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					                          Florida DEP-Division of Waste Management-Bureau of Petroleum Storage Systems- Petroleum Cleanup Preapproval Program

                                                                  PROPERTY REPORTING FORM

List non-expendable equipment/personal property (excluding software), costing $1,000 or more that was purchased under the DEP Preapproval
work order or task assignment listed below. Submit one completed form for each modular skid or trailer mounted system.
I. General Information
Contractor Name                                                                                  Date Purchased
Pre-Approval Work Order#                                                                         Manufacturer
State Cleanup Contract #/Task Assignment #                                                       System Model #
Location (DEP Facillity ID#)                                                                     System Serial #

II. Treatment System Costs
Vendor Cost $ (w/tax & shipping)
Contractor Markup
Total Cost
DEP Cost Share (%)
DEP Cost

III. Treatment System Type (Check system type that applies and indicate whether skid or trailer mounted . If multiple treatment types are mounted
     on one skid or trailer check all types that apply. Check "other" if treatment system type is not listed or if purchasing individual components).
     Air Sparging                   Diffused Aerator                 Thermal Oxidizer         Skid Mounted (list dimensions)
     Airstripper                    Dual Phase Extraction            Other                    Building Mounted (list dimensions)
     Carbon System                  Pre-treatment                                             Trailer Mounted (list dimensions)
     Catalytic Oxidizer             Soil Vapor Extraction                                              (& list trailer VIN number)

IV. System Components (Check box near each component and indicate make/model, serial #, vendor unit cost and additional description).
System Component                       Make/Model                             Serial #         Vendor Unit Cost *           Additional Description
                                 (complete make/model)                                            (if >$1,000)       Specify power(hp & phase), air flow(scfm & psi), water,
                                                                                                                     flow(gpm), tank cap.(gal), air stripper stages/dimensions
Air Compressor
Air Stripper - Low Profile
Air Stripper - Tower
Blower
Control Panel
Dual Phase Extraction Pump
Diffused Aerator
Equalization Tank
Filter

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                          Florida DEP-Division of Waste Management-Bureau of Petroleum Storage Systems- Petroleum Cleanup Preapproval Program

                                                                  PROPERTY REPORTING FORM

 System Component                      Make/Model                             Serial #         Vendor Unit Cost *          Additional Description
                                                                                                    (if >$1,000)
 Moisture Separator
 Oil-Water Separator
 Product Storage Tank
 Flow Meter #1
 Flow Meter #2
 Submersible Pump #1
 Submersible Pump #2
 Submersible Pump #3
 Telemetry
 Transfer Pump #1
 Transfer Pump #2

 Other Components:
 System Component                     Make/Model                              Serial #          Vendor Unit Cost*          Additional Description
                                                                                                  (if >$1,000)




 * Attach copy of vendor invoice or other documentation of purchase.

 Contractor Name:

 Contractor Representative:
                                         (Signature)                                       (Date)

                                                                Below for DEP Use Only
Organization Code:

DEP Project Manager:

DEP PROPERTY SECTION/DEP FINANCE & ACCOUNTING:                  Above items should be recorded as OCO.

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Florida DEP-Division of Waste Management-Bureau of Petroleum Storage Systems- Petroleum Cleanup Preapproval Program

                                        PROPERTY REPORTING FORM




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