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2094 Quartz Lane - Reimbursement FormsC!ty of aafl cpiA uncucr INFLOW & INFILTRATION REIMBURSEMENT PROGRAM Make Check Payable to: EAt■ KE s 'Z- tE (Property owner(s) name) And (if applicable) Property Address: Z' - Q Pt r- ... Total Costs incurred by Property Owner: $ (4 5 �-- Iotal Eligible Costs as determined by Staff: $ 56, Total Amount of Reimbursement to be issued (check one) 50% of eligible costs $ I - 7S, i 100% of eligible costs- Only if assessed (100% option MUSI have signed Assessment Waiver Form attached) Account Code: #6245 - 6440 CHECK ALL ATTACHMENTS THAT APPLY Property owner's original receipts (must be on 8'/ x 11 paper) X Copy of Certificate of Compliance (Contractor /Company name) ) Private Contractor's Original Quote and Final Invoice Contractor's Lien Waiver (in lieu of being named as a co -payee on City check) ( "Taxpayer Identification Number and Certification (IRS Form W -9) (Required if reimbursement amount exceeds $600) (Z) Waiver of Special Assessment Hearing Form (Note: Claim must exceed $200) I declare that this claim is just and in accordance with the City Council's Inflow & Infiltration (I & I) Reimbursement Policy and that no part of it has been paid A rthorized City Staff Printed Name /Sign- re Date /6/ bc) Form date 09- 01 -10, REV. 9- 27-10 LS s 2% GARD RE.Q A TE MENARDS BURNSVIL.L.E 2700 Hwy 13 West rnev 1 J1 MN 5533 t1 1 11 111 11 1I1 111 Merchandise Return INV NO 090457 Original Stofe : 3021 Original-Register; 03 0riginal Trans # : 2163 Original Date ; oeNt o 24" CHANNEL GRATE - .6899558 5 @12 57 CHANNEL 5889529 311 & 4" CHANNEL END 6389532 3 @2.87 4" 90DEO SEWER ELBOW 6894647 4" - 90DEG SEWER ELBOW 6894647 ' 6894647 't4 4" 900E0 SEWER ELBM _ - 10 CHANNEL. DRAIN - 6899574 TOTAL TAX AT 7 1 TOTAL SALE SANK 9407 cv-m-4 _ . 14/2" 45DEG PVC ELBOW C4806 2 6692322 200.73 2,34 3 X 4 SEWER DRAIN ADAPTER 9 C4800-SD 689.3237 103..96 47,81 PREPLUMB SUMPPITW/PUMP 129,57 3985C 9,23 138,80 6893685 10199 99 128,80 e 4 . €Q4,4,-Ert,,ostr2777 ---------------------------------- Customer 3fgaature 62:85 Menards has released this transaction tp pqr firmolal inatitution. Your financial institution is responsible for prpoo5pine thia refund to your account, Please contact your finanoie institution for fund avallability vno vil?0 r 1114,in Trl..rt ,r • 11! 1111 Mr. Dean P. McKe ragan M'aNitz551-72" 2_2037e 4 BURNSVILLE 2700 HWY 13 WEST BURNSVILLE, MN 55337-6023 1111111 Return Receipt This is not an original cash register receipt Not valid for rebate submissions Allowable returns for items on this receipt will be in the form of an in store credit voucher if the retum Is done after 12/12/2010 1-1/4" PVC COUPLING C429-012 6891860 100 53 53 1441mikilakiniiiiiiii4~01°@REW troilifidiiii46.14 ---- •1-1/4" 90DEG PVC ELBOW C406-012 6891873 200 64 1 28 1•1/4' PVC MALE ADAPTER C436-312 6891899 2eo 38 . 2,88 4" PVC COUPLING C.4801 6892034 1@1 88 4" 90DEG STREET SWR ELBOW M41POST 6894715 1@3 49 1-1/4" PVC UNION LAIU-12 6895549 104 53 1111111 111111111 76 1 88 1 46 3 96 199 99 —two, cr.4) c l/ 49 4' SEWER COUPLING M4!' 6894702 1C.P1 14 1.14 349 1-112X1-1/4 REDUC BUSHING C439- 212 M X F 6897482 1t24 7x PIA li RtigHT 44 c). 251 M X F 6697495 101.69 CHANNEL END CAP #247G 6899516 102.88 4=1:::=E @6.11.4grelOTRORi 44iiidgien— i&lihriii$32PrkagIRI CHANNEL BOTTOM OUTLET #2351 6899545 1014 97 14 97 1 oR4i3* 1-1/4' X 10' PVC PIPE ASTM D1785/2665 6899972 1@2 83 1-1/4" RUBBER CHECK VALVE #2460 6911559 1@7 49 80Z PURPLE PRIMER/CLEANER 30756 6931157 1©344 8 OZ REG CLEAR PVC CEMENT #31013 6931173 102 98 Payment Method(s) Used: \Asa - NIX " fif) or 1:24 1 69 2 88 4 143,44e- 001e 2 83 7 49 3:44 2 98 413.62 13Vi 4 5 50-5 4605 03 2163 39/13/10 4:39 PM 3321 4 53 Mom salting. Mom cloitis) 3220 DENMARK AVENUE EAGAN MN 55121 (651)452- -2322 2813 00088 64100 09/22/10 07 ;27 PM CASHIER EDDIE -- EJP5822 45$44489 C allU/ 050169001929 4S0BX1 /2 +3/4 <A> 0.93 1?4 30 f LATE i, ,_A# 012871559334 FITTING <A> 0 13 012871626654 1 -1/2 BUSHNG <A> 0.95 611942109456 11 /2X2PV0PIP 4A- 2.55 611942112760 4X2 PVC PIPE <A> 5.97 012871623790 PVC ELBOW <A> 1 58 012871624599 1 -1/4 ELBOW <A> 280,98 1 9 012871628108 PVC BUSHING <A} 012871626074 1 -1/4 ADAPTR <A- 0.90 78179740423 SCREWS 'A> 0.98 611942117048 1 34. 4 FILVSgrn 182893 - 11 /2)iCLGANPL 'A> 2.13 SUBTOTAL SALES TAX TOTAL XXXXXXXXXXXX2407 VISA AUTt1 CODE 825031/5881956 NEW LOWER F (NLf' >sAviNI $ � II i 1 hih 281:. 38 G4100 09/22/2010 8936 RETURN POL L f DEFINITIONS POLICY TO DAYS POLICY EXPIRES ON A 1 91 12/21/2010 THE HOME 11i 01 Rl ..f ; . 11 - ft - : HIGHT TO LIMIT ri[NY RETURNS. I LFA FT- 11(E RETUR. POLICY ' Li N IN ,T 'r = 108 D TATI f;!.)AHAFNEE) L01. PRICE� LE)OK FOR HL DPEOS OF LOWER PRICES STORC IDE X***W * *Y[ * *]r :r * *A*&AXXX XA' ***r •,t% 15,1 6. 33 . 135.47 9.65 $145 12 145 12 3220 DENMARK AVENUE EAGAN. MN 55121 (611)152 - 2323 2813 00088 86327 10/01/10 02 ;41 CASHIER DEBRA DBE9YU 754826203458 OWV PIPE <A> 032888646384 PVC UNION <A> 012871558771 FITTING -A> 300.84 012871559365 FITTING <A> 012871559280 FITTING <A> 012871558740 FITTING =A> 012871559341 FITTING <A> SUBTOTAL SALES TAX TOTAL. XXXXXXXXXXXX2407 VISA RUTH CODE 468786/6884757 SUBTOTAL 38.55 SALES TAX 2..75 XXXXXXX2407 TOT $41 30 CODE 401129/8013786 41 30 2813 8 11 1111111111111111111111111111111111-11P RET RN POLICY DEFINITIONS POLICY ID DAYS A 1 90 tHF HOME DEPOT RE.SEPVES THE NNHT TO 1 T Mi T / DENY RE i URNS . PLEASE SEE THE L:TIIRN POLICY STO IN STORES FOR DEW 6UARANI ELL; LOOK FIR Hi LOWER Pf 1 •E`, 1 1� 3 More saving. Mote doing 7b PM 2 52 1 92 0.90 11.99 0 19 30 94 2 20 $33.11 33 14 TA More ai MOM i 3220 DENMARK AVENUE a E'A9AN, MN 55121 (651)452 -2325 l3 00001 35939 10/19/10 02 ;17 iHIER LORI - LAC293 A ,74 8 71626098 1 -1/2 ADAPTR <A> 8 8 71552151 FITTING <A> 671626654 1 -1/2 BUSHNG <A> ?80.95 37 1627477 PVC BUSHING <A= ` 19 IN PLUG <>> 71559273 FITTING <A> I ft EL I 470 0.1 2 1e 1.4 Wifir 0 813 01 35939 10/19/2010 7720 - ICYUID POLICY DE POLICY O EXPIRES ON 1 90 0 1/17/2011 OME DEPOT RESERVES THE RIGHT TO / DENY RETURNS. PLEASE SEE THE .1RN POLICY SIGN IN STORES FOR DETAILS GUARANTEED LOW PRICES LONER PRICESNSSTOREVIDE MOM Salting. M ore doing 3220 DENMARK AVENUE EAGAN. MN 55121 (551)452 -2323 2813 00002 81931 10/12/10 03:48 PM CASHIER JOSHUA - .JPS5477 039645110183 6@3.54 039645110263 045242223046 012871559488 045242225774 045325140444 0343752212293 076308002626 30L.B CONCRET <A> 604 MORTAR <A> HOLE$AW <A> FITTING <A> 3/8 ARBOR <A> 1 /4)(13MSNDBT =A> THREAD SEAL <A B€ NDO <A> SUBTOTAL SALES TAX TOTAL. XXXXXXXXXXXX2407 VISA AUTH CODE 053179/5025513 ailRVld! 1IIflI RETURN POLICY DEFINITIONS POLICY ID DAYS POLICY EXPIRES ON. A j 90 01/10/2011 THE HOME DEPOT RESERVES THE RIGHT 1 LIMIT / DENY RETURNS PLEASE SEE THE RETURN POLICOESIGNSIN STORES FOR GUARANTEED LOW PRICES LOOK FOk HUNDREDS OF LOWER PRICES STOREWIDE 6) -77 21 24 3 77 10.97 1 18 14 , 97' 7.97 1.94 9. 97 72.01 5.13 $ 77,T Fi 17070 Kenrick Ave Lakeville, MN 55041 (952) 435 -3832 ******* * * * *i: * * * * * *** * * * * * * * * * * * * * *r** Your Cashier Today is Ryan T PIPE FITTING 1 33 T 3 PIPE FITTING 2 53 T 2 9 1 25 3856170 715 PIPE FITTING 0 53 I 2 9 0 25 3856170/15 UNION 10 29 T 3856137220 2 QW1 K CAP 3 13 T 185 7800319 COUPLING 3 83 I 1857800 SUBTOTAL 21 76 TAX 1 55 ** ** BALANCE 23 31 Acct Number: * * * * * * * * * ** *2107 Visa $23.31 Purchase APPROVED 055146 V i s a 23 31 CHANGE 0.00 TOTAL NUMBER OF ITEMS SOLD = 8 10/12/10 05 28pm 2500 7 206 124 Thank You for Shoppins With Milts Fleet Farm When you prcvide a check as waylent, you authorize us to use information from your check to make a one-time electronic fund transfer from y:aur account Mil II 111 * * * * * * * * * * ** * * ** * ** * * * * * * * * * * * * * * * * ** Valid for returns until 12/11/13 * * * * * * * * ** * * * * * * * * * * * *x** * * ** :s * **- *** 11 M ore Salting. More doing; ' 3220 DENMARK AVENUE AGAN, MN 55121 (651)452 -2323 3 00001 00479 09/28/10 08 :49 PM TIER ELISE - EMG6749 343025417 25' POLY <A> 169005603 1 °7 /8''HDY BX <A> 0.73 313072190 1 /4X1 /8BPBSH 44> '.®1.41 2 82 '.58463003 0W ELBOW <A> 2.9$ 43071995 1 /8BRPIPETEE <A> 3.50 69007525 4 "SOBXCVFLBL <A> 0.57 43072039 1 /8BRPPSTELB <A> @2 65 SUBTOTAL SALES TAX TOTAL. CASH 2 82 5..30 18 72 1.33 $20 05 20 05 11 T1111111 I 1111 2813 01 00479 €39/28/2010 1345 RETURN POLICY DEFINITIONS 'OL.ICY ID DAYS POLICY EXPIRES ON 1 90 12127/2010 ' HOME DEPOT RESERVES THE RIGHT TO LIT / DENY RETURNS PLEASE SEE THE ETURN POLICY SIGN IN STORES FOR DETAILS GUARANTEED LOW PRICES LOOK FOR HUNDREDS OF LOWER PRICES STOREWIDE