on the 10 day of
(Building or work)
April 201 6 and ending the 16 day of April 201 6 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person. other than permissible
deductions as defined in Regulations. Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat. 948, 63 Stat 108, 72 Stat 967. 76 Stat 357. 40 U.S.C. 276c), and described below
Federal. Fica. State and Local tax. 401 K. Loan re -payment. Insurance. garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll. an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5.REMARKS
6. NAME (Last First, Middle Initial)
i TITLE
6 SIGNAT+4RE
Forrest, Stephanie
Payroll Administrator
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or crimina rosecution.
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
UU rUKM D/y, MAK y5 (ttzi) PREVIOUS EDITON MAY BE USED
R07371 Aegion Corporation 4/20/2016 14:36:03
Certified Payroll Register Page - 45
Pay Period Ending Date 4/16/2016
INSITUFORM TECHNOLOGIES LLC Pro'ect and Location 202221 Period Number 4
17988 EDISON AVE RE�TON - WA- CAG-15-149
CHESTERFIELD MO 63005 CASCADE INTERCEPTOR -PHASE II
4784'x 14,18,21,24" CIPP
WA
St SMS SDep FMS FDep Sex EEO Union ....................... Craft ......................... Step .........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
NO WORK PERFORMED
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 12150149
Expires Jun 30. 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per responseincluding the time for reviewing instructions searching existing data sources,
gathering and maintaining the data needed. and completing and reviewing the collection of information Send comments regarding this burden estimate or any other aspect of this collection
of information including suggestions for reducing this burden. to Department of Defense. Washington Headquarters Services. Directorate for information Operations and Reports. 1215
Jefferson Davis Highway. Suite 1204. Arlington. VA 27202-4302. and to the Office of Management and Budget. Paperwork Reduction Project (12154149) Washington DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1 PAYROLL NUMBER
2 PAYROLL PAYMENT DATE (YYMMDD)
3 CONTRACT NUMBER
4 DATE (YYMMDD)
26
1 16/04/01
1 16/04/01
I. Stephanie Forrest Payroll Administrator do hereby state
(Name of signatory party) (Title'
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (contractor or submittractorl
on the CAG-15-149 that during the payroll period commencing on the 20 day of
(Budding or work)
March 201 6 and ending the 26 day of March 201 6 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subcontracton
and that no deductions have been made either directly or indirectly from the full wages earned by any person. other than permissible
deductions as defined in Regulations. Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat 948. 63 Stat. 108, 72 Star 967 76 Stat 357. 40 U.S.C. 276c). and described below'
Federal. Fica. State and Local tax. 401 K. Loan re -payment. Insurance, garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete, that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That.
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5. REMARKS
6 NAME (Last. First. Middle Initial)
TITLE
8 SIGNATURE .
Forrest, Stephanie
Payroll Administrator
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal pr6Seau1 cn.
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
UD FURM 879, MAR 95 (E(3) PREVIOUS EDITON MAY BE USED
R07371 Aegion Corporation 3/30/2016 13:47:42
Certified Payroll Register Page - 47
Pay Period Ending Date 3/26/2016
INSITUFORM TECHNOLOGIES LLC Pro'ect and Location 202221 Period Number 1
17988 EDISON AVE RE�TON - WA- CAG-15-149
CHESTERFIELD MO 63005 CASCADE INTERCEPTOR -PHASE II
WA84'x 14,18,21,24" CIPP
St SMS SDep FMS FDep Sex EEO Union ....................... Craft ......................... Step .........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
NO WORK PERFORMED
i
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No. 12150149
L
Expires Jun 30. 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per response. including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed and completing and reviewing the collection of information. Send comments regarding this burden estimate of any other aspect of this collection
of information, including suggestions for reducing this burden. to Department of Defense. Washington Headquarters Services. Directorate for Information Operations and Reports. 1215
Jefferson Davis Highway Suite 1204 Arlington VA 22202-4302. and to the Office of Management and Budget Paperwork Reduction Project (1215-0149) Washington. DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES, RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1 PAYROLL NUMBER
r7AYROLL PAYMENT DATE (YYMMDDi
3 CONTRACT NUMBER
c DATE (YYMMDD)
27
16/04/08
116/04/08
I, Stephanie Forrest Payroll Administrator do hereby state
(Name of signatory party) (Title,
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Contractor or subcontractor)
on the CAG-15-149 that during the payroll period commencing on the 27 day of
(Building or work)
March 201 6 and ending the 2 day of April 201 6 all persons employed
on said project have been paid the full weekly wages earned that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
!Contractor or subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined In Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat 948, 63 Stat 108, 72 Stat 967, 76 Stat 357. 40 U.S C. 276c). and described below:
Federal, Fica. State and Local tax. 401 K, Loan re -payment. Insurance, garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete, that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract. that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State. are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
XX -Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5 REMARKS
6 NAME (Last. First. Middle Initial)
7 TITLE
8 SIGNATURE
Forrest, Stephanie
Payroll Administrator
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal prosecution.
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
UU t-1 6/9, MAK Yb (El PREVIOUS EDITON MAY BE USED
r
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Pro'ect and Location 202221
RATON - WA- CAG-15-149
CASCADE INTERCEPTOR -PHASE II
4784'x 14,18,21,24" CIPP
WA
4/7/2016 7:41:07
Page - 45
Pay Period Ending Date 4/2/2016
Period Number 2
St SMS SDep FMS FDep Sex EEO Union ....................... Craft......................... Step.........................
Social Security No Ethnic Cat ....... Regular ....... ....... Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
I NO WORK PERFORMED
a
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No. 1215-0149
Expires Jun 30, 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden, to Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports, 1215
Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302, and to the Office of Management and Budget, Paperwork Reduction Project (1215-0149) Washington, DC 20503,
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1. PAYROLL NUMBER
2. PAYROLL PAYMENT DATE (YYIvl
3. CONTRACT NUMBER
4. DATE (YYMMDD)
24
1 16/03/18
1 16/03/18
1, Stephanie Forrest Payroll Administrator do hereby state
(Name or signatory party) (Title)
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Contractor or subcontractor)
on the CAG-15-149 ; that during the payroll period commencing on the 6 day of
(Building or work)
March 201 6 and ending the 12 day of March 201 6 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat. 948, 63 Stat. 108, 72 Stat. 967, 76 Stat. 357 40 U.S.C. 276c), and described below:
Federal, Fica, State and Local tax, 401K, Loan re -payment, Insurance, garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract; that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
-Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5.REMARKS
6. NAME (Last, First, Middle Initial)
TITLE
8. SIGNATUREForrest,
Stephanie
TpayrollAdministrator
I � J
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or criminaLgposyution.
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
DD FORM 879, MAR 95 (EG) PREVIOUS EDITON MAY BE USED.
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Pro'ect and Location 202221
RE4TON - WA- CAG-15-149
CASCADE INTERCEPTOR -PHASE II
WA4'x 14,18,21,24" CIPP
3/16/2016 13 26:20
Page - 61
Pay Period Ending Date 3/12/2016
Period Number 3
St SMS SDep FMS FDep Sex EEO Union ....................... Craft ......................... Step .........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job I ........ Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
-- NO WORK PERFORMED ---------
a
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30. 1997
Public reporting burden for tins collection of information is estimated to average 16 minutes per responseincluding the time for reviewing instructions, searching existing data sources.
gathenng and maintaining the data neededand completing and reviewing the collection of information Send comments regarding this burden estimate or any other aspect WINS collection
of informationincluding suggestions for reducing this burden. to Department of Defense. Washington Headquarters Services, Directorate for Information Operations and Reports, 1215
Jefferson Davis Highway Suite 1204. Arlington VA 22202-4302. and to the Office of Management and Budget. Papenwon, Reduction Project (1215-01491 Washington. DC 20503
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1 PAYROLL NUMBER
2 PAYROLL PAYMENT DATE (YYMMDD)
3 CONTRACT NUMBER
4 DATE (YYMMDD)
25
1 16/03/25
1 16/03/25
1, Stephanie Forrest Payroll Administrator do hereby state
(Name or signatory parfy, !Tire,
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade interceptor Rehab Phase II (contractor or subcontracrop
on the CAG-15-149 that during the payroll period commencing on the 13 day of
(Building or work)
March 201 6 and ending the 19 day of March 201 6 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person. other than permissible
deductions as defined in Regulations, Pali 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act. as amended
(48 Stat 948, 63 Stat 108 72 Stat 967: 76 Stat 357; 40 U.S.C. 276c), and described below
Federal. Fica. State and Local tax, 401 K, Loan re -payment, Insurance. garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete: that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor
(4) That.
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
-Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed In the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5 REMARKS
6 NAME (Last �Irst Middle Initial)
7. TITLE
6 SIGNATURE
__J/J
Forrest, Stephanie
Payroll Administrator
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal p ufio .
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
DID FORM 879. MAR 95 (EG) PREVIOUS EDITON MAY BE USED
R07371 Aegion Corporation 3/24/2016 7:48 04
Certified Payroll Register Page - 45
Pay Period Ending Date 3/19/2016
INSITUFORM TECHNOLOGIES LLC Project and Location 202221 Period Number 4
17988 EDISON AVE RENTON - WA- CAG-15-149
CHESTERFIELD MO 63005 CASCADE INTERCEPTOR -PHASE II
4784'x 14,18,21,24" CIPP
WA
St SMS SDep FMS FDep Sex EEO Union ....................... Craft......................... Step.........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
NO WORK PERFORMED
t
'P,
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 12150149
Expires Jun 30, 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per response, including the time for reviewing instructionssearching exrstmg data sources
gathering and maintaining the data needed, and completing and reviewing the collection of information Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burtlen. to Department of Defense Washington Headquarters Services. Directorate for Information Operations and Reports. 1215
Jefferson Davis Highway. Suite 1204. Arlington. VA 222024302. and to the Office of Management and Budget. Paperwork Reduction Project (12150149) Washington DC 20503
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1 PAYROLL NUMBER
2. PAYROLL PAYMENT DATE (YYMMDD;
3 CONTRACT NUMBER
4 DATE (YYMMDD
22
1 16/03104
1 16/03/04
Stephanie Forrest Payroll Administrator do hereby state
(Name of signatory parry) iTne
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Contractor or subcontractor
on the CAG-15-149 that during the payroll period commencing on the 21 day of
(Building or work)
February 201 6 and ending the 27 day of February 201 6 all persons employed
on said project have been paid the full weekly wages earned that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act. as amended
(48 Stat 948. 63 Stat. 108, 72 Stat 967. 76 Stat. 357. 40 U. S C 276c). and described below
Federal. Fica. State and Local tax. 401K. Loan re -payment. Insurance. garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete. that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training. United States Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll. payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees.
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract..
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5 REMARKS
6 NAME (Last, First. Middle Initial)
TITLE
8. SIGNATURE
Forrest, Stephanie
Tpayroll Administrator
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal p c ion.
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code
DID FORM 879, MAR 95 (EG) PREVIOUS EDITON MAY BE USED
R07371
Aegion Corporation
Certified Payroll Register
INSITUFORM TECHNOLOGIES LLC Pro'act and Location 202221
17988 EDISON AVE RE�TON - WA- CAG-15-149
CHESTERFIELD MO 63005 CASCADE INTERCEPTOR -PHASE II
4784'x 14,18,21,24" CIPP
WA
St SMS SDep FMS FDep Sex EEO Union ....................... Craft......................... Step.........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
NO WORK PERFORMED
4
3/2/2016 14:25:01
Page - 53
Pay Period Ending Date 2/27/2016
Period Number 1
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30. 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per response, including the time for reviewing instructions, searching existing data sources.
gathering and maintaining the data needed. and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden. to Department of Defense, Washington Headquaners services, Directorate for Information Operations and Reports, 1215
Jefferson Davis Highway. Suite 1204, Arlington, VA 22202-4302. and to the Office of Management and Budget. Paperwork Reduction Project (12150149) Washington, DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1. PAYROLL NUMBER
AYROLL PAYMENT DATE (YYMMDD)
T
3. CONTRACT NUMBER
4. DATE (YYMMDD)
23
16/03/11
16/03/11
i. Stephanie Forrest Payroll Administrator do hereby state
(Name of signatory party) (Trfre)
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (contractor or subcontactp
on the CAG-15-149 that during the payroll period commencing on the 28 day of
(BuONng or work)
February 201 6 and ending the 5 day of March 201 6 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations. Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat. 948. 63 Stat. 108, 72 Stat. 967: 76 Stat. 357, 40 U.S.C. 276c). and described below
Federal, Fica, State and Local tax, 401K, Loan re -payment Insurancegarnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete, that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract; that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
-Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5.REMARKS
6. NAME (Last, First, Middle Initial)
TITLE
8 SIGNATURE
Forrest, Stephanie
TpayrollAdministrator
I NI
The wilHul falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal pr9secu
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
uu r vim or a, lvimr,. vu tw) h'KEVIUUS EUI IUN MAY BE USED
a
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Pro ect and Location 202221
RE�TON - WA- CAG-15-149
CASCADE INTERCEPTOR -PHASE II
WA4'x 14,18,21,24" CIPP
3/9/2016 1325,11
Page - 56
Pay Period Ending Date 3/5/2016
Period Number 2
St SMS SDep FMS FDep Sex EEO Union ....................... Craft......................... Step.........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
NO WORK PERFORMED
I
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per responseincluding the time for reviewing instructions searching existing data sources.
gathering and maintaining the data needed and completing and reviewing the collection of information Send comments regarding this burden estimate or any other aspect of this collection
of information. including suggestions for reducing this burden. to Department of Defense. Washington Headquarters Services. Directorate for Information Operations and Reports. 1215
Jefferson Davis Highway. Suite 1204. Adingion. VA =02-4302. and to the Office of Management and Budget. Paperwork Reduction Project (1215-0149) Washington, DC 20503
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1 PAYROLL NUMBER
PAYROLL PAYMENT DATE (YYMMDD)
3 CONTRACT NUMBER
4 DATE (YYMMDD)
19
16/02/12
1 16/02/12
I Stephanie Forrest Payroll Administrator do hereby state
(Name of signatory party, (Title,
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Contractor a subcontractor)
on the CAG-15-149 that during the payroll period commencing on the 31 day of
(Building or work)
January 201 6 and ending the 6 day of February 2016 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor a subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person. other than permissible
deductions as defined in Regulations. Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat. 946. 63 Stat 106. 72 Stat 967: 76 Stat 357: 40 U S C 276c). and described below-
Federal, Fica, State and Local tax, 401K. Loan re -payment, Insurance, garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete: that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained In any wage determination
incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training. United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor
(4) That
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
2E-Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5 REMARKS
6 NAME (Last. First. Middle Initial)
TITLE
B. SIG
Forrest, Stephanie
Payroll Administrator
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or trim'IN,ecution.
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
DD FORM 879, MAR 95 (EG) PREVIOUS EDITON MAY BE USED
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Pro'ect and Location 202221
RE�TON - WA- CAG-15-149
CASCADE INTERCEPTOR -PHASE II
4784'x 14,18,21,24" CIPP
WA
2/10/2016 12:46:07
Page - 52
Pay Period Ending Date 2/6/2016
Period Number 2
St SMS SDep FMS FDep Sex EEO Union ....................... Craft ............. ........... Step .........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
NO WORK PERFORMED -
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 12150149
Expires Jun 30 199-
Public reporting burden for this collection of information is estimated to average 16 minutes per response. including the time for reviewing instructions. searching existing data sources.
gathenng and maintaining the data neededand completing and reviewing the collection of information Send comments regarding this burden estimate or any other aspect of this collection
of information_ including suggestions for reducing this burden. to Department of Defense. Washington Headquarters Services Directorate for Information Operations and Reports. 1215
Jefferson Davis Highway. Suite 1204. Arlington.. VA 22202-4302, and to the Office of Management and Budget. Paperwork Reduction Project (1215-0149) Washington. DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
? PAYROLL NUMBER
T7AYROLL PAYMENT DATE (YYMMDD)
3. CONTRACT NUMBER
4 DATE , YYMMDD
20
16/02/19
16/02/19
Stephanie Forrest Payroll Administrator do hereby state
(Name of signatory party) "fie
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Contractor or sobcom"cf r)
on the CAG-15-149 that during the payroll period commencing on the 7 day of
(Building or work.)
February 201 6 and ending the 13 day of February 201 6 all persons employed
on said project have been paid the full weekly wages earned that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person. other than permissible
deductions as defined In Regulations. Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat 948, 63 Stat. 108 72 Stat 967: 76 Stat, 357: 40 U.S.C. 276c), and described below
Federal. Fica. State and Local tax. 401 K. Loan re -payment. Insurance. garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete, that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained i^ any wage deterrninabun
incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform with the work performed
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training. United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5 REMARKS
6 NAME (Last. First Middle Initial)
TITLEForrest,
8 SIGNATURE
Stephanie
TP ayroll Administrator
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal prosecut
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code
UU 1-(-)KM bi`Y. MAN 9b (EG) PREVIOUS EDITON MAY BE USED
R07371 Aegion Corporation 2/17/2016 13:26:25
Certified Payroll Register Page - 52
Pay Period Ending Date 2/13/2016
INSITUFORM TECHNOLOGIES LLC Pro11'ect and Location 202221 Period Number 3
17988 EDISON AVE RENTON - WA- CAG-15-149
CHESTERFIELD MO 63005 CASCADE INTERCEPTOR -PHASE II
4784'x 14,18,21,24" CIPP
WA
St SMS SDep FMS FDep Sex EEO Union ....................... Craft ......................... Step .........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ..... I ..... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
— NO WORK PERFORMED
N
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No. 1215-0149
Expires Jun 30. 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per responseincluding the time for reviewing instructions searching existing tiara sources.
gathering and maintaining the data needed and completing and reviewing the collection of information Send comments regarding this burden estimate or any otner aspect of this collection
of informationincluding suggestions for reducing this burden. to Department of Defense Washington Headquarters Services . Directorate for Information Operations and Reports. 1215
Jefferson Davis Highway Suite 1204, Arlington, VA 22202-4302and to the Office of Management and Budget, Paperwork Reduction Project (1215-01491 Washington. DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1 PAYROLL NUMBER
r7AYROLL PAYMENT DATE (YYMMDD)
3 CONTRACT NUMBER
- DA?G " MMDD
21
16/02/26
16/02/26
I. Stephanie Forrest Payroll Administrator do hereby state
(Name of signatory party) ci_
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (contractor or suocontraorav
on the CAG-15-149 that during the payroll period commencing on the 14 day of
(Building or work)
February 201 6 and ending the 20 day of February 201 6 all persons employed
on said project have been paid the full weekly wages earned that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
fc-tractor or S'Dcont—for)
and that no deductions have been made either directly or indirectly from the full wages earned by any person. other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act as amended
(48 Stat. 948, 63 Stat 108 72 Stat, 967, 76 Stat 357, 40 U S.C. 276c), and described below:
Federal. Fica, State and Local tax, 401K. Loan re -payment. Insurance. garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete, that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract: that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training. United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the Contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5 REMARKS
6 NAME (Last, First, Middle Initial)
_ TITLE
8 SIGNATURE
Forrest, Stephanie
Payroll Administrator
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal p ion.
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code
vt� rvnrvl or Z7. lvimr-, :Ij tw) F'KEVIOUS EDI TON MAY BE USED.
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Pro and Location 202221
RTON - WA- CAG-15-149
CASCADE INTERCEPTOR -PHASE II
4784'x 14,18,21,24" CIPP
WA
2/24/2016 12 37:21
Page - 55
Pay Period Ending Date 2/20/2016
Period Number 4
St SMS SDep FMS FDep Sex EEO Union ....................... Craft ......................... Step .........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ... I ....... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
NO WORK PERFORMED_ 1
J
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No. 12150149
Expires Jun 30, 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection
of information. including suggestions for reducing this burden, to Department of Defense. Washington Headquarters Services, Directorate for Information Operations and Reports, 1215
Jefferson Davis Highway. Suite 1204. Arington. VA 22202-4302. and to the Office of Management and Budget, Paperwork Reduction Project (1215-0149) Washington. OC 20503
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1 PAYROLL NUMBER
2. PAYROLL PAYMENT DATE (YYMMDD)
3. CONTRACT NUMBER
4 DATE (YYMMDD)
1
17
1 16/01 /29
16/01 /29
Stephanie Forrest Payroll Administrator do hereby state
(Name of signatory party) (Title)
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Contractor or subcontractor)
on the CAG-15-149 that during the payroll period commencing on the 17 day of
(Bui)ding or work)
January 201 6 and ending the 23 day of January 201 6 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat. 948, 63 Stat. 108, 72 Stat 967, 76 Stat. 357, 40 U.S.C. 276c), and described below:
Federal Fica State and Local tax 401K Loan re -payment. Insurance garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete: that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract: that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training. United States Department of Labor
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-in addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5.REMARKS
6 NAME (Last, First, Middle Initial)
7 TITLE
8. SIGNATURE
Forrest, Stephanie
Payroll Administrator
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal c tion.
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
DD FORM 879, MAR 9b (L(3) PRLVIUU5 LUI IUN MHY Ct UJtU.
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Pro'ect and Location 202221
REKTON - WA- CAG-15-149
CASCADE INTERCEPTOR-PHASEII
4784'x 14,18,21,24" CIPP
WA
St SMS SDep FMS FDep Sex EEO Union ....................... Craft......................... Step.........................
Social Security No Ethnic Cat ....... Regular. , . ........... Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
L
NO WORK PERFORMED -
1/27/2016 14.27 40
Page - 52
Pay Period Ending Date 1/23/2016
Period Number 4
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per response. including the lime for reviewing instructions searching existing data sources.
gathering and maintaining the data needed and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection
of information including suggestions for reducing this burden to Department of Defense Washington Headquarters Serves. Directorate for Information Operations and Reports. 1215
Jefferson Davis Highway. Suite 1204. Arlington. VA 22202-4302. and to the Office of Management and Budget. Paperwork Reduction Protect (12150149) Washinqton. DC 20503
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES, RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
PAYROLL NUMBER
2. PAYROLL PAYMENT DATE (YYMMDD
3 CONTRACT NUMBER
4 DATE (YYMMDDi
18
1 16/02/06
16/02/05
I Stephanie Forrest Payroll Administrator do hereby state
(Name of signatory party, '11 =
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II fConba-fdr or subcontractor
on the CAG-15-149 that during the payroll period commencing on the 24 clay of
!Building or work'
January 201 6 and ending the 30 day of January 201 6 all persons employed
on said project have been paid the full weekly wages earned that no rebates have been or will De made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations. Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Star 948. 63 Stat 108, 72 Stat. 967: 76 Stat. 357, 40 U.S.0 276c), and described below.
Federal Fica. State and Local tax. 401 K. Loan re -payment. Insurance. garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and Complete, that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates Contained in any wage determination
incorporated into the contract, that the classifications set forth therein for each laborer or mechanic Conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training. United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training. United States Department of Labor.
(4) That
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
-Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract.
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5 REMARKS
6 NAME (Last. First. Middle initial)
TITLE
8. SIGNATURE
Forrest, Stephanie
TpayrollAdministrator
The willful falsr icatton of any of the above statements may subject the contractor or subcontractor tc civil or cnmi o .
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
DID FORM 879, MAR 95 (EG) PREVIOUS EDITON MAY BE USED.
a
R07371 Aegion Corporation 2/2/2016 11 15:38
Certified Payroll Register Page - 49
Pay Period Ending Date 1/30/2016
INSITUFORM TECHNOLOGIES LLC Project and Location 202221 Period Number 1
17988 EDISON AVE RENTON - WA- CAG-15-149
CHESTERFIELD MO 63005 CASCADE INTERCEPTOR -PHASE 11
4784'x 14,18,21,24" CIPP
WA
St SMS SDep FMS FDep Sex EEO Union ....................... Craft ......................... Step .........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
NO WORK PERFORMED
•
Ae ;
M
� X
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30, 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per response including the time for reviewing instructions, searching existing data sources.
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspen of this collection
of information, including suggestions for reducing this burtlen. to Department of Defense. Washington Headquarters Services, Directorate for Information Operations and Reports. 1215
Jefferson Davis Highway. Suite 1204. Arlington. VA 22202-4302and to the Office of Management and Budget. Paperwork Reduction Protect (1215-0149) Washington. DC 20503
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1 PAYROLL NUMBER
2 PAYROLL PAYMENT DATE (YYMMDDI
3 CONTRACT NUMBER
4 DATE (YYMMDD:
16
1 16/01 /22
1 16101 /22
I, Stephanie Forrest Payroll Administrator do hereby state
(Name of srgna(ory party) `me
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Contractor or subcontractor
on the CAG-15-149 that during the payroll period commencing on the 10 day of
(Budding w work)
January 201 6 and ending the 16 day of January 201 6 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subcbntracton
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined In Regulations. Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act as amended
(48 Stat. 948. 63 Stat 108, 72 Stat 967, 76 Stat 357. 40 U.S C 276c), and described below.
Federal. Fica, State and Local tax. 401 K, Loan re -payment. Insurance, garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete, that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
Incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform with the work performed
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
-Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract.
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5 REMARKS
B. NAME (Last. First. Middle Initial)
_ TITLE
8 SIGNATURE
Forrest, Stephanie
Payroll Administrator
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal
ton.
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code
DID FORM 879. MAR 95 (EG) PREVIOUS EDITON MAY BE USED
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Pro'act and Location 202221
RE�TON - WA- CAG-15-149
CASCADE INTERCEPTOR -PHASE II
4784'x 14,18,21,24" CIPP
WA
1/21/2016 7:45:47
Page - 50
Pay Period Ending Date 1/16/2016
Period Number 3
St SMS SDep FMS FDep Sex EEO Union ....................... Craft ......................... Step .........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
NO WORK PERFORMED
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30. 1997
Pubhc reporting burden for this collection of information is estimated to average 16 minutes per response including the time for reviewing instructions searching existing cata sources.
gathenng and maintaining the data needed. and completing and reviewing the collection of information. Send comments regarding this ourden estimate or any other aspect of this collection
of informationincluding suggestions for reducing this burden. to Department of Defense Washington Headquarters Services. Directorate for Information Operations and Reports 1215
Jefferson Davis Highway. Suite 1204. Arlington VA 22202-4302. and to the Office of Manaaemem and Budget. Paperwork Reduction Project (1215-0149) Washington. DC 20503
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES, RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER-
1 PAYROLL NUMBER
2 PAYROLL PAYMENT DATE (YYMMDD:
3 CONTRACT NUMBER
4 DATE (YYMMDD)
15
1 16/01116
16/01/16
Stephanie Forrest Payroll Administrator do hereby state
(Name of signatory party) (1,Hl
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Contractor orsubcontractor,
on the CAG-15-149 that during the payroll period commencing on the 3 day of
(Building or work)
January 201 6 and ending the 9 day of January 201 6 all persons employed
on said project have been paid the full weekly wages earned that no rebates have been or will be made either directly or Indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subcontractor,
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations. Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act as amended
(48 Stat. 948, 63 Stat. 108, 72 Stat. 967. 76 Stat. 357, 40 U.S.C. 276c), and described below
Federal Fica. State and Local tax. 401 K Loan re -payment. Insurance. garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete, that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed In the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS. OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees.
except as noted in Section 4 (C) below
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll.. an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract.
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5.REMARKS
6. NAME (Last. First. Middle Initial)
TITLE
8 SIGNATURE
Forrest, Stephanie
Payroll Administrator
T
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or cumin scut
n.
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code
DD FORM 879, MAR 95 (EG) PREVIOUS EDITON MAY BE USED v
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Pro'ect and Location 202221
RATON - WA- CAG-15-149
CASCADE INTERCEPTOR -PHASE II
4784'x 14,18,21,24" CIPP
W.4
St SMS SDep FMS FDep Sex EEO Union. . . .................... Craft......................... Step.........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
— -- NO WORK PERFORMED
1/14/2016 9:17:06
Page - 54
Pay Period Ending Date 1/9/2016
Period Number 2
0
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30. 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per responseincluding the time for reviewing instructions. searching existing data sources.
gathering and maintaining the data needed and completing and reviewing the collection of information Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden. to Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports. 1215
Jefferson Davis Highway Suite 1204. Arlington. VA 22202-4302and to the Office or Management and Budget Paperwork Reduction Protect (1215-0149) Washington. DC 20503
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1 PAYROLL NUMBER
PAYROLL PAYMENT DATE (YYMMUDi
3 CONTRACT NUMBER
4 DATE !YYMMDD .
14
F 16/01/02
1 16/01/02
Stephanie Forrest Payroll Administrator do hereby state
(Name of signatory party) `e,e
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II Con acto asubcon aco l
on the CAG-15-149 that during the payroll period commencing on the 27 day of
(Budding or work,
December 201 5 and ending the 2 day of January 201 6 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subconfractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined In Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat 948. 63 Stat 108. 72 Stat. 967 76 Stat 357, 40 U.S.C. 276c), and described below.
Federal, Fica. State and Local tax, 401 K, Loan re -payment. Insurance, garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete, that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training. United States Department of Labor. or if no such recognized
agency exists in a State. are registered with the Bureau of Apprenticeship and Training, United States Department of Labor
(4) That
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees.
except as noted in Section 4 (C) below.
I WHERE FRINGE BENEFITS ARE PAID IN CASH
XX -Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5 REMARKS
B NAME (Last, First Middle Initial)-
`ITLE
8 SIGNATURE
Forrest, Stephanie
Payroll Administrator
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or cnmjnal o cu on
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code
DD FORM 879. MAR 95 (EG) PREVIOUS EDITON MAY BE USED
R07371
Aegion Corporation
1/5/2016
12:47:26
Certified Payroll Register
Page -
45
Pay Period Ending Date
1/2/2016
INSITUFORM TECHNOLOGIES LLC
Protect and Location 202221
Period Number
1
17988 EDISON AVE
RENTON - WA- CAG-15-149
CHESTERFIELD MO 63005
CASCADE INTERCEPTOR -PHASE II
4784'x 14,18,21,24' CIPP
WA
St SMS SDep FMS FDep Sex EEO Union .......................
Craft......................... Step.........................
Social Security No Ethnic Cat
....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date
Hours Rate Hours Rate Hours Hours Amount Description Amount
NO WORK PERFORMED
I'
CITY OF RENTON
PRECONSTRUCTION MEETING
Cascade Interceptor Rehabilitation Phase H
WWP-27-3831
FIFTH FLOOR CONFERENCE ROOM-511-11:00 A.M.
J anu41 1`F, GVIV
City Project Manager: John Hobson Office: 425-430-7279
Fax: 425-430-7241
Email: jhobson@ rentonwa.gov
City Inspector: Tom Main Mobile # 206-999-1833
Insituform Technologies, LLC
Project Manager: Mark Werts Office: 916-729-2209
INTRODUCTIONS:
SCHEDULE:
• Estimated start date.
• Contractor's proposed schedule and work plan
• Standard work hours are weekdays, 7:00 AM to 5:00 PM. Depending on construction caused
traffic disruptions. Work on Saturday by approval only and no work will be allowed on Sundays. Any
changes to work hours shall have prior approval from the City of Renton. No work on Sundays or holidays.
No equipment shall be started prior to 7:00 a.m.
Work on Tiffany Park Elementary School grounds shall take place on non -school days only.
• Holidays: Martin Luther King Jr. Birthday (Monday, January 18)
• Progress Payments: Typically once a month. When we issue the notice to proceed, we will agree on the
schedule. Quantities from inspection reports will take precedence. Cut off for quantities will typically be
the Friday before our Finance Cutoff Day (see finance calendar). Submittals of quantities should be by the
end of the day the Tuesday before our Finance Cutoff Day. This should give us opportunity to work out
discrepancies. If they can not be worked out prior to our cutoff day, we will use inspection reports and
work it out for the next pay estimate.
Checks are typically mailed (or electronically transferred) 11 days after the Finance Cutoff Day.
• Final acceptance shall be after review of the post -installation TV inspection.
PRIVATE UTILITIES
• A.
PUGET SOUND ENERGY — POWER
• B.
PUGET SOUND ENERGY — GAS
• C.
QWEST TELEPHONE COMPANY
• D.
COMCAST CABLE, INC.
• E.
METRO
• F.
RENTON SCHOOL DISTRICT - TRANSPORTATION
GENERAL:
• Overtime takes special authorization. Pay schedule is $75 per hour for overtime. The City shall cover
inspection overtime hours from 3:00 — 5:00 PM, Monday -Friday and all hours on weekends while working
on School property.
• Keep the streets clean. Truck washing and other measures, as approved, are required for the duration of the
project. Provide whatever measures necessary for cleanup and dust control during the job and at night. All
truck maneuvering and materials storage to be within the project area only. Right of way to remain
unobstructed when possible.
• Haul legal loads.
• Keep a set of approved City construction drawings and construction documents on -site at all times.
Contractors are advised to only use sets of drawings stamped and signed by the City of Renton for
constructing utility and transportation improvements.
• Notification of residents / property owners / School officials — start of work / during construction
• Bypass pumping
• Certified Payroll
SPECIAL PROJECT CONSIDERATIONS:
• Proposed staging areas?
• Minimize construction vehicles on residential streets outside of the project area.
• Traffic Control shall be per the approved plans.
A. MANUAL ON UNIFORM TRAFFIC CONTROL DEVICES (M.U.T.C.D.)
B. TRAFFIC CONTROL PLAN (RESPONSIBLE PERSON)
C. FLAGMAN — CERTIFIED BY STATE
D. PROJECT SIGNING (BEGINNING AND END)
• SAFETY AND HEALTH REQUIREMENTS O.S.H.A./W.I.S.H.A. AND DESIGNATION OF SAFETY
OFFICER. CONFINED SPACE ENTRY PROCEDURES.
CITY INSPECTION
• City inspection (Tom Main)
All work to be inspected by City inspector during installation.
The inspector or City's project manager shall be onsite during side sewer re-establishment
H:\File Sys\WWP - WasteWater\WWP-27-03831 Cascade Interceptor Rehabilitation Phase II\Construction\Precon Agenda Cascade
Interceptor Rehab Ph Il.doc
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30. 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per responseincluding the time for reviewing Instructions, searching existing data sources.
gathering and maintaining the data needed r antl completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden, to Department of Defense. Washington Headquarters Services, Directorate for Information operations and Reports, 1216
Jefferson Davis Highway, Suite 1204. Arlington, VA 22202-4302. and to the office of Management and Budget. Paperwork Reduction Protect (1215-0149) Washington. DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1. PAYROLL NUMBER
2. PAYROLL PAYMENT DATE (YYMMDD)
3. CONTRACT NUMBER
4. DATE (YYMMDD)
12
1 15/12/24
1 15/12/24
Stephanie Forrest Payroll Administrator do hereby state
(Name of signatory party) (Tile)
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Contractor or subcontracrwl
on the CAG 15-149 , that during the payroll period commencing on the 13 day of
(Building or work)
December 201 5 and ending the 19 day of December 201 5 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insitufonn Technologies, LLC from the full weekly wages eamed by any person
(Contracts or subcorl"clor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat. 948, 63 Stat. 108, 72 Stat 967, 76 Stat. 357: 40 U S. C. 276c), and described below.
Federal, Fica, State and Local tax, 401 K, Loan re -payment, Insurance, garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete: that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
-Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5.REMARKS
6 NAME (Last. First, Middle Initial)
7. TITLE
8. SIGNATU�
Forrest, Stephanie
Payroll Administrator
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal on.
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
DD FORM 879, MAR 95 (EG) PREVIOUS EDITION MAY BE USED.
R07371 Aegion Corporation 12/22/201510:07:22
Certified Payroll Register Page - 64
Pay Period Ending Date 12/19/2015
INSITUFORM TECHNOLOGIES LLC Pro ect and Location 202221 Period Number 4
17988 EDISON AVE RE�TON - WA- CAG-15-149
CHESTERFIELD MO 63005 CASCADE INTERCEPTOR -PHASE II
4784'x 14,18,21,24" CIPP
WA
St SMS SDep FMS FDep Sex EEO Union ....................... Craft...........,............. Step.........................
Social Security No Ethnic Cat .... I .. Regular ....... ....... Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
NO WORK PERFORMED
•
♦ .A"''
=orm Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30. 1997
Public reporting burden for this Collection of Information is estimated to average 16 minutes per responseincluding the time for reviewing instructions searching existing data sources.
gathering and maintaining the data needed and completing and reviewing the collection of Information Send comments regarding this burden estimate or any other aspect of this collection
of information. including suggestions for reducing this burden. to Department of Defense Washington Headquarters Services, Directorate for information Operations and Reports. 1215
Jefferson Davis Highway. Suite 1204, Arington, VA 222024302and to the Office of Management and Budget, Paperwork Reduction Protect (1215-0149) Washington. DC 20503
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1 PAYROLL NUMBER
AYROLL PAYMENT DATE (YYMMDD,
F
3 CONTRACT NUMBER
4 DATE (YYMMDD)
13
15112/31
1 15/12/31
Stephanie Forrest Payroll Administrator do hereby state
(Name of signatory party, ➢ties
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Contractor or subcontractor)
or the CAG-15-149 that during the payroll period commencing on the 20 day of
fauddmg or wpA'
December 201 5 and ending the 26 day of December 201 5 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or 5ubcontracror)
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations. Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat. 948, 63 Stat 108, 72 Stat 967, 76 Stat 357: 40 U.S.C. 276c), and described below'
Federal. Fica. State and Local tax, 401K. Loan re -payment. Insurance. garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete:. that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training. United States Department of Labor
(4) That
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
-Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5 REMARKS
6 NAME (Last First. Middle Initial)
7. TITLE
8 SIGNATURE
Forrest, Stephanie
Payroll Administrator
The wilHul falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal prosEc ion
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code
UU rUKM 6(9, MAK 95 (LU) PREVIOUS EDITON MAY BE USED
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Pro'ect and Location 202221
RE�TON - WA- CAG-15-149
CASCADE INTERCEPTOR-PHASEII
4784'x 14,18,21,24" CIPP
WA
12/29/201512:58 24
Page - 57
Pay Period Ending Date 12/26/2015
Period Number 5
St SMS SDep FMS FDep Sex EEO Union ....................... Craft......................... Step.........................
Social Security No Ethnic Cat ....... Regular ....... ....... Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
— NO WORK PERFORMED
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No. 1215-0149
Expires Jun 30. 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per responser including the time for reviewing instructions, searching existing data sources.
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden, to Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports, 1215
Jefferson Davis Highway, Suite 1204. Arlington, VA 22202-4302. and to the Office of Management and Budget. Paperwork Reduction Protect (1215-0149) Washington, DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1. PAYROLL NUMBER
2 PAYROLL PAYMENT DATE (YYMMDD)
3 CONTRACT NUMBER
4 DATE (YYMMDD)
11
15/12/18
1 15/12/18
Stephanie Forrest Payroll Administrator do hereby state
(Name of signatory party) (Title)
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Conoerxor or subcontractor)
on the CAG-15-149 that during the payroll period commencing on the 6 day of
(Buliding or work)
December 201 5 and ending the 12 day of December 201 5 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Confracror or submittradon
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat. 948, 63 Stat. 108, 72 Stat. 967, 76 Stat. 357, 40 U.S. C. 276c). and described below:
Federal, Fica, State and Local tax, 401K, Loan re -payment, Insurance, garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or 0 no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5.REMARKS
6. NAME (Last. First, Middle Initial)
7. TITLE
8 SIGNATURE
Forrest, Stephanie
Payroll Administrator
�)
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal 11cution.
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
DD FORM 879, MAR 95 (EG) PREVIOUS EDITON MAY BE USED.
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Pro1'ect and Location 202221
RENTON - WA- CAG-15-149
CASCADE INTERCEPTOR-PHASEII
4784'x 14,18,21,24" CIPP
WA
12/16/201514 07:23
Page - 59
Pay Period Ending Date 12/12/2015
Period Number 3
St SMS SDep FMS FDep Sex EEO Union ....................... Craft ......................... Step .........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ......... .
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
-- NO WORK PERFORMED ------
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30, 1997
Public reporting burden for this collection of Information Is estimated to average 16 minutes per response. including the time for reviewing instructions searching existing data sources.
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection
of information. including suggestions for reducing this burden. to Department of Defense. Washington Headquarters Services, Directorate for Information Operations and Reports. 1215
Jefferson Davis Highway, Suite 1204. Arlington. VA 22202-4302. and to the Office of Management and Budget. Papenvmrk Reduction Project (1215-0149) Washington. DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1 PAYROLL NUMBER
2 PAYROLL PAYMENT DATE (YYMMDD)
3. CONTRACT NUMBER
4 DATE (YYMMDD)
10
1 15/12/11
1 15/12/11
Stephanie Forrest Payroll Administrator do hereby state
(Name of signatory party) (Title)
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (contractor or subcontractor)
on the CAG-15 149 . that during the payroll period commencing on the 29 day of
ffl.admg or work)
November 201 5 and ending the 5 day of December 201 5 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subcontracorl
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat. 948, 63 Stat, 108, 72 Stat. 967, 76 Stat. 357, 40 U.S.C. 276c), and described below:
Federal, Fica, State and Local tax, 401 K, Loan re -payment, Insurance, garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete, that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract. that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
W7-Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5.REMARKS AL
6 NAME (Last, First, Middle Initial)
8 SIGNATU
17TITLE
Forrest, Stephanie
Payroll Administrator
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or cllecution
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
DD FORM 879, MAR 95 (EG) PREVIOUS EDITON MAY BE USED
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Pro act and Location 202221
REATON - WA- CAG-15-149
CASCADE INTERCEPTOR -PHASE II
4784'x 14,18,21,24" CIPP
WA
St SMS SDep FMS FDep Sex EEO Union ....................... Craft......................... Step.........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
- NO WORK PERFORMED ----
12/9/2015 12:15A9
Page - 58
Pay Period Ending Date 12/5/2015
Period Number 2
r OL
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30, 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per response, including the time for reviewing instructions. searching existing data sources,
gathering and maintaining the data needed. and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden. to Department of Defense, Washington Headquarters Services. Directorate for Information Operations and Reports, 1215
Jefferson Davis Highway Suite 1204. Arlington. VA 22202-4302and to the Office of Management and Budget. Paperwork Reduction Project (1215-0149) Washington, DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1 PAYROLL NUMBER
2 PAYROLL PAYMENT DATE (YYMMDD)
3 CONTRACT NUMBER
4 DATE (YYMMDD)
9
1 15/12/04
1 15/12/04
I, Stephanie Forrest Payroll Administrator do hereby state
(Name of signatory party) (Tree)
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (contractor or subcontractor)
on the CAG-15-149 that during the payroll period commencing on the 22 day of
(Building or wank)
November 201 5 and ending the 28 day of November 201 5 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(contractor or subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat. 948, 63 Stat. 108, 72 Stat. 967, 76 Stat. 357,- 40 U. S. C. 276c), and described below.
Federal, Fica, State and Local tax, 401 K, Loan re -payment, Insurance, garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
FTI-Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5 REMARKS
6. NAME (Last, First, Middle Initial)
TITLE
8. SIGNATURE
Forrest, Stephanie
TpayrollAdministrator
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal pro n.
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
UU t-UKM tsfy, MAN y5 (LU) PREVIOUS EDITON MAY BE USED
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Pro'ect and Location 202221
REATON - WA- CAG-15-149
CASCADE INTERCEPTOR -PHASE II
4784'x 14,18,21,24" CIPP
WA
12/2/2015 11:49:35
Page - 58
Pay Period Ending Date 11/2812015
Period Number 1
St SMS SDep FMS FDep Sex EEO Union ....................... Craft ......................... Step .........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
NO WORK PERFORMED J
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30. 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per response, including the time for reviewing instructions. searching existing data sources.
gathering and maintaining the data needed. and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden, to Department of Defense. Washington Headquarters Services, Directorate for Information Operations and Reports, 1215
Jefferson Davis Highway. Suite 1204. Arlington. VA 22202-4302. and to the Office of Management and Budget. Paperwork Reduction Protect (12150149) Washington. DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1. PAYROLL NUMBER
AYROLL PAYMENT DATE (YYMMDD)
3. CONTRACT NUMBER
4. DATE (YYMMDD)
8
F15/11/27
1 15/11127
I, Stephanie Forrest Payroll Administrator do hereby state
(Name of signatory party) (77tie)
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase 11 (Contractor or subcontractor)
on the CAG-15-149 that during the payroll period commencing on the 15 day of
(Building or work)
November 201 5 and ending the 21 day of November 201 5 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat. 948, 63 Stat. 108, 72 Stat. 967: 76 Stat. 357, 40 U.S.C. 276c), and described below:
Federal, Fica, State and Local tax, 401 K, Loan re -payment, Insurance, garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete, that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract; that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
71 -In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
-Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5.REMARKS
6. NAME (Last, First, Middle Initial)
TITLE
8. SIGNATLI 2Forrest,
Stephanie
TpayrollAdministrator
1 ),
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal proses n.
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
DID FORM 879, MAR 95 (EG) PREVIOUS EDITON MAY BE USED.
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO53005
St SMS SDep FMS FDep Sex
Social Security No Ethnic Cat
Name/Address
Aegion Corporation
Certified Payroll Register
Prolict and Location 202221
RE TON - WA- CAG-15-149
CASCADE INTERCEPTOR-PHASEII
4784'x 14,18,21,24" CIPP
WA
11 /24/201511:41:32
Page - 70
Pay Period Ending Date 11/21/2015
Period Number 4
EEO Union ....................... Craft......................... Step.........................
....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
L NO WORK PERFORMED j
I
I
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30. 1997
Public reporting burden forthis collection of information Is estimated to average 16 minutes Per response. including the time for reviewing instructions. searching existing data sources,
gathering and maintaining the data needed, and completing and renewing the collection of information Send comments regarding this burden estimate or any other aspect of this collection
of informationincluding suggestions for reducing this burden, to Department of Defense Washington Headquarters Semces. Directorate for Information Operations and Reports. 1215
Jefferson Davis Highway Suite 1204 Arlington. VA 22202-4302 and to the Office of Management and Budget Paperwork Reduction Project (1215-0149) Washington. DC 20503
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1 PAYROLL NUMBER
2. PAYROLL PAYMENT DATE (YYMMDD)
3. CONTRACT NUMBER _T
Dr;TE ;vvMMDD,
7
15/11/20
15/11/20
Stephanie Forrest Payroll Administrator do hereby stare
(Name of signatory party) !Tbe,
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (contractor or subcontractor)
on the CAG-15-149 that during the payroll period commencing on the 8 day of
IBuildmg or work)
November 201 5 and ending the 14 day of November 201 5 all persons employed
on said project have been paid the full weekly wages earned. that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subcontraotorn
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat. 948. 63 Stat. 108, 72 Stat, 967: 76 Stat. 357, 40 U.S.C. 276c), and described below:
Federal. Fica. State and Local tax. 401K. Loan re -payment. Insurance, garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training. United States Department of Labor.
(4) That
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll. an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5 REMARKS
6 NAME (Last, First, Middle Initial)
7 TITLE
8_ SIGNA
Forrest, Stephanie
Payroll Administrator
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or co s ution.
See Section 1001 of Title 16 and Section 231 of Title 31 of the United States Code
DD FORM 879. MAR 95 (EG) PREVIOUS EDITON MAY BE USED
R07371
Aegion Corporation
Certified Payroll Register
INSITUFORM TECHNOLOGIES LLC PrMct and Location 202221
17988 EDISON AVE RE�TON - WA- CAG-15-149
CHESTERFIELD MO 63005 CASCADE INTERCEPTOR -PHASE II
4A84'x 14,18,21,24" CIPP
St SMS SDep FMS FDep Sex EEO Union ....................... Craft ......................... Step .........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
NO WORK PERFORMED
11 /18/201513:50:34
Page - 73
Pay Period Ending Date 11/14/2016
Period Number 3
V
Form Approved
STATEMENT OF COMPLIANCE 202221
'OMB No 1215-0149
Excites Jun 30. 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per response, including the time for reviewing instructions, searching existing data sources
gathering and maintaining the data neededand completing and reviewing the collection of information Send comments regarding this burden estimate or any other aspect of this collection
o' information. including suggestions for reducing this burden. to Department of Defense. Washington Headquarters Serves. Directorate for information Operations and Reports 1215
Jeflerson Davis Highway Sune 1204 Adingtor. VA 22202-4302 and to the Office of Management and Budge! Paperwork Reduction Project 0215-0149) Washington. DC 20503
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
' PAYROLL NUMBER
2 PAYROLL PAYMENT DATE (YYMMDD
3 CONTRACT NUMBER
4 DATE (YYMMDD)
6
15/11/13
15/11/13
I. Stephanie Forrest Payroll Administrator do hereby state
(Name of signatory party, , "be
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (contractor or subcontractor)
on the CAG-15-149 that during the payroll period commencing on the 1 day of
i S,ddmg or work)
November 201 5 and ending the 7 day of November 201 5 all persons employed
on said project have been paid the full weekly wages earned that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subcon7actop
and that no deductions have been made either directly or indirectly from the full wages earned by any person. other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(46 Stat 948. 63 Stat, 108. 72 Stat 967. 76 Stat 357. 40 U S. C. 276c). and described below'
Federal. Flca. State and Local tax. 401K. Loan re -payment. Insurance. garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete. that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract: that the classifications Sat forth therein for each laborer or mechanic conform with the work performed
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training. United States Department of Labor, or if no such recognized
agency exists in a State. are registered with the Bureau of Apprenticeship and Training, United States Department of Labor
(4) That
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5 REMARKS
6 NAME (Last, First. Middle Initial)
7 TITLE
8. SIGNATURE
Forrest, Stephanie
Payroll Administrator
)�
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or crimina cution.
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code,
DID FORM 879, MAR 95 (EG) PREVIOUS EDITON MAY BE USED
R07371 Aegion Corporation 11/10/201515.40,54
Certified Payroll Register Page - 78
Pay Period Ending Date 11/7/2015
INSITUFORM TECHNOLOGIES LLC ProJ''e�ct and Location 202221 Period Number 2
17988 EDISON AVE RATON - WA- CAG-15-149
CHESTERFIELD MO 63005 CASCADE INTERCEPTOR -PHASE II
4784'x 14,18,21,24' CIPP
WA
St SMS SDep FMS FDep Sex EEO Union ....................... Craft ......................... Step ........................ .
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
NO WORK PERFORMED
OL,
corm Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per response. including the time for reviewing instructions searching existing data sources,
gathering and maintaining the data needed and completing and renewing me collection of information Send comments regarding this burden estimate or any other aspect of this collection
of information. including suggestions for reducing this burden, to Department of Defense. Washington Headquarters Services. Directorate for Information Operations and Reports. 1215
Jefferson Davis Highway Suite 1204 Adingtor VA. 27202-4302and to the Office of Management and Budoet. Paperwork Reduction Project (1215.0149) Washington DC 20503
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER,
1 PAYROLL NUMBER
2 PAYROLL PAYMENT DATE(YYMMDD)
NUMBER
4 DATE (YYMMDD:
5
1 15/11 /06
F-CONTRACT
15111 /06
Stephanie Forrest Payroll Administrator do hereby state
(Name dt srgnarory party, Tare
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II icontractor or suoconrrecron
on the CAG-15-149 that during the payroll period commencing on the 25 day of
/building or work)
October 201 5 and ending the 31 day of October 201 5 all persons employed
on said project have been paid the full weekly wages earned that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contracts, or subcontractor
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations. Part 3 (29 CFR Subtitle A). issued by the Secretary of Labor under the Copeland Act, as amended
(46 Stat 948. 63 Stat 108. 72 Stat 967. 76 Stat. 357. 40 U.S.C. 276c) and described below:
Federal. Fica. State and Local tax. 401 K. Loan re -payment. Insurance garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete, that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor. or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor
(4) That.
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
W7-Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5 REMARKS
6 NAME (Last. First. Middle Initial)
TITLE
8 SIGNATURE
Forrest, Stephanie
Tpayroll Administrator
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or cri os cution.
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
DD FORM 879. MAR 95 (EG) PREVIOUS EDITION MAY BE USED
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Pro''ect and Location 202221
RENTON - WA- CAG-15-149
CASCADE INTERCEPTOR -PHASE II
4784'x 14,18,21,24" CIPP
WA
11/4/2015 7:34:13
Page - 76
Pay Period Ending Date 10/31/2015
Period Number 1
St SMS SDep FMS FDep Sex EEO Union ....................... Craft......................... Step.........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job .......... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
---NO WORK PERFORMED ----
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30. 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per response, including the time for reviewing instructions, searching existing data sources.
gatnenng and maintaining the data needed and completing and reviewing the collection of information Send comments regarding this burden estimate or any other aspect of this collection
of informationincluding suggestions for reducing this burden. to Department of Defense. Washington Headquarters Services Directorate for Information Operations and Reports. 1215
Jefferson Davis Highway Suite 1204 Artmolon. VA 22202-4302 and to the Office of Management and Budge! Paperwork Reduction Project (12150149) Washington DC 20503
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1 PAYROLL NUMBER
AYROLL PAYMENT DATE (YYMMDD
3 CONTRACT NUMBER
4 DATE (YYMMDD)
3
F15/10123
1 15/10/23
Stephanie Forrest Payroll Administrator do hereby state
(Nairn of signatory parry, (rite,
(1) That I pay or supervise the payment of the persons employed by insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (contractor or subcontractor,
on the CAG-15-149 that during the payroll period commencing on the 11 day of
(Building or work,
October 201 5 and ending the 17 day of October 201 5 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(contractor or subcontractor
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act. as amended
(48 Stat 948, 63 Stat 108. 72 Stat. 967, 76 Stat, 357: 40 U S C 276c), and described below
Federal. Fica. State and LDcal tax, 401K. Loan re -payment. Insurance, garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
Incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform with the work performed
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training. United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That.
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees.
except as noted in Section 4 (C) below
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract.
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5.REMARKS
B NAME (Last First Middle Initial)
TITLE
B SIGNATURt-�,V)
Forrest, Stephanie
Payroll Administrator
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal tion.
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
UU F-UKM b/9, MAK 9b (EU) PREVIOUS EDITON MAY BE USED
R07371 Aegion Corporation 10/21/201514.15:54
Certified Payroll Register Page - 81
Pay Period Ending Date 10/17/2015
INSITUFORM TECHNOLOGIES LLC Project and Location 202221 Period Number 4
17988 EDISON AVE RENTON - WA- CAG-15-149
CHESTERFIELD MO 63005 CASCADE INTERCEPTOR -PHASE II
4A84'x 14,18,21,24" CIPP
St SMS SDep FMS FDep Sex EEO Union ....................... Craft......................... Step.........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
NO WORK PERFORMED
I
.._ -A
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30, 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per response, including the time for reviewing instructions, searching existing data sources.
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden, to Department of Defense, Washington Headquarters services, Directorate for Information Operations and Reports, 1215
Jefferson Davis Highway, Sure 1204, Arlington, VA 22202-4302, and to the Office of Management and Budget, Paperwork Reduction Project (1215�0149) Washington, DC 20503
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1. PAYROLL NUMBER
2 PAYROLL PAYMENT DATE (YYMMDD)
3. CONTRACT NUMBER
4. DATE (YYMMDD)
4
1 15/10/30
1 15/10/30
I, Stephanie Forrest Payroll Administrator do hereby state
(Name of signatory party) (7-M.)
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Contra or subcontractor)
on the CAG-15-149 that during the payroll period commencing on the 18 day of
(Building or work)
October 201 5 and ending the 24 day of October 201 5 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor Or subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat. 948. 63 Stat. 108, 72 Stat. 967, 76 Stat. 357, 40 U.S.C. 276c), and described below:
Federal, Fica, State and Local tax, 401 K, Loan re -payment, Insurance, garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete, that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract; that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
-Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5.REMARKS
6. NAME (Last, First, Middle Initial)
TITLE
8. SI NAForrest,
Stephanie
TpayrollAdministrator
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or mi secution.
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code
DID FORM 879, MAR 95 (EG) PREVIOUS EDITON MAY BE USED.
R07371 Aegion Corporation 10/28/201514:33:01
Certified Payroll Register Page - 77
Pay Period Ending Date 10/24/2015
INSITUFORM TECHNOLOGIES LLC Pro'ect and Location 202221 Period Number 5
17988 EDISON AVE RE - WA- CAG-15-149
CHESTERFIELD MO 63005 CASCADE INTERCEPTOR -PHASE II
4784'x 14,18,21,24' CIPP
WA
St SMS SDep FMS FDep Sex EEO Union ....................... Craft ......................... Step .........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
NO WORK PERFORMED ---
1IK .1,
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30, 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per responseincluding the time for reviewing instructions, searching existing data sources.
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of thrs collection
of information, including suggestions for reducing this burden, to Department of Defense. Washington Headquarters services , Directorate for Information Operations and Reports. 1215
Jefferson Davis Highway, Sude 1204, Arlington, VA 22202-4302. and to the Office of Management and Budget, Paperwork Reduction Project (1215-0149) Washington. DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER-
1 PAYROLL NUMBER
2 PAYROLL PAYMENT DATE (YYMMDD)
3 CONTRACT NUMBER
4 DATE (YYMMDD)
2
15/10/16
1 15/10/16
1, Stephanie Forrest Payroll Administrator do hereby state
(Name of signatory party) (Title)
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (contractor or subcontractor)
on the CAG-15-149 that during the payroll period commencing on the 4 day of
(Building or work)
October 201 5 and ending the 10 day of October 201 5 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subconbactor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat. 948, 63 Stat. 108, 72 Stat. 967; 76 Stat. 357; 40 U.S.C. 276c), and described below:
Federal, Fica, State and Local tax, 401 K, Loan re -payment, Insurance, garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5.REMARKS
6. NAME (Last, First, Middle Initial)
TITLE
8. SK3NA
Forrest, Stephanie
TpayrollAdministrator
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or c y l prosecution.
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
DID FORM 879, MAR 95 (EG) PREVIOUS EDITON MAY BE USED
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Pro''ect and Location 202221
RENTON - WA- CAG-15-149
CASCADE INTERCEPTOR-PHASE11
4784'x 14,18,21,24" CIPP
WA
St SMS SDep FMS FDep Sex EEO Union ....................... Craft......................... Step.........................
Social Security No Ethnic Cat ..... Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
----- NO WORK PERFORMED --- —
10/15/2015 7:37:27
Page - 80
Pay Period Ending Date 10/10/2015
Period Number 3
I
f.
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30. 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per response including the time for reviewing instructions searching existing data sources.
gathering and maintaining the data needed and completing and reviewing the collection of information Send comments regarding this burden estimate or any other aspect of this collection
of Information, including suggestions for reducing this burden. to Department of Defense. Washington Headquarters Services Directorate for Information Operations and Reports, 1215
Jefferson Davis Highway Suite 1204. Arington VA 22202-4302, and to the Office of Management and Budget. Paperwork Reduction Project (1215-0149i Washington DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1 PAYROLL NUMBER
2. PAYROLL PAYMENT DATE (YYMMDD)
3 CONTRACT NUMBER
4 DATE (YYMMDD)
1
15/10/09
1
15/10/09
Stephanie Forrest Payroll Administrator do hereby state
(Name of sr9-1-y panyi j Tmel
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II /Contractor or subcontradorl
on the CAG-15-149 that during the payroll period commencing on the 27 day of
IBuddrng or wwk,
September 201 5 and ending the 3 day of October 201 5 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contracra or subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations. Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat 948, 63 Stat 108 72 Stat 967. 76 Stat 357: 40 U.S C 276c), and described below:
Federal, Fica, State and Local tax. 401 K. Loan re -payment, Insurance. garnishments
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract. that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
XX -Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract.
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5 REMARKS
6. NAME (Last. First. Middle Initial)
TITLE
8 SIGMA UREForrest,
Stephanie
Tpayroll Administrator
The wiltful falsification of any of the above statements may subject the contractor or subcontractor to civil or cn alp cation.
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
DID FORM 879, MAR 95 (EG) PREVIOUS EDITON MAY BE USED.
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Project and Location 202221
RENTON - WA- CAG-15-149
CASCADE INTERCEPTOR -PHASE II
4784'x 14,18,21,24" CIPP
WA
St SMS SDep FMS FDep Sex EEO Union ....................... Craft .........................
Social Security No Ethnic Cat .. I .... Regular .............. Overtime ...... Other
Name/Address Work Date Hours Rate Hours Rate Hours
MO S S 8 M 008 1971 For HBU 1971 Accrual PIPL Pipelayer
XXX-XX4960 White
Christopher,Charlie Blake FR 10/2/2015 5.00 38.000
1170 SW 170th Ave Pipelayer 5.00
#203
Beaverton OR 97003
United States
MO S
XXX-XX-0002
Adam E Clary
1768 Pine Street
Silverton OR 97381
United States
Subtotal for Payment Number:04874032 5.00
Christopher,Chadie Blake 5.00
S M 008 1971 For HBU 1971 Accrual PIPL Pipelayer
White
FIR 10/2/2015 5.00 38.300
Pipelayer 5.00
10/7/2015 14:12:49
Page - 86
Pay Period Ending Date 10/3/2015
Period Number 2
Step.........................
Total
Job
........... Check Detail ..........
Hours
Amount
----
Description Amount
--- --- --
default
5.00
190.00
Payment Number: 04874032
5.00
190.00
Gross Pay
1,752.32
OR Departmen
91.69
FED W/H Tax
170.19
FICA W/H
107.44
Medicare W/H
25.13
MEDICAL
20.67
DENTAL
3.18
VISION
.32
HTHFSA
4.81
401K EE Ded
87.62
Roth
87.62
Total Deduct
598.67
Net Pay
1,153.65
Hrs This Chk
45.00
5.00 190.00
5.00 190.00
default
5.00 191.50 Payment Number:04874007
5.00 191.50 Gross Pay
1,779.20
OR Departmen
137.05
FED W/H Tax
343.33
FICA W/H
107.52
Medicare W/H
25.14
Chd Sup $/%
98.08
MEDICAL
49.60
DENTAL
5.46
OP CH LIFE
.84
R07371
Aegion Corporation
10/7/2015 14:12:49
Certified Payroll Register
Page - 87
Pay Period Ending Date 10/3/2015
INSITUFORM TECHNOLOGIES LLC
Pro'ect and Location 202221
Period Number 2
17988 EDISON AVE
RE�TON - WA- CAG-15-149
CHESTERFIELD MO 63005
4784'x 14 18,21 24" CIPP
CASCADI= INTERCEPTOR -PHASE II
WA
St SMS SDep FMS FDep Sex EEO Union ....................
Craft .................... Step ..................
Social Security No Ethnic Cat
....... Regular .............. Overtime ...... Other Total
Job
........... Check Detail ..........
Name/Address Work Date
Hours Rate Hours Rate Hours Hours
Amount
Description Amount
Short Term D
4.39
Total Deduct
771.41
Net Pay
1,007.79
Hrs This Chk
45.00
Subtotal for Payment Number:04874007
5.00 5.00
191.50
Adam E Clary
5.00 5.00
191.50
MO M M M 008 1971 For HBU 1971 Accrual PIPL Pipelayer
default
XXX-XX-2066 White
Ryan Thomas Hagemann FIR 10/2/2015
5.00 36.550
5.00
182.75
Payment
Number: 04874011
203 Faith Dr. Pipelayer
5.00
5.00
182.75
Gross Pay
1,723.27
Jefferson OR 97352
OR Departmen
114.90
United Slates
FED W/H Tax
183.63
FICA W/H
97.84
Medicare W/H
22.88
MEDICAL
144.92
DENTAL
9.72
VISION
1.32
Total Deduct
575.21
Net Pay
1,148.06
Hrs This Chk
45.00
Subtotal for Payment Number: 04874011
5.00
5.00
182.75
Ryan Thomas Hagemann
5.00
5.00
182.75
MO M M 3 M 008 1971 For HBU 1971 Accrual PIPL Pipelayer default
XXX-XX-9446 Two or More Races
Brent E Robinett FR 10/2/2015 5.00 34.260 5.00 171.30 Payment Number:04874033
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
St SMS SDep FMS FDep Sex
Social Security No Ethnic Cat
Name/Address
1271 Dorval Avenue NW Pipelayer
Salem OR 97304
United States
Aegion Corporation
Certified Payroll Register
Pro'ecI and Location 202221
RE�TON - WA- CAG-15-149
4784'x 14 18,21 24" CIPP
CASCADI` INTERCEPTOR -PHASE II
WA
EEO Union .................... Craft....................
....... Regular .............. Overtime ......
Work Date Hours Rate Hours Rate
5.00
10/7/2015 14:12:49
Page - 88
Pay Period Ending Date 10/3/2015
Period Number 2
Step..................
Other Total Job ........ Check Detail ..........
Hours Hours Amount Description Amount
5.00 171.30 Gross Pay
2,098.59
OR Departmen
137.25
FED W/H Tax
231.18
FICA W/H
127.30
Medicare W/H
29.77
MEDICAL
44.05
DENTAL
9.72
VISION
1.32
OP EE LIFE
1.20
OP SP LIFE
2.22
OF CH LIFE
.84
401K EE Ded
104.93
Short Term D
4.91
Total Deduct
694.69
Net Pay
1,403.90
Hrs This Chk
52.00
Subtotal for Payment Number:04874033
5.00
5,00
171.30
Brent E Robinett
5.00
5.00
171.30
RENTON - WA- CAG-15-149
20.00
20.00
735.55
��► _
T// tat
Request for Approval of Material
Contract Number
FA Number
SR
Date
UAG- I 5-118(City of Renton No. WW9-27-03712)
11 2 201
Section / Title of Project
County
Central Renton Sewer Interceptor Reline & Upsize
King
Contractor
Subcontractor
Road Construction Northwest, Inc.
This form shall be completed prior to submittal. If this form is not complete at time of
submittal it may be returned for information that was omitted.
For WSDOT Use Only
For assistance in completing, see Instructions and Example
RAM # 001-2
Bid
Material or
Name and Location of Fabricator,
Specification
PE/QPL
Hdqtr. QPL
Item No.
Product/Type
Manufacturer or Pit Number
Reference
Code
Code
8
84" ID Sewer Manhole
Shope Concrete Products
Puyallup,WA
7-05
O
Project Engineer
Date
State Materials Engineer
Date
Acceptance Action Codes for use by Project Engineer and State Materials Laboratory
1. Acceptance Criteria: Acceptance based upon 'Satisfactory' Test Report for samples of materials to be incorporated into project.
2. Acceptance Criteria: Mfg. Cert. of Compliance for 'Acceptance' prior to use of material.
3. Acceptance Criteria: Catalog Cuts for'Acceptance' prior to use of material. Catalog Cut Approved 1"e. No
4. Acceptance Criteria: Submit Shop Drawings for'Approval' prior to fabrication of material.
5. Acceptance Criteria: Only 'Approved for Shipment', 'WSDOT Inspected' or'Fabrication Approved Decal' material shall be used.
6. Acceptance Criteria: Submit Certificate of Materials Origin to Project Engineer Office.
7. Acceptance Criteria: Request Transmitted to State Materials Laboratory for Approval Action
8. Source Approved.
9 Approval Withheld: Submit samples for preliminary evaluation.
10. Approval Withheld:
11. Miscellaneous Acceptance Criteria.
Remarks:
Project Engineer Distribution
❑ Contractor
❑ Region Operations Engineer
❑ Fabrication Inspection
DOT Form 350-071 EF
Revised 1212012
❑ Region Materials
❑ State Materials Lab
M/S 47365
State Materials Engineer Distribution
❑ General File ❑ Signing Inspection
❑ Other
Central Renton Sewer Interceptor Reline & Upsize
Contractor Responses
Approval of Material: Bid Item 8- 84-inch Diam. Sewer Manhole
1. 84" Manhole shall be WSDOT B-15.60-01as submitted on Shope Concrete Products cut sheet.
The Shope cover letter specifies the incorrect WSDOT spec (B-15.40-00).
Please see attached Catalog Cut for Shope Contcete Products 84" Type 3 Precast Manhole.
WSDOT Spec B-15.60-01 referenced in heading. Please disregard previously submitted cover
letter.
2. Predl Systems Drawing No. 20.1 does not appear to be applicable to this project. Contractor
shall note that a polypropylene wall liner is not required for this manhole. As an option,
Contractor may provide Predl Systems polypropylene wall liner in lieu of Wasser MC-Aroshield
coating for all interior concrete surfaces above the FRP base liner, provided there is no
additional cost to the Owner.
Drawing No. 20.1 is deleted from submittal package. No interior coating / liner will be
used or provided on surfaces above the FRP base liner. Per review, this is an option
that is not required and original polypropylene liner is not an acceptable option.
3. Predl Systems Drawing No. 89 includes a polypropylene wall liner above the FRP base liner. As
previously indicated, a polypropylene wall liner is not required for this manhole. As an option,
Contractor may provide Predl Systems polypropylene wall liner in lieu of Wasser MC-Aroshield
coating for all interior concrete surfaces above the FRP base liner, provided there is no
additional cost to the Owner.
See response above stating that no interior coating / liner will be used on surfaces
above the FRP base liner. Per review, this is an option that is not required and original
polypropylene liner is not acceptable.
4. Contractor to verify skewed angles and invert elevations prior to fabrication of base liner as
noted on Detaill , Drawing C-2. Submit revised shop drawing (Predl Systems Dwg No. 89)
indicating field verified angles and invert elevations. Adjust manhole dimensions as appropriate.
Skewed angles and invert elevations related to the FRP Base liner are approved per
attached review.
84" Type 3 Precast Manhole
WSDOT B-15.60-01
Flat Top Slab Reinforcing
• #6 deformed rebar
• Round opening
Manhole Wall Reinforcing
• Minimum 0.24 square inches / linear foot
Base Reinforcing
• © Separated base slab 0.39 square inches / linear
foot in both directions
Hole or Knock Out Dimensions
■ Maximum hole size is 72 inches
■ 12 inches of minimum distance between holes
■ 3 inch diameter lifting holes provided
Conformity Standards
• ASTM C478 - 97 Manhole
■ ASTM C443 rubber gasket joint
■ ASTM D - 4101 polypropylene steps and ladders
• Washington State APWA / WSDOT Standard
Options Available
■ Specialized coatings
■ Prechanneled base
• Custom hatches
• Kor-N-Seal boots
Note: drawings not to scale
manhole products
Top Slab Plan View
Sh Shope Enterprises, Inc. (253) 848-1551 1-800-422-7560 [Toll Free]
I I 1618 East Main Avenue Fax Line 1 (253) 845-0292 www.shopeconcrete.com
Concrete products Puyallup, WA 98372-3142 Fax Line 2 (253) 864-6172
AI k
I State
MH Base Liner Approval Only
Request for Approval of Material
Contract Number FA Number SR
7AG-15-11B(Cit) of Renton No. W1N'9-27-03712)
Section I Title of Project County
Central Renton Sewer Interceptor Reline & Upsize king
Contractor Subcontractor
Road Construction ?northwest, Inc.
Date
j W24,12015
This form shall be completed prior to submittal. If this form is not complete at time of For WSOOT Use Only
submittal it may be returned for information that was omitted. y
For assistance in completing, see Instructions and Example IRAM#
Bid Material or
Item No Product/Type
Name and Location of Fabricator,
Manufacturer or Pit Number
Specification
Reference
PE/QPL
Code
Hdqtr /QPL
Code
8 84" ID Sewer Manhole
Predl Systems
Burnaby, BC
7-05
Project Engineer j Date
State Materials Engineer
Date
Acceptance Action Codes for use by Project Engineer and State Materials Laboratory
1 Acceptance Criteria Acceptance based upon 'Satisfactory' Test Report for samples of materials to be incorporated into project
2 Acceptance Criteria Mfg. Cert of Compliance for 'Acceptance' prior to use of material.
3 Acceptance Criteria Cata'og Cuts for 'Acceptance'prior to use of material Catalog Cut Approved ❑ Yes ❑ No
4 Acceptance Criteria Submit Shop Dravnngs for'Approval' prior to fabrication of material.
5 Acceptance Criteria Oniy'Approved for Shipment'. WSDOT Inspected' or'Fabrication Approved Decal' material shall be used
6 Acceptance Criteria Submit Certificate of Materials Origin to Project Ergineer Office.
7 Acceptance Criteria Request Transmitted to State Materials Laboratory for Approval Action
8 Source Approved
9 Approval Withheld Submit samples for preliminary evaluation.
10 Approval Withheld
11 Miscellaneous Acceptance Criteria
Remarks. A 7s ib2 r,.,c-- M
C— IAA-!` S`•aV•%T.-,L
rrVJ@G[ cnglneer wistrioutton
❑ Contractor ❑ Reg on Materials
❑ Region Operations Engineer ❑ State Materials Lab
❑ Fabrication Inspection M/S 47365
DOT Form 350-071 EF
Revised 122012
State Materials Engineer Distribution
❑ General File ❑ Signing Inspection
❑ Other
CENTRAL RENTON SEWER INTERCEPTOR RELINE & UPSIZE PROJECT
SANITARY SEWER AS —BUILT SURVEY EXHIBIT
FOR ROAD CONSTRUCTION NORTHWEST
PACCAR / WSDOT
EXISTING RIGHT OF WAY
SSW RIM 3917 /
CJI1R STR,.I
— h 181.•E893 � / /SSW RN 12.32
E 1 3C3 53/ 11 / IE WEST 312T 04' PPE) CNTR STR.! / SSMH RY SS.K
N 131 0745 CNTR CNNIl M05
SECTION INE
�170.11'
$$ E: 1,303.a057)`122,09' (CNTR STRC)STINGRIWAY S 10.147G N ill Wei
E FAST 31.OB' (i/' P PE / 1 E EAST : 3139 (17 CANC.') E 1303.92953
4TH ST N ( X I.EawLY:3l. or(is- E) / 3
UAGVARw
1 M4G N41 /
_ nle.sr U
EXISTING RIGHT OF WAY /� _ / E •Y'T''/d2 y IE WEST :l1.77It7 CONC7)
7 E F: /' 3S
`/ >
U
O
Wco
hh
/N Y
O' my
C
2
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a' IE IELY: 33K (If PPE)
mSSW RIM: 4332
O a� stRµ
N $K7xN
E 11/101372
GRAPHIC SCALE
20 0 20 40 RO
1 INCH = 40 FT.
DETAIL OF PROPOSED
SMH 1968
�^ ..
SCALE:
1 NCH - 10 FEET
W 4235
IE 31.4 E, 12'
i
IE 3t.2.2 W, 24'
/
E 31.7 S, 15
SSMH RIM
CItfR SLR..'
/
N 1aL1e71s
E +,393105.3e
I.E. WEST. 312Y(N PPE)
N: 1a1,1aa.06
/
E. 1303.a02.05
CENTER OF PROPOSED
SEWER MANHOLE SW 19aa,1 FOOT
SOUTH OF COORDINATES LISTED ON
SHEET G1 OF THE PROJECT
CONSTRUCTION PINS
N
SS
EL�
EAST:31.N CONC7)
l'OltLE
(17
/LE
SNLY: 31JR )15 PPE)
GENERAL NOTES
1. THIS AS -BUILT SURVEY WAS CONDUCTED ON THE GROUND ON SEPTEMBER 11, 2015.
2. FIELD SURVEY CONDUCTED USING A SPECTRA S SECOND DIRECT READING ROBOTIC TOTAL STATION. PRECISION
OF CONTROL TRAVERSE 15 AT A HIGHER LEVEL THAN MINIMUM STANDARDS REQUIRED BY WAC 332-130-090.
METHOD OF FIELD SURVEY: TRAVERSE AND RADIAL SURVEY.
3. THE HORIZONTAL AND VERTICAL GROUND CONTROL UTILIZED FOR THIS SURVEY WAS PER PROJECT PLAN
COORDINATES.
4. THE VERTICAL BENCHMARK USED FOR THIS ASBUILT SURVEY WAS A MAG NAIL FOUND IN A CONCRETE SEAM IN
THE LOCATION SHOWN HEREON; HELD AN ELEVATION OF 41.09 UNITED STATES FEET.
S. THE HORIZONTAL ACCURACY FOR THE CENTER OF EXISTING SANITARY MANHOLE POSITIONS 15 ASSUMED TO BE
WITHIN PLUS OR MINUS THREE (3) INCHES.
2015-09-22
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No 1215-0149
Expires Jun 30. 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per response. including the time for reviewing instructions searching existing data sources.
gathering and maintaining the data needed. and completing and reviewing the collection of information Send comments regarding this burden estimate or any other aspect of this collection
of information. including suggestions for reducing this burtlen. to Department of Defense, Washington Headquarters Services. Directorate for Information Operations and Reports 1215
Jefferson Davis Highway Suite 1204 Anmgton VA 22202-4302 and to the Office of Managemem and Budget Paperwork Reduction crolect (1215-01491 Washington. DC 20503
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1 PAYROLL NUMBER
2 PAYROLL PAYMENT DATE (YYMMDD)
3 CONTRACT NUMBER
4 DATE YYMMDD.
56 Final
1 16/10/28
16/10/28
Stephanie Forrest Payroll Specialist do hereby state
!Name of signatory party, -fie
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Contractoro subcontractor
on the CAG-15-149 that during the payroll period commencing on the 16 day of
(8u0drng or work',
October 201 6 and ending the 22 day of October 201 6 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
lContnac7w or subcomrracfon
and that no deductions have been made either directly or indirectly from the full wages earned by any person other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat 948, 63 Stat. 108, 72 Stall 967, 76 Stat. 357, 40 U.S.C. 276c). and described below'
Federal. Fica. State and Local tax. 401 K. Loan re -payment. Insurance. garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete: that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract: that the classifications set forth therein for each laborer or mechanic conform with the work performed
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training. United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS. OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll. payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5 REMARKS
6 NAME (Last. First Middle Initial)
TITLE 7ialist
8. SIGNATU
Forrest, Stephanie
Payroll Spec
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or trim al pr a uti
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code
DID FORM 879, MAR 95 (EG) PREVIOUS EDITON MAY BE USED
R07371
INSITUFORM TECHNOLOGIES LLC
17988 EDISON AVE
CHESTERFIELD MO 63005
Aegion Corporation
Certified Payroll Register
Pro'ect and Location 202221
RE
�TON - WA- CAG-15-149
CASCADE INTERCEPTOR-PHASEII
4A84'x 14,18,21,24" CIPP
10/26/201614:19:04
Page - 39
Pay Period Ending Date 10/22/2016
Period Number 4
St SMS SDep FMS FDep Sex EEO Union ....................... Craft......................... Step.........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ........... CReck Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
NO WORK PERFORMED
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No. 12150149
Expires Jun 30. 1997
Public reporting burden for this collection of information is estimated to average 16 minutes per response. including the time for reviewing instructions, searching existing data sources,
gathenng and maintaining the data needed. and completing and reviewing the Collection of information. Send Comments regarding this burden estimate or any other aspect of this collection
of information. including suggestions for reducing this burden to Department of Defense. Washington Headquarters Services. Directorate for Information Operations and Reports, 1215
Jefferson Davis Highway, Suite 1204. Arlington. VA =02-4302. and to the Office of Management and Budget. Paperwork Reduction Project (1215-0149) Washington, DC 20503,
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER.
1. PAYROLL NUMBER
2. PAYROLL PAYMENT DATE (YYMMDD)
3 CONTRACT NUMBER
4. DATE (YYMMDD)
55
1 16/10/21
1 16/10/21
I, Stephanie Forrest Payroll Specialist do hereby state
(Name of signatory pally) (Title)
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Contractor or subcontractor)
on the CAG-15-149 that during the payroll period commencing on the 9 day of
(auitdrrrg a• work)
October 201 6 and ending the 15 day of October 201 6 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
(Contractor or subcontractor)
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat. 948. 63 Stat. 108, 72 Stat. 967: 76 Stat 357, 40 U.S.C. 276c). and described below.
Federal, Fica, State and Local tax, 401 K, Loan re -payment, Insurance, garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete, that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract; that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
-Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5.REMARKS
6 NAME (Last, First, Middle Initial)
TITLE
8 SIGNA
Forrest, Stephanie
TPayrollSpecialist
� ) V )
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or ina a tjon.
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
DD FORM 879, MAR 95 (EG) PREVIOUS EDITON MAY BE USED.
R07371 Aegion Corporation 10/20/2016 7:53:25
Certified Payroll Register Page - 38
Pay Period Ending Date 10/15/2016
INSITUFORM TECHNOLOGIES LLC Pro act and Location 202221 Period Number 3
17988 EDISON AVE RATON - WA- CAG-15-149
CHESTERFIELD MO 63005 CASCADE INTERCEPTOR -PHASE II
WA4'x 14,18,21,24" CIPP
St SMS SDep FMS FDep Sex EEO Union ....................... Craft ......................... Step .........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job I ........ Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
NO WORK PERFORMED
Form Approved
STATEMENT OF COMPLIANCE 202221
OMB No. 1215-0149
Expires Jun 30 1997
Public reporting burden for this collection of Information is estimated to average 16 minutes per response. including the time for reviewing instructionssearching existing data sources.
gathering and maintaining the data needed. and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden. to Department of Defense, Washington Headquarters services. Directorate for Information Operations and Reports. 1215
Jefferson Davis Highway. Suite 1204. Arlington, VA 222024302, and to the Office of Management and Budget. Paperwork Reduction Project (12150149) Washington. DC 20503
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO EITHER OF THESE ADDRESSES. RETURN THE COMPLETED FORM TO THE
CONTRACTING OFFICER-
1. PAYROLL NUMBER
FAYROLL PAYMENT DATE (YYMMDD)
3. CONTRACT NUMBER
4. DATE (YYMMDD)
54
16/10/14
16/10/14
I. Stephanie Forrest Payroll Specialist do hereby state
(Name of mgnatofY Party) (Title)
(1) That I pay or supervise the payment of the persons employed by Insituform Technologies, LLC
Cascade Interceptor Rehab Phase II (Contactor or subcontractor)
on the CAG-16-149 that during the payroll period commencing on the 2 day of
(Building or workl
October 201 6 and ending the 8 day of October 201 6 all persons employed
on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on
behalf of said Insituform Technologies, LLC from the full weekly wages earned by any person
fCor:ractor a- submnrracton
and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended
(48 Stat. 948, 63 Stat. 108, 72 Stat. 967, 76 Stat. 357, 40 U.S.C. 276c), and described below:
Federal, Fica, State and Local tax, 401K, Loan re -payment, Insurance, garnishments
NO WORK
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete, that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination
incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
-In addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of
fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees,
except as noted in Section 4 (C) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
W1-Each laborer or mechanic listed In the above referenced payroll has been paid as indicated on the payroll, an amount not less
than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,
(C) EXCEPTIONS
EXCEPTION (Craft)
EXPLANATION
5.REMARKS
B. NAME (Last, First, Middle Initial)
TITLE
8. SIGNATUR
Forrest, Stephanie
TPayroll Specialist
k IT
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or cnmina uti
See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
uu rumivi of a, MHK y0 Itzu) PREVIOUS EDITON MAY BE USED.
R07371 Aegion Corporation 10/13/2016 7:36:23
Certified Payroll Register Page - 34
Pay Period Ending Date 10/8/2016
INSITUFORM TECHNOLOGIES LLC Pro'ect and Location 202221 Period Number 2
17988 EDISON AVE RE�TON - WA- GAG-15-149
CHESTERFIELD MO 63005 CASCADE INTERCEPTOR -PHASE II
4784'x 14,18,21,24' CIPP
WA
St SMS SDep FMS FDep Sex EEO Union ....................... Craft......................... Step.........................
Social Security No Ethnic Cat ....... Regular .............. Overtime ...... Other Total Job ........... Check Detail ..........
Name/Address Work Date Hours Rate Hours Rate Hours Hours Amount Description Amount
NO WORK PERFORMED