Contract - Fab Tech - 2/11/2021" $ p-, kk' k'
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24211 NW Service RD
Warrenton, MO 63383
(314) 223-6473 or (262) 617-3010
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TO: John Heaps
City of Round Rock
Brushy Creek
3939 East Palm Valley Blvd
Round Rock, TX 78665
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Quotation NO. QFT-40646
DATE 11/30/2020
CUSTOMER ID RoundRockTX
Make o/I checks poyoble to FAB'TE-CH lvlviAASTEt,,VATER SOL LLC, TFIAINK YOLI F()ssf? YOUR BUSINESS!
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CERTIFICATE OF INTERESTED PARTIES
FORM 1295
10fi
Complete Nos, 1 4 and 6 if there are interested parties. OFFICE USE ONLY
Complete Nos. i, 21 31 5, and s if there are no interested parties. CERTIFICATION OF FILING
1
Name of business entity filing form, and the city, state and country of the business entity's place Certificate Number:
of business. 2021-705851
Fab Tech Wastewater Solutions, LLC
Warrenton, MO United States gate Filed:
2
Name of governmental entity or state agency that is a party to the- contract for which the form is 01/13/2021
being filed.
City of Round Rock, Texas Date Acknowledged:
01/14/2021
3
Provide the identification number used by the governmental entity or state agency to track or identify the contract, and provide a
description of the services, goods, or other property to be provided under the contract.
000000
Sale and Installation of rebuilt H60 Drive Unit
4
Name of Interested Party
City, State, Country (place of business)
Nature of interest
(check applicable)
Controlling
Intermediary
5
Check only if there is NO Interested Party. X
6
UNSWORN DECLARATION
My name is ,and my date of birth is
My address is
(street) (city) (state) (zip code) (country)
declare under penalty of perjury that the foregoing is true and correct.
Executed in County, State of , on the day of , 20
(month) (year)
Signature of authorized agent of contracting business entity
(Declarant)
Forms provided by Texas Ethics Commission www,ethics.state,tx,,us Version Vl,lceffd98a