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Sheet: Sheet1

FREE PRODUCT REMOVAL PROGRAM | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10 | PREAPPROVAL/CLAIM  AUTHORIZATION FORM | Unnamed: 12 | Unnamed: 13 | Unnamed: 14 | Unnamed: 15 | Unnamed: 16 | Unnamed: 17 | Unnamed: 18
 |  |  |  |  |  |  |  |  |  |  | Department of Environment & Natural Resources  -   Division of Waste Management
Site Name |  |  |  |  |  |  |  |  |  |  | City / County |  |  |  |  |  | Incident #
Responsible Party |  |  |  |  |  |  |  |  |  |  | Incident Mgr |  |  |  |  |  | Region
RP Type (Owner/Operator / Landowner / Attorney-in-fact) |  |  |  |  |  |  |  |  |  |  | TA Supplement / Change Order? |  |  |  |  |  | Prev. TA #
Primary Consultant |  |  |  |  |  |  |  |  |  |  | (Reserved for Incident Manager)
Phone / Fax Number |  |  |  |  |  |  |  |  |  |  | Task Authorization Number:
Project Mgr / Email |  |  |  |  |  |  |  |  |  |  | Site Risk / Rank / Abatement:
Proposal# / Scope Dates |  |  |  |  |  |  |  |  |  |  | Type (Comm  /  NonComm  /  Both)
Has STF Eligibility Been Determined?     YES    /    NO    /    Pending |  |  |  |  |  |  |  |  |  |  | Site Status (Active  or  NFA/Date)
Note:  This 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 you discover that unexpected tasks must be performed, incurring costs that exceed the amount preapproved in this authorization, 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 as well.  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.  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.
[NAME] all Main Consultant/Contractor invoices. |  |  |  |  |  |  |  |  | [NAME] proof of payment directly to the front of each invoice.
PREAPPROVAL / TASK AUTHORIZATION |  |  |  |  |  |  |  |  |  |  |  |  |  |  | FINAL REIMBURSEMENT
(See Instructions / RRD for Tasks requiring Preapproval / Task Authorization) |  |  |  |  |  |  |  |  |  |  |  |  |  |  | (Must Complete with [NAME])
Third Party? | Task # | Lab Code# / Subtask | Proposed  Quantity /  Unit Type (Consultant) |  |  | RO Auth |  | Proposed Rate/Price (Consultant) | CO Auth |  | Proposed Task Subtotal (Consultant) |  | Preapproved Subtotal (UST Section) |  | Dates of Work (Consultant) Started  /  Completed |  |  | Claimed Amount (Consultant)
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 |  |  |  |  |  |  |  |  |  |  | Requested |  | Preapproved |  |  |  |  | Claimed
 |  |  |  |  |  |  |  |  | TOTALS: |  | 0
 |  |  |  |  |  |  |  |  | Total Standard Costs (Non-Third Party) |  | 0 |  |  |  |  |  | Total Standard Costs
 |  |  |  |  |  |  |  |  | Total applied as Third Party Costs |  | 0 |  |  |  |  |  | Total Third Pty Costs
Main Consultant |  |  |  |  |  | Project Mgr Signature: |  |  |  |  |  |  |  |  | Date:
UST Section |  |  |  |  |  | RO Task Authorization: |  |  |  |  |  |  |  |  | Date:
 |  |  |  |  |  | CO Rate Authorization: |  |  |  |  |  |  |  |  | Date:
*Important:  The date of reimbursement of costs approved herein is dependent on the balance of funds in the Trust Fund.  There may
 | be a delay in the reimbursement of claims for work done.
** SSA = "See Supporting Attachment" for additional details on sub-task unit reductions in multi-phase tasks (e.g. Tasks 2.084, 4.090, 7.420, etc.)
***  +/- Reviewer Initials = Task, Unit count, or Rate approved in full as presented by Consultant.
DWM/UST Task Auth V.1/1/09.FP