FA-1015_19070_F_PATA_20150511_9 Food Lion 2015-05-11

Site Name City / County /Harnett Incident #19070
RP STF ID/Name (F/L)/Delahize America (Parent Co. of Food Lion)Incident Mgr Region FAY
RP Type (Owner/Operator / Landowner / Attny-in-fact)TA Supplement / Change Order?No Prev. TA #8
Consult. ID/Co.Name /
Phone / Fax Number /Task Authorization Number:9 ChangeOrd:
Email / PM Name (F/L)/Larry Hineline Site Risk / Rank / Abatement:I160D RRA Date:4/16/2013
Proposal# / Scope Dates /% Commercial (C=100%, NC=0%, Both=1%-99%)100%
Has STF Eligibility Been Determined? (T/F)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?
w 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 AuthProposed
Rate/Price
(Consultant)CO AuthProposed Task
Subtotal
(Consultant)
Preapproved
Subtotal
(UST Section)
Claimed
Amount2
(Consultant)
/
/
2.084 2 event y $350.00 y $700.00 $700.00 /
2.084 32 hours y $100.00 y $3,200.00 $3,200.00 /
2.084 12 wells y $50.00 y $600.00 $600.00 /
2.084 24000 gallon y $0.25 y $6,000.00 $6,000.00 /
2.084 2 night y $170.00 y $340.00 $340.00 /
/
6.022 2 report y $500.00 y $1,000.00 $1,000.00 /
12.010 242 miles y $2.06 y $498.52 $498.52 /
2.082 36 hours y $94.00 y $3,384.00 $3,384.00 /
12.030 2 night y $85.00 y $170.00 $170.00 /
/
/
/
/
/
/
/
/
/
/
/
/
/
Requested Preapproved Claimed2
TOTAL:$15,892.52 $15,892.52 TOTAL:
Total Standard Costs (Not Third Party)$15,892.52 $15,892.52 Total Standard Costs
Total applied as Third Party Deductible/Damage Costs $0.00 $0.00 Total Third Pty Costs
Process Tracking (Date)
TA Submittal:5/11/15 by:(PM)(Reserved for RO)
RO Review:5/13/15 by:(IM)Final Joint UST Preapproval Confirmed By:Date1 6/5/2015
CO Review:6/4/15 by:(STF)Consultant Receipt Confirmation Signature:Date 3
1 - If no work has been started, the ePATA expires one year from the Joint UST Preapproval date. Note: Tasks must also be claimed within one year of completion.
This one-year activity deadline from the authorization date does not supercede other regulatory deadlines (e.g., NORR's, NOV's, Enforcements, Remissions, etc.)
2 - Only Tasks included on this PATA form may be claimed. Do not include other Tasks or claimed costs (i.e., Claim preparation) that were not preapproved.
3 - Preapproval is not valid (i.e., claimable) until receipt is confirmed by Consultant. Signature does not indicate full agreement with any reductions, only that the TA was
received and read. Objections/appeals may be submitted via Change Order (which also does not supercede other regulatory deadlines as described in #1 above.)
DWM/UST NonDir Cert V.03/19/2013
Dunn
Dept of Environment & Natural Resources - Division of Waste Management
ELECTRONIC PREAPPROVAL TASK AUTHORIZATION FORM
(Must Complete with Claim Submittal)(See Instructions / RRD for Tasks requiring Preapproval / Task Authorization)
919.768.6241
(Reserved for Incident Manager)
PREAPPROVAL / TASK AUTHORIZATION
Food Lion Distribution Center #4
Note:This Electronic Preapproval Task Authorization Form should beused to receive preapproval from the UST Section.A proposal must be attached to elaborate onthe 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 or for tasks not originally included with this form,you must complete and submit a separate preapproval request designated as a "TA Supplement /Change Order"in the
provided space above.Include a copy of the prior preapproval form for confirmation.Please attach this form to the cover of the corresponding claim when requesting reimbursement.
IMPORTANT:Only one claim may be submitted during a quarter or 3-month period.All preapprovals 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 vary depending on 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.
JJP
JME
(Initials)
TLH
DIRECTED COSTS
Proposed
Units / Type
(Consultant)
Jeremy Poplawski
ActiveTRUE
AMEC Foster Wheeler Environment & Infrastructure
Oct. 2014
[e-mail]
919.381.9901
Dates of Work1
(Consultant)
Started / Completed
FINAL REIMBURSEMENT
Two quarters with separate 2-day events, 8 operating hours per day, with an overnight stay between each day. [JME]