Spreadsheet: 3ef2d44f-07ca-4b1b-b998-03f5ae41528e
Sheet: Sheet1

(NOTE: CLAIM EITHER TASK 2.500 or 2.520 BASED ON THE REQUIREMENTS FOR UST CLOSURE | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6
AT YOUR SITE.  BOTH TASKS MAY NOT BE CLAIMED CONCURRENTLY.)
 |  |  |  |  |  | Incident _________  Pg _ of _
 |  |  | 2M - Non-Regulated Underground Storage Tank Closure with Over-excavation
Task 2.500: Non-Regulated UST Closure w/ Over-excavation (No Closure Groundwater Assessment required)
Closure Contractor: |  |  |  | UST Volume: |  | gallons
Excavation Dimensions: |  |  |  |  | Approximate   / | Surveyed
 |  | (length) | (width) | (depth) | (circle one)
Table A: Over-excavation Tonnage Costs
 | Date of | Total Volume | Rate per Ton | Maximum Volume | Maximum Rate | Over-excavation
 | Work | (tons)1 | ($[NAME]) | (tons)2 | (per ton) | SUBTOTALS
Excavation |  |  |  | 56.8 | 16 | 0
Backfill |  |  |  | 56.8 | 13 | 0
Disposal |  |  |  | 56.8 | 30 | 0
 |  |  |  |  | Total Over-excavation Costs (Table A) | 0
Table B: Soil Sampling Analytical Costs
RRD Sample | Sampling | Sample | Cost | Maximum | Maximum Rate | ANALYTICAL
Code | Date | Count | per Sample | Sample Count3 | (per sample) | SUBTOTAL
370 |  |  |  | 3 | 70 | 0
409 |  |  |  | 5 | 93 | 0
410 |  |  |  | 5 | 207 | 0
423 |  |  |  | 5 | 193 | 0
 |  |  |  |  | Total Analytical Costs (Table B) | 0
Table C: Additional Report Costs
Free Product Recovery Addendum to the Initial Abatement Action Report (not to exceed $245.00) |  |  |  |  |  | 0
 | (Additional costs if performed following tank closure activities and submitted with IAA Report)
Site-Specific Health and Safety Plan (not to exceed $117.00) |  |  |  |  |  | 0
 | (Additional costs if a copy was submitted to the Regional Office prior to tank closure activities)
Table D: Task Base / Miscellaneous Costs
Base rate for completion of Non-Regulated UST Closure (not to exceed $3,488.80) |  |  |  |  |  | 0
 | (Closure costs not defined in the above tables, including site preparation, utility clearance, consultant oversight,
 | sample collection, site restoration, travel, per diems, 20-Day and Initial Abatment Action Report preparation,
 | and any other miscellaneous cost associated with completing a non-regulated UST closure event.)
 |  | Total Cost From Tables "A","B","C",&"D" (Task 2.500) |  |  |  | 0
 |  | (not to exceed $9,877.00 without written authorization/preapproval)
1) Certified Weight Tickets (Weighmaster seal) must be provided to document any weighed tonnage claim.
2) Additional excavation volume may be approved by the Regional Office on a site-specific basis.  Include written authorization from RO with Claim.
3) Additional samples may be approved by the Regional Office (e.g., if multiple source area wells are required, etc).  Include written authorization/request in Claim.
DWM/UST 2003RRD Effective 7/1/2007
 |  |  |  |  |  | Incident _________  Pg _ of _
 |  |  | 2M - Non-Regulated Underground Storage Tank Closure with Over-excavation
Task 2.520: Non-Regulated UST Closure w/ Over-excavation and Groundwater Assessment
 | (Tank in Bedrock or the Water Table, over-excavation to the Water Table, or as required by the Regional Office)
Closure Contractor: |  |  |  | UST Volume: |  | gallons
Excavation Dimensions: |  |  |  |  | Approximate   / | Surveyed
 |  | (length) | (width) | (depth) | (circle one)
Table A: Over-excavation Tonnage Costs
 | Date of | Total Volume | Rate per Ton | Maximum Volume | Maximum Rate | Over-excavation
 | Work | (tons)1 | ($[NAME]) | (tons)2 | (per ton) | SUBTOTALS
Excavation |  |  |  | 56.8 | 16 | 0
Backfill |  |  |  | 56.8 | 13 | 0
Disposal |  |  |  | 56.8 | 30 | 0
 |  |  |  |  | Total Over-excavation Costs (Table A) | 0
Table B: Soil Sampling Analytical Costs
RRD Sample | Sampling | Sample | Cost | Maximum | Maximum Rate | ANALYTICAL
Code | Date | Count | per Sample | Sample Count3 | (per sample) | SUBTOTAL
370 |  |  |  | 3 / 6 4 | 70 | 0
409 |  |  |  | 5 / 6 5 | 93 | 0
410 |  |  |  | 5 / 6 5 | 207 | 0
423 |  |  |  | 5 / 6 5 | 193 | 0
 |  |  |  |  | Total Soil Analytical Costs (Table B) | 0
Table C: Monitoring Well Installation Costs
Well | Installation | Well Diameter | Total Depth 6 | Installation Cost 7 | Screened Interval | Depth to Water
Designation | Date | (inches) | (feet) | (per foot) | (feet bgs) | (feet bgs)
 |  |  |  |  | Total Monitoring Well Installation Costs (Table C) | 0
Table D: Groundwater Sampling Analytical Costs
RRD Sample | Sampling | Sample | Cost | Maximum | Maximum Rate | ANALYTICAL
Code | Date | Count | per Sample | Sample Count3 | (per sample) | SUBTOTAL
220 |  |  |  | 1 | 43 | 0
301 |  |  |  | 1 | 231 | 0
343 |  |  |  | 1 | 194 | 0
 |  |  |  |  | Total Groundwater Analytical Costs (Table D) | 0
Table E: Additional Report Costs
Free Product Recovery Addendum to the Initial Abatement Action Report (not to exceed $245.00) |  |  |  |  |  | 0
 | (Additional costs if performed following tank closure activities and submitted with IAA Report)
Site-Specific Health and Safety Plan (not to exceed $117.00) |  |  |  |  |  | 0
 | (Additional costs if a copy was submitted to the Regional Office prior to tank closure activities)
Table F: Task Base / Miscellaneous Costs
Base rate for completion of Non-Regulated UST Closure (not to exceed $4,183.80) |  |  |  |  |  | 0
 | (Closure costs not defined in the above tables, including site preparation, utility clearance, consultant oversight,
 | sample collection, site restoration, mobe/travel, per diems, 20-Day and Initial Abatment Action Report preparation,
 | and any other miscellaneous cost associated with completing a non-regulated UST closure event.)
 |  |  |  |  | Total Cost From Tables "A","B","C","D","E",&"F" (Task 2.520) | 0
 |  | (not to exceed $12,658.00 without written authorization/preapproval)
1) Certified Weight Tickets (Weighmaster seal) must be provided to document any weighed tonnage claim.
2) Additional excavation volume may be approved by the Regional Office on a site-specific basis.  Include written authorization from RO with Claim.
3) Additional samples may be approved by the Regional Office (e.g., if multiple source area wells are required, etc.).  Include written authorization/request in Claim.
4) TPH Sample count increases to a maximum of 6 (4 sidewalls, supply line, and stockpile) if the tank is located in or on the water table (prior to overexcavation)
4) Risk-based Sample count increases to a maximum of 6 (pit bottom, 4 sidewalls, and supply line) if groundwater assesment is directed per Section 5.3.A of the Guidelines.
6) Maximum well depth is assumed at 25 feet bgs.  Additional footage may be claimed where a deeper surficial water table is documented.
7) Maximum rate of $45.00/ft for the installation of a 2-inch permanent monitoring well.  If installing a 1-inch well, the rate may not exceed $35.00/ft.
DWM/UST 2003RRD Effective 7/1/2007