CH-P05-6.03-F3 Backcharge Notice - Purchase Orders

EXHIBIT C - ATTACHMENT C-11-1

Date Contract Number Back-Charge Number Contractor

I. Description of Back-Charge work: BACK-CHARGE NOTICE

Required completion of Back-Charge work to meet Project Schedule

II. Pricing Basis (check applicable basis): Agreed lump sum price of $

Actual incurred cost, plus mark up in accordance with Part III below. Estimated to be $

III In accordance with Exhibit C Section 11 Back-Charge Procedure 1 Actual cost of material and supplies, plus ten percent (10%). 2 Design Engineering, cost plus thirty percent (30%) 3 Actual other costs to CH2M HILL for CH2MHILL or others to perform the work described herein plus ten percent (10%) 4

IV. Confirmation of Verbal Notice to Subcontractor from CH2M HILL

Date and time called: Subcontractor Representative called or spoken to:

V Authorization by Subcontractor: (Delete as appropriate) Subcontractor hereby agrees to complete the work described in Part I above by the Completion date stated. OR Subcontractor understands and agrees that CH2M HILL shall perform, or cause to be performed, the work described in Part I - Description of Back-Charge work in accordance with the provisions of the Subcontract and that Subcontractor shall compensate CH2M HILL in accordance with the rates, prices, terms and conditions set forth therein.

(Signature Contractor Authorized Representative)Title Date

Attachment C-11-1, Back-Charge Notice Form Page 1 of 2 Form Rev 0, 2013-Dec-5 VI. Completion of the work required by this Back-Charge Notice: CH2M HILL confirms the work described Part 1 herein is now considered complete.

(Signature CH2M HILL Authorized Representative) Title Date

VII Final Back-charge Value: CH2M HILL confirms that in accordance with this Back-Charge Notice the Subcontractors work described Part 1 herein has been completed by others and, in doing so, has incurred costs in the total amount of ( ), which shall be back-charged to the Subcontractor in accordance with the provision of the Subcontract.