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HomeMy WebLinkAbout2002-208 CONT Chg Order 1 & 10 - LTM IncCITY OF ASHLAND DEPARTMENT OF PUBLIC WORKS CONTRACT CHANGE ORDER NO. 1 PROJECT: SISKIYOU BOULEVARD CONSTRUCTION LOCATION: SISKIYOU BOULEVARD CONTRACTOR: LTM INCORPORATED You are requested to perform the following described work upon receipt of an approved copy of this document or as described by the Engineer: Item No. Description Quantity Unit Price Amount CO 1 Install Sanitary Sewer 2" for Bus Shelter (sta. 44+25) Lump Sum $358.00 $358.00 Original Contract $1741600.00 Total this Change Order $358.00 Previous Change Orders $0.00 Revised Contract Total $174,958.00 The time provided for completion of this contract is increased by no calendar days. This document shall become an amendment to the contract and all provisions of the contract will apply. Recommended By: Engineer Dat Approved By: 7 6 En ineer Date Accepted By: LTM Incorporated PO Box 1145 Medford OR 97501 Contractor Date ENGINEERING Tel: 541-488-5347 20 E. Main Street Fax: 541-488-6006 Ashland, Oregon 97520 TTY: 800-735-2900 www.ashland.orms ?r G:1pub-wrkslengldept-admin\ENGINEERIPROJECT11999199-38 CO Sc D 1.doc DATE: MAY 1, 2003 PROJECT NO.: 99-38, SCDL D CITY OF ASHLAND A request for a Purchase Order REQUISTION FORM THIS IS A REQUEST FOR A: [ X ] Change Order (existing PO# 3611 Schedule D) Date of Request: 511!03 Required Date of Delivery/Service ASAP Vendor Name: LTM INCORPORATED Address: PO BOX 1145 City, State, Zip MEDFORD OR 97501 Phone: Project Title: SISKIYOU BOULEVARD RECONSTRUCTION Project Number: 99-38 Services Only Solicitation Process: [ ] Exempt [ ] 3 Written Quotes (copies attached) [ J Sole Source [ X ] Invitation to Bid (copies on file) [ ] Less than $5000 [ ] Request for Proposal (copies on file) Description Total Cost Account Number 260.08.12.00.704200 "Please attach the Original signed contract and Insurance Certificates. Employee Signature: Supervisor/ Dept. Head Signature: NOTE. By signing this requistiion form ertify the above request meets with Ctiy of Ashland Solicitiation Process requirements nd can be provided when necessary. G:Pubwrks\Eng\99-38 CO 1 Sch D Requisition.xls Updated on: 7/15/02 TM Incorporated Time and Materials Billing Summary Project Name: SISKIYOU BLVD. SCH. D Description of work: Sanitary Sewer 2" LABOR Job No.: 02271-601 Date: 01/24/2003 ' 3 x( 3?. 3 ??eF " ? r?, ?Xat',? gg 8 • r 4; }• ? 4 r r x p, C `r 1!Ar, Yi ?(?y?Jx, •, N, P."tl' x h? ? ?, ? k• fi i.Jx .,4?Gt,., ?pS?1.•.?? ?, tl ,` {; qaR? axt l'+R4+'ki ?P 3. 01/24/03 Foreman S. McClaffe 2.00 32.94 $65.88 01/24/03 Operator T. Marez 3.00 32.37 $97.11 01/24/03 Laborer T. McCullough 3.00 24.59 $73.77 LABOR TO TAL $236.76 EQUIPMENT 01/24/03 pickup 20123 2.00 $8.25 $16.50 01/24/03 JD 410E Backhoe 110079 2.00 $29.07 $58.14 1 1 i EQUIP. TO TAL $74.64 MATERIALS - a .....?, •M._ i. ?. ....'- ..s.,,, f... tr,?....c. ....?? "I4 ., .I.3.,l.a.s._ j.. ?+.im.,.., 3 •t h ,r:lk 4.? !) ?av..x. 01/24/03 2" ABS Pipe, various attachments 1 ea $134.05 $134.05 MATERIAL TOTAL $134.05 SERVICES / MISC. _ - 2 ~ { , al:.' . x ? _? .L ?? F. 4 •.?t i ? ;':fl. wit i'• i K i ?`?;Y ? ?. t..y??x, p f,{f`;, t?, I IN rt7?"xT3?.'x+??'?si54u F,d 3 4.."r. :d'?'x7?d'?7ad5d;A 1 ,ui.,.he'' JP?. . * ( tj ..tl ?" .ya '? •k? a ,ik. SERVICES TOTAL $0.00 Costs Subtotal (no markup) $445.45 Labor Mark-up 15% $35.51 Material s/Equ ipment/Services Mark-up 15% $31.30 Submitted by: Accepted by: TOTAL AMOUNT DUE $512.27 ndent Date: aIO?t 0.5 ? LTM DAILY EXTRA WORK REPORT Date: ; Foreman: r Job Name: j--'?'- ? - Job No: c?2-a l- (/'?,&' EMPLOYEE NAME CRAFT RATE ST.- HOURS OT. HOURS DESCRIPTION OF WORK qtr E / / . T MATERIALS USED DESCRIPTION SUPPLIER QTY. U a ` ve, , br I MISCELLANEOUS (SUB, HAULERS, MOBS) I k CUSTOMER SIGNATURE COMPANY EQUIPMENT EQUIPMENT NO. HOURS RENTAL EQUIPMENT EQUIPMENT NO. HOURS K/Contracting/Jenn`s Reports, etc./Misc Forms/Daily Extra Work Report MEDFORD R FOUR W 3RD ST E T O MEDFORD, OR M O M 97501-2600 T LININGER TRU MIX INC LTM B T PO BOX 1145 S L O MEDFORD, OR 97501-0231 T 1 T L 00001066 6 1066 SUBJECT TO TERMS AND CONDITIONS ON REVERSE SIDE CUSTOMER PICKUP BR CUSTOMER NO. SHIPPING DATE SHIPPED VIA SHIPPING CUSTOMER PURCHASE-ORDER CUSTOMER JOB DESCRIPTION 021 15568 1/22/03 Pickup Prepaid HC230064 IJC QUANTITY ORDERER, `: QUANTITY SHIPPED BACK/: . ORDERED: ITENfiDEu CRIEfiIQN UNIT.PRICE U/M DISC': IOM1F EX-TEN 1 80 80 2X10 ABS-DWV PIPE .36920 FT 29.54 2 1 1 16OZ ABS CEMENT BLACK 30892 8.48000 EA 35 5.51 3 1 1 8 X 6 CIXCI FLEX CPLG 1056-86 33.64000 EA 30 23.55 4 1 1 6X4 92767 ABS-DWV FLUSH BUSHING 24.23000 EA 15 20.60 5 1 1 4X2 92758 ABS-DWV FLUSH BUSH 9.08000 EA 15 7.72 6 5 5 2 93002 ASS-DWV COUPLING .90000 EA 15 3.83 OTHER CHARGES SUB-TOTAL 00- 90.75 .00 OTHER CHARGES 110, TAX .00 1N? TOTAL DUE so.7s Past due accounts will be charged a SERVICE CHARGE at an ANNUAL PERCENTAGE RATE of 18% ORIGINAL INVOICE FNW MEDFORD ru rsuA wv5 INVOICE NUMBER .: PORTLAND, OR 97228 021-7527968 (541) 773-4323 PAY THIS AMOUNT INVOICE DATE PAGE- 90.75 1/26/03 1 FAM001 FAM00101ATP 0000100 1 00001773 NNW MEDFORD R FOUR W 3RD ST E T O MEDFORD, OR M O M 97501-2600 1 T FNW MEDFORD ORIGINAL INVOICE PO BOX 5005 PORTLAND, OR 97228 021-7549748 (541) 773-4323 PAY THISAMOUNT INVOICE DATE PAGE 43.30 1/26/03 1 SUBJECT TO TERMS AND CONDITIONS ON REVERSE SIDE Ilrlrrlrrrlrlrlrllrrrrrrllllrrrrrlrlrrllrirrllr?rrl6lrlrrrll6l LININGER TRU MIX INC LTM B ,T, PO BOX 1145 H L O MEDFORD, OR 97501-0231 T I T L 00001994 11 1094 CUSTOMER PICKUP BR CUSTOMER NO. SHIPPING DATE SHIPPED VIA SHIPPING CUSTOMER PURCHASE ORDER CUSTOMER JOB DESCRIPTION 021 15568 1/24/03 P i ckup Prepa i d uD [''.,QUANTITY- . = ORDERED . QUANTITY SNIPPED. `BACW OFiDEAEO' = CLEW DESCRIPTION . UNIT PRICE-. U/M DISC: EXTENSION .`: 1 1 1 2 92502 ABS-DWV 1/8 BEND 1.98000 EA 15 1.68 2 1 1 4X2 92758 ABS-DWV FLUSH BUSH 9.08000 EA 15 7.72 3 1 1 DFW 4 SDL WYE 42.38000 EA 20 33.90 OTHER CHARGES SUB-TOTAL , 43.30 .00 OTHER CHARGES 0- .00 TAX Pilo- 43..30 TOTAL DUE 10- Past due accounts will be charged a SERVICE CHARGE at an ANNUAL PEHUtN IAGt HAI t of 161/0 'K K'? FAM001 FAMO9101.NTP 00001894100003106 CITY OF ASHLAND DEPARTMENT OF PUBLIC WORKS CONTRACT CHANGE ORDER NO. 10 PROJECT: SISKIYOU BLVD/ OTIA LOCATION: SISKIYOU BLVD./ 3RD STREET DATE: APRIL 30, 2003 PROJECT NO.: 99-38 (Schedule A) CONTRACTOR: LTM INCORPORATED You are requested to perform the following described work upon receipt of an approved copy of this document or as described by the Engineer: Item No. Description Quantity Unit Price Amount co 10 Item A Remove and reinstall inlet at the Fire Station No. 1 Lump Sum $569.01 $569.01 Item B Storm Drain & Catch Basin Slurry at Sta 6+73 Lump Sum $456.00 $456.00 Original Contract $802,592.60 Total this Change Orders $1,025.01 Previous Change Orders $9,955.57 Revised Contract Total $813,573.18 The time provided for completion of this contract is increased by no calendar days. This document shall become an amendm t he contract and all provisions of the contract will app y. 'ed Recommended By: 11 Engineer Dat Approved By: - 5-/7/03 gi neer Date Accepted By: LTM Incorporated PO Box 1145 M ord OR 97501 , Contractor Date ENGINEERING Tel: 541-488-5347 20 E. Main Street Fax: 541-488-6006 ?. Ashland, Oregon 97520 TTY: 800-735-2900 www.ashland.or.us 11COMPAQ1IDATAIGOV1pub-wrkslengldept-admin\ENG INEERIPROJECT11999\99-38 Sch A CO 10.doc CITY OF ASHLAND A request for a Purchase Order REQUISTION FORM Date of Request: THIS IS A REQUEST FOR A: [ X ] Change Order (existing PO# 3611 Schedule A) Required Date of Delivery/Service ASAP. Vendor Name: LTM INCORPORATED Address: PO BOX 1145 City, State, Zip MEDFORD OR 97501 Phone: Project Title: SISKIYOU BOULEVARD RECONSTRUCTION Project Number: 99-38 Services Only Solicitation Process: (] Exempt I ] 3 Written Quotes (copies attached) [ ] Sole Source [ X ] Invitation to Bid (copies on file) [ ]Less than $5000 [ ] Request for Proposal (copies on file) Description Total Cost Siskiyou Blvd/ Ashland St Reconstruction Project $ 802,592.60 Original Contract Cost Change Orders 1 thru 9 $ 9,955.57 Change Order 10 - Itemized Below Item A - Remove & Reinstall inlet at Fire Station No. 1 $ 569.01 CO 10 Item A Item B - Storm Drain & Catch Basin Slurry Sta 6+73 $ 456.00 CO 10 Item B $ 813,573.18 REVISED CONTRACT Account Number 260.08.12.00.704200 Please attach the Original signed contract and Insurance Certificates. Employee Signature: Supervisor/ Dept. Head Signature: NOTE: By signing this requistiion 10 70 ce . tha the above request meets with Ctiy of Ashland Solicitiation Process requirement and can be provided when necessary. G:Pubwrks\Eng\99-38 CO 10 Sch A Requisition.xls Updated on: 7/15/02 : r LTM Incorporated Time and Materials Billing Summary Project Name: SISKIYOU BLVD. SCH. A orf - Description of work: Remove & Reinstall Inlet rrZe srgYi 01'! LABOR Job No.: 02271-16 Date: 04/16/2003 # `4. ir:,, ".. .... ,,.. , ,.... ? u, ?;t*?,?f ",'', d ?;' w 6 ';'?' :°.: •,? ;'. i„, .• r?i'?x?r i 'a'k'*' yCY.J'RStl ?w?l? ?" i. ..."° .. ,..:.p ... ° ' ,,, .; (fi v';H, . AY.. ?}.h?,yJ?Aa? '. a. :5' ".^" .' ti ,. do 4 ?L g, 04/16/03 Foreman Easter 3.00 32.94 $98.82 04/16/03 Operator Thoren 2.00 32.37 $64.74 04/16/03 Laborer Faye 3.00 27.74 $83.22 04/16/03 Laborer Luster 2.00 27.74 $55.48 04/16/03 Teamster Groom 2.00 24.59 $49.18 LABOR TOTAL $351.44 EQUIPMENT MATERIALS ? u MATERIAL TOTAL $0.00 SERVICES / MISC. " MI V T. SERVICES TOTAL $0.00 Costs Subtotal (no markup) $494.79 Labor Mark-up 15% $52.72 Materials/Equipment/Services Mark-up 15% $21.50 Submitted by: Accepted by: TOTAL AMOUNT DUE $569.01 tendent Date: TM DAILY EXTRA WORK REPORT Date:- /f'' 03 . : oreman : Job Name: Job No: 4;?p EMPLOYEE NAME CRAFT RATE ST. HOURS OT. HOURS DESCRIPTION OF WORK 69"BtNX r 3 - ?Le rcit A GUSlex Gf'?2 MATERIALS USED DESCRIPTION SUPPLIER QTY. I MISCELLANEOUS (SUB. HAULERS. MOBS) I CUSTOMER SIGNATURE COMPANY EQUIPMENT EQUIPMENT NO. HOURS //0401-3 Z- g RENTAL EQUIPMENT J EQUIPMENT NO. HOURS H:/Contracting/Jenn's Reports, etc./Misc Forms/Daily Extra Work Report TM Incorporated Time and Materials Billing Summary Project Name: SISKIYOU BLVD. SCH. A Job No.: Description of work: Storm Drain & Catch Basin, Slurry 6+73 Date: LABOR 02271-05 02/06/2003 02/07/2003 •?., ? xf :,; N:,s, ??., ?('!'?!', .iA f???N „`•"?'! P'..?? ^' ?. ? ryl Mt F .pi Tgk r'E ? P''•', ? " i aTKr ..w n,,'', t;`,*i'P 4)Y r^?';: k'DA,b •, ., ll'ylnM'uTIFV Y Lp?SS '.',^1,. , ,.. ye p, . w 'Nil1llE" .??., '.p• .,lfr,r 'OURS . :•d'.y ."YT AR ?l?R !r",,i E ,u ,T 4:.,'• .E:,{" ,. m.: •, M A{1,1•,;N .. ,?:Y'yTf , ° ` L'S?, n"7h': iS"?T',Tu •Ti S, 02/06/03 Foreman Easter 4.00 0.50 32.94 43.77 $153.65 02/06/03 Operator Marez 8.00 32.37 $258.96 02/06/03 Laborer Fa 8.00 27.74 $221.92 02/06/03 Teamster Johnson 4.25 24.59 $104.51 02/07/03 Foreman Easter 2.00 32.94 $65.88 02/07/03 O erator Marez 6.00 32.37 $194.22 02/07/03 Laborer Fa 5.00 27.74 $138.70 02/07/03 Laborer Farris 1.00 27.74 $27.74 t I I t - 1 LABOR TOTAL 1 $1,165.57 EQUIPMENT h ; 02/06/03 pickup 20078 4.50 $8.25 $37.13 02/06/03 JD 410E Backhoe 110083 8.00 $29.07 $232.56 02/06/03 LTM Transfer 31082 4.25 $47.94 $203.75 02/07/03 pickup 20078 2.00 $8.25 $16.50 02/07/03 JD 410E Backhoe 110083 5.00 $29.07 4 $145.35 1? EQUIP. TO TAL $635.28 MATERIALS , .,..a•' "A 11101 ?'a ;. J ?. IT , D! .,E LNI 'JE ..is? :41t 1 1. lC L` ,T 02/06/03 Slur 10 c $45.60 $456.00 MATERIAL TO UL $456.00 SERVICES / MISC. 4. ,4T.,rlI??hr:.yp r,,.,, F'S'Nr v ?': `?", R•:'""RS ., .. ATM :,?•? 7;y"1nGy ? Y !('„ ?' pw .S, r'i ,9RO y,F .., .. Y a •:, '..?, `?Ry:,?.` W I". 'W+SC* Y ,+;. ,?.,F?, '? ?a a.te1''t `•.rt,''Yn'.'d?'% i+ ,i??:, d'. a? '+ F'"',• a `rv.,%1" .t 4`?,. ESCRIP?TI© N,4., „{ ?"?a ;P..? N? ? ,? `.t w'? ' NQ:. S, '' ?? a+"F ey AMOI?NT# `,' ., , .a•r ?•,?.t' .a??:? !my,:, .?'&'?,•.'W WRT T SERVICES TOTAL $0.00 Costs Subtotal (no markup) $2,256.85 Labor Mark-up 15% $174.84 Materials/Equipment/Services Mark-up 15% $163.69 Submitted by: TOTAL AMOUNT DUE $2,595.38 (.cry, orb • ??d l M?a?a .,.Zs John Lotito, Jr - Construction Superintendent Accepted by: Date: ate: LTM DAILY EXTRA WORK REPORT Foreman:c ??'i I<i, t?C?.) Job Name: Job No: 0Z,2-- 71 CRAFT ST. OT. EMPLOYEE NAME RATE HOURS HOURS DESCRIPTION OF WORK cz?,- cop /f 100" C. ?,r9` z1- - ?.v-- ??r57?r R, e nw ,tea-et.A-v'&, vt-z l 5 A MATERIALS USED DESCRIPTION SUPPLIER QTY. a t MISCELLANEOUS (SUB, HAULERS. MOBS) cCUSTOMER SIGNATURE COMPANY EQUIPMENT EQUIPMENT NO. HOURS //oo "' 3 .J' _4 RENTAL EQUIPMENT EQUIPMENT NO. HOURS K/Contracting/Jenn's Reports, etc./Misc Forms/Daily Extra Work Report ate: L 1 IYI DAILY EXTRA WORK REPORT b -0 Foreman: - ;' Job Name: Job No: e2,2,71- 405' EMPLOYEE NAME CRAFT RATE ST. HOURS OT. HOURS DESCRIPTION OF WORK f Jf POP • Cry ! G+/ ulxx i" er i e A MATERIALS USED DESCRIPTION SUPPLIER QTY. I MISCELLANEOUS (SUB, HAULERS, MOBS) I CUSTOMER SIGNATURE COMPANY EQUIPMENT EQUIPMENT NO. HOURS 1/ 041 I' 3 Ze07 100 I Ds -*Z 72M F y. 2-5 RENTAL EQUIPMENT EQUIPMENT NO. HOURS l K/Contracting/Jenn's Reports, etc./Misc Forms/Daily Extra Work Report ri o CO CO 0 0 cw.$ N9N? ?I co t- ^ t a: j NhP- I O a: '71 Z T' r - o a w CO W w O F- c'v c ° - a . _ N ? 0 X ' - a Co .IC O C d O 0 +r - 4 ? 1 N ? U mmc: 2 VS . -Ca c c m E c 0 0 C-0 U U O Q 9) 0 C V ? Zo C. . .x N m n• E E m ev 8 a Cv oc) v? O i .? S?V7 -0 4S 1 ,0 W ' 0 ow C ?. O E 0 . L;6 om a c?? b s .. ?_ C W O W v m? Z N O Q ? C H o °'orn o? ` ? u-) fA °XSE o O N O = m J co U o t C Q X . -. O Ec ? pa 0 ' W m co m V ?,OZm ca m0 m .} f Um?mx X ?-. C a: W . ??RR V Z m(DCO 0Z ?to?m C = U dp !, i. 0 CL caEcc o ;A J` mNa?P, CO > r- M CD U 3 W 0 Z. D 0 N W vO L EcL0•° E 2 cd&cS 0 wm?0.. ? +. G m F- c aE f-uyi?V" E ca m Q ? o co ao E tmo?a Ga_ c_o N U W W mE W m a m 0 E E? Q? o 0 0 m coaa?.? w cis a m ?E m o o A2 ?arrN = U) C_ C 0 C) ' z„ ao O C U D ? m o O c N m a: a? m 0 O E c E co c = a m O co F- E U ;. c? O. O a 2 a c > z o . as ca ?m? c N z 0 . o E uu. a ¢ 0 - crn mom a >. ' cd ? a L D m via v t O . c U'RO > m r m ? w 0 E ,, o oft o rn t I tJ S 1a ' LL IX Q c w z? _. o ?L. 0 10 z t p' 1 p?.? e 0 ri rel 63 41. t . 0 dm 0 0W ts ? 2`0 D c a0 o a ? x 0 •.' 2 a LU LLI n 09- ai w U Cis 3 ° a .= LLJ 0 vi ce yea Q cC -'o aco o iNC OEW ?MNC ?? O W t W am m= 8 ? oQo 0i E L.. NIX p%wCD0 --?m V ? ?XF-Q?'vc?.Y U ..._ n ? E .= C? ri -i Sri Co L W s w 0 DU' 0 t M11 as z ~ z CO) w O z a Q ? b t; Cc t a - z ; Z U ;... s Q cc J U > U 5 ¢ - 0 J 0 W a. CITY OF ASHLAND 20 E MAIN ST. ASHLAND, OR 97520 (541 ) 488-5300 CITY RECORDER'S COPY DATE 09/17/2002 Page 1 /2 PO NUMBER 03611 VENDOR: 000100 LTM INC P O BOX 1145 MEDFORD, OR 97501 SHIP TO: Ashland Public Works (541) 488-5587 27-1/2 N MAIN STREET ASHLAND, OR 97520 FOB Point: Terms: Net 10th of Month Req. Del. Date: 09/09/2002 Special Inst: Req. No.: Dept.: PUBLIC WORKS Contact: Paula Brown Confirming? NO QuantitY unit Description unit Price Ext. price THIS IS A REVISED PURCHASE ORDER BLANKET PURCHASE ORDER Contract for the Siskiyou Blvd Redesi.qn 802,592.60 Proiect 99-38B. This requisition is applicable to Bid Schedules A, C, & D only, Bid Schedule B will require a separate requisition. Bid Schedule A - Bid Schedule C - 660,266.62 Bid Schedule D - 174,600.00 Bid Contract date: August 28, 2002 Start date: September 9, 2002 Completion date: March 2003 Insurance required/On file Revised purchase order 01-22-2003. 18,000.00 Chan.qe Order No. 1, CTB Excavation & Haul Away Revised purchase order 01-22-2003, 13,964.08 Change Order No. 2, Multiple Proiects, See attached list. Revised purchase order 02-11-2003 960.00- Schedule C 1 Change Order No. 3 - Si.qn Post Credit Change Order No. 4 - Bi-Directional 970.10I Markers SUBTOTAL BILL TO: TAX FREIGHT TOTAL Account Number Amount Account Number Amount E 260.08.12.00.704200 1,680,783.42 Authorized Signature VENDOR COPY Page 2 / 2 CITY OF ASHLAND 20 E MAIN ST. ASHLAND, OR 97520 (541) 488-5300 VENDOR: 000100 LTM INC P O BOX 1145 MEDFORD, OR 97501 FOB Point: Terms: Net 10th of Month Req. Del. Date: 09/09/2002 Special Inst: DATE PO NUMBER 09/17/2002 03611 SHIP TO: Ashland Public Works (541) 488-5587 27-1/2 N MAIN STREET ASHLAND, OR 97520 Req. No.: Dept.: PUBLIC WORKS Contact: Paula Brown Confirming? No Quanta Unit Description Unit Price Ext. Price Change Order No. 5 1,457.69- (A) Bid Item 37 Arrows Marking (B) Bid Item 38 Bicycle Lane Stencil (C) Bid Item 39 Line Markings Change Order No. 6 - Joint Seal Bridge 1,471.13 Revised purchase order 04/08/2003 9,955.57 Schedule A Change orders No. 1 to 9 Please see attached for descriptions of change orders 1 through 9. Revised purchase order 05/13/2003 1,023.01 Schedule A Change Order No. 10, Items A & B Revised purchase order 05/13/2003 358.00 Schedule D Change Order No. 1 SUBTOTAL 1,680,783.42 BILL TO: Account Payable TAX 0.00 20 EAST MAIN ST FREIGHT 0.00 541-552-2010 TOTAL 1,680,783.42 ASHLAND, OR 97520 Account Number Amount Account Number Amount S/ 3 0? P&Korized Signature VENDOR COPY