Spreadsheet: 022e4759-a666-407d-8de0-74b32c4c5ea3
Sheet: Non-Directed Certification

NON-DIRECTED CERTIFICATION |  |  |  |  |  |  |  |  | ELECTRONIC PREAPPROVAL TASK  AUTHORIZATION FORM
 |  |  |  |  |  |  |  |  | Dept of Environment & Natural Resources  -  Div of Waste Management
Site Name |  |  |  |  |  |  |  |  |  |  | City / County |  |  | / |  |  | Incident #
Responsible Party Name |  |  |  |  |  |  |  |  |  |  | Incident Mgr |  |  |  |  |  | Region
RP Type (Owner/Operator / Landowner / Attny-in-fact) |  |  |  |  |  |  |  |  |  |  | TA Supplement/C. Order? |  |  |  |  |  | Prev. TA #
Consultant Name |  |  |  |  |  |  |  |  |  |  | Proposal# / Scope Dates |  |  |  |  | /
Note:  An original, notarized version of this form should be submitted to the Regional Office by mail to be filed with a hard copy of the finalized   Non-Directed Electronic Preapproval Task Authorization request.  The associated Non-Directed ePATA cannot be approved without receipt of this certification document.  If, following receipt of the completed ePATA, you discover that other, unexpected tasks must be performed, incurring costs or using tasks not preapproved in this authorization, you must complete and submit a separate ePATA request with its own, separate Non-Directed Certification.  Additionally, a copy of this form should be attached to the hard copy of the ePATA form that is submitted with the formal 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 reused for a separate claim, even for any remaining, 'unclaimed' tasks from the earlier submittal.  Final reimbursement of costs associated with the total preapproved amount 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.
 |  |  |  |  |  |  |  |  |  |  | Requested Amount (as shown on the ePATA)
 |  |  |  |  |  |  |  |  | TOTAL NONDIRECTED REQUEST:
 |  |  |  |  |  |  |  |  | Total Standard Costs (Not Third Party Damages)
 |  |  |  |  |  |  |  |  | Total applied as Third Party Deductible/Damage Costs
I, ______________________________________ (tank owner/operator/landowner), understand and agree that reimbursement of claims submitted to the Department for costs incurred as a result of properly completing the tasks preapproved herein will not be paid until after the Department has paid all claims for tasks that the Department directs.
 |  |  |  | Signature |  |  |  |  |  |  |  |  | Date
County of |  |  |  |  |  |  |  | State of
I certify that the following person(s) personally appeared before me this day: __________________________________________,
each acknowledging to me that he or she signed the foregoing document: ____________________________________________.
 |  |  |  |  |  |  |  |  |  |  | (Describe if signed individually or in representative capacity)
WITNESS my hand and official seal, this ______ day of ______________ A.D. ________
Notary Public: |  |  |  |  |  |  |  |  |  |  |  |  | My Commission expires:
DWM/UST NonDir Cert V.03/19/2013