Cost Review Form Guidance
The Cost Review Form (CRF) is an update of the current GUST 91 and 92 forms.
Upon opening the Excel version of this form, you must "Enable Macros" when prompted; if this
wasn't done, the file must be closed, re-opened and "Enable Macros" checked.
General Guidance:
1) The forms are designed to provide a „One Page View‟ of all the costs associated with any
given report submitted to EPD.
Or
Any specific scope of work where a start date and end date can be established.
2) Each individual report will be viewed as a Task; a list of these routinely submitted reports
(now Tasks) are listed on the Common Data page of the CRF.
3) When submitting the initial CAP-Part A, one set of forms is required to cover all tasks &
costs (incurred & proposed) from the confirmed release thru completion of the Site
Investigation Plan.
4) When submitting the initial CAP-Part B, one set of forms is required to cover all tasks &
costs (incurred & proposed) from the preparation of the CAP Part B thru Remediation,
Monitoring and final Site Closure / Well Abandonment.
5) All reports submitted subsequent to the initial CAP Parts A or B submittals must have a
Task page attached showing the One Page View of the associated costs.
Individual Page Guidance:
1) Complete or Update the information on the “Common Data” page; you must provide the
information required in Sections 1, 2 and 3.
2) When completing “Section 2: Projected Tasks” on the “Common Data” page, note that ALL
Tasks that will be associated with that CAP A or B must be completed as described in items 3
and 4 of the General Guidance above.
3) If invoices are included with the forms, the “GUST-4D” must be completed.
4) If additional clarification is needed to explain unusually high personnel hours, complete the
“Supplemental” page.
5) Two example pages (Example 1 & 2) have been provided as guides for completing the “Task”
pages.
6) “Summary Page 1” summarizes Tasks 1 thru 5, while “Summary Page 2” summarizes Tasks
6 thru 10.
7) When completing the Task pages, make sure either “Proposed” or “Incurred” are checked
and that the “Duration of Events” and the “Annual # of Events” has been identified. Also,
the "Note" section must be filled out with specific details regarding the scope of work covered
by the Task #.
Note: Throughout the forms there are green highlighted cells; click on these cells to obtain
‘pop-up’ clarification or guidance. Additionally, some cells have been locked to protect
the formulas from being altered.
Cost Review Form Ver 7 Updated: July 30, 2010
Print Date: 12/4/2011
SECTION 1: COMMON DATA INPUT EPD RECEIVED DATE:
INFORMATION ENTERED ON THIS PAGE WILL AUTOMATICALLY APPEAR ON TASK & SUMMARY PAGES
Abiola Badru CAP A
County Facility ID # Release # Calvin Jones SIP or SISR
Facility Name; Address; City w/ Postal Code Darnell Manning Revised CAP A 75 50
EPD Project Officer David Humphris CAP A: Site Closure
James Mims
Consultant Project Manager (PM) Jay Kemberling CAP B
Consultant Company Name June Li Revised CAP B
Consultant PM Telephone Number Michael Taiwo CAP B: Assessment
Consultant PM Fax Number &/or Email Address Steve Burris CAP B: Site Closure
Consultant Company Address; City, State w/ Postal Code
Prog Rpt: System Installation
Responsible Party Representative Prog Rpt: System Start-Up
Responsible Party Company Name Carla Talley FP Removal Only
Responsible Party Telephone Number Cyprian Fonge Monitoring w/ Rpting
Responsible Party Fax Number &/or Email Address Karleen Francis O&M Only
Responsible Party Company Address; City, State w/ Postal Code Saquilla Hall Progress Rpt
Stanley Tam
SECTION 2: PROJECTED TASKS Well Abandonment
Task Task Detail (Optional) Task Task Detail (Optional)
TASK 1: TASK 6:
TASK 2: TASK 7:
TASK 3: TASK 8:
TASK 4: TASK 9:
TASK 5: TASK 10:
SECTION 3: CAP - SITE DATA
FOR THE FOLLOWIING QUESTIONS PROVIDE AN ANSWER OR PUT AN "X" IN THE BOX PROVIDED
Average Depth to Groundwater (ft)
Number of Monitoring Wells installed
What type of Drilling Method was used? Air Rotary Hollow Stem Other
Were Split Spoon Samples collected? Yes No Unknown
Average Number of Soil Samples per well
Monitoring Well diameter 2 inches 4 inches
Average Monitoring Well depth
What was the Monitoring Well Construction Material? PVC Sch 40 PVC Sch 80 Stainless Steel
Was development water drummed? Yes No Unknown
Were Drill Cuttings drummed? Yes No Unknown
What was the Formation Type? Consolidated Unconsolidated
SECTION 4: EAF/RCU COMPLIANCE
THIS SECTION IS FOR EPD USE ONLY
Regulatory Compliance Approval Date
Environmental Assurance Fee Approval Date
CAP Received Date
Cost Review Form Ver 7 Updated: July 30, 2010
Print Date: 12/4/2011
Itemized Summary of Invoices
(list only main invoices, not the associated backup/subcontractor invoices)
Brief Description (i.e., UST removal, free product Non-
Reimbursable Total Invoice(s)
Company Name Task # Invoice # Dates Covered removal, MW installation, soil boring, remediation Reimbursable
Amount Amount
equipment purchase/installation, etc.) Amount
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Totals $0.00 $0.00 $0.00
Cost Review Form Ver 7 Updated: July 30, 2010
CAP A Initial Submittal
Proposed: Incurred: x
County/Facility #/Release #:
Facility Name/Address/City:
Installed 3 MWs (20' ave depth) and prepared CAP A. [ALL ITEMS AND COSTS ARE EXAMPLES ONLY
SCOPE OF WORK: AND DO NOT REFLECT ACTUAL, EXPECTED OR NOT-TO-EXCEED LIMITATIONS.] 50
Dates Covered by this Task (If Incurred): 9/1/2004 to 11/20/2004
A. Personnel Duration of Events (Years) 1 Annual # of Events 1
Prep/Field Rpt Prep $/Hr Enter 1 if markup applies Total
Sr. Project Manager 4 1 x $95.00 = $475.00
Professional Geologist 8 4 x $85.00 = $1,020.00
Geologist 15 24 x $70.00 = $2,730.00
CADD 5 x $40.00 = $200.00
Technician 6 x $50.00 = $300.00
Administrative 2 x $35.00 = $70.00
Project Management - CRFs 4.5 x $80.00 = $360.00
Total Hours: 33 40.5
% Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $5,155.00
B. Travel
Units $/Unit Enter 1 if markup applies Total
Class 2 Vehicle Only 1.0 x $25.00 day = $25.00
What is the one-way mileage to site? 60.0 How many round trips to site per event? 2.0 240
Mileage 240 x $0.445 per mile = $106.80
Per Diem (must have overnight stay) 1 # of Travelers 2.0 day(s) @ rate = $36.00 average = $72.00
Lodging # of Travelers day(s) @ rate = =
Variable Rates for lodging 1 # of Travelers 2.0 day(s) @ rate = $75.50 = $151.00
=
% Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $354.80
C. Analytical
Type Method How Many Units $/Unit Enter 1 if markup applies Total
BTEX Soil Sample 8021 3 ea $35.00 1 = $105.00
BTEX Water Sample 8021 3 ea $35.00 1 = $105.00
PAH Water Samples 8270 3 ea $75.00 1 = $225.00
PAH Soil Samples 8270 3 ea $75.00 1 = $225.00
Related Analytical Items:
Small items - lump sum per well 3 ea $25.00 = $75.00
Oil/Water Interface Probe 1 days $50.00 = $50.00
PID/FID 1 days $50.00 = $50.00
% Markup on Sub Work = 15.0% Subcontracted Cost = $660.00 = $99.00
Total = $934.00
D. Drilling
Type of Drilling: Hollow Stem Air/Mud Rotary Air Hammer
Boring or MW: Size & Description How Many Units Per Units $/Unit Enter 1 if markup applies Total
MW Installation 3 20.0 ft $37.00 1 = $2,220.00
Development Materials 3 1.0 ea $15.00 1 = $45.00
=
=
Mob/Demob: 1 $250.00 1 = $250.00
Additional Drilling Costs:
=
=
% Markup on Sub Work = 15.0% Subcontracted Cost = $2,515.00 = $377.25
Total = $2,892.25
E. Waste Management
How many Units $/Unit Enter 1 if markup applies Total
Vacuum Truck =
Fluids Disposal =
Drill Cuttings Disposal 3 drum $150.00 1 = $450.00
=
=
% Markup on Sub Work = 15.0% Subcontracted Cost = $450.00 = $67.50
Total = $517.50
F. Miscellaneous
Description How Many Units $/Unit Enter 1 if markup applies Total
Survey: Site & Wells 1 event $150.00 1 = $150.00
=
=
=
=
=
=
=
=
=
% Markup on Sub Work = 15.0% Subcontracted Cost = $150.00 = $22.50
Total = $172.50
G. Cost per Event/Task A+B+C+D+E+F = $10,026.05
Cost Review Form Ver 7 Total Cost for Duration of Event(s)/Task(s) $10,026.05 Updated: July 30, 2010
Rem Start-Up Activities System Insallation
Proposed: x Incurred:
County/Facility #/Release #:
Facility Name/Address/City:
Install trailer-mounted DPE system, three (3) 4" recovery wells, and prepare a system installation & startup
SCOPE OF WORK: report. [THIS EXAMPLE DOES NOT REFLECT ACTUAL, EXPECTED OR NOT-TO-EXCEED LIMITATIONS.] 50
Dates Covered by this Task (If Incurred): to
A. Personnel Duration of Events (Years) 1 Annual # of Events 1
Prep/Field Rpt Prep $/Hr Enter 1 if markup applies Total
Sr. Project Manager 2 1 x $95.00 = $285.00
Professional Eng. &/or Geo. 34 8 x $85.00 = $3,570.00
Geologist 20 x $70.00 = $1,400.00
Technician 20 x $50.00 = $1,000.00
CADD 4 x $40.00 = $160.00
Administrative 4 x $35.00 = $140.00
Project Management - CRFs 2.5 x $80.00 = $200.00
Total Hours: 76 19.5
% Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $6,755.00
B. Travel
Units $/Unit Enter 1 if markup applies Total
Class 2 Vehicle Only 1.0 x $25.00 day = $25.00
What is the one-way mileage to site? 60.0 How many round trips to site per event? 2.0 240
Mileage 240 x $0.445 per mile = $106.80
Per Diem (must have overnight stay) 2 # of Travelers 3.0 day(s) @ rate = $36.00 = $216.00
Lodging 2 # of Travelers 3.0 day(s) @ rate = $65.00 = $390.00
=
=
% Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $737.80
C. Analytical
Type Method How Many Units $/Unit Enter 1 if markup applies Total
BTEX Soil Sample =
BTEX Water Sample =
=
=
Related Analytical Items:
Small items - lump sum per well =
=
=
% Markup on Sub Work = 15.0% Subcontracted Cost = $0.00 =
Total = $0.00
D. Drilling
Type of Drilling: Hollow Stem Air/Mud Rotary Air Hammer
Boring or MW: Size & Description How Many Units Per Units $/Unit Enter 1 if markup applies Total
4" Recovery Wells R1, R2 & R3 3 25.0 ft $60.00 1 = $4,500.00
=
=
=
Mob/Demob: 1 $250.00 1 = $250.00
Additional Drilling Costs:
Oil/Water Interface Probe 1 1.0 ea $50.00 = $50.00
PID/FID 1 1 ea $50.00 = $50.00
% Markup on Sub Work = 15.0% Subcontracted Cost = $4,750.00 = $712.50
Total = $5,562.50
E. Waste Management
How many Units $/Unit Enter 1 if markup applies Total
Vacuum Truck =
Fluids Disposal =
Drill Cuttings Disposal 4 drum $150.00 1 = $600.00
=
=
% Markup on Sub Work = 15.0% Subcontracted Cost = $600.00 = $90.00
Total = $690.00
F. Miscellaneous
Description How Many Units $/Unit Enter 1 if markup applies Total
Trailer Mounted DPE System 1 lump $50,000.00 1 = $50,000.00
Thermal/Catalytic Oxidizer 1 lump $36,000.00 1 = $36,000.00
Pumps 3 ea $1,500.00 1 = $4,500.00
Telemetry System 1 ea $2,000.00 1 = $2,000.00
Electrical Subcontractor 1 ea $5,000.00 1 = $5,000.00
Miscellaneous (separate list provided) 1 ea $1,000.00 1 = $1,000.00
Utilities Hookup 1 ea $1,500.00 1 = $1,500.00
DPE Installation Subcontractor - trenching 1 lump $40,000.00 1 = $40,000.00
Compound Fence 1 lump $1,500.00 1 = $1,500.00
=
% Markup on Sub Work = 15.0% Subcontracted Cost = $141,500.00 = $21,225.00
Total = $162,725.00
G. Cost per Event/Task A+B+C+D+E+F = $176,470.30
Cost Review Form Ver 7 Total Cost for Duration of Event(s)/Task(s) $176,470.30 Updated: July 30, 2010
Print Date: 12/4/2011
Supplemental - Personnel
(Optional - For Additional Breakdown/Clarification As Needed)
Facility County/ID:
Facility Name/Address/City: 0
NOTE:
Preliminary Planning/Field Work Task Task Task Task Task
POSITION/TITLE ACTIVITY/EXPLANATION Hrs $/Hr TOTAL Hrs $/Hr TOTAL Hrs $/Hr TOTAL Hrs $/Hr TOTAL Hrs $/Hr TOTAL
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
0.00 0.00 0.00 0.00 0.00
Report Generation/Results Analysis
POSITION/TITLE ACTIVITY/EXPLANATION Hrs $/Hr TOTAL Hrs $/Hr TOTAL Hrs $/Hr TOTAL Hrs $/Hr TOTAL Hrs $/Hr TOTAL
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
0.00 0.00 0.00 0.00 0.00
Totals: (Preliminary Planning/Field Work) & (Report Generation/Results Analysis) $0.00 $0.00 $0.00 $0.00 $0.00
$0.00
Task 1 Print Date: 12/4/2011
Proposed: Incurred: x Review Date: EPD REVIEW
County/Facility #/Release #: 0 0 1 County/Facility #/Release #: 0 0 1 INCURRED
Facility Name/Address/City: 0 Facility Name/Address/City: 0 0 INCURRED
SCOPE OF WORK: 1 SCOPE OF WORK: 0
Dates Covered by this Task (If Incurred): All
Dates Covered by this Task (If Incurred):
to Some to
Approved
Changed?
?
A. Personnel Duration of Events (Years) 1.0 Annual # of Events 1 A. Personnel Duration of Events (Years) 1.0 Annual # of Events 1.0 Deduction/Revision Clarification
Prep/Field Rpt Prep $/Hr Total Prep/Field Rpt Prep $/Hr Enter 1 if markup applies Total
x = x =
x = x =
x = x =
x = x =
x = x =
x = x =
Project Management - CRFs x = Project Management - CRFs x =
Total Hours: 0 0 Total Hours: 0 0
% Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
B. Travel B. Travel
Units $/Unit Enter 1 if markup applies Total Units $/Unit Enter 1 if markup applies Total
Class 2 Vehicle Only x day = Class 2 Vehicle Only x day =
What is the one-way mileage to site? How many round trips to site per event? 0 What is the one-way mileage to site? How many round trips to site per event? 0
Mileage x $0.000 per mile = Mileage x $0.000 per mile =
Per Diem (must have overnight stay) # of Travelers day(s) @ rate = = Per Diem (must have overnight stay) # of Travelers day(s) @ rate = =
Lodging # of Travelers day(s) @ rate = = Lodging # of Travelers day(s) @ rate = =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
C. Analytical C. Analytical
Type Method How Many Units $/Unit Enter 1 if markup applies Total Type Method How Many Units $/Unit Enter 1 if markup applies Total
BTEX Soil Sample = BTEX Soil Sample =
BTEX Water Sample = BTEX Water Sample =
= =
= =
Related Analytical Items: Related Analytical Items:
Small items - lump sum per well = Small items - lump sum per well =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
D. Drilling D. Drilling
Type of Drilling: Hollow Stem Air/Mud Rotary Air Hammer Type of Drilling: Hollow Stem Air/Mud Rotary Air Hammer
Boring or MW: Size & Description How Many Units Per Units $/Unit Enter 1 if markup applies Total Boring or MW: Size & Description How Many Units Per Units $/Unit Enter 1 if markup applies Total
= =
= =
= =
= =
Mob/Demob: = Mob/Demob: =
Additional Drilling Costs: Additional Drilling Costs:
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
E. Waste Management E. Waste Management
How many Units $/Unit Enter 1 if markup applies Total How many Units $/Unit Enter 1 if markup applies Total
Vacuum Truck = Vacuum Truck =
Fluids Disposal = Fluids Disposal =
Drill Cuttings Disposal = Drill Cuttings Disposal =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
F. Miscellaneous F. Miscellaneous
Description How Many Units $/Unit Enter 1 if markup applies Total How Many Units $/Unit Enter 1 if markup applies Total
= =
= =
= =
= =
= =
= =
= =
= =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
G. Cost per Event/Task A+ B + C + D + E + F = $0.00 G. Cost per Event/Task A+ B + C + D + E + F = $0.00
Cost Review Form Ver 7 Total Cost for Duration of Event(s)/Task(s) $0.00 Updated: July 30, 2010 Cost Review Form Ver 7 Total Cost for Duration of Event(s)/Task(s) $0.00 Updated: July 30, 2010
Task 1 Print Date: 12/4/2011
50
Task 2 Print Date: 12/4/2011
Proposed: Incurred: Review Date: EPD REVIEW
County/Facility #/Release #: 0 0 1 County/Facility #/Release #: 0 0 PROPOSED
Facility Name/Address/City: 0 Facility Name/Address/City: 0
SCOPE OF WORK: SCOPE OF WORK: 40
Dates Covered by this Task (If Incurred): All
Dates Covered by this Task (If Incurred):
to Some to
Approved
Changed?
?
A. Personnel Duration of Events (Years) 1.0 Annual # of Events 1 A. Personnel Duration of Events (Years) 1.0 Annual # of Events 1.0
Prep/Field Rpt Prep $/Hr Total Prep/Field Rpt Prep $/Hr Enter 1 if markup applies Total
x = x =
x = x =
x = x =
x = x =
x = x =
x = x =
Project Management - CRFs x = Project Management - CRFs x =
Total Hours: 0 0 Total Hours: 0 0
% Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
B. Travel B. Travel
Units $/Unit Enter 1 if markup applies Total Units $/Unit Enter 1 if markup applies Total
Class 2 Vehicle Only x day = Class 2 Vehicle Only x day =
What is the one-way mileage to site? How many round trips to site per event? 0 What is the one-way mileage to site? How many round trips to site per event? 0
Mileage x $0.000 per mile = Mileage x $0.000 per mile =
Per Diem (must have overnight stay) # of Travelers day(s) @ rate = = Per Diem (must have overnight stay) # of Travelers day(s) @ rate = =
Lodging # of Travelers day(s) @ rate = = Lodging # of Travelers day(s) @ rate = =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
C. Analytical C. Analytical
Type Method How Many Units $/Unit Enter 1 if markup applies Total Type Method How Many Units $/Unit Enter 1 if markup applies Total
BTEX Soil Sample = BTEX Soil Sample =
BTEX Water Sample = BTEX Water Sample =
= =
= =
Related Analytical Items: Related Analytical Items:
Small items - lump sum per well = Small items - lump sum per well =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
D. Drilling
Type of Drilling: Hollow Stem Air/Mud Rotary Air Hammer Type of Drilling: Hollow Stem Air/Mud Rotary Air Hammer
Boring or MW: Size & Description How Many Units Per Units $/Unit Enter 1 if markup applies Total Boring or MW: Size & Description How Many Units Per Units $/Unit Enter 1 if markup applies Total
= =
= =
= =
= =
Mob/Demob: = Mob/Demob: =
Additional Drilling Costs: Additional Drilling Costs:
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
E. Waste Management
How many Units $/Unit Enter 1 if markup applies Total How many Units $/Unit Total
Vacuum Truck = Vacuum Truck =
Fluids Disposal = Fluids Disposal =
Drill Cuttings Disposal = Drill Cuttings Disposal =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
F. Miscellaneous
Description How Many Units $/Unit Enter 1 if markup applies Total How Many Units $/Unit Enter 1 if markup applies Total
= =
= =
= =
= =
= =
= =
= =
= =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
G. Cost per Event/Task A+ B + C + D + E + F = $0.00 G. Cost per Event/Task A+ B + C + D + E + F = $0.00
Cost Review Form Ver 7 Total Cost for Duration of Event(s)/Task(s) $0.00 Updated: July 30, 2010 Cost Review Form Ver 7 Total Cost for Duration of Event(s)/Task(s) $0.00 Updated: July 30, 2010
Task 3 Print Date: 12/4/2011
Proposed: Incurred: Review Date: EPD Review
County/Facility #/Release #: 0 0 1 County/Facility #/Release #: 0 0 1 PROPOSED
Facility Name/Address/City: 0 Facility Name/Address/City: 0
SCOPE OF WORK: SCOPE OF WORK: 40
Dates Covered by this Task (If Incurred): All
Dates Covered by this Task (If Incurred):
to Some to
Approved
Changed?
?
A. Personnel Duration of Events (Years) 1.0 Annual # of Events 1 A. Personnel Duration of Events (Years) 1.0 Annual # of Events 1.0
Prep/Field Rpt Prep $/Hr Total Prep/Field Rpt Prep $/Hr Enter 1 if markup applies Total
x = x =
x = x =
x = x =
x = x =
x = x =
x = x =
Project Management - CRFs x = Project Management - CRFs x =
Total Hours: 0 0 Total Hours: 0 0
% Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
B. Travel B. Travel
Units $/Unit Enter 1 if markup applies Total Units $/Unit Enter 1 if markup applies Total
Class 2 Vehicle Only x day = Class 2 Vehicle Only x day =
What is the one-way mileage to site? How many round trips to site per event? 0 What is the one-way mileage to site? How many round trips to site per event? 0
Mileage x $0.000 per mile = Mileage x $0.000 per mile =
Per Diem (must have overnight stay) # of Travelers day(s) @ rate = = Per Diem (must have overnight stay) # of Travelers day(s) @ rate = =
Lodging # of Travelers day(s) @ rate = = Lodging # of Travelers day(s) @ rate = =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
C. Analytical C. Analytical
Type Method How Many Units $/Unit Enter 1 if markup applies Total Type Method How Many Units $/Unit Enter 1 if markup applies Total
BTEX Soil Sample = BTEX Soil Sample =
BTEX Water Sample = BTEX Water Sample =
= =
= =
Related Analytical Items: Related Analytical Items:
Small items - lump sum per well = Small items - lump sum per well =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
D. Drilling D. Drilling
Type of Drilling: Hollow Stem Air/Mud Rotary Air Hammer Type of Drilling: Hollow Stem Air/Mud Rotary Air Hammer
Boring or MW: Size & Description How Many Units Per Units $/Unit Enter 1 if markup applies Total Boring or MW: Size & Description How Many Units Per Units $/Unit Enter 1 if markup applies Total
= =
= =
= =
= =
Mob/Demob: = Mob/Demob: =
Additional Drilling Costs: Additional Drilling Costs:
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
E. Waste Management E. Waste Management
How many Units $/Unit Enter 1 if markup applies Total How many Units $/Unit Total
Vacuum Truck = Vacuum Truck =
Fluids Disposal = Fluids Disposal =
Drill Cuttings Disposal = Drill Cuttings Disposal =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
F. Miscellaneous F. Miscellaneous
Description How Many Units $/Unit Enter 1 if markup applies Total How Many Units $/Unit Enter 1 if markup applies Total
= =
= =
= =
= =
= =
= =
= =
= =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
G. Cost per Event/Task A+ B + C + D + E + F = $0.00 G. Cost per Event/Task A+ B + C + D + E + F = $0.00
Cost Review Form Ver 7 Total Cost for Duration of Event(s)/Task(s) $0.00 Updated: July 30, 2010 Cost Review Form Ver 7 Total Cost for Duration of Event(s)/Task(s) $0.00 Updated: July 30, 2010
Task 4 Print Date: 12/4/2011
Proposed: Incurred: Review Date: EPD REVIEW
County/Facility #/Release #: 0 0 1 County/Facility #/Release #: 0 0 1 PROPOSED
Facility Name/Address/City: 0 Facility Name/Address/City: 0
SCOPE OF WORK: SCOPE OF WORK: 40
Dates Covered by this Task (If Incurred): All
Dates Covered by this Task (If Incurred):
to Some to
Approved
Changed?
?
A. Personnel Duration of Events (Years) 1.0 Annual # of Events 1 A. Personnel Duration of Events (Years) 1.0 Annual # of Events 1.0
Prep/Field Rpt Prep $/Hr Total Prep/Field Rpt Prep $/Hr Enter 1 if markup applies Total
x = x =
x = x =
x = x =
x = x =
x = x =
x = x =
Project Management - CRFs x = Project Management - CRFs x =
Total Hours: 0 0 Total Hours: 0 0
% Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
B. Travel B. Travel
Units $/Unit Enter 1 if markup applies Total Units $/Unit Enter 1 if markup applies Total
Class 2 Vehicle Only x day = Class 2 Vehicle Only x day =
What is the one-way mileage to site? How many round trips to site per event? 0 What is the one-way mileage to site? How many round trips to site per event? 0
Mileage x $0.000 per mile = Mileage x $0.000 per mile =
Per Diem (must have overnight stay) # of Travelers day(s) @ rate = = Per Diem (must have overnight stay) # of Travelers day(s) @ rate = =
Lodging # of Travelers day(s) @ rate = = Lodging # of Travelers day(s) @ rate = =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
C. Analytical C. Analytical
Type Method How Many Units $/Unit Enter 1 if markup applies Total Type Method How Many Units $/Unit Enter 1 if markup applies Total
BTEX Soil Sample = BTEX Soil Sample =
BTEX Water Sample = BTEX Water Sample =
= =
= =
Related Analytical Items: Related Analytical Items:
Small items - lump sum per well = Small items - lump sum per well =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
D. Drilling D. Drilling
Type of Drilling: Hollow Stem Air/Mud Rotary Air Hammer Type of Drilling: Hollow Stem Air/Mud Rotary Air Hammer
Boring or MW: Size & Description How Many Units Per Units $/Unit Enter 1 if markup applies Total Boring or MW: Size & Description How Many Units Per Units $/Unit Enter 1 if markup applies Total
= =
= =
= =
= =
Mob/Demob: = Mob/Demob: =
Additional Drilling Costs: Additional Drilling Costs:
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
E. Waste Management E. Waste Management
How many Units $/Unit Enter 1 if markup applies Total How many Units $/Unit Total
Vacuum Truck = Vacuum Truck =
Fluids Disposal = Fluids Disposal =
Drill Cuttings Disposal = Drill Cuttings Disposal =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
F. Miscellaneous F. Miscellaneous
Description How Many Units $/Unit Enter 1 if markup applies Total How Many Units $/Unit Enter 1 if markup applies Total
= =
= =
= =
= =
= =
= =
= =
= =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
G. Cost per Event/Task A+ B + C + D + E + F = $0.00 G. Cost per Event/Task A+ B + C + D + E + F = $0.00
Cost Review Form Ver 7 Total Cost for Duration of Event(s)/Task(s) $0.00 Updated: July 30, 2010 Cost Review Form Ver 7 Total Cost for Duration of Event(s)/Task(s) $0.00 Updated: July 30, 2010
Task 5 Print Date: 12/4/2011
Proposed: Incurred: Review Date: EPD REVIEW
County/Facility #/Release #: 0 County/Facility #/Release #: 0 PROPOSED
Facility Name/Address/City: Facility Name/Address/City:
SCOPE OF WORK: SCOPE OF WORK: 35 50 40
Dates Covered by this Task (If Incurred): All
Dates Covered by this Task (If Incurred):
to Some to
Approved
Changed?
?
A. Personnel Duration of Events (Years) 1.0 Annual # of Events 1 A. Personnel Duration of Events (Years) 1.0 Annual # of Events 1.0
Prep/Field Rpt Prep $/Hr Total Prep/Field Rpt Prep $/Hr Enter 1 if markup applies Total
x = x =
x = x =
x = x =
x = x =
x = x =
x = x =
Project Management - CRFs x = Project Management - CRFs x =
Total Hours: 0 0 Total Hours: 0 0
% Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
B. Travel B. Travel
Units $/Unit Enter 1 if markup applies Total Units $/Unit Enter 1 if markup applies Total
Class 2 Vehicle Only x day = Class 2 Vehicle Only x day =
What is the one-way mileage to site? How many round trips to site per event? 0 What is the one-way mileage to site? How many round trips to site per event? 0
Mileage x $0.000 per mile = Mileage x $0.000 per mile =
Per Diem (must have overnight stay) # of Travelers day(s) @ rate = = Per Diem (must have overnight stay) # of Travelers day(s) @ rate = =
Lodging # of Travelers day(s) @ rate = = Lodging # of Travelers day(s) @ rate = =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
C. Analytical C. Analytical
Type Method How Many Units $/Unit Enter 1 if markup applies Total Type Method How Many Units $/Unit Enter 1 if markup applies Total
BTEX Soil Sample = BTEX Soil Sample =
BTEX Water Sample = BTEX Water Sample =
= =
= =
Related Analytical Items: Related Analytical Items:
Small items - lump sum per well = Small items - lump sum per well =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
D. Drilling D. Drilling
Type of Drilling: Hollow Stem Air/Mud Rotary Air Hammer Type of Drilling: Hollow Stem Air/Mud Rotary Air Hammer
Boring or MW: Size & Description How Many Units Per Units $/Unit Enter 1 if markup applies Total Boring or MW: Size & Description How Many Units Per Units $/Unit Enter 1 if markup applies Total
= =
= =
= =
= =
Mob/Demob: = Mob/Demob: =
Additional Drilling Costs: Additional Drilling Costs:
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
E. Waste Management E. Waste Management
How many Units $/Unit Enter 1 if markup applies Total How many Units $/Unit Total
Vacuum Truck = Vacuum Truck =
Fluids Disposal = Fluids Disposal =
Drill Cuttings Disposal = Drill Cuttings Disposal =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
F. Miscellaneous F. Miscellaneous
Description How Many Units $/Unit Enter 1 if markup applies Total How Many Units $/Unit Enter 1 if markup applies Total
= =
= =
= =
= =
= =
= =
= =
= =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
G. Cost per Event/Task A+ B + C + D + E + F = $0.00 G. Cost per Event/Task A+ B + C + D + E + F = $0.00
Cost Review Form Ver 7 Total Cost for Duration of Event(s)/Task(s) $0.00 Updated: July 30, 2010 Cost Review Form Ver 7 Total Cost for Duration of Event(s)/Task(s) $0.00 Updated: July 30, 2010
Cost Review Form - Summary Page 1 Print Date: 12/4/2011
Summary of All Project Cost
Facility County/ID: Facility Name/Address/City:
EPD Received Date:
EPD Pre-Approved Total EPD Pre-
Proposed Incurred
Per Event Cost Approved Costs
Events: Duration Per Event Per Event Duration
Task 1: 1 1 1 1
A. Personnel $0.00 $0.00 $0.00 $0.00
B. Travel $0.00 $0.00 $0.00 $0.00
C. Analytical $0.00 $0.00 $0.00 $0.00
D. Drilling ` $0.00 $0.00 $0.00 $0.00
E. Waste Management $0.00 $0.00 $0.00 $0.00
F. Miscellaneous $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 Empty
Events: Duration Per Event Per Event Duration
Task 2: 1 1 1 1
A. Personnel $0.00 $0.00 $0.00 $0.00
B. Travel $0.00 $0.00 $0.00 $0.00
C. Analytical $0.00 $0.00 $0.00 $0.00
D. Drilling $0.00 $0.00 $0.00 $0.00
E. Waste Management $0.00 $0.00 $0.00 $0.00
F. Miscellaneous $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 Empty
Events: Duration Per Event Per Event Duration
Task 3: 1 1 1 1
A. Personnel $0.00 $0.00 $0.00 $0.00
B. Travel $0.00 $0.00 $0.00 $0.00
C. Analytical $0.00 $0.00 $0.00 $0.00
D. Drilling $0.00 $0.00 $0.00 $0.00
E. Waste Management $0.00 $0.00 $0.00 $0.00
F. Miscellaneous $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 Empty
Events: Duration Per Event Per Event Duration
Task 4: 1 1 1 1
A. Personnel $0.00 $0.00 $0.00 $0.00
B. Travel $0.00 $0.00 $0.00 $0.00
C. Analytical $0.00 $0.00 $0.00 $0.00
D. Drilling $0.00 $0.00 $0.00 $0.00
E. Waste Management $0.00 $0.00 $0.00 $0.00
F. Miscellaneous $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 Empty
Events: Duration Per Event Per Event Duration
Task 5: 1 1 1 1
A. Personnel $0.00 $0.00 $0.00 $0.00
B. Travel $0.00 $0.00 $0.00 $0.00
C. Analytical $0.00 $0.00 $0.00 $0.00
D. Drilling $0.00 $0.00 $0.00 $0.00
E. Waste Management $0.00 $0.00 $0.00 $0.00
F. Miscellaneous $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 Empty
If additional Tasks beyond # 5 are required, put an "X" in
the box ===========> $0.00 $0.00 $0.00
$0.00
O/O TOTAL COSTS (PROPOSED & INCURRED):
EPD PRE-APPROVED TOTAL COSTS: $0.00
0 GA USTMP
(EPD Project Officer -Print Name) (Signature) (EPD Program) (Date)
404-362-4526 404-362-2654 & " NAME "@gadnr.org 4244 International Pkwy, Ste 104; Atlanta, Georgia 30354
(Phone #) (FAX # & Email Address) (Address/City/State/Zip)
0 0
(Consultant Project Manager - Print Name) (Signature of Representative) (Company) (Date)
0 0 0
(Phone #) (FAX # & Email Address) (Address/City/State/Zip)
I acknowledge that the actual amount reimbursed will be determined after all invoices, receipts, etc. are submitted and subjected to a technical and financial review and audit, respectively. I further understand
that the GA USTMP will reimburse costs in accordance with those identified on this form, and unless sound justification is provided and subsequently approved, the maximum amount eligible for reimbursement
will be the amount identified on this form. I also understand that this certification is not intended to limit what an Investigative/Remediation Contractor may charge.
0 0
(Responsible Party Representative - Print Name) (Signature of Representative) (Date)
0 0 0
(Phone #) (FAX # & Email Address) (Address/City/State/Zip)
Task 6 Print Date: 12/4/2011
Proposed: Incurred: Review Date: EPD REVIEW
County/Facility #/Release #: County/Facility #/Release #: PROPOSED
Facility Name/Address/City: Facility Name/Address/City:
SCOPE OF WORK: SCOPE OF WORK: 35 40 40
Dates Covered by this Task (If Incurred): All
Dates Covered by this Task (If Incurred):
to Some to
Approved
Changed?
?
A. Personnel Duration of Events (Years) 1.0 Annual # of Events 1 A. Personnel Duration of Events (Years) 1.0 Annual # of Events 1.0
Prep/Field Rpt Prep $/Hr Total Prep/Field Rpt Prep $/Hr Enter 1 if markup applies Total
x = x =
x = x =
x = x =
x = x =
x = x =
x = x =
Project Management - CRFs x = Project Management - CRFs x =
Total Hours: 0 0 Total Hours: 0 0
% Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
B. Travel B. Travel
Units $/Unit Enter 1 if markup applies Total Units $/Unit Enter 1 if markup applies Total
Class 2 Vehicle Only x day = Class 2 Vehicle Only x day =
What is the one-way mileage to site? How many round trips to site per event? 0 What is the one-way mileage to site? How many round trips to site per event? 0
Mileage x $0.000 per mile = Mileage x $0.000 per mile =
Per Diem (must have overnight stay) # of Travelers day(s) @ rate = = Per Diem (must have overnight stay) # of Travelers day(s) @ rate = =
Lodging # of Travelers day(s) @ rate = = Lodging # of Travelers day(s) @ rate = =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
C. Analytical C. Analytical
Type Method How Many Units $/Unit Enter 1 if markup applies Total Type Method How Many Units $/Unit Enter 1 if markup applies Total
BTEX Soil Sample = BTEX Soil Sample =
BTEX Water Sample = BTEX Water Sample =
= =
= =
Related Analytical Items: Related Analytical Items:
Small items - lump sum per well = Small items - lump sum per well =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
D. Drilling D. Drilling
Type of Drilling: Hollow Stem Air/Mud Rotary Air Hammer Type of Drilling: Hollow Stem Air/Mud Rotary Air Hammer
Boring or MW: Size & Description How Many Units Per Units $/Unit Enter 1 if markup applies Total Boring or MW: Size & Description How Many Units Per Units $/Unit Enter 1 if markup applies Total
= =
= =
= =
= =
Mob/Demob: = Mob/Demob: =
Additional Drilling Costs: Additional Drilling Costs:
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
E. Waste Management E. Waste Management
How many Units $/Unit Enter 1 if markup applies Total How many Units $/Unit Total
Vacuum Truck = Vacuum Truck =
Fluids Disposal = Fluids Disposal =
Drill Cuttings Disposal = Drill Cuttings Disposal =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
F. Miscellaneous F. Miscellaneous
Description How Many Units $/Unit Enter 1 if markup applies Total How Many Units $/Unit Enter 1 if markup applies Total
= =
= =
= =
= =
= =
= =
= =
= =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
G. Cost per Event/Task A+ B + C + D + E + F = $0.00 G. Cost per Event/Task A+ B + C + D + E + F = $0.00
Cost Review Form Ver 7 Total Cost for Duration of Event(s)/Task(s) $0.00 Updated: July 30, 2010 Cost Review Form Ver 7 Total Cost for Duration of Event(s)/Task(s) $0.00 Updated: July 30, 2010
Task 7 Print Date: 12/4/2011
Proposed: Incurred: Review Date: EPD REVIEW
County/Facility #/Release #: County/Facility #/Release #: PROPOSED
Facility Name/Address/City: Facility Name/Address/City:
SCOPE OF WORK: SCOPE OF WORK: 35 40 40
Dates Covered by this Task (If Incurred): All
Dates Covered by this Task (If Incurred):
to Some to
Approved
Changed?
?
A. Personnel Duration of Events (Years) 1.0 Annual # of Events 1 A. Personnel Duration of Events (Years) 1.0 Annual # of Events 1.0
Prep/Field Rpt Prep $/Hr Total Prep/Field Rpt Prep $/Hr Enter 1 if markup applies Total
x = x =
x = x =
x = x =
x = x =
x = x =
x = x =
Project Management - CRFs x = Project Management - CRFs x =
Total Hours: 0 0 Total Hours: 0 0
% Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
B. Travel B. Travel
Units $/Unit Enter 1 if markup applies Total Units $/Unit Enter 1 if markup applies Total
Class 2 Vehicle Only x day = Class 2 Vehicle Only x day =
What is the one-way mileage to site? How many round trips to site per event? 0 What is the one-way mileage to site? How many round trips to site per event? 0
Mileage x $0.000 per mile = Mileage x $0.000 per mile =
Per Diem (must have overnight stay) # of Travelers day(s) @ rate = = Per Diem (must have overnight stay) # of Travelers day(s) @ rate = =
Lodging # of Travelers day(s) @ rate = = Lodging # of Travelers day(s) @ rate = =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
C. Analytical C. Analytical
Type Method How Many Units $/Unit Enter 1 if markup applies Total Type Method How Many Units $/Unit Enter 1 if markup applies Total
BTEX Soil Sample = BTEX Soil Sample =
BTEX Water Sample = BTEX Water Sample =
= =
= =
Related Analytical Items: Related Analytical Items:
Small items - lump sum per well = Small items - lump sum per well =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
D. Drilling D. Drilling
Type of Drilling: Hollow Stem Air/Mud Rotary Air Hammer Type of Drilling: Hollow Stem Air/Mud Rotary Air Hammer
Boring or MW: Size & Description How Many Units Per Units $/Unit Enter 1 if markup applies Total Boring or MW: Size & Description How Many Units Per Units $/Unit Enter 1 if markup applies Total
= =
= =
= =
= =
Mob/Demob: = Mob/Demob: =
Additional Drilling Costs: Additional Drilling Costs:
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
E. Waste Management E. Waste Management
How many Units $/Unit Enter 1 if markup applies Total How many Units $/Unit Total
Vacuum Truck = Vacuum Truck =
Fluids Disposal = Fluids Disposal =
Drill Cuttings Disposal = Drill Cuttings Disposal =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
F. Miscellaneous F. Miscellaneous
Description How Many Units $/Unit Enter 1 if markup applies Total How Many Units $/Unit Enter 1 if markup applies Total
= =
= =
= =
= =
= =
= =
= =
= =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
G. Cost per Event/Task A+ B + C + D + E + F = $0.00 G. Cost per Event/Task A+ B + C + D + E + F = $0.00
Cost Review Form Ver 7 Total Cost for Duration of Event(s)/Task(s) $0.00 Updated: July 30, 2010 Cost Review Form Ver 7 Total Cost for Duration of Event(s)/Task(s) $0.00 Updated: July 30, 2010
Task 8 Print Date: 12/4/2011
Proposed: Incurred: Review Date: EPD REVIEW
County/Facility #/Release #: County/Facility #/Release #: PROPOSED
Facility Name/Address/City: Facility Name/Address/City:
SCOPE OF WORK: SCOPE OF WORK: 35 40 40
Dates Covered by this Task (If Incurred): All
Dates Covered by this Task (If Incurred):
to Some to
Approved
Changed?
?
A. Personnel Duration of Events (Years) 1.0 Annual # of Events 1 A. Personnel Duration of Events (Years) 1.0 Annual # of Events 1.0
Prep/Field Rpt Prep $/Hr Total Prep/Field Rpt Prep $/Hr Enter 1 if markup applies Total
x = x =
x = x =
x = x =
x = x =
x = x =
x = x =
Project Management - CRFs x = Project Management - CRFs x =
Total Hours: 0 0 Total Hours: 0 0
% Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
B. Travel B. Travel
Units $/Unit Enter 1 if markup applies Total Units $/Unit Enter 1 if markup applies Total
Class 2 Vehicle Only x day = Class 2 Vehicle Only x day =
What is the one-way mileage to site? How many round trips to site per event? 0 What is the one-way mileage to site? How many round trips to site per event? 0
Mileage x $0.000 per mile = Mileage x $0.000 per mile =
Per Diem (must have overnight stay) # of Travelers day(s) @ rate = = Per Diem (must have overnight stay) # of Travelers day(s) @ rate = =
Lodging # of Travelers day(s) @ rate = = Lodging # of Travelers day(s) @ rate = =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
C. Analytical C. Analytical
Type Method How Many Units $/Unit Enter 1 if markup applies Total Type Method How Many Units $/Unit Enter 1 if markup applies Total
BTEX Soil Sample = BTEX Soil Sample =
BTEX Water Sample = BTEX Water Sample =
= =
= =
Related Analytical Items: Related Analytical Items:
Small items - lump sum per well = Small items - lump sum per well =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
D. Drilling D. Drilling
Type of Drilling: Hollow Stem Air/Mud Rotary Air Hammer Type of Drilling: Hollow Stem Air/Mud Rotary Air Hammer
Boring or MW: Size & Description How Many Units Per Units $/Unit Enter 1 if markup applies Total Boring or MW: Size & Description How Many Units Per Units $/Unit Enter 1 if markup applies Total
= =
= =
= =
= =
Mob/Demob: = Mob/Demob: =
Additional Drilling Costs: Additional Drilling Costs:
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
E. Waste Management E. Waste Management
How many Units $/Unit Enter 1 if markup applies Total How many Units $/Unit Total
Vacuum Truck = Vacuum Truck =
Fluids Disposal = Fluids Disposal =
Drill Cuttings Disposal = Drill Cuttings Disposal =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
F. Miscellaneous F. Miscellaneous
Description How Many Units $/Unit Enter 1 if markup applies Total How Many Units $/Unit Enter 1 if markup applies Total
= =
= =
= =
= =
= =
= =
= =
= =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
G. Cost per Event/Task A+ B + C + D + E + F = $0.00 G. Cost per Event/Task A+ B + C + D + E + F = $0.00
Cost Review Form Ver 7 Total Cost for Duration of Event(s)/Task(s) $0.00 Updated: July 30, 2010 Cost Review Form Ver 7 Total Cost for Duration of Event(s)/Task(s) $0.00 Updated: July 30, 2010
Task 9 Print Date: 12/4/2011
Proposed: Incurred: Review Date: EPD REVIEW
County/Facility #/Release #: County/Facility #/Release #: PROPOSED
Facility Name/Address/City: Facility Name/Address/City:
SCOPE OF WORK: SCOPE OF WORK: 35 40 40
Dates Covered by this Task (If Incurred): All
Dates Covered by this Task (If Incurred):
to Some to
Approved
Changed?
?
A. Personnel Duration of Events (Years) 1.0 Annual # of Events 1 A. Personnel Duration of Events (Years) 1.0 Annual # of Events 1.0
Prep/Field Rpt Prep $/Hr Total Prep/Field Rpt Prep $/Hr Enter 1 if markup applies Total
x = x =
x = x =
x = x =
x = x =
x = x =
x = x =
Project Management - CRFs x = Project Management - CRFs x =
Total Hours: 0 0 Total Hours: 0 0
% Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
B. Travel B. Travel
Units $/Unit Enter 1 if markup applies Total Units $/Unit Enter 1 if markup applies Total
Class 2 Vehicle Only x day = Class 2 Vehicle Only x day =
What is the one-way mileage to site? How many round trips to site per event? 0 What is the one-way mileage to site? How many round trips to site per event? 0
Mileage x $0.000 per mile = Mileage x $0.000 per mile =
Per Diem (must have overnight stay) # of Travelers day(s) @ rate = = Per Diem (must have overnight stay) # of Travelers day(s) @ rate = =
Lodging # of Travelers day(s) @ rate = = Lodging # of Travelers day(s) @ rate = =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
C. Analytical C. Analytical
Type Method How Many Units $/Unit Enter 1 if markup applies Total Type Method How Many Units $/Unit Enter 1 if markup applies Total
BTEX Soil Sample = BTEX Soil Sample =
BTEX Water Sample = BTEX Water Sample =
= =
= =
Related Analytical Items: Related Analytical Items:
Small items - lump sum per well = Small items - lump sum per well =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
D. Drilling D. Drilling
Type of Drilling: Hollow Stem Air/Mud Rotary Air Hammer Type of Drilling: Hollow Stem Air/Mud Rotary Air Hammer
Boring or MW: Size & Description How Many Units Per Units $/Unit Enter 1 if markup applies Total Boring or MW: Size & Description How Many Units Per Units $/Unit Enter 1 if markup applies Total
= =
= =
= =
= =
Mob/Demob: = Mob/Demob: =
Additional Drilling Costs: Additional Drilling Costs:
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
E. Waste Management E. Waste Management
How many Units $/Unit Enter 1 if markup applies Total How many Units $/Unit Total
Vacuum Truck = Vacuum Truck =
Fluids Disposal = Fluids Disposal =
Drill Cuttings Disposal = Drill Cuttings Disposal =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
F. Miscellaneous F. Miscellaneous
Description How Many Units $/Unit Enter 1 if markup applies Total How Many Units $/Unit Enter 1 if markup applies Total
= =
= =
= =
= =
= =
= =
= =
= =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
G. Cost per Event/Task A+ B + C + D + E + F = $0.00 G. Cost per Event/Task A+ B + C + D + E + F = $0.00
Cost Review Form Ver 7 Total Cost for Duration of Event(s)/Task(s) $0.00 Updated: July 30, 2010 Cost Review Form Ver 7 Total Cost for Duration of Event(s)/Task(s) $0.00 Updated: July 30, 2010
Task 10 Print Date: 12/4/2011
Proposed: Incurred: Review Date: EPD REVIEW
County/Facility #/Release #: County/Facility #/Release #: PROPOSED
Facility Name/Address/City: Facility Name/Address/City:
SCOPE OF WORK: SCOPE OF WORK: 35 40 40
Dates Covered by this Task (If Incurred): All
Dates Covered by this Task (If Incurred):
to Some to
Approved
Changed?
?
A. Personnel Duration of Events (Years) 1.0 Annual # of Events 1 A. Personnel Duration of Events (Years) 1.0 Annual # of Events 1.0
Prep/Field Rpt Prep $/Hr Total Prep/Field Rpt Prep $/Hr Enter 1 if markup applies Total
x = x =
x = x =
x = x =
x = x =
x = x =
x = x =
Project Management - CRFs x = Project Management - CRFs x =
Total Hours: 0 0 Total Hours: 0 0
% Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
B. Travel B. Travel
Units $/Unit Enter 1 if markup applies Total Units $/Unit Enter 1 if markup applies Total
Class 2 Vehicle Only x day = Class 2 Vehicle Only x day =
What is the one-way mileage to site? How many round trips to site per event? 0 What is the one-way mileage to site? How many round trips to site per event? 0
Mileage x $0.000 per mile = Mileage x $0.000 per mile =
Per Diem (must have overnight stay) # of Travelers day(s) @ rate = = Per Diem (must have overnight stay) # of Travelers day(s) @ rate = =
Lodging # of Travelers day(s) @ rate = = Lodging # of Travelers day(s) @ rate = =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
C. Analytical C. Analytical
Type Method How Many Units $/Unit Enter 1 if markup applies Total Type Method How Many Units $/Unit Enter 1 if markup applies Total
BTEX Soil Sample = BTEX Soil Sample =
BTEX Water Sample = BTEX Water Sample =
= =
= =
Related Analytical Items: Related Analytical Items:
Small items - lump sum per well = Small items - lump sum per well =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
D. Drilling D. Drilling
Type of Drilling: Hollow Stem Air/Mud Rotary Air Hammer Type of Drilling: Hollow Stem Air/Mud Rotary Air Hammer
Boring or MW: Size & Description How Many Units Per Units $/Unit Enter 1 if markup applies Total Boring or MW: Size & Description How Many Units Per Units $/Unit Enter 1 if markup applies Total
= =
= =
= =
= =
Mob/Demob: = Mob/Demob: =
Additional Drilling Costs: Additional Drilling Costs:
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
E. Waste Management E. Waste Management
How many Units $/Unit Enter 1 if markup applies Total How many Units $/Unit Total
Vacuum Truck = Vacuum Truck =
Fluids Disposal = Fluids Disposal =
Drill Cuttings Disposal = Drill Cuttings Disposal =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
F. Miscellaneous F. Miscellaneous
Description How Many Units $/Unit Enter 1 if markup applies Total How Many Units $/Unit Enter 1 if markup applies Total
= =
= =
= =
= =
= =
= =
= =
= =
= =
= =
% Markup on Sub Work = Subcontracted Cost = $0.00 = % Markup on Sub Work = Subcontracted Cost = $0.00 =
Total = $0.00 Total = $0.00
G. Cost per Event/Task A+ B + C + D + E + F = $0.00 G. Cost per Event/Task A+ B + C + D + E + F = $0.00
Cost Review Form Ver 7 Total Cost for Duration of Event(s)/Task(s) $0.00 Updated: July 30, 2010 Cost Review Form Ver 7 Total Cost for Duration of Event(s)/Task(s) $0.00 Updated: July 30, 2010
Cost Review Form - Summary Page 2 Print Date: 12/4/2011
Summary of All Project Costs
Facility County/ID: Facility Name/Address/City:
EPD Received Date:
EPD Pre-Approved Total EPD Pre-
Proposed Incurred
Per Event Cost Approved Costs
Events: Duration Per Event Per Event Duration
Task 6: 1 1 1 1
A. Personnel $0.00 $0.00 $0.00 $0.00
B. Travel $0.00 $0.00 $0.00 $0.00
C. Analytical $0.00 $0.00 $0.00 $0.00
D. Drilling $0.00 $0.00 $0.00 $0.00
E. Waste Management $0.00 $0.00 $0.00 $0.00
F. Miscellaneous $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 Empty
Events: Duration Per Event Per Event Duration
Task 7: 1 1 1 1
A. Personnel $0.00 $0.00 $0.00 $0.00
B. Travel $0.00 $0.00 $0.00 $0.00
C. Analytical $0.00 $0.00 $0.00 $0.00
D. Drilling $0.00 $0.00 $0.00 $0.00
E. Waste Management $0.00 $0.00 $0.00 $0.00
F. Miscellaneous $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 Empty
Events: Duration Per Event Per Event Duration
Task 8: 1 1 1 1
A. Personnel $0.00 $0.00 $0.00 $0.00
B. Travel $0.00 $0.00 $0.00 $0.00
C. Analytical $0.00 $0.00 $0.00 $0.00
D. Drilling $0.00 $0.00 $0.00 $0.00
E. Waste Management $0.00 $0.00 $0.00 $0.00
F. Miscellaneous $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 Empty
Events: Duration Per Event Per Event Duration
Task 9: 1 1 1 1
A. Personnel $0.00 $0.00 $0.00 $0.00
B. Travel $0.00 $0.00 $0.00 $0.00
C. Analytical $0.00 $0.00 $0.00 $0.00
D. Drilling $0.00 $0.00 $0.00 $0.00
E. Waste Management $0.00 $0.00 $0.00 $0.00
F. Miscellaneous $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 Empty
Events: Duration Per Event Per Event Duration
Task 10: 1 1 1 1
A. Personnel $0.00 $0.00 $0.00 $0.00
B. Travel $0.00 $0.00 $0.00 $0.00
C. Analytical $0.00 $0.00 $0.00 $0.00
D. Drilling $0.00 $0.00 $0.00 $0.00
E. Waste Management $0.00 $0.00 $0.00 $0.00
F. Miscellaneous $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 Empty
$0.00 $0.00 $0.00
SUMMARY PAGE 1 & 2 INDIVIDUAL TOTALS: $0.00 $0.00 $0.00
O/O TOTAL COSTS (PROPOSED & INCURRED): $0.00
EPD PRE-APPROVED TOTAL COSTS: $0.00
0 GA USTMP
(EPD Project Officer -Print Name) (Signature) (EPD Program) (Date)
404-362-4526 404-362-2654 & " NAME "@dnr.state.ga.us 4244 International Pkwy, Ste 104; Atlanta, Georgia 30354
(Phone #) (FAX # & Email Address) (Address/City/State/Zip)
0 0
(Consultant Project Manager - Print Name) (Signature of Representative) (Company) (Date)
0 0 0
(Phone #) (FAX # & Email Address) (Address/City/State/Zip)
I acknowledge that the actual amount reimbursed will be determined after all invoices, receipts, etc. are submitted and subjected to a technical and financial review and audit, respectively. I further understand
that the GA USTMP will reimburse costs in accordance with those identified on this form, and unless sound justification is provided and subsequently approved, the maximum amount eligible for reimbursement
will be the amount identified on this form. I also understand that this certification is not intended to limit what an Investigative/Remediation Contractor may charge.
0 0
(Responsible Party Representative - Print Name) (Signature of Representative) (Date)
0 0 0
(Phone #) (FAX # & Email Address) (Address/City/State/Zip)