Spreadsheet: 022e4759-a666-407d-8de0-74b32c4c5ea3
Sheet: Preapproval ePATA

CLICK HERE FIRST TO USE DROPDOWN -> |  |  |  |  |  |  |  |  |  | ELECTRONIC PREAPPROVAL TASK AUTHORIZATION FORM
 |  |  |  |  |  |  |  |  |  | Dept of Environment & Natural Resources  -  Division of Waste Management
 | Site Name |  |  |  |  |  |  |  |  |  |  | City / County |  |  | / |  |  | Incident #
 | RP STF ID/Name (F/L) |  |  |  | / |  |  |  |  |  |  | Incident Mgr |  |  |  |  |  | Region
 | RP Type (Owner/Operator / Landowner / Attny-in-fact) |  |  |  |  |  |  |  |  |  |  | TA Supplement / Change Order? |  |  |  |  |  | Prev. TA #
 | Consult. ID/Co.Name |  |  |  | / |  |  |  |  |  |  | (Reserved for Incident Manager)
 | Phone / Fax Number |  |  |  |  |  |  | / |  |  |  | Task Authorization Number: |  |  |  |  |  | ChangeOrd:
 | Email / PM Name (F/L) |  |  |  |  |  |  | / |  |  |  | Site Risk / Rank / Abatement: |  |  |  |  |  | RRA Date:
 | Proposal# / Scope Dates |  |  |  |  |  |  | / |  |  |  | % Commercial (C=100%,  NC=0%,  Both=1%-99%)
 | Has STF Eligibility Been Determined? (T/F) |  |  |  |  |  |  |  |  |  |  | Site Status (Active  or  NFA Date) |  |  |  | Active
 | Note:  This Electronic Preapproval Task Authorization Form should be used to receive preapproval from the UST Section.  A proposal 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 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.
 | 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.
 | PREAPPROVAL / TASK AUTHORIZATION |  |  |  |  |  |  |  |  |  |  |  |  |  |  | FINAL REIMBURSEMENT
 | (See Instructions / RRD for Tasks requiring Preapproval / Task Authorization) |  |  |  |  |  |  |  |  |  |  |  |  |  |  | (Must Complete with [NAME])
 | 3rd Pty Ded? | Task # | Lab / SubCode | Proposed  Units / Type (Consultant) |  |  | RO Auth |  | Proposed Rate/Price (Consultant) | CO Auth |  | Proposed Task Subtotal (Consultant) |  | Preapproved Subtotal (UST Section) |  | Dates of Work1 (Consultant) Started  /  Completed |  |  | Claimed Amount2 (Consultant)
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 |  |  |  |  |  |  |  |  |  |  |  | Requested |  | Preapproved |  |  |  |  | Claimed2
 |  |  |  |  |  |  |  |  |  | TOTAL: |  |  |  |  |  |  |  | TOTAL:
 |  |  |  |  |  |  |  |  |  | Total Standard Costs (Not Third Party) |  |  |  |  |  |  |  | Total Standard Costs
 |  |  |  |  |  |  |  |  |  | Total applied as Third Party Deductible/Damage Costs |  |  |  |  |  |  |  | Total Third Pty Costs
 | Process Tracking |  | (Date) |  | (Initials)
 |  | TA Submittal: |  | by: |  |  | (PM) |  | (Reserved for RO)
 |  | RO Review: |  | by: |  |  | (IM) |  |  |  |  | Final Joint UST Preapproval Confirmed By: |  |  |  |  |  | Date1
 |  | CO Review: |  | 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 [NAME] (which also does not supercede other regulatory deadlines as described in #1 above.)
 | DWM/UST NonDir Cert V.03/19/2013