TEMPORARY RIGHT OF WAY AGREEMENT Galbreath, Crystal (Externial),
From: Galbreath, Crystal (External)
Sent: 'Tuesday, September 01, 2015 10:29 AM
To: chades.laneCa)mydearwater.corn
Subject: CSX File 799680
Good Morning,
I am oveirnig,hting the partially executed agreement to your attention for signature. Once the agreement is signed by
both parties,, I will provide the Outside Party request form so that the field personneel':can be notified.
Once the agreement is signed,you may email me a copy so that.we can expedite the form being submitted,
Thank you,
r-4-
y,0�24 aaz�we�
Oasis,On Site for CSX Real Property,Inc.
61737 Southpoint Drive South I J-18�O I Jacksonville,FL 32216
Office:(904)279-3883 1 Fax: ('9014)245-2937
Email:CrystaI Galbreath@_!;S3,colm
RS - FORM ROE�
RFNISH)APRIL, 3, 2008
A(.3RI`A`,N*'IN I'No US X799080
CSX TRANS PO RTATION, INC.
TEMPORARY RUG I IT OF NTRY AGREEMENT
THIS AGRE'EMENT. made and effi-_ctive ALIgLIA210. 2015, by and between CSX
TRANSPORTATION. IN,C',,, ,i Virginin corporation. whose madint, address is 5010 Water Street.
Jacksonville. Florida 32202. hereinaller callied TSXT." and CITY OFUL'ARWATER. a
municipal corporation, political SUbdivision or state agency, under the laws of the State of
Florida. whose mailing address is Po Box 4748, Clearwatm Florida 33758., hereinafter called
'Ticensee." WITNESSI-I"I'l 1:
WI-11FREAS, Licensee has submitteda xvi-Itten request/application to CSXT requesting
permission to enter CSXT's property located at or near Clearwater, Pinellas County. Florida.
.Jacksonville Division, Clearwater Subdivision. Milepost Sir"-8'74.41 hereinafter called
("["rope rty.") for the purpose of'performing a survey ofproperty boundaries fear' proposed
acquisition. as shown oil F"xhibit "A". attached heretoand made as part hereol (the "Pro,ject"), and,
"HEIR CSXT is willing to grant to I,icensec the hrrilted right and permission to
enter LIP011 the Property for tile limited purpose ol'perlorming the Project.
NOW TH FREF"OR L CSXThereby g
1 -1 grants to l,icensee the right and permission to enter
U[3011 UIC PPOI)CIly RH' the j)UI'j,)0S'C 01'p)CFI`Cffillim, said Project. subject to tile ternis and conditions
set J`orth below:
1. 'PROJECT: The PrQject shall be performed at the entire cost and, expense ofl,icerisee,
in accordarice with good and SOLInd oigincering practices, to the satisf,"Ictioll of CSXT,s Division
Engineer or his or her dUlly aUtliorized representative ("Division Engineer") and, in as manner to
avoid acciden(s, darriag", minccessary delays to or interference, with train 11-affic orCSXT. Prior
to entry, Licensee shall notify the Division Engineer's representative and arrange Im- flagging
protection in accordance Nvith Sections 5 and 7 ofthis Agreement. Licensee shall not dig in the
ballast line or within tile tracks loading influence area, or otherwise diStUrb the track structure.
Licensee and L,icensec's cniployees. agents. comractors and other representatives(collectively,
"Agents") shall maintain in their posscssion as Lopy ofthis A-reemcni al all times during thVil
OCCU Pat I Oil 0 f tile Property.
2. INDEMNITY:
2.1 JJCC]lSeC IICI-eby aSSUIlICS ride Ol'and agrees. to the fullest extent pertnitted by
State law (Constitutional or Statutory. as amended). to indemnify. defend, protect and save
CSXT and CSX"I"s Affiliates harmless with respect to ariyand all attorneys' fees, liabillity.
claims, demands. payments. writs. actions. recoveries. penalties, costs. legal expenses,
judgymcnts. willemeniq- and dlirnages of every nalure, degree. and kind (i]ICIUding direct. indirect.
cOnseqUelltial. incidental. and punitive darnages) Cor:
I personal injury. in&idin-. bLA not limited to bodily I111Ury to or d
cath
ofany person oi-persons whomsoever. including the agents. servarits. At'id iates or employees of
l Z�,
tile parties:
Ifloc 1 4ry1 7 ("1
C'
is- F(AW ROE I
REVISED APRIL 3, 2008
AGRELMENTNO. CSX799680
2.l.2 the loss or damage to any property whatsoever, i Ile ILid ing property
owned or in the care, custody or control ofthe parties hereto or their respective A IMiates:
2,1._3 any envirortmental damage and amr related remediation broUght or
recovered against CSXT or any ol'its Affiliates; laid
2.1 A any and all other losses or darriages:
L_ I
arising directly or indirectly froni the presence of Licensee or its Agents on or about the
Property, whether or not attribUtable in whole or part to the negligence or gross negligence of
CISM"or its Affiliates.
2.2 The rmi-tics waive any and all right or oppOrtUility tea contest the enforceability
of this Section and agree that, in the event this Secflon. or any pgjft ()fthis '�ectiojj, is found
unenforceable by the final, UilappealablejUdgment 0FA COL-Ift ()f'coiTil)eteiit.jui-isdictioll. this
Section shall be construed so as to be enforceable to the maxinlum extent permitted by
applicable law. In the event, that miCh COUrt ()I'�coiiipeteiit.itii•isdicti(,,jii finds that Florida statutory
construction contract indemnity monetary limits apply to this Agreement with respect to
Ucensee's inderi'mil1cation oI'(.'SXT and its AI'l-iliates, For liability caused in whole or in part by
any act, omission or default by CSXT or its Afflihates, the pat-ties hereto agree that SUCII 11111it
shall be equal 10 the JiMItS (CXCILISiVe oI'dcdUCtihlCS) ofthe applicable insurance required by
scctic ras 3 and 4 oi'this Agreement. The parties acknowled
115 _gc and agree than (his 11-ioncLary halit.
Ifl-eqUired, bears as commercially reasonable relationship tea this Agreement. in so i'ar as, amoll,,
offier t,actors, the parties have taken into account the availability all(] cost o C insurance and other
risk trunsFerence devices, the scope ol'the Pro'cet, the risks as'sociated vvifli the Project. and the
compensation and any other benefits exchanged between the parties in connection with this
Agreement, Notwithstanding anything contained In this A�;reemerit, the limitations of t� Z7 1
contained in the state statutes, as amended Frorn time to tirne, shall not linlit SXT's, ability to
collect under the insurance policies reqUired to be maintained under this Agreement.
2,11 Licensee steal I comply with any federal, state, or local IaWS. SWtUtCS.
codes, ordinances. rules, and reguWlons applicable to its presence or per'f'ormance of ally activity
on the Property and agrees, to the fullest extent permitted by State lave (C011StitUtional or
StaftltOrV. as amended). to indera ni(y. d0end, and hold CSXT and its Afl-Oiates, harmless Nxidl
respect to any fines. penalties, liabilities, or other conscqUeIlCeS Ibr its failure to so comply.
For the put•pose oi'this Agreement, the tense "Affiliates" includes all
entities. directly or indirectly owned or controlled by. car Under cornmon control ofa party or its
respective offlicers. directors. employees and agents, and in the CaaSV 01'C'SXT, hlClUdc,"', C.'1SX
Corporation. CSXT and their Affiliates and their respective of'flicers, directors. employees and
m4ctlts.
2.2.3) The provisions oi'this Section shal I survive the tern,iinatioll or
expiration of'this A-reement,
Pagc .2 o17
PS - FORNI ROFA
REVISED APRIL 3.,2008
AGREENIF'NT NO,CSX799080
3,. GENERAL LIABILITY INSURANCE:
3.1 Licensee shall procure and niairitain. at its experise: (i) statutory Worker's
Compens-ation and Employcrs Liability hism-mce with available Hillits ot'not less than 0NE
MR-LION ANI 00/100 U.S, DOLIARS (S1,000,000,0(I), which insurance must contain a
W,RiVer Of'SLibrogation against CSXTand its Affiliates. ifpermitted by state law. (d) Commerckal
General Liab0ity covcragu (il1C1LJSiVC Of c()JlVaCtLlai liability) with available iiiiiiits of'not less
than F1VF MILLION AND 00/100 U.S. DOLLARS ($5,000.00(,00) in combined single hillits
for bodily inJL111-y and property damage and covering the COTIV.1clUid liabilities aSSURled Under this
Agreenictit; (iii) business autornobile liability ilISUrailCe with ::avail able: linihs of not less, than
ONF` MILLION AND 00/100 U.S. DOLLARS ($1,000.000M)combined single limit for bodily
ittiffy and/or property damage per•OCCUrrence, and (iv) such other MSM-ance as CSXTmay
reasonably, require. Upon reqUest, Licensee shall providt CSXTivith ,u copy ofl,i Ceti see's
applicable hISUrance policies. A policy endorsement narning CSXT, and/or itsdesigrice, as all
additional HISUred and specifyimy, such coverage shall be furnished to CSXT prior to tile
execution of this Agreement. and the required coverage %vill be kept in fOl-Ce Ll;ltil all of'
Licensee's obligations under this Agreement have be<m fully discharged and fulfiile(L Or Lintill
Licensee shall have been specifically rcleased by it VViAttC11 ffiStRIBICIA Sig raced by Z111 aLlth0riZCd
ofl-wer of("SXT. Liccrisec shall 'also provide CSXT with as copy of tile insurance Policies. The
insurance policies shall provide that the insurancc carrier 171LIS,1 give CISXT 110tiCe tit least thirty
(30) days in advancc ofcanccllatiori of coverage-, of any chan-e in coverage, or ol'cancellation of
tile Policy. Notwithstanding any provisions ofthis Section, the liability assunied by Licensee
shall not be limited to the required insurance coverage,
-ovis'ons cad'Section 3.1, IJC�el-ISCC. PUI-SUant to SWc
Notwithstanding the pi I
acted liability arising
Slatute(s). IM'ly SCI f-irISM-C or sel fasSU111C, in arly arriOLIM(S), any coriW
under this ALircement. under as Imided prognam ol'Self'-HISUrance. which fund will respond to
liability of Licensee imposed by arid in accordance with the procedures established by Law.
4. RAILROAD PROTECTIVE LIABILITY INSURANCE:
I n the cvcnt Licenscc finds it necessary to perform surveying, consLi'LictiOn or demolition
operations withirt fitly I'M (5(l') of'any operated railroad track(s)or affecting any railroad bridge.
trestle, turincl. track(s). roadbed, overpass car- underpass. Licensee shall: (a) notify CSXT; and (b)
proCUrC and maintain &I-ill" the period ofconstruction or demolition operatiolls, at no cost to
CSX'F. Railroad Protective Liability (R PL) insurance, naming CSXT. and/or its designee, as
Named ITISLII•Cd. vvritten oil the current ISOMMA Form (IS0 Form No. C(3 00 35 01 96) with
limits of FIVP' M HLION AND 00/100 11.5'�, 1X)1,l,ARS ($5MO.000.00) per occurrence for
bodfly injury and property damage, with at [east TEIN MILJJON AND 00/100 U.S, [)OLLARS
($10,000.000.00,)aggregate himit per amival policy period, with Pollution FXCILISion Amendment
(ISO} (-,'G 28 3I 11 85) if an older IS0 Form CG 00 35 is used. The ori-inal Of'SLICII RPI., policy
shal I be sent to and approved by CSXT prior to cornmericcment ofsoc h SUI•Vey. construction or
derilolitioll, CSXT reserves the jjgJjt to Jjj�lljej fill1itS.
PS- FORM ROF1
REMSED APRIL,3), 2008
AGRFEME'NT NO.CS X799680
At C'SK17's option. In 1ICU OfpUrchasing RPL Insurance from an insurance company (but
I10t, CGI, ir)SUrance), Licensee may pay CSXT, at CSX'FS CLU'rent rate at tia-ic of'request. the cost
ofaddirig, ally SUrveying, Construction or demolition activities,to CSXT's blanket Rai lroad
Protective Liability (RPL) Policy for the period of actual SUrveying. construction o,clera,ao itiora
activities. This coverage is o(Tered at CSXT's discretion and ri'i,ay not be available Under aH
c ircurnstames.
-5. PRIOR NOTIFICATION. Licensee or Licensee's Agents shall notify CSXT at
feast 10 days prior to requiring entry on the Property and shall abide by tile ilistrLIC0011S OfAIC
Division l'Ingineer, or his or her authorized representative. Licensee :shall complete and SUbIllit
CSX-FS 0L1t-SidC Party NUMbff RieclLICSt Form (Form 4 OP) by fiacsimile, to facsimile numbers:
(904) 245-3692. Liccrisec may also scan and emai I as completed form to email address:
OP-ReqLICst(�'�csx.com. A blank 11orm. as well as additional instructions and infori-nation, can be
obtaincd Irom CSXT's web site, via web link:
h le/('Ustomcrs�Non
I't•eiglit,-Scrvices/Pt,c)pct.-ty_ Real ["St',Ite/OLItSide.,_l)ai-ty_NLti,nbet,', 'RCClLIeS1__Form.pd1'
6. CLEARANCES: Neither Licensee nor Agents shall perl'orni any Project or place or
operate any equip ment. cat`licensee or Agents at a distance closer Ulan fifty (50) feet from tile
center ot'any track without the prior approval ofthe Division Ftigineer. The Division [-`ngincer
array reqUire protective services Or such other services as decilled u1eCC&SZlI'Y 01'appropriate.
["quipment shall be nloved across CSXT's track(s) only at as pLihfiC CrOSSillt UrIleSS prior
urram, n
,C11:1ula" havc bml Illudc With, (hu Divi�'iosl und a Private Ciussim, AurcciticnL is
Z' L
Fully executed and in place. Licensee and Agents shall take all precaLltiC)IIS necessary to avoid
iritcrference with or damage to CSXT's property and signal and C0111111111lication CacifitieS durill
their performance oNhe Project.
7. PRO TEC11 11VE 8 ERVICES- I I'prowctive services, sucli as 11agging protectiM, at'k:
-1 -1 the Division Emdneer to furnish SLICh
roqUired fey CSXT. Licensee shall niake �arraiigements with - C�
Personnel. flagman or watchman, that In the Division Fngineer's opillion may be necessary to
protect flic facilities and traffic of C SXT dUrill'y the perforniance ofthc Project.ect. Licensee shall
cln I
pay IM t11C COSt 0TSUCh SCIVICCS. including all applicable SLArcharges and additives,
8. PAYMENT FOR PROTECTIVE SEIMCEX Payment sh.aH Lac made by l.icensee
in accordance with the 116flowint
I L4 designated option:
Option 1; Licensee shall make ail advance deposit of funds bascd on all C'stimate,ol,
the cost of'proiective or other services as determined by C" XT.. The cost For C,SXT's services
shall then be assessed by CSXT against this advance deposit, Upon completion of'the Project.
any unused funding will be returned to Licensee. 1CCSYl-'s costs exceed the advance dep osit(,';).
a reqLWSt will be made to I.Acensee for additional l'unds or an invoice will be iSSUCd to [.JCCIISCe
For final payment. lJcensce shall remit payment to CSXT within thirty (30) days of'reccipt of
cilliern reque"I for addilional finuk" or nn invoice
Page ,4 kfl'7 o
PS - FORM ROF-I
REVISED APRI1. 33, 2008
MiKI-IHNIH-A I No .('SX799680
X ) Option 2: Licensee shall promptly reirnburse CS XT For the cost of'protective ()I-
other services on an &,.,-incurred basis., including all applicable surcharges. upon reccipt of bill(s)
therefore.
9. ENVIRONMENTAL: This Agreement dnv� not include and expressly excludes
the 1wrformance of any site investigation activities designed to determine environmental
conditions on,abolut or beneath the Property. Pred tided activities i IIC lUde performingswi I
borings fear purposes other than geotechnical Investigation. obtaining soil, sediment, grOLIndwater
and surface vvater samples. and conducting field or laboratory analyses ofany soil. sediment,
ground",mer 01 SUITaCC watcr samples obtained fi-oin C.SXT property tca identil'y chunical
composition or envirormmental condition. If`any type of envirom-nental investigation is desired. as
separate right of entry agreement iSSLIOCI through C'SM",; F'nvironniental Departmellt II1LIst be
SCCUred.
10. CLAIMS: Licensee shall. or shall require Agents. to promptly notify the Division
1-1,1gineer ofany �oqs, damn irjnry nr death arising out ofor in connection with the Pro
Z-1 ge, I ject.
It. REMEDIATION: ft [S U[ICICI'StOod and agreed that, LIPOII C0111pleti0t) Of the PrOj✓Ct,
the Property shall be left in a condition satiskaclory to Division l"ngincer or his or her duly
authorized representative.
12. SAFETY:
12.1 All personnel entering the property MUSt comply with C'SM'sat'ety rules, and
rQcC[Uirements (0 illClUdC, wifliout exception, the wearing ofhard hats and approved safety shoes
and satbty glasses with side shields. Anyone not in cornpliance with these RkS aancl Ngtflations
will be asked to leave the Property,
12,2 Before performing am work aLItl1OHZCd by tNS Agrecinc cc c its
Y 11see. 'It i
sole cost and expense. shall obtain all necessary permit(s) Oncluding bUt not limited to z-oninl.
bUilding. construction, health, saFety or environmental matters), letter(s) cor certificatc(s) of'
approval'. Liccilsce expressly ugl-CCS and VVWTUOS that it shall coiflOrm and limit its activities to
the terms Olr'SUCh permit(s), approval(s) and aLIthOrIZati0I'1(S). and shall comply with all
applicable ordinances, I'Liles. regulations. re1LjLIirCI1ICIItS '111d laws of any goverriftlelltal aUthority
(state. l'ederal or local) having jUrisdiction ovcr Licensee',; activitics, including the location.
contact, excavation and protection regulations o,f the Occupational, Saf'ety and I lealth Act
(OSI IA) (29 CFR 1926,65 1(h), et al.). and State "One Call" -"Call BO"ON YOU Dig"
requirements,
13. TERM: This Right of-Entry Agreement and the pernIission conf"erred and the license
aranted by it does not constitute as tyrant ofpermanent e,,,isement and shall terminate upon
completion ofthe Pro_lect cam`at midnight. December 19. 2015. whichever occurs first, unless,
extended in writing by (''S XT. In the event Licensee fbils to comply w4li terms arld provisions,
of this Agm-cement. Licensee agrees. to pay and agrees that C.SXT shall be entitled to recover' costs
alld CXpCtISCS HICUrred by CSXT including! legal Pecs and expenses. to enforce the terms ofthis
Ps- FORM RoV,I
RLMSEDAPRII,1 2008
AGREENIENTNO, CSX799680
14, SEVERABILITY: The parties agree that ifUlly Part. MITI Or PrOViSi011 of the
AgreeMent is held to be illegal, LnWnforceaNe or in conflict with any applicable Cederal, state, or
local law or regulation. SUCh part, term or provision shall be severaMe, with the remainder ofthe
Agreement remaiiiing valid and enforceable. If any provision or any part of a provision offfic
Agreement shall be finally determined to be superseded. invalid, illegal, or otherwise
WlCllf'orce,able PUrsuant to any applicable law, ordinance, rule or regulation, such determination
shall not iriq.)air or otherwise affect the validity. legality, or enl*orceability rap`the remaining
provislon or parts ofthe provision of the Agreement, which shall remain in Full force and effect
as if the unenforceable provision or Dart were deleted.
15. ENTIRE AGREEMENT- This Agreernent embodies tile entire understanding ofthe
parties, may not be waived or mudificd cxcvpt in at Nvi-Wng signed by awhurizvd represcriw0wrs;
of both parties. and SUPCI-SC(ICS,all prior or contemporalleOUS written or oral understandings.
agreements or negotiations regarding its subject matter.
16. NOTICES: All notices, consents and approvals required or lieraiitted by this
agreement shal I be in writing and shall be deemed delivered; Upton personal delivery, upon the
expiration ofthree (3) bUSir)CSS days f'ollowing ii'miling by U.S`,. first class mail, or Up011 the 11CM
IMSIIIeSS,day I'ollowing mailing, by a nationally recognized overnight carrier, to tile Ijcensee at
1, C/(.1 (""X'IL("Oil
the address above, and to Licensor at the address shown oil Page _.,i tract
Aciminiqn-ation, J 19(): or art such other addresses as either pnrty may- desk,mate by delivery of
prior notice to the other party
17. TERMINA"HON. CSXTshall have the right at any tirne and at its sole discretion to
terminate this Agreement upon notice to I.icensce.
I& WAIVER: I felther jxirty Fails to enforce its respective rights Under this Agreement,.
or fails to ilISiSt UpOrl the: pC11bralance of`the other party's obligations hereunder, such failUre
shall not be construed as a permanent waiver ol'any rights or obligations in this Agreement.
19. ("'OVERNING LAW; VENUE- This Agreement shall he ,governed by and COIIStrUCCI
Under the laws of the State of Florida, without reomx] to tile Cholce coal'haw llrovi',ions I 110'reof,
VCl1UC lor any action arising t'•om, or brought to enforce. this Agreement, shall vest exclusively
in the state or Federal courts located in Duv,,,fl COUrIty, Florida, and the parties agree to submit to
tile personaljUl-iSdiCtiOl1 ofany state or federal court. located in DUVal COUnty. Florida.
20. NO, ASSIGNMENT: Notwithstanding arlythiilw to the contrary clontaffled in this
Agreement, Licensee shall not pern-lit Agents to enter the Property WithOUt first requiring. Ag
gents
to agree in writing to comply with all of the terms or dlis Agreement, Notwithstanding the
foregoing. Licensee Shall ColitillLiC to be responsible Cor insuring that Agents corllj--)ly with all of
the terrns and conditions or this Agreement and shall indemnify and hold C SXT harmless, Im ally
daniages described in Section 2 above caused in whole or in part by SUCII SUhCO1ltraCtO1•.
Assignment ofthis Agrcement tc any party other than Agents in accordance widi this Sect ion
shall not be permitted CXCCp)t U[)On the prior N&rritten consent ()F(' X'1 which consent filay be
,-ranted or withheld at C'SX I's sole discretion. This A1reement shall be binding Lip)i I the I)a rt i
CS
,acrd their re.spective successors,and assigi s.
Paue 6 oF7
P - MMI ROE a
R VISt:[:7 APR[[.3 2008
IN W I,.I NVS,�, WHITFOF. tlae p ar-ties hei-etca have caused this Agr-eernlent to be exeCLIted
aaS O f the effective date of this Ageenlent.
Witness for CSXT: CSXTRAMOORTAT�K")N; INC
r
r ,
� � V
r,
I"arttl
Ike Name: r'a'+'°a�fi ��u..
Print/Type Title:
***SEE A' `"rA HED c'1'ry OR CLEARWTsT R 'SIGNATURE PAGE***
Witness for I iclensce: CITY OF C"LEARWA"I.ER
I3v:
Who, by the execution hereof'. affirms that liclshe has�s
the aauthaar itv to do so and to bind the Licensee to the
tentas aarnd conditions ofthis Agi-cement,
fli,i ttl°. ype aame:
l''tdrat.l"LYpc Tit.le:.
'I"ax H)NCB.:
Aa111101-ityl Mider'Ot-d'enance car•
Kesoll.10 era No.
D,atcc6
CSX TRANSPORTATION, INC.
TEMPORARY RIGHT OF ENTRY AGREEMENT
Countersigned: CITY OF CLEARWATER, FLORIDA
By
George N, Cretekos William B. Horne 11
Mayor City M�anager
Approved as to form: Attest,
J
La0rai My aho�ny Rosemarie Call
Assistant City Attorney City Clerk
[ ,f0CwrQMS0fF0XwM0w, 1
Mall Application,Maps,and Fee(s)To:
CSX Transportation, Inc,
ATTN. Corridor Occupancy Services
67;37 Southpoint Drive South„J-180
Jacksonville, PL 32216
w
Appllcatlt7r7 fate: ri'r l CSXT FlIe7Agreernent N'tarrrf7er:
(C X Use Only)
ALL FIELDS MARKED WITH AN ASTERICK(")ARE REQUIRED FIELDS AND MUST BE COMPLETED
� .� (required)
'Ownier's Comp t,
m
Legal r�arw�e of Pa Pe #I7e gN"�r•k myo wr_.._
Lk` a'I'1.47rt�pc3lrtgf IrlciPt-il ;.�1
L p Adoress 'f r i a,n g-y'
Legal Address( ).
State.
*Business T yp e: Corporation Limited Liability Company l Limit*eild y artnershu�p.._
— � Municipality Llrnite a Lratrdlrly Partnership General Partnership F
I
"Mate of incorporation: �� - .� � .. �t7Ver Business Type-Dt sbu ub .
r;orparatmr�n: �..
fi
Billing Address
qi (&,ck box if sanic as above,:.0 n krl ra :complete br-4 a
i
Dulling Address(1):
Belling Address(2):
Pro'ett Contact inf alp:
C°.uty:": Mate:
9 o rmmaClrr it°m
'Conp,aet£dame ,.�
k ?.°fe
I Offirae Phone air "I",IS I/ � Mobile Phone
w
/CZ �
Et"nail: �Wn gym . �. �r �� ��� .� �u a" r r ( 7 ,'
�u1�.
dIN • AF
�ts this a five exteiasc rmo recta aG ca r mr yeti P to add ama aa1�lltrorual I cation to an existing ri nt�ot-entry agreement?
Yes P'rovid'e Agreement#and/or Tate:
Is this project related to another trans;acvowpro)ect with GSX
r
Yes Describe. 7� � - � 1 �� ...o ���
No
Reference Nurnbe.
1�rovicta r�pplmcant',>Project Reter� r��_. .. .��_..__��_.
c ... ...,
"City: Count : (/,I 'State:
In addition to,the above location information,a minimum of one of the below location references must be provided for processing:
Latitude: LcngltUdn
feet (Directon)from AA /DOT Road Crossing Number
feet (Direction)from CS'X Paftoad Milepost Number �
Protect S,cop,a__.
Check box to indicate type of entry request.
General Access. Environmental investigation:
F Bridge lnspcction(unaludo DOT Crossing Number) G rnuo id W"va'tPr:Sgimpling
i
I'r Engineering I Sediment Sampling
House Moving Soil Sampkng
I Staging Area Remediat'ion
entechnic.al Soil ezriin,cts Monitoring VVeHs of Welts
Surveying l if state or Federal Site,provide
Other (Non-Construction) Site,#
Ralfroad OIper'aticns.
How close will the proposed activity be to the nearest railroad track:.
Will the proposed activlity regwre crossing railroad Craw k(5):
G. 'Yes Descrbe:.
t
No
Pre tion
'Detailed Scope of Work s
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