WI-28993_48187_F_PATA_20220117

Site Name City / County /Columbus Incident #48187
Resp Pty Name / Contact Incident Mgr Region WIL
RP Type (Owner/Operator / Landowner / Attny-in-fact)Change Order?Prev. TA #0
Consultant / Project Mgr /Ethan Rogerson
Telephone / Fax Number /Task Authorization Number:1 ChangeOrd:
Project Mgr Email Site Risk / Rank / Abatement:unk RRA Date:
Proposal# / Scope Dates /% Commercial (C=100%, NC=0%, Both=1%-99%)
Has STF Eligibility Been Determined? (Y/N)Site Status (Active or NFA Date)
With Claim: [ ] All Main Consultant/Contractor invoices attached?[ ] Proof of payment attached directly to the front of each invoice?
 Important: The date of reimbursement is dependent on the Trust Fund balance. There may be a delay in the reimbursement of claims for work under this ePATA.3rd Pty Ded?Task #Lab /
SubCode
RO IM AuthProposed
Rate/Price
(Consultant)RO Supv. AuthProposed Task
Subtotal
(Consultant)
Preapproved
Subtotal
(UST Section)
Claimed
Amount3
(Consultant)
2.600 1 /site y $4,324.00 Y $4,324.00 $4,324.00 /
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Requested Preapproved Claimed3
TOTAL:$4,324.00 $4,324.00 TOTAL:
Total Standard Costs (Not Third Party)$4,324.00 $4,324.00 Total Standard Costs
Total applied as Third Party Deductible/Damage Costs $0.00 $0.00 Total Third Pty Costs
Process Tracking (Date)
TA Submittal:1/17/22 by:(PM)(Reserved for RO)
RO Review:1/25/22 by:(IM)Joint UST Preapproval Confirmed By:Date1 1/31/2022
RO Supv. Review:1/25/22 by:(STF)RP or Designee Receipt Confirmation By:Date 4
1 - This ePATA expires one year from the Joint UST Preapproval date. This does not extend, alter, or supersede any regulatory deadlines (e.g., NORR's, NOV's, Enforcements, etc.)
2 - THE ONE YEAR STATUTE OF LIMITATIONS APPLIES TO EACH INDIVIDUAL TASK. Costs must be claimed within one year of completion of that task to be reimbursable.
3 - Only Tasks included on this ePATA may be claimed. Do not include other Tasks or claimed costs (i.e., Claim preparation) that were not preapproved or the claim will be returned.
4 - Preapproval is not valid (i.e., claimable) until receipt is signed as 'Confirmed' by the RP or their designee within a week of approval. The signed pre-approval must be submitted
in the submitted claim. Signature indicates acknowledgement of the tasks and amounts approved. Any objections/appeals must be submitted via Change Order prior to work
proceeding. Scope/cost negotiations do not supersede other regulatory deadlines as described in #1 above. Also, any ePATA that has been signed as 'Confirmed' by both the
UST Section and RP is not to be modified without written consent by all signatories.
5 - Tasks approved on Directed - CAB Only ePATAs must be performed in accordance with all applicable rules, statutes, and RRD Task Scopes of Work to be reimbursed in full.
DWM/UST ePATA 8/1/2020
DIRECTED - CAB ONLY
Nakia
(Must Complete with Claim Submittal)(See Instructions / RRD for Tasks requiring Preapproval / Task Authorization)
Owner/Operator
704-845-4010
(Reserved for Incident Manager)
PREAPPROVAL / TASK AUTHORIZATION
Home Race Mart #1
Note:This Electronic Preapproval Task Authorization (ePATA)shall be used to receive preapproval from the UST Section.A proposal,including maps and figures,must be
attached to elaborate on the costsfor the tasks listed below that describes the scope of work and the rationale for the proposed activities.If,following completionof this ePATA,you discover that unexpected tasks must be performed,incurring costsfor tasks not originally included with this form,you mustcomplete and submit a separate ePATA request
designated as a "ChangeOrder"in the provided space above prior toconducting those tasks.Include a copy of the prior ePATA form for confirmation.Please attachthis form to
the cover of the corresponding claim when requesting reimbursement.IMPORTANT:Only one claim may be submitted per ePATA and all work on the ePATA must have beencompletedwithin12monthsofthecompletiondateoftheFIRSTcompletedtasktoremainwithintheStatuteofLimitations.All ePATAs submitted within a claim are closed withthatclaim,and may not be re-used ina separate submittal,evenforcosts or tasksthat were not originally claimed.Finalreimbursement of costs associated with the Total Claimed
amount below may be affected by the eligibility status of the site (i.e.,deductibles,apportionment,etc.),and the documentary validation of incurred costs as reasonable and
necessary expenses per 15A NCAC 2P .0402 and .0404.
CW
MHH
(Initials)
Clark Wipfield
ER
Proposed
Units / Type
(Consultant)
Clark Wipfield
FALSE
22-026 January 2022
704-845-4012
Dates of Work
(Consultant)
Started1 / Completed2
FINAL REIMBURSEMENT
100.00%
[e-mail]
Naji Ahmed K & S LLC
Geological Resources, Inc.
ELECTRONIC PREAPPROVAL TASK AUTHORIZATION FORMDept of Environmental Quality -Division of Waste Management