<p> EXHIBIT C - ATTACHMENT C-11-1</p><p>Date Contract Number Back-Charge Number Contractor</p><p>I. Description of Back-Charge work: BACK-CHARGE NOTICE</p><p>Required completion of Back-Charge work to meet Project Schedule </p><p>II. Pricing Basis (check applicable basis): Agreed lump sum price of $</p><p> or </p><p>Actual incurred cost, plus mark up in accordance with Part III below. Estimated to be $ </p><p>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</p><p>IV. Confirmation of Verbal Notice to Subcontractor from CH2M HILL</p><p>Date and time called: Subcontractor Representative called or spoken to:</p><p>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.</p><p>(Signature Contractor Authorized Representative)Title Date</p><p>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.</p><p>(Signature CH2M HILL Authorized Representative) Title Date</p><p>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.</p>