Bid Package - Superior Landscaping & Lawn Service Inc.PROPOSAL SUBMITTAL FORM
Citywide Landscaping Services
This checklist indicates the forms and documents required to be submitted for this Request for Proposal
(RFP) to be presented by the deadline set for within the RFP. Please check off and submit documents in
the order listed below. Fulfillment of all proposal requirements listed is mandatory for consideration of
proposals. The proposal shall include the following items:
rf Bidder Qualification Statement
Non- Collusion Affidavit
7
Public Entity Crimes and Conflicts of Interest
Drug Free Workplace
Acknowledgement of Conformance with OSHA Standards
List of Proposed Subcontractors and Principal Suppliers
In emnification and Insurance Documents
Cost Proposal, (Pricing Sheets)
r � ' • is . • la � • M • I `: ♦... s r;
30
6130 Sunset Drive
South Miami, FL. 33143
Citywide. Landscaping Services RFP
A. Title Page
LEGAL NAME OF BIDDER:
Superior Landscaping & Lawn Services, Inc.
MAILING ADDRESS:
2200 NW 23rd Avenue
CITY, STATE, ZIP CODE:
Miami, Florida 33142
TELEPHONE NUMBER:
e
NAME /TITLE:
Orlando Otero /President
PHONE NO:
634 -0717
FAX NO:
(305) 634 -0744
E -MAIL ADDRESS:
superlandscape c bellsoutlr:net
6130 Sunset Drive
South Miami, FL. 33143
City-wide Landscaping Services
B. Table of Contents
A. Title Page
B. Table of Contents
C. Letter of Interest
D. Qualifications and Experience
E. Attachment 41 Sworn Statement
F. Attachment #2 Drug Free Workplace
G. Attachment #3 No Conflict of Interest /Non Collusion Affidavit
H. Cost Proposal
I. Other Documents
6130 Sunset Drive
South Miami, FL. 33143
Citywide Landscaping Services
C. Letter of Interest
Please see the attached Letter of Interest.
April 5, 2012
City of South Miami
Ladies and. Gentlemen:
After careful analysis of the landscape maintenance needs of City of South Miami, the following
is a horticultural: plan that we believe is the best and most cost effective for the city.
This plan is created with sufficient manpower, hours and variety of services to enable us to
maintain an eye for detail without "rushing through" the services.
Our crews will be deployed from our Miami facilities. Landscaping services will be performed
by a crew of minimum three gardeners as per the rfp for mowing, edging, "weed eating", ail'
blowing; raking any plant material debris, removing fallen palm frowns and tree limbs. Year
services will also be supported by a horticultural specialist, irrigation technicians who will check
irrigation system on a monthly basis, and arbor care personnel, which will provide expertise in
their different fields. The City will also be assigned their own account manager; Daniel Roque.
This representative will be your point of contact and will be your single `go -to' person
responsible for a smooth transition; service scheduling, and meeting with City for walkthroughs,
question & answer, new enhancement and beautification ideas, etc.
We believe that having weekly visits with sufficient time, personnel; and supervision, and
following cornett horticultural practices will Jeep the focus oil you, tile customer.
The reason why some companies fail in delivering is not having enough hours or services built
into the job to be able to tackle every aspect of the maintenance with every visit resulting it)
cutting corners to make a profit. In other words, taking the focus away from you and
concentrating on then- bottom line.
Thank you for allowing Superior Landscaping & Lawn Service, Inc. an opportunity to provide
excellent services to your property and grow a relationship for years to come.
Sincerely,
Raul C. Aguilar
Business Developer
6130 Sunset Drive
South Miami, FL. 33143
Citywide Landscaping Services
D. Qualifications and Experience
D1. Approach
In all out years of providing our services to the state of Florida; we have developed an
Assurance plan that guarantees our customer's Landscaping goals are met in a specialized and
thorough manner.
This plan includes a six step process that' has guided us on providing the best possible service.
ASSESSMENT
A skilled consultant from our company will meet with you and survey your property in order to
establish the needs of the project and your preferences. A written proposal will be delivered for
your review incorporating the findings of our assessment while fitting your Budget
PLANNING
Planning is crucial to accomplish the desired result. Selection of quality material and a schedule
that fits your time requirements will ensure functional, long term, design solutions. At this stage,
your requests are implemented in order to achieve ultimate customer satisfaction.
IMPLEMENTATION
Our team of dedicated employees will work towards your goal for the duration of the project by
working diligently according to schedule; maintaining the premises clean and orderly at all
times.
RESULT
Upon completion of the project, our consultant will perform a final walkthrough with you in
order to make certain all objectives were met and you are satisfied.
MAINTENANCE
This is most essential step in our Landscape Assurance Plan. Superior offers the most affordable
and detailed maintenance programs available. We will develop a thorough and comprehensive
plan designed specifically for your property. Our maintenance services will allow you to enjoy
your surroundings and protect you investment.
FOLLOW UP
Your Account Specialist will visit and inspect your property periodically to guarantee that your
landscape and irrigation are maintained at the highest level of quality and offer
recommendations for future enhancements.
D2. Administrative Resumes
Please see the attached resume's from our corporate officers.
ORLANDO OTERO
Pri n cipall.Pr'esident
PROFESSIONAL EXPERIENCE
Superior Landscaping & Lawn Service, Inc.
OymerlPresident
• Direct Business Operations
• Responsible for providing quality services to my company's clients
• Strive for continued growth and expansion of services
Founded the company over twenty years ago
a Establish sound and ethical working practices for the company
o Responsible for overseeing all daily operations of the company
Responsible for stockholder decision- making
EDUCATION
Florida International University, 1990
BA Business Administration
Major: Finance
CERTIFICATIONS
February 1982 - present
Certified Tree Trimmer, Certificate of Competency
Miami, Florida
American Management Association, Managing Conflicts in the Workplace
American Management Association; Strategies to Improve Performance
American Management Association, Creating a Positive and Productive Workplace
Lawn Care Professional
MARIA VALUES
Office Manager
PROFESSIONAL EXPERIENCE
Superior Landscaping & Lawn Service, Inc.
Miami, FL
Office Manager
• Supervise office staff
• Staff trainng
• Accounts receivable and collections analysis
• Contact person for clients with special requests and or concerns
• Customer Service
Fernando Fonseca, MD
Miami, FL
Office Manager
• Supervise office staff
• Staff training
• Manage Accounts Receivable and Payables
• Monthly bank reconciliations
• Responsible for Month -end and year -end entries
EDUCATION
Miami Dade Community College
Miami, FL 19 87
Associate in Arts - Business Administration
Florida International University
Miami, FL 1990
BA in Arts- Business Administration
January 1993 present
January 1990 - January 1993
BETSY QUEVEDO
Financial Controller
PROFESSIONAL EXPERIENCE
Superior Landscaping & Lawn Service, Inc.
Miami, FL
Financial Controller
• Supervise an Accounting Department of Five employees
• Supervise Payroll, Accounts Payable, Accounts Receivable, Job Costing
• Reconcile bank statements, credit cards and notes payable
• Reconcile to trial balance
May 2008 present
• Post journal entries, percent of completion entries, and closing entries
• Create Work In Progress reports for $20,000,000 contract totals
• Work with Bank Account Managers, Bonding Companies and CPA for company needs
• Meet with Owners to create & discuss Business Plan
• Create Financial Statements including P & L, Balance Sheet and Cash Flow reports
Superior Landscaping & Lawn Service, Inc,
Miami, FL
ProjectMartager
January 2007 — May 2005
• Process all awarded contracts including analyzing contract language, obtaining Certificates of
Insurance, Performance Bonds, and all paperwork required for execution
• Preparing for and attending Pre - Construction meetings and submittal of all pertinent forms and
paperwork
• Planning and scheduling for construction using Primavera 6.0 software
• Continuously analyzing budgets, costs, Project P & L's for maximum job profit and decision- making
• Worked with rest of Project Team (Construction Manager; Superintendents; Foremen) to bring in
project on budget, in time and gain final acceptance from Owner
• Responsible for all of the company's larger projects - a total of
;$20,000,000
Superior Landscaping & Lawn Service, Inc.
Miami, FL
Assistant General Manager
August 2004 — January 2007
• Responsible for creating and submitting customer proposals; obtaining and preparing new bids for
larger projects
• Created all monthly invoices, including monthly maintenance and construction type monthly pay
applications, notice to owner, and releases of lien
• Prepared daily bank deposits
• Handled customer service including service calls, work follow up calls and account calls
• Assisted Owner with all of his daily responsibilities
Hi -Tech School of Miami
Miami /Hialeah, FL
School Adnrinistrator
February 1999 August 2004
• Served as Self - Evaluation Report committee leader for all school campuses
• Prepared periodic Accreditation (ACCSCT) applications and Self Evaluation Reports
• Represented the school at FAPSC, ACCSCT and USDOE meetings and seminars
• Continuously audited each school department for adherence to Department of Education and
Accreditation standards & regulations
EDUCATION
Miami -Dade College, Miami, FL
AA in Computer Sciences and Business Administration
Microsoft Office Specialist — Certiport
SKILLS
MS Word and MS Excel
QuickBooks; MS Word, MS Excel, MS PowerPoint, MS Publisher, MS Outlook, MS Project, Primavera
Fluent in English and Spanish
D8, Similar Contracts
Please see the attached details of similar contracts.
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D4. References
Please see the attached reference list.
FLUDD�:liiDJMMMM
UTA Management
1111 Lincoln Road, STE 260
Miami Beach, FL 33139
Contact: Jeff Weinstein
Ph: (305) 978 8370
Fax (305) 531 -4409
Contract: $794,000
PRIME
City of Miami Beach
Parks &.Recreation
2100 Meridian Avenm
Miami Beach, FL 33139
Contact: Millie McFadden
Ph: (305) 673 7720
Contracts Over $800,000
Maintenance, Daily Landscaping and other services
PRIME
MIA
Aviation Department
PO Box 526624
Miami, Florida 33152 -6624
Contact: Jeff Dawson
Ph: (305 876 0656
Contracts $750,000
Maintenance,, Daily Landscaping and other services
PRIME
2200 NW 23 `" Avenue Miami, Florida 33142.
D5. Operational "R6 sumes
Please see the attached resume's from our operations staff.
Betty Gerdts
Maintenance Division Manager
PROFESSIONAL EXPERIENCE
Superior Landscaping & Lawn Service, Inc. September 2011— present
Maintenance Division Manager
• Provide administrative staff assistance to upper management.
• Plans and implement goals and objectives for the maintenance department and
ensures that company policies and procedures are adhered to at all times.
• Directs, oversees and participates in department work plans, assign work activities,
operations and maintenance programs.
• Monitors work flow and project status.
• Visits job sites to oversee work in progress and provide needed direction, responds
to emergencies at any time and evaluates the progress of ongoing maintenance
activities.
• Oversees the maintenance of department records and files.
• Attends weekly department meetings with my staff.
• Reviews costing reports.
• Coordinates the fertilization program for all properties, including to ordering tile
materials and keeping an organized inventory control.
• Interviews and hires new staff, prioritizes, assigns and reviews work
• Approve time off for payroll purposes and participates in weekly payroll meetings.
Vila & Son Landscaping Corp.
Office Manager
March 2009 - August 2011
• Act as liaison between customers and Account Managers. Followed up and resolved
customer concerns.
• Request insurance and federal bonds for constriction projects.
• Managed all office personnel as well as providing support to our Corporate Office as
needed.
• Responsible for all aspects of billing, A /R, Collections and A/P postings.
• Input all customer information as well as the monthly billings in Great Plains
Dynamic Accounting Software.
• Create weekly financial projections reports for the corporate office.
• Participate in all staff meetings and conference calls in order to provide feedback and
maintain company standards.
• Managed Payroll and HR personnel.
• Prepared all hiring packages and offer letters for new hires for salary personnel.
• Order Office Supplies.
• Maintained records of all workman compensation claims.
Spanish Broadcasting System, Inc.
Office Manager and Executive Assistant to C.O.O.
December 1996 April 2008
• Managed all aspects of the office, including a full range of administrative support for
the organizations President, C.O.O„ C.F:O and Board of Director. Duties included
word processing of letters, internal memos, and expense reports.
• Created weekly and monthly reports; pulling data from Arbitron and Nielsen
systems as well as provided analysis to help the non- researchers understand the
different dayparts performances. In addition to regularly scheduled reports, pulled
data and provided analysis to respond to various requests from Programming; Sales
and Marketing departments.
• Other responsibilities included tracking the competition and other audience analysis;
as needed. Coordinated a wide range of projects involving critical media analyses;
research briefs and articles relating to broadcasting.
• Coordinating all travel arrangements for upper management, talent, clients and
contest wimieis.
• Handled invoices, drafting of weekly production reports, and all correspondence.
Maintained'persormel files and employment contracts.
• Adhered to the highest degree of professional standards and strict confidentiality in
matters that require discretion.
Peter. Collins & Associates Law Office.
Legal Secretary
February 1993 — December 1996
Head assistant to two senior partners. Responsible for court filings, preparation of legal
documentation, scheduling depositions and court appointments.
• Responsibilities included scheduling appointments; researching case laws, arguing
motions; conferencing cases in pre -trial procedure; drafting notices of discovery,
subpoenas, and complaints; and preparing clients for examination before trial hearings.
• Participated in civil, family law and criminal trials, took depositions, and drafted court
decisions.
• Prepared all monthly billings and filings of legaLdocuments with different courts.
Performed extensive research and heavy filing.
• Answered phones and met with clients to assist with preparation of documents and
answer questions.
Fafi1114Y.M010,21l
Miami Dade Community College
Miami Sunset Senior High School
Other Certifications: State of Florida Notary
LISANDRO IGLESIAS
Landscape Superintendent
PROFESSIONAL EXPERIENCE
Superior Landscaping .& Lawn Service, Inc.
Landscape Superintendent
• Manage, more than 800 thousand dollars in commercial accounts
• Provide customer service to clients
• Produce monthly schedules for landscape crews
• Produce monthly schedules for water trucks division
+ Sell additional work and schedule billable enhancements
• Purchasing of miscellaneous materials, inventory
• Employee training- Application, safety and disposal.
DHL (Ft. Lauderdale & Miami)
Manager
January 2007 - present
January 2004 — January 2007
• Manage Truck Routes For: Over 40 trucks route and more than 100 commercial accounts
• Package Tracking
• Control Truck inventory
• Head safety Meetings
• Maintain employee uniform supply
• Provide fast and reliable services that exceeded customer expectations
M.C.E.S.C. Adult Day Care June 2000 — May 2004
Transportation Coordinator
• Produced schedules for drivers to meet budgeted hours
• Customer relations
• Employee safety Meetings, trucks Inventories applications
•. Maintained vehicle inventory
• Trained drivers for CPR Courses
City of New Jersey Table to Table Org January 1994 — June 2000
This is a non - profit organization dedicated to pick up food and clothing for the homeless
• Responsible for receiving and coordinating all calls for food deliveries
• With only 3 trucks we managed to feed 4000 people a day
•
Managed/Planned auctions for fundraising
• Coordinated meetings with the City
• Created activities for the organization.
EDUCATION
High School Diploma
CDL License- Class AY
Work zone Traffic Control: Intermediate Level
JORGEARROYO
Account Manager Miami
Inc 0149M19MV -1110 vaW11401 11
Superior Landscaping & Lawn Service, Inc,
Account Manager Miarni
January 1999 - present
• Manage all landscape projects including estimating, planning, purchasing, cost control,
subcontracting and labor
• Provide estimates for commercial and high -end projects
• Direct landscape projects
• Responsible for site inspections and permits
• Respoinsible for conducting customer satisfaction surveys & completion surveys
Oscar's Landscaping & Lawn Service, Inc. Miami, FL January 1995 — January 1999
Lanriscape -Crezo Foreman
Supervised four landscape crews
Dealt directly with customer to prepare & provide estimates
Employee Hiring and placement
EDUCATION
Miami -Dade College, 1995
Associates
CERTIFICATIONS - SPECIALIZED TRAINING
Landscape Technician Training
6130 Sunset Drive
South Miami, FL. 33143
Citywide Landscaping Services
E_ Attachment #1 Sworn Statement
ATTACHMENT #1 PUBLIC ENTITY CRIMES AND CONFLICTS OF INTEREST
Citywide Landscaping Services
Pursuant to the provisions of Paragraph (2) (a) of Section 287.133, Florida State Statutes "A
person or affiliate who has been placed on the convicted vendor list following !a conviction for
public entity crime may not submit a Bid on a Contract to provide any goods or services to a
public entity, may not submit a Bid on a Contract with a public entity for the construction or
repair of a public building or public work, may not submit bids on leases of real property to a
public entity, may not be awarded to perform work as a Contractor, supplier, Subcontractor,
or Consultant under a Contract with any public entity; and may not transact business with any
public entity in excess of the threshold amount Category Two of Section 287.617, Florida
Statutes, for thirty six (36) months from the date of being placed on the convicted vendor list' ".
The award of any contract hereunder is subject to the provisions of Chapter 112, Florida State
Statutes. BIDDERS must disclose with theii` Bids, the name of any officer, director, partner,
associate or agent who is also an officer or employee of the City of South Miami or it's
agencies.
SWORN STATEMENT PURSUANT TO SECTION 287.133 (3)(a),
FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES
for d[ t k `�,r"C a e
fprint name cl entity sub ltting sworn statement]
2. 1 understand that a "public entity crime" as defined in Paragraph 287.133 (1)(g), Florida
Statutes, means a violation of any state or federal law by a person with respect to and
directly related to the transaction of business with any public entity or with an agency
or political subdivision of any other state or of the United States, including, but not
limited to , any bid or contract for goods or services to be provided to any public entity
or an agency or political subdivision of any other state or of the United States and
involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material
misrepresentation.
3. 1 understand that "convicted" or "conviction" as defined in Paragraph 287.133 (1)(b),
Florida Statutes; means a finding of guilt or a conviction of a public entity crime, with or
46
without un adjudication of guilt, in any federal or state trial court of record relating to
charges brought 6v indictment or information after July -|.|989,uoo result ofujury
verdict, non-jury trial, or entry cJa plea of guilty ornoincontende;"o.
4� l understand that an ^'affiiiute''ua defined in Paragraph 287.133 /!\(a)` Elorida Statutes,
means:
66 A predecessor or successor of a person convicted of a public entity crime; or
(b) An entity under the control of any natural person �o is active in the
`management ufthe entity and who has been convicted of public entity crime. The
term "affiliate" includes those officers, directors, executives, partners, shareholders,
employees, members, and agents who are active in the management of an affiliate. The
ownership by one person of shares constituting a controlling interest in any person, or a
pooling of equipment or income among persons when not for fair market value under
on arm's length agreement, shall 6no prima facie case that one person controls another
person. /\ person who knowingly enters into 8 joint venture with x who
been convicted ofu public entity crime |n Florida during the preceding 36 months shall
bu considered unaffiliate.
�. i understand that "person" as defined in Paragraph 287'133 /1\(e), Florida Statutes,
means any natural person or entity organized under the laws of any state or of the
United States with the legal power to enter into a binding contract and which bids or
applies to bid on contracts for the provision af goods ur set-vices led bupQ6{iten1iqy,
or which otherwise transacts or applies tntransact business with o public entity, The
term "person" includes those officers, directors, executives, partners, shareholders,
employees, members, and agents who are active in management of an entity.
6. Based on information and belief, the statement which I have marked below iz true in
relation to the entity submitting this sworn statement. [Indicate which statement
7 applies.
7�Neither the entity subnoiVbh8 this sworn statement, nor any of its officers,
directors, executives, partners, shareholders, employees, members, or agents who are
active in the management of the entity, nor any offi|iztenf the entity has been charged
with and convicted ofo public entity crime subsequent toJuly 1, 1489.
The entity submitting this ovvurn statement, or one or more of its officers,
directors, executives, partners, shareholders, employees, members, ur agents who are
active in the management of the entity, oran affiliate ofthe entity has been charged with
and convicted Afu public entity crime subsequent cnJuly 1. 1984.
The entity submitting this sworn statement, or one or more of its officers,
directors, executives, partners, shareholders, employees, members, or agents who are
active in the management of the entity, or an affiliate of the entity has been charged with
and convicted ofa public entity crime subsequent ofJuly 1, 1489. However, there has
been u subsequent proceeding before a Hearing Officer ofthe State of Florida, Division
of Administrative Hearings and the Final Order entered by the Hearing Officer
determined that |t was not ib the public interest tu place the entity submitting this
sworn statement on the convicted vendor list. {attach a copy of the final orden]
47
Continuation of Attachment #2 Public Entity Crimes and Conflicts
r • r.. .. r e r� , r
s r r s ' • • +� r►
Sworn to and subscribed before me this
/Personally (mown or
Produced identification
(Type of identification)
?j day ofrzrr' 5 20 /".
Notary Public — State of BOOeI6
My commission expires
(Printed, typed or
Form PUR 7068 (Rev,06 /I 1/92)
f�
48
m
6130 Sunset Drive
South Miami; FL. 33143
Citywide Landscaping Services
F. Attachment #2 Drug Free Workplace
ATTACHMENT #2 DRUG FREE WORKPLACE
Citywide Landscaping Services
Whenever two or more Bids which are equal with respect to price; quality and service are
received by the State or by any political subdivisions for the procurement of commodities or
contractual services, a Bid received from a business that certifies that it has implemented a
drug -free workplace program shall be given preference in the award process. Established
procedures for processing tie Bids will be followed if none of the tied vendors have a drug -free
workplace program. In order to haven drug -free workplace program, a business shall:
I. Publish a statement notifying employees that the unlawful manufacture, distribution,
dispensing, possession; or use of a controlled substance is prohibited in the workplace
and specifying the actions that will be taken against employees for violations of such
prohibition.
2. Inform employees about the dangers of drug abuse in the workplace, the business'
policy of maintaining a drug -free workplace, any available drug counseling, rehabilitation,
and employee assistance programs, and the penalties that may be imposed upon
employees for drug abuse violations.
3. Give each employee engaged in providing the commodities or contractual services that
are under Bid copy of the statement specified in Subsection (1).
4, In the statement specified in Subsection (1), notify the employees, that, as a condition of
working on the commodities or contractual services that are under Bid, the employee
will abide by the terms of the statement and will notify the employer of any conviction
of, or plea of guilty or polo contendere to; any violation of Chapter 893 or of any
controlled substance law of the United States or any state, for a violation occurring in
the workplace no later than five (5) days after such conviction.
5. Impose a sanction on; or require the satisfactory participation in a drug abuse assistance
or rehabilitation program if such is available in the employee's community; by any
employee who is so convicted.
6. Make a good faith effort to continue to maintain a drug -free workplace through
implementation of this section.
As the person authorized to sign the statement, (Certify -that this "firm complies fully with the
above requirements.
PROPOSER's
Signature:
Print Name:
Date: i
49
6130 Sunset Drive
South Miami; PL. 33143
Citywide Landscaping Services
G. Attachment #3 No Conflict of Interest /Non Collusion Affidavit
ATTACHMENT #3 No CONFLICT OF INTEREST/ ON- COLLUSION
CERTIFICATION
Citywide Landscaping Services
Submitted this day of l., ► , 20
The undersigned, as Bidder /Proposer, declares that the only persons interested in this RFP are named
herein that no other person has any interest in this RFP or in the Contract to which this RFP pertains;
that this response is made without connection or arrangement with any other person; and that this
response is in every respect fair and made in good faith, without collusion or fraud.
Signature:
Printed Name:
Title: Vt r - " tore e
Telephone: i ° re / rOIL7 p
Company Name p @t clYe G c Gx�r ep t / f
50
Continuation of Attachment #4No Conflict of inter /Non - Collusion Certification
NOTARY PUBLIC:
STATE OF )V9
—LLM d(/ —
COUNTY OF i'14n) i (
The foregoing instrument was acknowledged before me this _��day of
20_Q— by _jQ,(a.,pL (name of
pets n whose signature is being notarized) who is
M
SEAL
My COMMtSajoM a EE 77
F
_XplRES july 0% 2014 61t v *
j,01 :pv'-W
I
Personally known tome, or
Personal identification:
Type of Identification Produced
--ZDid take an oath, or
(Name of 64 4 f Public: Print, Stamp
or type as commissioned.)
FAILURE TO COMPLETE SIGN, &RETURN THIS -FORM MAY DISQUALIFY YOUR RESPONSE
51
6130 Sunset Drive
South Miami, FL. 33143
Citywide Landscaping Services
H, Cast Proposal
PRICING SHEETS
Citywide Landscaping Service
*CYCLE CUTS
2 -Year Contract Extension
Offm
16
ma
PRICING SHEETS
Citywide Landscaping Service
Fertilizer Zones I s 5: Three Times Per Year
� e
17
PRICING SWEETS
Citywide Landscaping Set-vice
.. t MAR: 17
Fertilizer Zones I ® 5: Three Times Per Year
• a • TFTIUXNr •
91121 •
18
6130 Sunset Drive
South Miami, FL. 33143
Citywide Landscaping Services
1, Other Documents
THIS CERTIFICATE IS ISSUM
CERTIFICATE DOES NOT AF
BELOW, THIS CERTIFICATE
the terms
1NSURED
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Service, Inc.
AMEND, EXTEND OR AL'
)NSTITUTE: A CONTRACT
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THIS IS TO CERTIFY THAT 7HE POLICIES OF INSURANCE LISTED BELOW Ad BEEN ISSUED TO THEINSUREO NAPAED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHOH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
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TYPE OF INSURANCE
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POLIUY NUMBER
POLdpYYEFF
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PD"11 E%P
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CAMMEROW.GENERALLLIRILETY
LOBI02620
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ACORb fi6 (200 in) TheAOORD Ha[ille ARR logo aro roljlstored IDAHs ofAGORD
SUPERIOR LANDSCAPING & LAWN
SERVICE INC
2200 N NW 23 AVE PR E5
MIAMI FL 33142
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CITY OF MIAMI BEACH
CERTIFICATE OF USE, ANNUAL FIRE FEE, AND BUSINESS TAX RECEIPT
1700 Convention Center Drive
Miami Beach, Florida 33139 -1819
TRADE NAME: SUPERIOR LANDSCAPING & LAWN RECEIPT NUMBER: RL- 96219454
IN CARE OF: ORLANDO OTERO - PRES Beginning: 10101/2011
ADDRESS: 2200 NW 23RD AVE Expires: 0913012012
MIAMI, FL 33142' Parcel No: 0232020000000
A penalty is imposed for failure to keep this Business Tax Receipt TRADE ADDRESS: 1702 CONVENTION CENTER DR
exhibited conspicuously at your place of business
A certificate of Use i Business Tax Receipt issued under this article
does not waive or supersede other City laws, does not constitute City
approval of.:a particular business activity and does not excuse the
licensee from all other laws applicable to the licensee's business.
This Receipt may be transferred:
A Within 30 days of a bonafide sale, otherwise a complete annual
payment Is due.
B. To another location within the City if proper approvals and the
Receipt are obtained prior to the opening of the new location
Additional Information
Storage Locations
Code
Certificate of Uaehoccupation
011100
LANDSCAPE ARCHITECTS, NURSERY
471200
LANDSOAPE MAINTENANCE
CERTIFICATE OF USE
8888
PREVIOUS BALANCE
$ 0.00
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Landscape Maint FF
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FROM: CITY OF MIAMI BEACH PRESORTED
1700 CONVENTION CENTER DRIVE FIRST STAGE
t/.5. POSTAGE
MIAMI BEACH, FIL 33139 -1819
PAID -
MIAMI BEACH, FL
:PERMIT No 1525
ORLANDO OTERO
PO BOX 350095
MIAMI, FL 33135 -0095
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5:08 PM Superior Landscaping & Lawn Service, Inc.
11108111 Fixed Asset Listing
November 8, 2011
Item
Purchase bate
Purchase Description
Blower -1233
06/22/2009
KAW Blower Tube Throttle KRB750B -A3
Blower -1235
0612212009
KAW Blower Tube ThrottleKRB750B -A3
Blower -1248
06/22/2009
KAW Blower Tube Throttle KRB750B -A3
Blower -1249
06122/2009
KAW Blower Tube ThrottleKRB750B -A3
Blower -1254
06/2212009
KAW Blower Tube Throttle KR67508 -A3
Blower -1259
06/22/2009
KAW Blower Tube Throttle KRB750B -A3
Blower -1264
06/22/2009
KAW Blower Tube Throttle KRB750B -A3.
Blower -1266
06/22/2009
KAW Blower Tube Throttle KRB750B -A3
Blower -1268
06122/2009
KAW Blower Tube Throttle KRB750B -A3
Blower -1289
06/22/2009
KAW Blower Tube Throttle KR8750B -A3
Blower -1687
09/17/2009
KAW Blower Tube Throttle KRB750B -A3
Blower -1704
02/1812010
KAW Blower Tube Throttle KRB750B -A3'
Blower -1705
09/17/2009
KAW Blower Tube Throttle KRB750B -A3
Blower -1711
0211812010
KAW Blower Tube Throttle KRB750B -A3
Blower -1714
02/18/2010
KAW Blower Tube Throttle KRB750B -A3
Blower -1721
02/18/2010
KAW Blower Tube Throttle KRB750B -A3
Blower -2329"
0 710 112 0 1 0
KAW Blower Tube Throttle KRB750B -A3
Blower -2332
07/21/2010
KAW Blower Tube Throttle:KRB750B -A3
Blower -2336
07/21/2010
KAW Blower Tube Throttle KRB750B -A3
Blower -2337
07/21/2010
KAW Blower Tube Throttle KRB750B -A3
Blower -2338
07/01/2010
KAW Blower Tube Throttle KRB750B -A3
Blower -2339
07/0112010
KAW Blower Tube Throttle KRB750B -A3
Blower -2343
07/21/2010
KAW Blower Tube Throttle KRB750B -A3
Blower -2359
0710112010.
KAW Blower Tube Throttle KRB750B -A3
Blower -3030
08/27 /2005
Honda. I-W Ho 13HP Blower
Blower -3814
11/03/2008
Blower 65CC RH BP
Blower -5494
02/15/2011
Echo 630C Blower
Blower -5500
02/1512011
Echo 63CC Blower
Blower -5631
02/15/2011
Echo 63CC Blower
Blower -5650
02/15/2011
Echo 63CC Blower
Blower -8299
08/25/2008
Honda 13HP Blower
Blower -9314
07/0812008
Echo 63CC Blower
Blower -9499
07/08/2008
Echo 63CO Blower
Blower -9569
07/0812008
Echo 63CC Blower
Blower -9578
07/08/2008
Echo 63CC Blower
Blower -9678
08/2212009
KAW Blower Tube Throttle KRB750B -A3
Blower -9679
06/22 /2009
KAW Blower Throttle KRB750B -A3
Blower -9680
06122 /2009
KAW Blower Tube ThrottleKRB750B -A3
Blower -9681
06/22/2009
KAW. Blower Tube Throttle KRB750B -A3
Blower -9683
0612212009
KAW Blower Tube Throttle KRB750B -A3
Blower -9702
09111/2009
KAW Blower Tube Throttle KR6750B =A3
Blower -9703
06/22/2009
KAW Blower Tube Throttle KRB750B -A3
Blower -9704
06/22/2009
KAW Blower Tube Throttle KRB750B -A3
Blower -9705
09/11/2009
KAW Blower Tube: Throttle.KR8750B -A3
Blower -9706
01/21/2010
KAW Blower Tube Throttle KRB75®B -A3
Page 1 of 8
6:08 PM
Superior
Landscaping & Lawn Service, Inc.
11108/1,
Fixed Asset Listing
November 8; 2011
Item.
Purchase Date
Purchase Description
Blower -9707
09/11/2009
KAW Blower Tube Throttle KRB750B -A3
Blower -9726
06/22/2009
KAW Blower Tube Throttle KR8750B -A3
Blower -9728
06/2212009
KAW Blower Tube Throttle KRB750B -A3
Blower -9729
06/22/2009
KAW Blower Tube Throttle KRB750B -A3
Blower -9731
0911112009
KAW Blower Tube Throttle KRB750B -A3
Chainsaw -1
08/25/2005
EchoChalnsaw CS8000 -32
Chainsaw -2028
12/29/2009
Stihl Chain Saw STEMS192T -16
Chainsaw -2697
07/01/2011
Shhl Chain Saw STEMS192T -16"
Chainsaw -2826
07/01/2011
SUN Chain' SawSTEMS192T -16
Chainsaw -2833
07/01/2011
Stihl Chain Saw STEMS192T -16
Chainsaw -2856
08118/2008
Stihl Chain SawSTEMS192T -16
Chainsaw -3144
01/2912010
SUM Chain' SawSTEMS192T -16
Chainsaw -3145
01/29/2010
Stihl Chain .Saw STEMS192T -16
Chainsaw -3157
01/29/2010
Stihl Chain Saw STEMS192T -16
Chainsaw -3175
01/18/2010
Stihl Chain Saw: STEMS390 -25
Chainsaw -3298
09/06/2008
SUN Chain Saw STEMS192T -16
Chainsaw -3329
09/06/2008
Stihl Chain Saw STEMS192T -16
Chainsaw -3331
09/0612008:
Stihl Chain Saw STEMS192T -16
Chainsaw -3352
09/06/2008
Stihl Chain Saw STEMS192T -16
Chainsaw -3362
09106/2008
SUN Chain Saw STEMS192T -16
Chainsaw -3735
08/23/2011
SUN Chain Saw STEMS39125
Chainsaw -4093-
09/17/2009
Stihl 16" Chain Saw MS192TC -E -16
Chainsaw -5034
12/08/2010
Stihl Chain Saw STEMS192T -16
Chainsaw -6287
08118/2008
SUN Chain Saw STEMS192T -18
Chainsaw -6288
08118/2008
Stint Chain Saw STEMS192T -16
Chainsaw -6300
08/18/2008
Stihl Chain Saw STEMS192T -16
Chainsaw -6353
12129/2009
Stihl Chain Saw STEMS192T -16
Chainsaw -5713
0613012008
Stihl Chainsaw SSTEMS192T -16
Chainsaw -6717
05/30/2008
Stihl Chainsaw SSTEMS192T -16
Chainsaw -7263
09/17/2009'
Stihl 16" Chain Saw MS192TC -E -16
Chainsaw -7528
01/29/2010
SIMI Chain Saw:STEMS192T -16
Chainsaw -7556
07/01/2010
Stihl 16" Chain Saw MS192TC -E -16
Chainsaw -7559
07/01/2010
Stihl 16" Chain Saw MS192TC -E -16
Chainsaw -7582.
07/01/2010
SIMI 16" Chain Saw MS192TC -E -16.
Chainsaw -8039.
03/0912011
Stihl Chain Saw:STEMS192T -i6
Chainsaw -8049
03/09/2011
Stihl Chain SawSTEMS192T -16
Chainsaw -8050
03/09/2011
Stihl Chain Saw STEMS192T -16
Chainsaw -8058
0310912011
Stihl Chain SawSTEMS192T -16
Chainsaw -8063
03/09/2011
SUN Chain Saw STEMS192T -16
Chainsaw -8339
12/08/2010
Stihl Chain Saw STEMS192T -16
Chainsaw -9828
08/1812008
Stihl Saw 210 STEMS21:016
Chainsaw -9851
0811812008
Stihl Saw 210 STEMS21016
Chipper -0855
04/2112010
2003 Vermeer BC1400 Chipper
Chipper -2002
04105/2010
2007 Vermeer BC1800XL
Chipper -5324
10/13/2009
2004 Vermeer BC1000XL Chipper
Page 2 of 8
6:48 PM Superior Landscaping & Lawn Service; Inc.
111/081,1 Fixed Asset Listing
November 8, 2011
(tern
Purchase Date
Purchase. Description
Edger -1364
07/01/2011
Shindaiwa Edger SHELE254
Edger -1390
07101/2011
Shindaiwa Edger SHELE254
Edger -1392
07/01/2011
Shindaiwa. Edger SHELE254
Edger -1393
07/01/2011
Shindaiwa Edger SHELE254
Edger -1394
07/01/2011
Shindaiwa Edger SHELE254
Edger -1416
07/01/2011
Shindaiwa Edger SHELE254
Edger -2545
06/2212009
KAW Edger KEL27B-A1
Edger -2546
06/22/2009
KAW Edger KEL27B-A1
Edger -2550
06122/2009
KAW Edger KEL27B -A1
Edger -2552
06/22/2009
KAW Edger KEL27B -A1
Edger -3457
06122 /2009
KAW: Edger KEL27B-A1
Edger -3458
06/22/2009
KAW Edger KEL27B -A1
Edger -3459
06/22/2009
KAW Edger KEL278-Al
Edger -3460
06122 /2009
KAW. Edger KEL2713-A1
Edger -3469
06/22/2009
KAW Edger KEL27B -A1
Edger -3462.
06122/2009
KAW Edger KEL27B -A9
Edger -3463
06/2212009
KAW Edger KEL27B -A1
Edger -3464
06/22/2009
KAW Edger KEL27B -A1
Edger -3465
06/22/2009
KAW Edger KEL27B -A1
Edger -3466
06/22/2009
KAW Edger KEL27B•A1
Edger -3467
06/22/2009
KAW Edger KEL27B -A1
Edger -3468
06122/2009
KAW Edger KEL278-Al
Edger -3685
02/1812010
KAW EdgerKEL27B-A1
Edger -3686
07/0112010
KAW Edger KEL27B =A1
Edger -3688
07/01/2010
KAW Edger KEL27B -A1
Edger -3689
02/18/2010
KAW Edger KEL27B=A1
Edger -3690
02/18/2010
KAW Edger KEL27B -A1
Edger -4009
0911712009
KAW Edger KEL27B -A1
Edger -4010
09/17/2009
KAW Edger KEL27B-A1
Edger -4012
0211812010
KAW Edger KEL2713-A1
Edger -4014
02/1812010
KAW Edger KEL276 -A1
Edger -4015
02/18/2010
KAW Edger KEL27B -Ai
Edger -4017
01121/2010
KAW Edger KEL27B -A1
Edger -4020
07101 /2010
KAW Edger KEL27B -A1
Edger -6713
07/0812008
Shindaiwa Edger SHELE261
Edger -6714
07/08/2008
Shindaiwa Edger SHELE261
Edger -8899
07/10/2008
Shindaiwa Edger SHELE261
Edger -8900
07/10/2008
'Shindaiwa Edger SHELE261
Excavator -1031
08/2112009
Yanmar Model V10273 Mini Excavator
Hedge Clip -0108
06/22/2009
KAW Long Fix Hedge Clip KCL60OA -A1
Hedge Clip -0109
06/22/2009
KAW Long Fix: Hedge Clip KOL60OA•Al
Hedge Clip -0508
06/2212009
KAW Long Fix Hedge Clip KCL60OA -A1
Hedge Clip -0509
06122/2009
KAW Long Fix Hedge Clip KCL60OA -Al
Hedge Clip-0566
0712172010
KAW Long Fix Hedge Clip KCL60OA -A1
Hedge Clip -0569 07121/2010 KAW Long Fix Hedge Clip KCL60OA -A1
Page 3 of 8
5:08 PM Superior Landscaping &:Lawn Service, :Inc.
,1108/1, Fixed Asset Listing
November8, 2011
item
Purchase Date
Purchase Description
Hedge Clip -0570
07/21/2010
KAW Long Fix Hedge Clip KCL60OA -A1
Hedge Clip -0571
07/21/2010
KAW Long Fix Hedge Clip KCL60OA -Al
Hedge Clip -0572
07/21/2010
KAW Lang Fix Hedge Clip KCL60OA -A1
Hedge Clip -0573
07/21/2010
KAW Long Fix Hedge Clip KOL60OA -A1
Hedge Clip -0574
07121/2010
KAW Long Fix Hedge Clip KCL600A -Al
Hedge Clip-0575
07/2112010
KAW Long Fix Hedge Clip KCL60OA -A1
Hedge Clip-0576
07/21/2010
KAW Long Fix Hedge Clip KCL600A -A1
Hedge Clip -0577
07/21/2010
KAW Long Fix Hedge Clip KCL600A -A1
Hedge Clip -0579
07/21/2010
KAW Long Fix: Hedge Clip KCL60OA -Al
Hedge Clip-0580
07/21 /2010
KAW tong Fix Hedge Clip KCL60OA -Al
Hedge Clip -0618
06122/2009
KAW Long Fix Hedge: Clip KCL60OA -Al
Hedge Clip -0622
06/22/2009
KAW Long Fix Hedge Clip KCL60OA -A1
Hedge Clip -0625
06/22/2009
KAW Long Fix Hedge Clip KCL60OA -A1
Hedge Clip -0626
06/22/2009
KAW Long: Fix Hedge Clip KCL60OA -A1
Hedge Clip-0646
07/21/2010
KAW Long fix Hedge Clip KCL60OA -Al
Hedge Clip -0795
07/21 /2010
KAW Long :Fix Hedge Clip KCL60OA -At
Hedge Clip -0915
09/11 /2009
KAW 80 '.ArUc Hedge :Clipper KCL525A -A2
Hedge Clip -0919
09/11/2009
KAW 80' Artic Hedge Clipper KCL525A -A2
Hedge Clip -0966
09/17/2009
KAW 89 Artic Hedge Clipper KCL525A -A2
Hedge Clip -4483
09/17/2009
KAW 80' ArticcHedge: Clipper KCL525A -A2
Hedge Clip-4512
09/17/2009
KAW 80' ArticHedge Clipper KCL525A -A2.
Hedge Clip -4598
0112112010
KAW80'Artic Hedge Clipper KCL525A -A2
Mower -0001
07/29/2009
John Deere 1600 Turbo. Mower
Mower -0004
0612212009
62" SCAG 27 HP KOL STC61 V -27CV
Mower -0005
06122/2009
62" SCAG 27 HP KOL STC61 V -27CV
Mower -0006
06/2212009
62" SCAG 27 HP KOL STC61 V -27CV
Mower -0007
07/29/2009
John Deere 1600 Turbo Mower
Mower -0049
06/22/2009
62" SCAG 27 HP KOL STC61V-27CV
Mower -0052
06/22/2009
62" SCAG 27 HP KOL STC61V -27CV
Mower -0053
06/22/2009
62" SCAG 27 HP KOL STC61V -27CV
Mower -0118
03/26/2010
60" Z Master GS 29HP KAW
Mower -0135
03/25/2010
36" KAW 17HP Hydro Walk Mower
Mower -0183.
08119/2008
Wildcat 61" 26KAW
Mower -0363
05/1012010
60" Z. Master G3 29HP KAW
Mower -0365
05/1012010
60" Z Master G3 29HP KAW
Mower -0366
05/10/2010
60" Z Master G3 29HP KAW
Mower -0367
05/10/2010
60" Z Master G329HP: KAW
Mower -0398
05110/2010
60" Z Master G3 29HP KAW
Mower -0473
02/2112011
60" ZMaster G3 29HP KAW
Mower -0474
02/21/2011
60" Z Master 'G329HP KAW
Mower -0476
02/21/2011
60" Z Master G3 29HP KAW
Mower -0536
08114/2008
Scag 61" 26HP KAWLIQ.
Mower -0592
07/21/2010
Toro Z Master G3 29HP 60
Mower -0746
07/21/2010
Toro Z Master G329 HP 60
Mower -0747
07/2112010
Toro Z. Master G329 HP 60'
Page 4 of 8
6:08 PM Superior Landscaping & :Lawn Service, Inc.
11/08111 Fixed Asset Listing
November 8, 2011
Item
Purchase Date
Purchase Description
Mower -0750
07/21/2010
Toro Z.Master G329. HP 60'
Mower -0751
07/21/2010
Toro Z. Master G3 29 HP 60'
Mower -0752
07/21/2010
Toro Z Master G329 HP 60'
Mower -0753
07/21/2010
Toro Z. Master G3 29 HP 60'
Mower -0758
07121/2010
Toro Z Master G3 HP 60'
Mower -0828
09/17/2009
48" 17HPKAW Hydro Mower
Mower -1121
05710/2010
60" Z Master G329HPKAW
Mower -1235
03/3112005
SCAG 61" ADV 29 HP Mower STT61Z -29KA.
Mower -1420
08/14/2008
Scag 61" 26HP KA LIQ
Mower -1510
11104/2009
60" ZMaster: GS "29HPKAW
Mower -1525
11/04/2009
69' Z: Master GS 29HP. KAW
Mower -1530
11/04/2009
60" Z Master GS 29HP KAW.
Mower -3905
03/31/2005
SCAG 61" ADV 29 HP Mower STT61Z -29KA
Mower -4
09/19/2005
SCAG 61" ADV 29 HP Mower STT61Z -29KA
Mower -5
09/19/2005
SCAG 61" ADV 29 HP MowerSTT61Z -29KA
Mower -6
05/31/2005
DW- HOR- AG- SADDLES 46" DIA x 12' LONG
Mower -7
0513112005
DW- HOR -AG- SADDLES 46" DIAX 12' LONG
Mower -7012
07/01/2009
Snapper Ninja 21" Mower
Mower -8424.
08/25/2008.
Snapper 21" EasySpeed KAW SHP Mower
Mower- Green2.
07/01/2009
Snapper Ninja 21 " Mower
Pole Saw -1935
08/14/2009
Stihl Pole Saw 7.9 to 11.5'- 31.4cc HT101
Pressure -0513
03/31/2010
2004. Hydro Tek Pressure Washer w/ Trailer
Pressure -0569
06/1712006
2006 Hydro Tek Pressure Washer w/
Pressure -3040
03/31/2010
2004 Hydro Tek Pressure Washer w/ Trailer
Pruner -0756
12/0112009
STEHT101;Extendible: Pruner
Pruner -1872
08127/2005
Echo PPT260 Power Pruner 26cc
Pruner -1875
08/27/2005
Echo PPT260 Power Pruner 26cc
Pruner -2105
08/01/2009
Echo PPT260 Power Pruner 26cc
Pruner -2136
08/27/2005
Echo PPT260 Power Pruner 26cc
Pruner -2148
08/27/2005
Echo PPT260 Power Pruner 26cc
Pruner -2951
08101/2009
Echo PPT260 Power Pruner 26cc
Pruner -2811
07/0112010
Echo PPT265 Power Pruner 12'8" Fully
Pruner -8250
08/01/2009
Echo PPT265 Power Pruner 12'8" Fully
Rump -0240
08/1712009
Honda Water: Pump Model WH2OX
SprayComp -001
09/23/2011
Herbicide Spray Computer
Sprayer -l.
0312512009
Sprayer P 10OG 5.5HP KAW
Sprayer -2
03/19/2009
Sprayer P 100E 5r5 HP KAW 112 "X300'
Sprayer -2464
10/21/2008
Sprayer P 200Gal GNC
Sprayer -4600
10/21/2008
Sprayer P.200Gal GNC
Spreader -1
09/16/2008
Vortex Spreader 50db
Spreader -2
12/30/2008
John Deere 80 -Ib Walk - behind Spreader
Spreader -3
10/1812011
Terra Topper Fertilizer Unit
Slump -l.
09/10/2004
:Carlton 27HP Stump Grinder
Stump -2
02/0112006
2003 Vermeer SC352 Stump Grinder
Trencher -0600
02/24/2006
2004 Vermeer Trencher RT450.
Page 6 of 8
.5:06 PM Superior Landscaping & Lawn Service, inc..
11/08/11 Fixed Asset Listing
November 8, 2011
Item
Purchase Date
Purchase Description
Trimmer -0047
10/13/2008
Echo Trimmer SRM280T
Trimmer -0580
10/14/2008
Echo Trimmer SRM280T
Trimmer -0584.
10/14/2008
.Echo Trimmer SRM280T
Trimmer -0597
10/14/2008
.Echo Trimmer SRM280T
Trimmer -0771
09/29/2008
Hedge Trimmer 40" SS
Trimmer -1'164
06/15/2009
KAW 44" Hedge Trimmer KHS1100 -B1
Trimmer -1661
08/15/2009
KAW 44" Hedge Trimmer KHS1100 -B1
Trimmer -1662
06115/2009
KAW 44" Hedge Trimmer KHSi 100 -61
Trimmer -1665
06/15/2009
KAW 44" Hedge Trimmer KHS1100 -61
Trimmer -1667
06/15/2009
KAW 44" Hedge Trimmer KHS1100 -B1
Trimmer -1668
06/15/2009
KAW 44" Hedge Trimmer KHS1100 -B1
Trimmer -1772
02/18/2010
KAW 44" Hedge Trimmer KHS1100 -Bl
Trimmer -1773
02/1812010
2009 KAW 44" Hedge Trimmer KHS1100 -B1
Trimmer -1774
02/18/2010
2009 KAW 44" Hedge Trimmer KHS1100 -B1
Trimmer -1910
0611512009
2009 KAW 44" Hedge Trimmer KHS1100 -B1
Trimmer -1912
06/15/2009
2009 KAW 44" Hedge Trimmer .KHS1100 -B1
Trimmer -1915
06/15/2009
2009 KAW 44" Hedge Trimmer KHS1100 -Bl
Trimmer -1917
06/15/2009
2009 KAW 44 ° Hedge Trimmer KHS1100 -B1
Trimmer -1 "920
06115/2009
2009 KAW 44" Hedge Trimmer KHS1100 -131
Trimmer -1988
07/01/2011
Stihl Hedge. Trimmer STEHL -100
Trimmer -1990
0710112011
Stihl Hedge Trimmer STEHL -100
Trimmer -1993.
07/01/2011
Stihl Hedge Trimmer STEHL -100
Trimmer -1995
07/01/2011
Stihl Hedge Trimmer STEHL -100
Trimmer -1997.
07/0112011
SRI Hedge Trimmer STEHL -100
Trimmer -1998
07/01/2011
Stihl Hedge Trimmer STEHL -100
Trimmer -2124
06715/2009
KAW Solid Shaft Trimmer KGT27B -A1
Trimmer -2180
06/1512009
KAW Solid Shaft Trimmer KGT27B -A1
Trimmer -2191
0611512009
KAW Solid Shaft Trimmer KGT27B -A1
Trimmer -21.99
06115/2009
KAW Solid Shaft Trimmer. KGT27B -A1
Trimmer -2282
06/15/2009
KAW Solid Shaft Trimmer KGT27B -Ai
Trimmer -2284
06/1572009
KAW Solid Shaft Trimmer KGT27B -A1
Trimmer -2295
06/15/2009
KAW 44" Hedge Trimmer KHS1100 -B1
Trimmer -2341
02/18/2010
KAW 44" Hedge Trimmer KHSi100 -B1
Trimmer -2345
02/18/2010
KAW 44" Hedge Trimmer KHS1100 -61
Trimmer -2377
01/05/2010
Echo Hedge Trimmer ECESH0265.
Trimmer -2393
01/05/2010
Echo Hedge Trimmer ECESHC265
Trimmer -2405
09117/2009
2009 KAW 44" Hedge Trimmer KHS1100 -61.
Trimmer -24Q6
01/0512010
Echo Hedge Trimmer ECESHC265
Trimmer -2407
0911712009
2009 KAW 44" Hedge Trimmer KHS1100 -B1
Trimmer -2410
09/17/2009
2009 KAW 44" Hedge Trimmer KHS1100 -Bl
Trimmer -2412
02/18/2010
2009 KAW 44 " Hedge Tnmmer KHS1100 -Bt
Trimmer -2429
01/0512010.
Echo Hedge Trimmer ECESHC265
Trimmer -2509
07/01 /2010
KAW 44" Hedge Trimmer KHS11Q0•B1
Trimmer -2511
07/01/2010
KAW 44" Hedge Trimmer KHS1100 -B1
Trimmer -2516
07/01/2010
KAW 44" Hedge Trimmer KHS1 i00 -B1
Page 6 of 8
5:08 PM
Superior Landscaping &.Lawn Service, Inc.
1v 0e /ii
Fixed Asset Listing
November 8, 2011
Item
Purchase Date
Purchase Description
Trimmer -2517
07/01/2010
KAW 44" Hedge Trimmer KHS1100 -B1
Trimmer -2662
06/15/2009
2009 KAW Solid Shaft Trimmer KGT27B -A1
Trimmer -2664
06/1512009
2009 KAW Solid Shaft Trimmer KGT27B -A1
Trimmer -2665
06/15/2009.
2009 KAW Solid Shaft Trimmer KGT27B -A1
Trimmer -2668
06/15/2009
2009 KAW Solid Shaft Trimmer KGT27B -At
Trimmer- 2702
0611512009
:2009 KAW Solid Shaft Trimmer KGT27B -A1
Trimmer -2704
06115/2009
2009 KAW Solid Shaft Trimmer KGT27B -A1
Trimmer -2706
06115/2009
2009 KAW Solid Shaft Trimmer KGT27B -A1
Trimmer -2717
06/15/2009
2009 KAW Solid Shaft: Trimmer KGT27B -A1
Trimmer -2720
06/15/2009
:2009 KAW Solid Shaft Trimmer KGT27B -A4
Trimmer -2734
01/21/2010
:2009 KAW 44" Hedge Trimmer KHS1100 -B1
Trimmer -2760
06/15/2009
2009 KAW Solid Shaft Trimmer KGT27B -A1
Trimmer -3021
10113/2008
Echo Trimmer
Trimmer -3069
10/1312008
Echo Trimmer SRM280T
Trimmer -3724
07/08/2008
Shindaiwa T270A Trimmer
Trimmer -3725
07/08/2008
Shindaiwa. T270A Trimmer
Trimmer -3790
07/08/2008
Shindaiwa T270A Trimmer
Trimmer -3900
07/08/2008
Echo Hedge TrimmerECESHC265
Trimmer -3932.
07/08/2008
Echo Hedge. Trimmer ECESHG265
Trimmer -3990.
07/08/2008
Shindaiwa T270A Trimmer
Trimmer -3991
07108/2008
Shindaiwa T270A Trimmer
Trimmer -4086
07/31/2008
Shindaiwa T270A Trimmer
Trimmer -4087
07131/2008
Shindaiwa T270A Trimmer
Trimmer -4170
07/08/2008
Echo Hedge Trimmer ECESHG265
Trimmer -4185
07/08/2008
Echo Hedge Trimmer ECESHG265
Trimmer -4605
09/11/2008
2009" KAW Solid Shaft Trimmer KGT27B -A1
Trimmer -4613
09/11/2008
2009! KAW Solid Shaft Trimmer KGT27B -Ai
Trimmer -4618
02118/2010
2009 KAW Solid Shaft Trimmer KGT27B -A1
Trimmer -4618
02118/2010
.2009 KAW Solid Shaft Trimmer KGT27B -A1
Trimmer -4787
06/1512009
2009 KAW Solid Shaft Trimmer KGT27B -A1
Trimmer -4789
06/15/2009
2009 KAW Solid Shaft Trimmer KGT27B -A1
Trimmer -4790
06/15/2009
2009 KAW Solid Shaft Trimmer KGT27B -A1
Trimmer -4792
06/15/2009
2009 KAW Solid Shaft Trimmer KGT27B -Ai
Trimmer -4820
07/01/2011
ShindaiwaSHET282 Trimmer
Trimmer -4821
07/01/2011
Shindaiwa: SHET282 Trimmer
Trimmer -4874
07/0112011
ShindaiwaSHET282 Trimmer
Trimmer -4964
09/17/2009
2009 KAW Solid Shaft Trimmer KGT27B -A7
Trimmer -4965
01/21/2010
2009 KAW Solid Shaft Trimmer KGT27B -Ai
Trimmer -4987
09117/2009
2009 KAW Solid Shaft Trimmer KGT27B -Ai
Trimmer -4988
02/18/2010
2009: KAW. Solid Shaft Trimmer KGT27B -A1
Trimmer -4990
09/17/2009
2009 KAW Solid Shaft Trimmer KGT27B -A1
Trimmer -4991
09/17/2009
2009 KAW Solid Shaft Trimmer KGT27B -A1
Trimmer -4992
02/18/2010
2009 KAW Solid Shaft Trimmer: KGT27B -A1
Trimmer -4993
01/21/2010
2009 KAW Solid Shaft Trimmer.KGT27B -At
Trimmer -4995
02/18/2010
2009 KAW Solid Shaft. Trimmer' KGT27B -A1
Page 7 of 8
5:08 PM Superior Landscaping &,Lawn :Service,. Inc.
11108/11 Fixed Asset Listing
November 8, 2011
Item
Purchase Date
Purchase: Description
Trimmer -4996
02/18/2010
2009 KAW Solid Shaft Trimmer KGT27B -A1
Trimmer -4998
02/1812010
2009 KAW Solid Shaft Trimmer KGT27B -A1
Trimmer -4999
02/18/2010
2009KAW Solid Shaft Trimmer KGT27B -A1
Trimmer -5066
0911112008
Shindaiwa HT23040 Hedge Trimmer
Trimmer -5099
01/2112010
2009 KAW Solid Shaft Trimmer KGT27B -A1
Trimmer -5276
07!01/2011
Shindaiwa SHET282 Trimmer
Trimmer -5500
02/1512011
Shindaiwa SHET282 Trimmer
Trimmer -5501
02/1512011
Shindaiwa SHET282 Trimmer
Trimmer -5850
02114 /2011
KAW Solid Shaft Trimmer KGT27B -A2 27cc
Trimmer -5954
02/1512011
Shindaiwa 'SHEHT231 -30 Hedge Trimmer
Trimmer -5955
02/15/2011
ShindaiwaSHEHT231 =30 Hedge Trimmer
Trimmer- 5985VD
07/21/2010
KAW Solid Shaft Trimmer KGT27B -A1
Trimmer -6042
07/21/2010
KAW Solid Shaft Trimmer KGT278-A1
Trimmer -6043
07/21/2010
KAW Solid Shaft Trimmer KGT27B -A1
Trimmer -6044.
07121 /2010
KAW Solid Shaft Trimmer KGT27B -Ai
Trimmer -6058
07/01/2010
KAW Solid Shaft Trimmer KGT27B -A1
Trimmer -6059
07/01/2010
KAW Solid Shaft Trimmer KGT27B -A1
Trimmer -6060
07/01/2010
KAW :Solid Shaft Trimmer KGT27B -A1
Trimmer -6001
07121/2010
KAW Solid Shaft Trimmer KGT27B-A1
Trimmer -6002
07/21/2010
KAW .Solid Shaft Trimmer KGT27B -A1
Trimmer -6063
07121/2010
KAW Solid Shaft Trimmer .KGT27B -A1
Trimmer -6070
0712112010
KAW Solid Shaft Trimmer KGT27B -A1
Trimmer -6072
07/21/2010
KAW Solid Shaft Trimmer KGT27B -A1
Trimmer -0074
07/21/2010
KAW Solid Shaft Trimmer KGT27B -A1
Trimmer -6075
07/21/2010
KAW Solid Shaft TrimmerKGT27B-A1
Trimmer -6070
07/21/2010
KAW Solid Shaft Trimmer KGT27B -A1
Trimmer -6077
07121/2010
KAW Solid Shaft Trimmer KGT27B-A1
Trimmer -6078
07121/2010
KAW Solid Shaft: Trimmer KGT27B -A1
Trimmer -6079
07/21/2010
KAW Solid Shaft Trimmer KGT27B -A1
Trimmer -6080
07/21/2010
KAW Solid Shaft Trimmer KGT27B -A1
Trimmer- 6114VD
07/21/2010
KAW Solid Shaft Trimmer KGT27B -Ai
Trimmer -7590
02/15/2011
Shindaiwa STEHS45.24Trimmer
Trimmer -7940
0710112011
Shindaiwa SHET282 Trimmer
Trimmer -7941
07/01/2011
Shindaiwa SHET282 Trimmer
Trimmer -9736
07/01/2011
SUN Hedge Trimmer STEHL -100
Trimmer -9743
07/01/2011
SUM Hedge Trimmer STEHL -100
Trimmer -9752
07/01/2011
SIMI Hedge Trimmer: STEHL -100
Trimmer -9776
07/01/2011
SUN Hedge Trimmer STEHL -100
Trimmer -9941
07101/2011
Stihi Hedge Trimmer STEHL -100
Trimmer -9957
07/01/2011
SUM Hedge Trimmer STEHLA00
Trimmer -9967
07/01/2011
SUN Hedge Trimmer STEHL -100
Trimmer -9972
07101/2011
SUN Hedge Trimmer STEHL -100
Utility8779
07/27/2011
John Deere 6x4 diesel Model #419195
Page 8 of 8
5:08 PM
Superior Landscaping fir. Lawn: Bernice, Inc.
01105!12
Ash "aw
Item
FAM Number Purchase DatFixed
02/18/2006 2004 Ai< A rl `l� 14
TR -06
TR -07
02/17/2006 2004 Ford F150
TR -100
10/25/2007 2007 Isuzu NPR -HD Flatbed
TR -101
10/30/2007 2001 Sterling AT9500
TR -102
11/28/2007 2007 Ford Focus SE
TR 103
03/31/2008 2004 Ledwell 2000 Water Truck 2000 -3000 Gal
TR -104
09/0312008 2008 Nissan Sentra
TR -105
09/03/2008 2008 Nissan Sentra
TR -106
04/25/2008 2005F -550 Crewcab 10'FB
TRA 07
04118/20082005 Ford F550 CrewCab
TR -108
04/10/20082007:GMC W4500 Crew Cab
TRA 09
09103120082008 Nissan Sentra
TRA 1
04/12/2001 J998 Isuzu Pickup
TRA 10
09/03/2008 2008 Nissan Sentra
TRA 11
09103/20082008 Nissan Sentra
TRA 12
0910312008 2008 Nissan Sentra
TRA 13
09/03/2008 2008 Nissan Sentra
TRA 14
03101/2009:2006 GMC W4500 Dump Body
TR -115
01127/2009 2006 GMC W550 Flat Bed
TRA 16
05/14/2009 2007 Chevy CW5500 Crew Cab Dump
TRA 17
05120/2009. 2007 Isuzu NPR HD
TRA 18
06105/2009 2006 Isuzu NPR Crew Cab
TRA 19
05/29/2009 2007 Isuzu Crew: Cab'12'FB
TR -120
06119/2009 2006 Ford F150 Reg Cab
TR -121
06/1912009 2006 Ford F650. Reg Cab
TR -122
07/0312009 2006 Ford F450 Reg Cab
TR -123
07/0372009 2006 Ford F550 Reg Cab
TR -124
06/05/2009 2006 Ford :F450Reg Cab
TRA 25
07/0312009 2005 Ford F550 Reg Cab
TR -126
07/03/2009 2005 Ford F550 Reg Cab.
TR -127
05/18/2010 2007 Chevy CW4SO42
TR -17
01/2512003 1999 International C- 470018': Flatbed Truck
TR -20
09/22/2006 2001 International 4700
TR -23
07/24/2003 1997 GMC 7500 W /LR111 Boom & Chipper Damper
TR -26
0212712004 .2004 Ford F750 w/ Peterson lightning loader
TR -27
02/27/2004 2004 Ford F150 XLT
TR -28
02/27/2004 2004 Ford F150 XLT
TR -32
06117/2004 2004 Isuzu NPR w /14' Landscape body
TR -33
06117/2004 2004 Isuzu NPR. w/ 14' Landscape body
TR -34
07/0212004'1997GMC 7500 w/ Lrill Boom Truck
TR36
07/2212004 2003 Ford F250 EXT Cab
TR -37
09/27/2004 2004 Ford F150 AT
TR -38
09/27/2004 2004 Ford F150 AT
TR -39
09/27/2004 2004 Ford F150 XLT
TR -43
10/01/2004 1998 GMC 7500 Bucket truck w/ LR1V
Page 1 of 3
6:08 PM
Superior Landscaping & Lawn Service; Inc.
01/05H2
Ash sU n%n
Item
FAM Number Purchase DatFixed
TR -44:
10120120042005 L.
TR -45
10/20/2004 2005 Ford F150 XLT
TR -46
10/22/20042005Isuzu Grew Cab 94':ALUM LS body
TR -48.
01/13/20052001 International 4744 Water Truck
TR -49 .
02/17/20052005 Ford E150 (IRRIG)
TR -50
02117/2005 2005 Ford F950Lariat
TR -51
03/24/2005 2005 Isuzu NPR -HD Crew Cab Steel Body
TR -52
05119/20052005 Isuzu Crew Cab 14'. ALUM LS Body
TR -53
07/20/2005 2006 Ford E150(Irrig) Van
TR -55
07120/2005 2006 Isuzu Crew Cab14'.Alum LS Body
TR -56
09/28/2005 2006 Isuzu Grew Cab 14' Alum LS body
TR -60
06123/2006 2006 Ford El 50
TR -63
07/12/2006 2007 Isuzu NPR -HD CrewCab
TR -64
08/15/2006 2007 Isuzu NPR -HD CrewCab
TR -65
09/06/2006 2004 Ford F650
TR -66
09/06/2006 2004 Ford F650
TR -67
01/01/2007 2007 Ford F150
TR -68
02/1812006 2005 Ford F750
TR -69
10/31/2006 2007 NPR -HD CrewCab
TR -70
01101/2007 2007 Ford F150
TR -71
01/0192007 2007 Ford F150
TR -72
01/01/2007 2007 Ford F150
TR -73
01/01/2007 2007 Ford F150
TR -74
01/01/2007 :2007 Ford F150
TR -75
01/01/2007 :2007 Ford F150
TR -76
01/01/2007 2007 Ford F150
TR -77
01/01/2007 2007 Ford F150
TR -78.
01/01/2007 2007 Ford F150.
TR -79
01/0112007 2007. Ford F150
TR -80
01/01/20072007 Ford F150
TR - -81
01/0112007 2007 Ford F150
TR -82
01/01120072007 Ford F150
TR -83
01/01/2007 2007 Ford F150
TR -84
01101/2007 2007 Ford F150
TR -85
11/19/2006 2006 International 4300 Bucket. Truck.
TR -86
11/19/2006 2006 International 4300 Bucket Truck.
TR -87
- 01101/2007 2007 Ford E150 Cargo Van
TR -88
01/01/2007 2007 Ford E150 Cargo Van
TR -89
01/01/2007 2007 Ford E-150 Cargo Van
TR -90
01/0112007 2007 Ford Explorer
TR -91
01/01/2007 2007 Ford Explorer
TR -92
01101/2007 2007 Ford E150 Cargo Van
TR -94
06/20/2007 2005 Ford F650
TR -95
07/11/2007 2607 Ford F350 10' Flat Bed
TR -96
0711.3/2007 2006 Isuzu NPR -HD
Page 2 of 3
5:08 PM
Superior :Landscaping &..Lawn Service, Inc.
01/05/12.
' gin
.Item
FAM Number Purchase DatFixedAs s
TR -97
07/13/2007.2006 1MAW
TR-98
07/27/2007 2002 Freightliner /Ledwell Water Truck
TR -99
08129/2007 2003 Ford. F650 Water Truck
TR -01
04/01/2001 Ford F -250
TR -02
01/0112002 Truck
TR -04
01/01/2003 Truck
Trailer 03
0812612005 2005 Kendall Trailer 7'x20'
Trailer 15
01/3012004 2004 Kendall Trailer 7'x18'- Enclosed
Trailer 16
05/11/2004 2004 Southwest Trailer: 7'x18'Enclosed
Trailer 17
06/24/2004 2004 Southwest Trailer 7'x18' Enclosed
Trailer 18
06/25/2004 2004 Southwest Trailer 7'xl8':Enclosed
Trailer 22
03/24/2005 2005 Kendall Trailer Tx16'
Trailer 23
03/24/2005 2005 Kendall Trailer 7'x20'
Trailer 27
06/30/2006 2006 Suncoast 18' Trailer
Trailer 28
07108/2006 2006 Anderson &'x25' Trailer
Trailer 29
07117/2006 2007 Suncoast 18' Trailer
Trailer 35
0210112007 2006 Anderson Trailer
Trailer 36
02/08/2007 2007 Anderson Trailer
Trailer 39
06/20/2007 2006 Trailer Tx18'6 Ton
Trailer 40
0712812007 2007 Anderson Trailer 7 Ton
Trailer 41
08/29/2007 2007 Anderson Trailer
Trailer 42
08/2912007 2007 Anderson Trailer
Trailer 43
11/1612007 1991 Fruehauf Drop Deck Trailer
Trailer 46
06/11/2009 .Enclosed trailer '6' -10 "x 16'x 65"
Trailer 47
10/02/2009 2005 Anderson Trailer
Trailer 49
03/05/2010 8'x 16' Enclosed Trailer
Trailer 54
10118/201'1 1991 Great Dane 48' trailer
Trailer 55
10/18/2011 2009 Better Built Trailer
Trailer 01
04101/2001 Trailer
Trailer 02
08/1712006 Suncoast Trailer
Page 3 of 3
OSHA "s Form 300A
summary of .LLJurles and 111n osses
estobllrhmentXDt 12. 24765£38409 °5
Number or Cases
Total number or ,Total number of Total number of
Total mmn)bsr e cases with Job otter
of deaths cases with clays transfer or recordable
away hom work restiictloo cases
0 4 1. 0
(G) (H) (1) (J)
Number of )ays
Total lumber of days away
from work
4
(K)
Injoi v and Illness "types
Total numberof,:,
(M)
Pago l of 6
listnblistmrent Infornoi Uon
Your
eabihlishment
ltnniel
stroet:
SUPERIOR
LANDSCAPING &
LAWN SFRVICG
ATTENi MANAGCR
2200 NW 23111) AVL
Total number of days ofjob 'transfer Clty;MIAMI. Stato:FL ZIP: 33142
01, restrictlon
2J.
(1) Injuries
4 (4) Polsoilln4ls
(2) Skin
disorders
L (5) Hearing loss
(3)
Respiratory
0 (6) All other
,_. _ ., Illnesses
conditions
(C.) Employment loformatlon
Annual average number of 368
employees ; -
0 Total hours Worked by all 366538
employees last year: —
6—
_,0 ,.. <
Page 2 of Ey
Pist'alAishment Comments — Section I &Section 2
listnbllshnientXDi 1)- 206688409 -5
o No comments to rgoi t.
Pago 3 of(i
9ecOon 3 - Reporting Cases %vital (lays Away from Wolk
h5tabllshmentID., 12- 296588409 -5
Employee Name: rdwardIlicks
Joii TIEIe: Foreman
Data of Injury or onsot or Illness: i0 /;tunoo9
Number of clays away from work: 7.
Number of (lays of job transfer or restrictlon: 0
i. Type of Job or Work:
2, OlIployee's race or ethnic backgrounds.
o White
3; Employee's age: 52 and dato of blithe 08 /28/1957
4. Employee's (late fih'ed: 06/30/2008 and Lengui of service: -From i to s years
5. Employee's gender; Mille
6. Time employee began work; 0630 AM
7, Tune of event: 0300 PM '
Event, Occurred: During workshift
8. Whatevas the employee doing before the Incklent7
Edward file]($ WEIS in the troes reuloving some Fioridn Holly Branches. When one of them got uncle),
his glasses and poled him oil jets eye causing a lncer<htlon.
9, What happened?
Edward hicks was In the trees removing some Florida Holly Dvanches whon one of there got under
Ills glasses and holed $1111 cu Ills eye gaeirehig a laceration.
in. What was the injury ar Illness?
He Scratched his cornea.
lt: What object or substance directly harmed the employee?
A rlovIda Holly Branche.
case Comments:
Pago 4 of
Section $ - Reporting Cases. With Days Away from Work
RstaflishillonttDt 12- 299x88409 -'s
Employee Name: Joan c Ftaly
Job 1111o: Crow Leader,
Date of iajuly or onsot of Illness: 10/16 /2009
Number, of days away from work: 1
Number of days of jab tiansfer or restrictioh; 0
I. Type of Job or Work:
2. Crnplogee`s race or etbhic backgrOUnd:
o FSlnck or AfrIcrvn American
3, rilli oyce't. ale: 19 and date of birth: 04/11/1950
4. Enriiloyee's date hired: OCs /12/ 2008 wid Length of service: From S to rx:years
5, imployee's genclor: Mato
G. Time employee began work; 0030 AM
7. 'rime of evont: 020o pM
Event Occurred: During work shift
8, What was the employee doing before the Incident?
Dumping Garbage
9, What happoned?
Jean Holy was going to dump garbage whorl he got onto the truak and -he foil from the truck to the
ground hating fits hone[ rosulting ar pribi oil the heart.
10: What was the injury or illness?
He fell and hurt Ills bead.
11, What object or substarice directly harmed the employee?
noire
Case Coftllllonts;
Pago5 of 6
Section 3 - Reporting Cases with Days Away from Work
listablishment XD,,
t3nployee Nanie: Christopher Walker
Job Title: Foreman
Date of Injury onset of illness; 11/is/2009
NUlnbor of days away from work: :i
Number of days of job transfer or restrlclton: 0
1, Type Of 301) or Work:
2, E roployea 's raw oil ethnicbackground:
o White,
3. Employee's age: 34 and dato of birth: 10025/1975
4, Employees (Bate blred: 11/11/2000 will length of service: less: than 3 months
5. Gmployou's gender; Main
5, Thine employee began work: 0630 AM
Y: Time of event: 1100 AM
Event Occurred: During work shift
8, What was the employee doing before the Incident?
Chl'stopharWalkel,wig runrrinco an ottgo,
9: What happened?
Chrstopher Walker was runtzinp an edge and was possibly stung by a bee all mr ant causing air
altorgia reaction to [its sithi,
10, What was the injury oil illness?
109111 arm.
11. What object oilsubatanco directly harmed the employee?
Stung by a bee or ris Ant,
Case Comments:
Page 0 of G
Section 3 - Reporting Cases with Days Away from Work
L °stablIshmentM 12- 296508409-5
Employe Name! 311ata Lahvez
Job Title: Laborer
Date of Injury or onset of Illness; 12/08/2009
Number of days away from works 1.
Number of days of job transfer at, reshidton: 2J.
1. Type of Job or Work:
2� Employee 'e race or ethnic background:
o Hispanic or Lotino
3, Employee's age! 37 and date of birth:. OG/24/1972
4: Employee's elate hired. 02/27/200£8 and Length of service! from J. to 5 years
5. hinployeo's gender; Mole
G• Tian employeo began work: 0030 AM
7, T'lave of event., 1130 AM
Event Occurred: during work shift
8. What was the employea doing before the lneklent?
Juan Laitvoz wasshovoling dirt.
9. What happened?
Joan l alnes was shovoRng dirt when im tvtisted anti felt soave pain and hurnInp sensation o❑ his
abdomen.
10: What was the injuty or Illness?
.Oustnlnod :a Hernia on his abdomen. We has a restriction of not lifting nothing heavier than 1:13
pounds,
11. What object or substance directly h?rined the employee?
Movement of ehoveling flirt.
Coca Comnionts:
If you have tluestions or comments please sand e -mull to: osft.lieipdesk@blsslov
version: 8.0
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