Spreadsheet: 7fc90575-2025-43f7-a601-604c13f55a93
Sheet: Sheet1

NC UST STF - 2010 RRD - COST SUMMARY CLAIM FORM | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Incident No. | Unnamed: 9
Site Name
Site Address |  |  |  |  |  |  |  | City or Town
Main Consultant/Contractor and Contact
Owner/Operator/LandOwner/Attorney-in-fact
IMPORTANT DIRECTIONS: PLEASE READ!
Include all Cost Summary Forms with each claim.  Include only those [NAME] and Secondary Forms with claimed tasks.
Fill-in the requested amount for each of the tasks that were completed from the [NAME] task claim forms.
All dollar amounts listed below must match the dollar amount listed on the [NAME] task claim forms.
The total of the invoices billed to the client must equal or exceed the claim amount.
Attach all Main Consultant/Contractor invoices to the back of the Certification of Costs form.
Attach the proof of payment directly to the back of each Main Consultant/Contractor and Subcontractor invoices.
Follow the instructions listed under each task on the Primary & Secondary Forms or in the 2010 RRD Scope of Work Document.
SECTION ONE |  |  |  |  | Form | Total Cost | Claim Prep* | Approved Amt. | REMINDER!
PRE-ASSESSMENT ACTIVITIES |  |  |  |  |  |  |  | (DWM only)
1.01 | Initial Project Review & Setup |  |  |  | P-1 |  |  |  | Requires PreApp.
1.02 | Site Recon. & Receptor Survey |  |  |  | P-1 |  |  |  | Requires PreApp.
1.025 | Site Recon. & Receptor Update |  |  |  | P-1 |  |  |  | Requires PreApp.
1.04 | Health & Safety Plan |  |  |  | P-1 |  |  |  | Copy on file at RO
1.05 | Right-of-Access agreement |  |  |  | P-1 |  |  |  | Req. PreApp. / One per Prop.
1.061 | Request for Bid |  |  |  | P-1 |  |  |  | Sec-J / Typically Req. PA
 | TOTAL SECTION ONE COSTS |  |  |  |  | 0 | 0
SECTION TWO |  |  |  |  |  | Total Cost | Claim Prep* | Approved Amt. | REMINDER!
FREE PRODUCT RECOVERY |  |  |  |  |  |  |  | (DWM only)
2.071 | Cost of Free Product Evaluation |  |  |  | P-2a |  |  |  | Requires PreApp.
2.072 | Cost for a Passive Skimmer |  |  |  | P-2a |  |  |  | Requires PreApp.
2.073 | Installation/Service of Pass. Skimmer |  |  |  | P-2a |  |  |  | Requires PreApp.
2.074 | Hand Bailing of Free Product |  |  |  | P-2a |  |  |  | Requires PreApp.
AFVR
2.082 | Field Supervision of AFVR |  |  |  | P-2b |  |  |  | Except 1st EmergencyResp, Req PA
2.084 | Cost for AFVR |  |  |  | P-2b |  |  |  | [NAME]
2.085 | Rental - AFVR Emiss. Control Equip. |  |  |  | P-2b |  |  |  | Requires PreApp.
2.086 | Reg. Reporting Requirements (AFVR) |  |  |  | P-2b |  |  |  | Requires PreApp.
2.087 | Free Product Level Check |  |  |  | P-2b |  |  |  | Except 1st EmergencyResp, Req PA
FREE PRODUCT / VAPOR RECOVERY
2.09 | Specify FP/VR System |  |  |  | P-2c |  |  |  | Requires PreApp.
2.1 | Cost of FP/VR System |  |  |  | P-2c |  |  |  | Req. PreApp. / Sec-J
2.121 | Field Superv. FP/VR Sys. Install. |  |  |  | P-2c |  |  |  | Requires PreApp.
2.13 | Cost to Install FP/VR System |  |  |  | P-2c |  |  |  | Req. PreApp. / Sec-J
2.141 | FP/VR Sys. Maint. (pers. costs) |  |  |  | P-2c |  |  |  | Req. PreApp. / Sec-E
2.15 | O&M Expenses FP/VR |  |  |  | P-2c |  |  |  | Req. PreApp. / Sec-E
2.17 | Init. Site Eval./Measure & Mon. Vapor |  |  |  | P-2c |  |  |  | Req. Fire Dept Report
2.2 | Cost for Leasing a VR System |  |  |  | P-2c |  |  |  | Req. PreApp. / Sec-J
BOOM MAINTENANCE
2.281 | Boom/Sorbent Maintenance |  |  |  | P-2d |  |  |  | [NAME]
2.29 | Cost for Booms and Sorbents |  |  |  | P-2d |  |  |  | [NAME]
2.3 | Cost for Drums for FP/Sorbents |  |  |  | P-2d |  |  |  | Except 1st EmergencyResp, Req PA
UST REMOVAL & CLOSURE
2.33 | Preparation of UST Closure Work Plan |  |  |  | P-2e |  |  | NOT REIMBURSABLE | [NAME]
2.34 | UST Closure Permit Application |  |  |  | P-2e |  |  | NOT REIMBURSABLE | [NAME]
2.35 | UST Closure Notice of Intent |  |  |  | P-2e |  |  | NOT REIMBURSABLE | [NAME]
2.36 | Removal of UST System and Contents |  |  |  | P-2e |  |  | NOT REIMBURSABLE | [NAME]
2.37 | Asphalt/Concrete/Over-burden Removal |  |  |  | P-2e |  |  | NOT REIMBURSABLE | [NAME]
2.381 | Supervision of IAA Over-excavation |  |  |  | P-2e |  |  |  | [NAME]
2.4 | Cost for Excav./Stockpiling Soil (IAA) |  |  |  | P-2e |  |  |  | [NAME]
2.41 | Cost for Backfilling Over-excav. Pit (IAA) |  |  |  | P-2e |  |  |  | [NAME]
2.413 | Cost for NC Prof. [NAME] |  |  |  | P-2e |  |  |  | [NAME]
2.415 | Cost for Trans./Disp. [NAME]. Soil (IAA) |  |  |  | P-2e |  |  |  | [NAME]
2.5 | Non-Comm UST Closure / IAA |  |  |  | P-2f |  |  |  | [NAME] Part 1
2.51 | In Situ Non-Comm UST Closure / IAA |  |  |  | P-2f |  |  |  | [NAME] Pt 1&2
2.52 | Non-Comm UST IAA w/ [NAME]. |  |  |  | P-2f |  |  |  | [NAME] Pt 1&2
SECTION TWO (Cont.) |  |  |  |  |  | Total Cost | Claim Prep* | Approved Amt. | REMINDER!
LIMITED SITE ASSESSMENT |  |  |  |  |  |  |  | (DWM only)
2.6 | Phase I LSA |  |  |  | P-2f |  |  |  | [NAME]
2.61 | Phase II LSA |  |  |  | P-2f |  |  |  | [NAME]
2.62 | Phase I LSA - Receptor and Soil Only |  |  |  | P-2f |  |  |  | [NAME]
 | TOTAL SECTION TWO COSTS |  |  |  |  | 0 | 0
SECTION THREE |  |  |  |  |  | Total Cost | Claim Prep* | Approved Amt. | REMINDER!
PRE-DRILLING TASKS |  |  |  |  |  |  |  | (DWM only)
3.025 | Clearing Access |  |  |  | P-3a |  |  |  | Requires PreApp.
3.03 | DOT Agreement (mon. [NAME]) |  |  |  | P-3a |  |  |  | Requires PreApp.
3.04 | DOT Agreement (rem. wells) |  |  |  | P-3a |  |  |  | Requires PreApp.
3.06 | Cost for Utility Clearance (sub.) |  |  |  | P-3a |  |  |  | Sec-A.1 (or Req PreApp)
3.08 | Procure Well Permits |  |  |  | P-3a |  |  |  | Requires PreApp.
MULTI-PHASE VERTICAL DRILLING
3.101 | Supervision of Drilling Field Work |  |  |  | P-3b |  |  |  | Sec-A.2 or Sec-F (Req PA)
3.111 | [NAME] (HA or SB) |  |  |  | P-3b |  |  |  | Req. PreApp. / Sec-F
3.112 | 1-inch Well (1A) |  |  |  | P-3b |  |  |  | Sec-A.2 or Sec-F (Req PA)
3.113 | 2-inch Well (2A) |  |  |  | P-3b |  |  |  | Sec-A.2 or Sec-F (Req PA)
3.114 | 4-inch Well (4A) |  |  |  | P-3b |  |  |  | Req. PreApp. / Sec-F
3.115 | Telescoping Type III Well (T3) |  |  |  | P-3b |  |  |  | Req. PreApp. / Sec-F
3.116 | Geoprobe 1-inch Well (1P) |  |  |  | P-3b |  |  |  | Sec-A.2 or Sec-F (Req PA)
3.117 | Geoprobe 2-inch Well (2P) |  |  |  | P-3b |  |  |  | Sec-A.2 or Sec-F (Req PA)
HORIZONTAL & SPECIALTY DRILLING
3.31 | Cost Specialty Drilling (S) |  |  |  | P-3c |  |  |  | Req. PreApp. / Sec-J
MISC. DRILLING COSTS
3.351 | Surveying Top of Well Casing |  |  |  | P-3c |  |  |  | Requires PreApp.
3.398 | Cost for Drill Rig Mobilization |  |  |  | P-3c |  |  |  | Sec-A.2 or Sec-F (Req PA)
3.399 | Well Abandonment |  |  |  | P-3c |  |  |  | Requires PreApp.
3.4 | Locking Rem. Well Vault & Installation |  |  |  | P-3c |  |  |  | Requires PreApp.
3.5 | [NAME] Per Diem |  |  |  | P-3c |  |  |  | Req. PreApp. / Sec-F
 | TOTAL SECTION THREE COSTS |  |  |  |  | 0 | 0
SECTION FOUR |  |  |  |  |  | Total Cost | Claim Prep* | Approved Amt. | REMINDER!
SAMPLING & ANALYTICAL COSTS |  |  |  |  |  |  |  | (DWM only)
4.02 | Composite Stockpile Soil Samp. (<200yds) |  |  |  | P-4a |  |  |  | Sec-A.1 (or Req PreApp)
4.031 | Cost for Sampling Monitoring Well |  |  |  | P-4a |  |  |  | Sec-A.2 or Sec-G (Req PA)
4.041 | Cost for Sampling Supply Well |  |  |  | P-4a |  |  |  | Sec-A.2 or Sec-G (Req PA)
4.045 | Cost for Samp. Contaminated WSW |  |  |  | P-4a |  |  |  | Sec-G (Req PA) & 3rd Pty
4.051 | Cost for Samp. Surface Water |  |  |  | P-4a |  |  |  | Sec-A.2 or Sec-G (Req PA)
4.06 | Cost for Samp. Influent/Effluent |  |  |  | P-4b |  |  |  | Req. PreApp. / Sec-G
4.07 | Costs for Samp. VE System Air Stream |  |  |  | P-4b |  |  |  | Req. PreApp. / Sec-G
4.09 | Cost for Analytical & Shipping |  |  |  | P-4b |  |  |  | Sec-A.1/A.2 or Sec-H (Req PA)
4.095 | Analytical & S/H - Third Party Deductible |  |  |  | P-4b |  |  |  | Sec-H (Req PA) & 3rd Pty
 | TOTAL SECTION FOUR COSTS |  |  |  |  | 0 | 0
SECTION FIVE |  |  |  |  |  | Total Cost | Claim Prep* | Approved Amt. | REMINDER!
FIELD TESTING & EVALUATION |  |  |  |  |  |  |  | (DWM only)
5.01 | Slug Testing |  |  |  | P-5 |  |  |  | Requires PreApp.
5.02 | Step Drawdown Test |  |  |  | P-5 |  |  |  | Requires PreApp.
5.03 | 12-hr Aquifer Test |  |  |  | P-5 |  |  |  | Requires PreApp.
5.05 | Soil Vapor Extraction Test |  |  |  | P-5 |  |  |  | Requires PreApp.
5.06 | In Situ Air Sparge Test |  |  |  | P-5 |  |  |  | Requires PreApp.
5.07 | Contam. Fate &Trans. Modeling |  |  |  | P-5 |  |  |  | Requires PreApp.
5.08 | Hydrogeological Parameter Test |  |  |  | P-5 |  |  |  | Requires PreApp.
 | TOTAL SECTION FIVE COSTS |  |  |  |  | 0 | 0
SECTION SIX |  |  |  |  |  | Total Cost | Claim Prep* | Approved Amt. | REMINDER!
REPORTS |  |  |  |  |  |  |  | (DWM only)
6.01 | 20-Day Report |  |  |  | P-6a |  |  |  | Sec-A.1 (or Req PreApp)
6.015 | Initial Abatement Action Report |  |  |  | P-6a |  |  |  | Sec-A.1 (or Req PreApp)
6.022 | Free Product Recovery Report |  |  |  | P-6a |  |  |  | Requires PreApp.
6.04 | Comp. Site Assess. (soil only) |  |  |  | P-6a |  |  |  | Requires PreApp.
6.041 | Soil Assess. Report |  |  |  | P-6a |  |  |  | Requires PreApp.
6.05 | Comp. Site Assess. (soil & gw) |  |  |  | P-6a |  |  |  | Requires PreApp.
6.06 | Comp. Site Assess. [NAME] |  |  |  | P-6a |  |  |  | Requires PreApp.
6.07 | CAP (Active - soil & gw) |  |  |  | P-6b |  |  |  | Requires PreApp.
6.071 | CAP (Active - soil only) |  |  |  | P-6b |  |  |  | Requires PreApp.
6.08 | [NAME] ([NAME]. Atten.) |  |  |  | P-6b |  |  |  | Requires PreApp.
6.081 | Soil Cleanup Plan |  |  |  | P-6b |  |  |  | Requires PreApp.
6.082 | Public Notification |  |  |  | P-6b |  |  |  | Requires PreApp.
6.09 | [NAME]. (preCap-Initial) |  |  |  | P-6b |  |  |  | Requires PreApp.
6.091 | [NAME]. (preCap-Subs.) |  |  |  | P-6b |  |  |  | Requires PreApp.
6.1 | Active Rem. Mon. [NAME]. (Initial) |  |  |  | P-6b |  |  |  | Requires PreApp.
6.101 | Active Rem. Mon. [NAME]. (Subs.) |  |  |  | P-6b |  |  |  | Requires PreApp.
6.12 | System [NAME]. |  |  |  | P-6c |  |  |  | Requires PreApp.
6.121 | New Technology Cleanup Plan |  |  |  | P-6c |  |  |  | Requires PreApp.
6.13 | Air Emissions Mon. Rpt. |  |  |  | P-6c |  |  |  | Requires PreApp.
6.14 | Non-Discharge Permit Rpt. |  |  |  | P-6c |  |  |  | Requires PreApp.
6.15 | POTW [NAME]. |  |  |  | P-6c |  |  |  | Requires PreApp.
6.16 | [NAME]. |  |  |  | P-6c |  |  |  | Requires PreApp.
6.17 | Site [NAME]. |  |  |  | P-6d |  |  |  | Requires PreApp.
6.171 | Soil Cleanup & Site Closure Rpt. |  |  |  | P-6d |  |  |  | Requires PreApp.
6.173 | Cost for NC Prof. Surveyor |  |  |  | P-6d |  |  |  | Requires PreApp.
6.174 | Deed Recordation (NoRP/LUR) |  |  |  | P-6d |  |  |  | Requires PreApp.
6.18 | [NAME] |  |  |  | P-6d |  |  |  | Requires PreApp.
6.19 | Miscellaneous Letter Report |  |  |  | P-6d |  |  |  | Requires PreApp.
 | TOTAL SECTION SIX COSTS |  |  |  |  | 0 | 0
SECTION SEVEN |  |  |  |  |  | Total Cost | Claim Prep* | Approved Amt. | REMINDER!
REMEDIAL SERVICES |  |  |  |  |  |  |  | (DWM only)
7.015 | Design/Specify Rem. System(s) |  |  |  | P-7a |  |  |  | Requires PreApp.
7.02 | Cost for Pump & Treat System |  |  |  | P-7a |  |  |  | Req. PreApp. / Sec-J
7.04 | Cost for SVE System |  |  |  | P-7a |  |  |  | Req. PreApp. / Sec-J
7.06 | Cost for Air Sparge System |  |  |  | P-7a |  |  |  | Req. PreApp. / Sec-J
7.065 | Cost for Mult-Tech. Rem. Syst. |  |  |  | P-7a |  |  |  | Req. PreApp. / Sec-J
7.081 | Rem. Syst. Install. Inspection/Certif. |  |  |  | P-7a |  |  |  | Requires PreApp.
7.1 | Cost for Installation of Rem. System |  |  |  | P-7a |  |  |  | Req. PreApp. / Sec-J
7.121 | Rec. Trench Install Inspect./Certif. |  |  |  | P-7b |  |  |  | Requires PreApp.
7.14 | Cost for Installation of Rec. Trench |  |  |  | P-7b |  |  |  | Req. PreApp. / Sec-J
7.161 | Infilt. [NAME]. Inspect./Certif. |  |  |  | P-7b |  |  |  | Requires PreApp.
7.18 | Cost for Installation of Infilt. Gallery |  |  |  | P-7b |  |  |  | Req. PreApp. / Sec-J
7.201 | Cost for Rem. System Maintenance |  |  |  | P-7b |  |  |  | Req. PreApp. / Sec-I
7.25 | Cost for Rem. Supplies & Equip. |  |  |  | P-7b |  |  |  | Req. PreApp. / Sec-I
7.26 | Cost for Rem. Operating. Expen. |  |  |  | P-7b |  |  |  | Req. PreApp. / Sec-I
7.261 | Cost for GAC/AG Replacement |  |  |  | P-7c |  |  |  | Req. PreApp. / Sec-I
7.291 | Field Superv. Excav. [NAME]. |  |  |  | P-7c |  |  |  | Requires PreApp.
7.3 | Cost for Excav. & Backfilling |  |  |  | P-7c |  |  |  | Requires PreApp.
7.34 | Cost for NC Prof. Surveyor |  |  |  | P-7c |  |  |  | Requires PreApp.
7.36 | Cost for Trans./Disposal of Cont. Soil |  |  |  | P-7c |  |  |  | Requires PreApp.
7.39 | Lease Therm/CATOX |  |  |  | [NAME] |  |  |  | Req. PreApp. / Sec-J
7.4 | Purchase [NAME]/CATOX |  |  |  | [NAME] |  |  |  | Req. PreApp. / Sec-J
7.41 | Lease Remediation System |  |  |  | [NAME] |  |  |  | Req. PreApp. / Sec-J
7.42 | Cost for MMPE Event |  |  |  | [NAME] |  |  |  | Req. PreApp. / Sec-D
RELOCATION OF REMEDIAL SYSTEM
7.5 | Relocation Remedial System |  |  |  | [NAME] |  |  |  | Req. PreApp. / Sec-J
 | TOTAL SECTION SEVEN COSTS |  |  |  |  | 0 | 0
SECTION EIGHT |  |  |  |  |  | Total Cost | Claim Prep* | Approved Amt. | REMINDER!
PERMITS |  |  |  |  |  |  |  | (DWM only)
8.01 | Certificate Of Disposal (UST-71) |  |  |  | P-8a |  |  |  | Requires PreApp.
8.02 | Permit for Land Application (UST-70) |  |  |  | P-8a |  |  |  | Requires PreApp.
8.03 | Agmt for Land Application (UST-72) |  |  |  | P-8a |  |  |  | Requires PreApp.
8.04 | Air Quality Permit |  |  |  | P-8a |  |  |  | Requires PreApp.
8.041 | Air Quality Registration |  |  |  | P-8a |  |  |  | Requires PreApp.
8.05 | Injection Well Permit |  |  |  | P-8a |  |  |  | Requires PreApp.
8.06 | NonDischarge Permit |  |  |  | P-8a |  |  |  | Requires PreApp.
8.07 | NPDES Individual Permit |  |  |  | P-8b |  |  |  | Requires PreApp.
8.08 | NPDES General Permit |  |  |  | P-8b |  |  |  | Requires PreApp.
8.09 | POTW Discharge Permit |  |  |  | P-8b |  |  |  | Requires PreApp.
8.091 | CAMA Permit (Minor Dev.) |  |  |  | P-8b |  |  |  | Requires PreApp.
8.092 | CAMA Permit (Major [NAME].) |  |  |  | P-8b |  |  |  | Requires PreApp.
8.1 | Cost for Permit Fees (non-MW) |  |  |  | P-8b |  |  |  | Requires PreApp.
8.105 | County Monitoring Well Permit Fees |  |  |  | P-8b |  |  |  | Sec A.2/LSA (or Req PA)
8.11 | Cost for Performing Variance |  |  |  | P-8b |  |  |  | Requires PreApp.
 | TOTAL SECTION EIGHT COSTS |  |  |  |  | 0 | 0
SECTION NINE |  |  |  |  |  | Total Cost | Claim Prep* | Approved Amt. | REMINDER!
DISPOSAL SERVICES |  |  |  |  |  |  |  | (DWM only)
9.02 | Cost for Disp. Product/GW |  |  |  | P-9 |  |  |  | Sec-A.1 or Sec-J (Req PA)
9.04 | Cost for Disp. Sorbents |  |  |  | P-9 |  |  |  | Req. PreApp. / Sec-J
9.06 | Cost for Disp. Drummed Soil |  |  |  | P-9 |  |  |  | Req. PreApp. / Sec-J
 | TOTAL SECTION NINE COSTS |  |  |  |  | 0 | 0
SECTION TEN |  |  |  |  |  | Total Cost | Claim Prep* | Approved Amt. | REMINDER!
SITE REPAIR |  |  |  |  |  |  |  | (DWM only)
10.011 | Structure Repair/Stabilization |  |  |  | P-10 |  |  |  | Sec-A.1 or Sec-J (Req PA)
10.03 | Cost for Repairing/Replacing Utilities |  |  |  | P-10 |  |  |  | Sec-A.1 (or Req PreApp)
10.05 | Cost for Repairing Landscaping |  |  |  | P-10 |  |  |  | Sec-A.1 (or Req PreApp)
10.07 | Cost for Repairing Asphalt/Concrete |  |  |  | P-10 |  |  |  | Sec-A.1 or Sec-J (Req PA)
 | TOTAL SECTION TEN COSTS |  |  |  |  | 0 | 0
SECTION ELEVEN |  |  |  |  |  | Total Cost | Claim Prep* | Approved Amt. | REMINDER!
CONNECTING TO PUBLIC WATER |  |  |  |  |  |  |  | (DWM only)
11.02 | Agreements to [NAME] |  |  |  | P-11 |  |  |  | Req. PreApp. / 3rd Party?
11.04 | Coordination & Verif. Connections |  |  |  | P-11 |  |  |  | Req. PreApp. / 3rd Party?
11.05 | Cost for Water Connections |  |  |  | P-11 |  |  |  | Req. PA / Sec-J / 3rd Pty?
 | TOTAL SECTION ELEVEN COSTS |  |  |  |  | 0 | 0
SECTION TWELVE |  |  |  |  |  | Total Cost | Claim Prep* | Approved Amt. | REMINDER!
TRAVEL TIME & LODGING |  |  |  |  |  |  |  | (DWM only)
12.01 | Consultant Travel |  |  |  | P-12 |  |  |  | Sec-A.1/A.2 (or Req PreApp)
12.03 | Overnight Lodging |  |  |  | P-12 |  |  |  | Sec-A.1 (or Req PreApp)
 | TOTAL SECTION TWELVE COSTS |  |  |  |  | 0 | 0
 | SUBTOTAL COSTS |  |  |  |  | 0 | 0
 | TOTAL CLAIM COSTS |  |  |  |  | 0
* Claim Preparation costs may not exceed $20.00 per claimed task.