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EVERETT <br />WASHINGTON <br />City of Everett <br />Construction Management <br />Affidavit of Amounts Paid DBE Participants <br />Contractor: <br />American Process Group LLC <br />Address: <br />1201 Pacific Ave , Suite 600 <br />Project Title: <br />2022 Biosolids Removal and Disposal <br />City: <br />Tacoma <br />Federal Aid Project Number (if Federally Funded) <br />Contract Bid Price: <br />$ 1,463,366.86 <br />Date: <br />April 25, 2023 <br />State: <br />WA <br />Zip Code: <br />98402 <br />Project Work Order 4: <br />UT 3752-30 <br />DBE Participant <br />Name and Address <br />None <br />• <br />DBE Condition of Award. <br />$ 0.00 <br />Ethnic <br />Code <br />Contract <br />Type <br />Ethnic Code: <br />B = Black <br />H = Hispanic <br />A = Asian American <br />Bid Item <br />No.(s) <br />I = American Indian and <br />Alaskan Native <br />0 = Other <br />Contract Type: <br />S = Subcontractor <br />M = Material Supplier <br />JV = Joint Venture <br />Amount Paid Participants <br />(Including retainage held) <br />Total DBE Participation Achieved <br />$ 0.00 <br />Affidavit <br />I, the undersigned, do hereby certify that in connection with all work on the project for which this <br />each DBE participant contracted by me has beenpaid the� statement is submitted, <br />amounts shown for bid items, or portions thereof, listed. <br />Notary <br />Seal <br />Signature <br />Title General Manager <br />,Doug Van der Veen <br />Subscribed and sworn before me this: 7 day of 442(2q, &cfl <br />)uSTyia pietAY2?) <br />residing at <br />Province of Alberta, Canada <br />Notary Public in and for the State-oLWa isgtes- <br />spriger 6-fe «�.. fit, fsea -rer , CAN ra..o frit <br />JUSTIN DANZO <br />Barrister & Solicitor <br />A Commissioner for Oaths and Notary Public <br />In and for the Province of Alberta <br />My Commission Expires at His Majesty's Pleasure <br />THIS FORM IS REQUIRED WITH THE FINAL ESTIMATE <br />FROM THE PRIME CONTRACTOR ON ALL PROJECTS <br />