Go to the Federal Communications Commission homepage at www.fcc.gov

FCC Form 399: Reimbursement Request

Approved by OMB 3060-1178
Go to the Federal Communications Commission homepage at www.fcc.gov

(REFERENCE COPY - Not for submission) FCC Form 399: Reimbursement Request

Facility ID:
52887
Service:
DCA
Call Sign:
KCNZ-CD
Channel:
21 (UHF)
File Number:
0000028325
FRN:
0026495465
Date Submitted:
05/22/2019

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

Poquito Mas Communications LLC

Doing Business As: Poquito Mas Communications LLC

Randy Nonberg

15200 SUNSET BOULEVARD

Suite 202

Pacific Palisades, CA 90272

United States

+1 (310) 573-1600 randynonberg@cnzcommunications.com Limited Liability Company

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant Address Phone Email

[Confidential]

 

 

 


Preparer Contact Information

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Preparer Contact Name and Information

Applicant Address Phone Email

Robert Wayne Jordan

Engineer

ACME RF INC

Robert Wayne Jordan

9851 CENTER DRIVE

VILLA PARK, CA 92861

United States

+1 (714) 412-1951 rjordan@acmerf.com

Broadcaster Information and Transition Plan

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Question Response
Will the station be sharing equipment with another broadcast television station or stations (e.g., a shared antenna, co-location on a tower, use of the same transmitter room, multiple transmitters feeding a combiner, etc.)? If yes, enter the facility ID's of the other stations and click 'prefill' to download those stations' licensing information. Yes
Briefly describe transition plan Current transmission system consists of a single transmitter feeding a flexible transmission line which connects to an antenna on the tower. Work includes tower study/rehabilitation to support new antenna, mounting antenna and replacing transmitter.

Transmitters

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Section Question Response
Transmitter Related Expenses Do you have transmitter related expenses? Yes

Primary Transmitter

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Existing Transmitter Information

Section Question Response
Existing Transmitter Description Type of change Purchase New
Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is this transmitter currently shared with another station? No
Is this transmitter currently in operating condition? Yes
Existing Transmitter Manufacturer and Type Manufacturer
Model UTV2
Year 2006
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 2 kW

Primary Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Primary (Main)
Change Type Purchase New
Is this a request for upgraded equipment? No
Manufacturer
Model TMU9-4
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 2 kW
Justification for New Transmitter Existing transmitter cannot be converted to repacked channel per manufacturer and manufacturer is no longer in business.

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) No
Switchgear (industrial 800 amp) Yes
Transformer (480V) No
Power N/A
Rigid Conduit and Wiring Yes
Size 2 inches
Length 50.0 feet
Other Electrical Service No
Description N/A
HVAC Service Does the replacement transmitter require HVAC Service? No
Type N/A
Size N/A
Other Size N/A
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? Yes
Size 100.0 square feet
Channel 14 Costs Is an RF Consulting Engineer needed? N/A
Is a channel 14 Mask Filer needed? N/A
Is additional field engineering time needed? N/A
Number of Days N/A

Primary Transmitter

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Other Transmitter Cost Not Listed

Information not provided.

Antennas

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Section Question Response
Antenna Related Expenses Do you have antenna related expenses? Yes

Primary Antenna

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Existing Antenna Information

Section Question Response
Existing Antenna Description Type of change Purchase New
Antenna Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing antenna shared with another station or stations? No
Is the existing antenna directional? Yes
Is antenna in operating condition? No
Is antenna located on or in close proximity to an antenna farm? No
Existing Antenna Manufacturer and Type Class Class A
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 1
Number of Panels 4
Design power capacity in use 25.0 %
Lower Limit 470.00 MHz
Upper Limit 700.00 MHz
Other Antenna Type N/A
ERP: 15.0 kW
Manufacturer
Model k723147
Year 2005

Primary Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Primary (Main)
Description of Use N/A
Change Type Purchase New
Is this a request for upgraded equipment? Yes
Ownership Owned
Owner N/A
Is antenna shared? No
Is antenna directional? Yes
Will antenna be located on or in close proximity to an antenna farm? No
New Antenna Manufacturer and Types Class Full Power
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 1
Number of Panels/Bays 16
Lower Limit 470.00 MHz
Upper Limit 700.00 MHz
Design power capacity in use 10.0 %
Other Antenna Type N/A
ERP: 350.0 kW
Manufacturer
Model TUA-C3 4/12
Year 2017
Justification for New Antenna Existing antenna has failed and is more cost effective to replace than to repair. It also cannot handle the expected power.

Primary Antenna

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Other Antenna Costs

Section Question Response
Combiner for Shared Antenna Do you need a Combiner for a Shared Antenna? No
Type
Number of channels supported N/A
Frequencies of channels supported N/A
Frequency N/A
Do you need a combiner output splitter/switcher for dual feed lines? N/A
Elbow Complex Do you require the separate purchase of the Elbow Complex? Yes
Broadband or Single Channel? Broadband
Feed Line Size 3 1/8 inches inches
Side Mount Brackets Do you require the separate purchase of side mount brackets for a high power antenna? No
Pattern Scatter Analysis Do you require separate purchase of pattern scatter analysis for a side mount high or medium power antenna? No
Sweep Test Do you require the sweep testing of transmission line and antenna? Yes

Primary Antenna

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Other Antenna Cost Not Listed

Information not provided.

Transmission Line

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Section Question Response
Transmission Line Related Expenses Do you have transmission line related expenses? No

Tower Equipment And Rigging Costs

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Section Question Response
Tower Equipment or Rigging Costs Changes Do you have tower equipment or rigging costs changes? Yes

Primary Tower

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Existing Tower

Section Question Response
Existing Tower Description Type of change Modify Existing
Tower Use Primary (Main)
Description of Use N/A
Ownership Leased
Is this tower consider Complex? No
Is this tower currently shared with any other stations? Yes
One or more FM, AM or TV radio broadcaster(s) Yes
Others Types of Users No
Is tower documented for structural analysis? Unknown
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1205149
Coordinates (NAD83) Latitude (NAD83) 37° 41' 14.4" N-
Longitude (NAD83) 122° 26' 05.3" W-
Overall Structure Height 311.02 feet
Support Structure Height 306.10 feet
Ground Elevation Above Mean Sea Level (AMSL) 1255.89 feet
Structure Type LTOWER - Lattice Tower
Tower Owner American Towers, LLC.
Date Constructed 03/02/2001

FM, AM or TV radio broadcasters. Facility ID's, Call Signs and Services of other broadcast stations with whom the tower is shared

Facility ID Call Sign Service
22644 KKPX-TV DTV
37511 KTSF DTV

Primary Tower

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Tower Modification Costs

Section Question Response
Engineering Study Please what type of engineering study is required, if any: Study needed for undocumented/poorly documented tower
Tower Reinforcements Please select whether tower reinforcements are needed: Minor Reinforcements needed

Primary Tower

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Tower Rigging Costs

Section Question Response
Tower Rigging Costs Complex Tower N/A
Helicopter Services Required Are helicopter services required? No

Primary Tower

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Other Tower Expenses Not Listed

Information not provided.

Outside Professional Services Costs

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Section Question Response
Outside Project Management Services Do you require outside project management services? Yes
Number of Hours 200
Explanation Applicant has no internal resources capable of overseeing, identifying, purchasing, installing and commissioning this repack project. It will rely solely on outside services to manage all work required.
Outside RF consulting Engineering Services Perform engineering study for new channel assignment and antenna development Yes
Prepare engineering section of Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare engineering section of Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority No
Quantity N/A
Do you have Distributed Transmission System engineering services? N/A
Critical Facility N/A
Terrain-Shielded Facility N/A
Attorney and Other Outside Consulting Services Prepare and file Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare and file Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority No
Quantity N/A
NEPA Section 106 environmental review No
Environmental Assessment No
ASR Modification No
FAA Consultation (including preparation of FAA Form 7460) No
Negotiation of Lease and other Matter for Shared Locations Yes
Prepare or Review FCC Form 399 for Reimbursement Yes
Address transition timing and coordination issues w/ other stations and wireless providers Yes
RF Field Engineering Services Comprehensive coverage verification via field study No
RF exposure measurements No
Additional Field Engineering Service No
Number of Days N/A
Justification N/A

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Information not provided.

Other Expenses

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Section Question Response
AM Pattern Disturbance Is an Impact Study needed? No
Is Remediation needed? No
Facility Expenses Name N/A
Other Distributed Transmission System Expenses Not listed N/A
Name N/A
Is Notification of a Medical Facility required as a result of DTV broadcasting? Yes
Permit and Filing Costs Local Zoning Yes
Non-zoning permits Yes
BLM or NFS Coordination No
FCC Construction Permit Minor Change Yes
FCC License to Cover Application Yes
FCC Special Temporary Authority Application No
Other Miscellaneous Expenses Does this relocation require paying Disposal Costs (for equipment and other waste, net of any salvage value)? Yes
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? Yes
Does this relocation require Equipment Storage? Yes
Does this relocation require the Development and Airing of an Announcement regarding an upcoming channel change? Yes
Does this relocation require MVPD Notification of a Channel Change? Yes

Other Expenses

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Other Expenses Not Listed

Information not provided.

Cost Information

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Transmitters

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $185,500.00 $177,550.00 N/A $87,662.22 N/A
Total for all systems $751,355.00 $715,975.00 N/A $100,641.22 N/A
Primary Transmitter TMU9-4 $185,500.00 $177,550.00 $87,662.22
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $126,000.00 $120,000.00 N/A $87,662.22 N/A
Switchgear - industrial 800 amp $38,200.00 $36,300.00 N/A N/A N/A
2" Rigid Conduit and Wiring (Cost per foot) $1,300.00 $1,250.00 N/A N/A N/A
Other -- Building Addition Size: 100.0 $20,000.00 $20,000.00 Equipment room is cramped we assume some modification will be required to accommodate the new equipment N/A N/A

Components

Actual Information Description File Name
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW

Component Description:
Invoice for the materials and products used in the installation of the R&S TMU9 Digital Transmitter.
Amount:
$4,426.59

Component Description:
Invoice for the installation of R&S TMU9 digital TV Transmitter at San Bruno, CA facility.
Amount:
$9,500.00

Component Description:
Transmitter and Filter Kit: TMU9-4 2.4KW UHF (Quote, Purchase Order and Invoice).
Amount:
$73,735.63
Switchgear - industrial 800 amp Information not provided.
2" Rigid Conduit and Wiring (Cost per foot) Information not provided.
Other -- Building Addition Size: 100.0 Information not provided.

Cost Information

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Antennas

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $205,570.00 $195,280.00 N/A $0.00 N/A
Total for all systems $751,355.00 $715,975.00 N/A $100,641.22 N/A
Primary Antenna TUA-C3 4/12 $205,570.00 $195,280.00 $0.00
UHF - Lower Power Side Mount, One station - 200-500 kW, horizontally polarized $189,500.00 $180,000.00 N/A $0.00 N/A
Sweep test of existing antenna $6,730.00 $6,400.00 N/A N/A N/A
Elbow complex, broadband, at antenna input, per 3 1/8. feedline (if needed) $9,340.00 $8,880.00 N/A N/A N/A

Components

Actual Information Description File Name
UHF - Lower Power Side Mount, One station - 200-500 kW, horizontally polarized

Component Description:
Freight cost for the UHF antenna system.
Amount:
$2,801.28

Component Description:
Ceva International Inc customs brokerage fees for the UHF antenna system.
Amount:
$322.28

Component Description:
Radio Frequency Systems invoice 765477455 dated July 18, 2018 for one UHF antenna system
Amount:
$31,115.00
Sweep test of existing antenna Information not provided.
Elbow complex, broadband, at antenna input, per 3 1/8. feedline (if needed) Information not provided.

Cost Information

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Transmission Line

Information not provided.

Cost Information

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Tower Equipment and Rigging Costs

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $268,500.00 $255,000.00 N/A $3,850.00 N/A
Total for all systems $751,355.00 $715,975.00 N/A $100,641.22 N/A
Primary Tower LTOWER $268,500.00 $255,000.00 $3,850.00
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study $26,300.00 $25,000.00 N/A $3,850.00 N/A
Short Tower (less than 500') $84,200.00 $80,000.00 N/A N/A N/A
Minor tower reinforcement/modifications $158,000.00 $150,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study

Component Description:
Complete tower services to map and measure tower members; gather tower documentation; information for use of propagation analysis/study and antenna stand-off design and configuration.
Amount:
$3,850.00
Short Tower (less than 500') Information not provided.
Minor tower reinforcement/modifications Information not provided.

Cost Information

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Outside Professional Services

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $60,790.00 $57,750.00 N/A $8,691.50 N/A
Total for all systems $751,355.00 $715,975.00 N/A $100,641.22 N/A
Outside Professional Services $60,790.00 $57,750.00 $8,691.50
Attorney Fees - Negotiation of lease and other matters for shared locations $4,210.00 $4,000.00 N/A N/A N/A
Project management of the transition $31,600.00 $30,000.00 N/A $1,500.00 N/A
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A N/A N/A
Address transition timing and coordination issues w/ other stations and wireless $2,630.00 $2,500.00 N/A $612.50 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A $2,625.00 N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,500.00 N/A N/A N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 N/A $2,012.50 N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 N/A $1,941.50 N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,365.00 $2,250.00 N/A N/A N/A

Components

Actual Information Description File Name
Attorney Fees - Negotiation of lease and other matters for shared locations Information not provided.
Project management of the transition

Component Description:
Repack project management services. Research and coordination with engineering, attorney, equipment vendors and site owner. Included is the name of the person who performed the service.
Amount:
$1,500.00
Prepare and or review reimbursement form Information not provided.
Address transition timing and coordination issues w/ other stations and wireless

Component Description:
Prepare CP and assist with 399 preparation and review.
Amount:
$525.00

Component Description:
Determination of transmitter power needed at tower locations Sutro and Bruno.
Amount:
$87.50
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
Channel repack plan and preparation of construction permit exhibits.
Amount:
$2,625.00
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Perform engineering study for new channel assignment and antenna development

Component Description:
Engineering repack services; Quarter 3 2018 progress report submittal.
Amount:
$175.00

Component Description:
Engineering repack services: cover letter for elliptical antenna and redo of FCC invoices.
Amount:
$175.00

Component Description:
Antenna configuration, transmission system and transmitter power determination.
Amount:
$1,575.00

Component Description:
Engineering services: Q2 progress report.
Amount:
$87.50

Component Description:
Quarterly progress report.
Amount:
$175.00
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
Consultation with attorney regarding CP amendment.
Amount:
$486.50

Component Description:
Review, revise and refile 399.
Amount:
$814.00

Component Description:
Research status and revise application; correspond with FCC staff.
Amount:
$641.00
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.

Cost Information

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Other Expenses

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $30,995.00 $30,395.00 N/A $437.50 N/A
Total for all systems $751,355.00 $715,975.00 N/A $100,641.22 N/A
Other Expenses $30,995.00 $30,395.00 $437.50
MVPD Notification of Channel Change $5,000.00 $5,000.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $2,500.00 $2,500.00 N/A N/A N/A
Equipment Storage $2,000.00 $2,000.00 N/A N/A N/A
Equipment Delivery and Handling Charges $2,500.00 $2,500.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $2,000.00 $2,000.00 N/A N/A N/A
Non-zoning permits $2,000.00 $2,000.00 N/A N/A N/A
Local Zoning $2,000.00 $2,000.00 N/A N/A N/A
DTV Medical Facility Notification $11,550.00 $11,000.00 N/A $437.50 N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $325.00 N/A N/A N/A
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $1,070.00 N/A N/A N/A

Components

Actual Information Description File Name
MVPD Notification of Channel Change Information not provided.
Develop and air announcement of upcoming channel change Information not provided.
Equipment Storage Information not provided.
Equipment Delivery and Handling Charges Information not provided.
Disposal Costs (for equipment and other waste, net of any salvage value) Information not provided.
Non-zoning permits Information not provided.
Local Zoning Information not provided.
DTV Medical Facility Notification

Component Description:
Engineering repack services: Qtr 4 2018 reports and coverage map for DTV reception threshold contour.
Amount:
$437.50
FCC Filing Fees - Form 2100 license to cover application Information not provided.
FCC Filing Fees - Form 2100 minor change CP application Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $751,355.00 $715,975.00 $100,641.22

Reimbursement Status

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Question Response
The facility has ceased operating on its pre-auction channel. No
Construction of final facilities or all necessary modifications are complete. No
All receipts for reimbursement have been submitted no further costs are expected to be incurred. Note this will lock the Form 399 from further editing and begin close-out procedures with the Fund Administrator. No

Certification

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Section Question Response
Submission of Estimated Expenses Statements

WILLFUL FALSE STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503), AND ANY FALSE STATEMENTS COULD SUBJECT THIS ENTITY TO LIABILITY UNDER THE FALSE CLAIMS ACT.

  1. The Authorized Person signing below certifies that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity.

  2. The above-named entity acknowledges that all certifications and attached documentation are considered material representations.

  3. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.

  4. The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (broadcasters) or to continue to carry the signal of a broadcaster that changes channels (MVPD).

  5. The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund.

  6. The above-named entity certifies that it will maintain and provide to the Commission detailed records, including receipts, of all costs eligible for reimbursement actually incurred.

  7. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.

  8. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a pre-requisite for obtaining the payments herein requested.

I declare, under penalty of perjury, that I am an authorized representative of the above-named applicant for the Authorization(s) specified above.

Randy E Nonberg

Manager


05/22/2019

Certification

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Section Question Response
Submission of Actual Cost Documentation Statements

WILLFUL FALSE, FRAUDULENT, OR FICTITIOUS STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISIONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503), AND ANY FALSE AND/OR FRAUDULENT STATEMENTS COULD SUBJECT THIS ENTITY TO LIABILITY UNDER THE FALSE CLAIMS ACT (U.S. CODE, TITLE 31, SECTIONS 3729-3733).

  1. The Authorized Person signing below certifies and represents that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity.

  2. The above-named entity certifies that the statements in this form and attached documentation are true, complete, and correct.

  3. The above-named entity acknowledges that all certifications and attached documentation are considered material representations.

  4. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.

  5. The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (full power and Class A stations) and/or otherwise modify a television station’s facility as a result of the spectrum repack (LPTV/TV Translator stations); or to minimize service disruption resulting from a repacked television station (FM stations); or to continue to carry the signal of a broadcaster that changes channels (MVPD) .

  6. The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund.

  7. The above-named entity certifies that the cost information/documents submitted reflect costs actually incurred.

  8. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.

  9. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a prerequisite for obtaining the payments herein requested.

I declare, under penalty of perjury, that I am an authorized representative of the above-named applicant for the Authorization(s) specified above.

Randy E Nonberg

Manager


05/22/2019

Attachments

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