R2010-121 AUTHORIZING THE EXECUTION OF AN AGREEMENT

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� TRANSFORTATItJN Form#OP OUTSIDE PARTY NUMBER REQUEST FORM � • All information must be TYPED ar CLEARLY PRINTED • Proof of insurance as required by CSX and/or indicated in your agreement • Note: If flagging protection is required, the average cost is$800.00/day, this is not an invoice. A separate invoice for actual costs of flagging services will be sent to the Licensee or Project Owner upon completion of the project. • Please provide a check for processing fees of: Scheduling PAID Railroad Protective Liability Insurance PAID • Please submit this form in one of the following manners: Mail: Property Services Fax: 904.245.3692 Email: OP_Request@csx.com c/o Flagging Projects 500 Water Street,J180 Jacksonville, FL 32202 For Flagging Coordination Contact 904-633-1566. Please allow time for scheduling before calling. ��ia��ar I:E�ect llesc�r��rtc�nr A �t Inf�ttasu City: Decatur _ CSXT Agreement No.: C5X654431 _. .... . . ......... . ......................... .... .......... .. ... ..... County: MaCon CSXT Agreement Date: May 25,2010 _...._..._...._....._........._.................._...._._._.._._...._._.._._._...._. .._. ......._._....__._.._... ._.._... State: IL A eement Holder: Decatur Cit Of _...._.._ ...._........ ......... ..._....... ........._...... �' _.._._....._.........._._...............Y._......._..._...._............_....................................._.........._._._.... Requested Start Date: Railroad Milepost: BD 272.95 ......... ......................._..._...._....._._....................._. New Maintenance Duration in Days: Installation: X ------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------- Sco of work: Re lacement of existing 10 watermain with new 12" watermain. �i Iufar�at�on ft�r A Hds�erlPr eet€l�wner . Pr et C�xtaeE P�e�t fre�r►�tl�ti Contact Name: Contact Name: Company Name: Company Name: ..... .. Company Billing Address: Company Addres Address(2 Address(2): City: City: State/Zip: State/Zip: Phone: Phone: Fax: Fax: Email: Email: R ~ �i�M�ta�csr Name: Name: .......................... ..........._.........._..........._._..................._................._.......__..._ Division: - .7 ..................................................._.............,....._.....,..................................,....,.......................,....,.....,..,......... �,� Outside Part (OP)Numbe Valid Th Ins ection REQUIRED Actual Start Dat .