WI-29265_48433_F_PATA_20230320_TA2

Site Name City / County /Duplin Incident #48433
Resp Pty Name / Contact Incident Mgr Region WIL
RP Type (Owner/Operator / Landowner / Attny-in-fact)Change Order?Prev. TA #1
Consultant / Project Mgr /Laura Minor
Telephone / Fax Number /Task Authorization Number:2 ChangeOrd:
Project Mgr Email Site Risk / Rank / Abatement:I 150 A RRA Date:2/28/2023
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)
Final
Preapproved
Subtotal
(UST Section)
Claimed
Amount3
(Consultant)
3.060 1 /event y $1,000.00 Y $1,000.00 $1,000.00 /
3.101 45 /feet y $12.50 Y $562.50 $562.50 /
3.101 40 /feet y $18.00 Y $720.00 $720.00 /
3.113 45 /feet y $50.00 Y $2,250.00 $2,250.00 /
3.115 40 /feet y $75.00 Y $3,000.00 $3,000.00 /
3.118 85 /feet y $5.00 Y $425.00 $425.00 /
//
3.397 1 /Mobe y $100.00 Y $100.00 $100.00 /
3.398 1 /Mobe y $350.00 Y $350.00 $350.00 /
3.500 6 /nights y $151.00 Y $906.00 $906.00 /
4.031 5 /wells y $110.00 Y $550.00 $550.00 /
4.080 8 /sample pt.y $45.00 Y $360.00 $360.00 /
4.090 #240 5 /samples y $94.00 Y $470.00 $470.00 /
4.090 #272 1 /sample y $66.00 Y $66.00 $66.00 /
4.090 #280 4 /samples y $45.00 Y $180.00 $180.00 /
4.090 #330 4 /samples y $14.00 Y $56.00 $56.00 /
4.090 #341 4 /samples y $56.00 Y $224.00 $224.00 /
4.090 #640 2 /samples n $129.00 N $258.00 $0.00 /
4.091 2 /shipments y $60.00 Y $120.00 $120.00 /
5.010 1 /event n $1,300.00 N $1,300.00 $0.00 /
6.032 1 /report y $1,800.00 Y $1,800.00 $1,800.00 /
12.030 3 /nights y $151.00 Y $453.00 $453.00 /
12.050 2 /trips y $250.00 Y $500.00 $500.00 /
12.055 2 /trips y $50.00 Y $100.00 $100.00 /
3.080 1 /agreement y $250.00 Y $250.00 $250.00 /
3.351 5 /wells y $80.00 Y $400.00 $400.00 /
1.050 1 /agreement y $300.00 Y $300.00 $300.00 /
Requested Preapproved Claimed3
TOTAL:$16,700.50 $15,142.50 TOTAL:
Total Standard Costs (Not Third Party)$16,700.50 $15,142.50 Total Standard Costs
Total applied as Third Party Deductible/Damage Costs $0.00 $0.00 Total Third Pty Costs
Process Tracking (Date)
TA Submittal:3/8/23 by:(PM)(Reserved for RO)
RO Review:3/14/23 by:(IM)Joint UST Preapproval Confirmed By:Date1
RO Supv. Review:3/17/12 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 4/1/2022
DIRECTED - CAB ONLY
Warsaw
(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
Friendly Mart 4
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 costs for the tasks listed below that describes the scope of work and the rationale for the proposed activities.If,following completion of this ePATA,you discover that
unexpected tasks must be performed,incurring costs for tasks not originally included with this form,you must complete and submit a separate ePATA request designated as a "Change
Order"in the provided space above prior to conducting those tasks.Include a copy of the prior ePATA form for confirmation.Please attach this 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 been completed within 12 months of the
completion date of the FIRST completed task to remain within the Statute of Limitations.All ePATAs submitted within a claim are closed with that claim,and may not be re-used in a
separate submittal, even for costs or tasks that were not originally claimed.Final reimbursement 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)
LM
Proposed
Units / Type
(Consultant)
Clark Wipfield
YES
23-068 March-April 2023
704-845-4012
Dates of Work
(Consultant)
Started1 / Completed2
FINAL REIMBURSEMENT
100.00%
[e-mail]
Campbell Oil, Inc.
Geological Resources, Inc.
ELECTRONIC PREAPPROVAL TASK AUTHORIZATION FORM
Dept of Environmental Quality -Division of Waste Management
Re-opened site due to discovery of new FP
in MW-1. Please move one Type II MW to
the former TMW 2 area to help with FP
delineation. CCW
3/20/2023