A. SITE INFORMATION
Total EARLY ACTION $

ELECTRONIC FILING, RECEIVED, CLERK’S OFFICE, SEPTEMBER 23, 2005***USI(PC#65)***
ELECTRONIC FILING, RECEIVED, CLERKS OFFICE, SEPTEMBER 23, 2005***(JSI(PC#68)***
TANKS SITES
TotalCORRECTIVE ACTION $

ELECTRONIC FILING,

RECEIVED,

CLERK’S OFFICE,

SEPTEMBER 23, 2005

***~~p

~(PC#68)***

C~r

Sample

Budget

Billing

Forms

ELECTRONIC FILING,

RECEIVED, CLERK’S OFFICE, SEPTEMBER 23, 2005

***~~

~(PC#68)***

General

Forms

(Included with each Budget

or Billing Package

as applicable)

ELECTRONIC FILING,

RECEIVED, CLERK’S OFFICE, SEPTEMBER 23, 2005

***USL

~(PC#68)***

BUDGET AND

BILLING

FORM

FOR

LEAKING

UNDERGROUND

STORAGE

TANKS

SITES

SITE INFORMATION

Site

Name:

_____________

Site

Address:

_______________________________________________City:

______________________________

Zip:

_______________________________

County:

_____________________________________

JEPA Generator No.:

_________________________

IEMA Incident No.:

____________________________

ILMA Notification Date;

______________________

Date this form was Prepared:

__________________________________

This form

is being submitted as a:

_________

Budget Proposal

_________

Budget Amendment (Budget Amendments

must include only the

cost

•

over the previous

budget.)

Amendment Number:

______________________

Billing Package for costs

incurred

Name(s) of report(s)

documenting the costs

requested:

_____________

________________________________________Date(s):

____________

____EXPIDITED

____NON-EXPEDITED

This form is being

submitted for the Site Activities indicated below (check one):

Site Investigation

_________

Early Action

_________

Site Classification

______

Stage

_________

Low Priority Corrective Action

_________

High Priority Corrective Action

______

Stage 2

___________

Other (indicate activities)

____________________________________________________

_______

Stage

DO NOT SUBMIT “NEW PROGRAM” COSTS

AND “OLD PROGRAM”

COST AT THE SAME TIME. ON THE SAME FORMS.

A-I

This form must

be submitted in duplicate.

The A~eoCyii audw,rizcd to reqitrethin infonnl,ion under 4t5 fitS

5(1

Disclo,urr

this information

required.

Failure ‘ado so rm’y

retaIl in the delaysir denial ofanv teidgel

sir

payment reqliesl

hereunder.

ELECTRONIC FILING,

RECEIVED, CLERKS

OFFICE,

SEPTEMBER 23,

2005

***~~~

~(PC#68)***

Incident #

______________

If eligible for reimbursement,

where should reimbursement checks

be sent?

Please note that only owners or operators

of USTs may be eligible for reimbursement.

Therefore, payment can only be made to an owner or operator

Pay

to the order of:

____________________________________________________________________________

Send in care

of:

Address:

City:

_________________________________________ State:

_________________________

Zip:

________________

Number of Petroleum USTs inIllinois presently owned or operated

the owner or operator; any subsidiary,

parent or joint stock company of the owner or operator; and any company owned by

any parent, subsidiary or

joint stock company of the owner or operator

Fewer than

101:

101

or more:

Number of USTs

at the site:

_________

(Number of USTs includes USTs presently at the site and USTs that have

beenremoved)

Number of incidents reported to JEMA:

Incident Numbers

assigned to the

site due to releases from USTs:

____________________________________

Please list all

tanks

which have ever been located at the site and are presently located

at the site.

Size

Did UST

Type of

Product Stored

(gallons)

havea release?

Incident No.

Release

________

Yes

_______

Yes

_______

Yes

__________

Yes

_______

Yes

_______

Yes

_______

Yes

_______

Yes

_______

Yes

_______

Yes

_______

Yes

4-2

This form must be submitted in duplicate.

ELECTRONIC FILING,

RECEIVED, CLERK’S OFFICE,

SEPTEMBER 23, 2005

***UsI

Incident#

_________________

HANDLING CHARGES

Handling Charges are eligible for payment on

subcontractor billings

and/or field purchases only

if they are

equal to or less than the amountsdetermined by the following table:

Subcontractor or Field

Eligible Handling Charges as a

Purchase Cost

Percentage of Cost

$1-$5,000

$5,001

$15,000

$600

of amt. over $5,000

$15,001

$50,000

$1,600

of amt. over 15,000

$50,001

$100,000

$4,400

of amt. Over $50,000

$100,001

$1,000,000

$6,900

of amt. over $400,000

Section in these

Forms where

Subcontractor

Nameor Field Purchase

Cost

is Listed

Subcontract Amount

Total Subcontractor

and Filed Purchases:

HANDLING CHARGES:

Handling

ELECTRONIC

FILING,

RECEIVED, CLERK’S OFFICE,

SEPTEMBER 23, 2005

***II

_(Pr~R~\*~~

111inoWEh~h1ynmekta1ttoIRt~bWAgency

Owner/Operator

and Professional Engineer Budget Certification

Form for

Leaking Underground Storage Tanks

Sites

In accordance with 415 ILCS 5/5.7, if an owner or operator intendsto seek payment from the UST Fund, an

owner or operator must submit to the

Agency, for the

Agency’s approval or modification, a budget which

includes an accounting of all

costs associated with the implementation of the investigative, monitoring

and/or corrective action plans.

I hereby certify that

I intend to seek payment from the UST FUND for performing

__________________________

____________________________________________

activities at

________________________________________________

LUST site.

1 further certify that the costs

set forth in this budget

are

necessary activities and are reasonable

and accurate to the best of my knowledge and belief.

I also certify that the costs included

in this budget

are

not for correctiveaction in excess ofthe minimum requirements of 415

ILCS 5/57 and no costs are

included in this budget which are not described inthe corrective action plan.

frirther certify that costs

ineligible for payment from the Fund pursuant to 35

Illinois Administrative Code Section

732.606 are not

included in the budget proposal or amendment.

Such

ineligible costs include but are not limited to:

Costs associated

with ineligible tanks,

Costs associated with siterestoration (e.g.,

pump islands,

canopies).

Costs associated

with utility replacement (e.g. sewers,

electrical, telephone, etc.).

Costs incurred prior to IEMA notification.

Costs associated with planned tank pulls.

Legal defense costs.

Costs incurred prior to July 28,

1989.

Costs associated with installation ofnew USTsor the repair ofexisting USTs.

Owner/Operator:

______________________________________________________Title:

________________________

Signature:

___________________________________________________________ Date:

________________

Subscribed and sworn to before mc the

____________________day of

_________________

200!

(Budget Proposals and Budget Amendments

must

be notarized when

the certification is signed.)

_______________________________________________________________

Seal:

(Notary

Public)

________________________________________________________ Seal:

P.R.

Signature:

_____________________________________________________Date:

__________________

Subscribed and sworn tobefore me the

___________________day of

___________________

2001

(Budget Proposals and Budget Amendments must be notarized when the

certification is signed.)

__________________________________________________________

Seal:

(Notary

Public)

The Agency is authorized to require this information under 415

ILCS 5/1.

Disclosure of this information

required.

Failure to do

so may result in the

delay or denial of any budget or payment requested hereunder.

This form has been approved by the Forms Management Center

532-2273

LPC

495

Feb-99

ELECTRONIC

FILING,

RECEIVED, CLERKS OFFICE, SEPTEMBER 23, 2005

***u~sI-W9~#~8~Y”~

Illinois

n’ñrdnme

tec

Agency

Owner/Operator and Professional Engineer

BillingCertification Form for

Leaking Underground Storage Tanks Sites

I hereby certify

that that attatched bills are for performing

________________________________________

activities at

_______________________________________________ LUST sitefor the billing period of

_________________

_________

_________________

_________

I further certify

that the costs

included

in this billing

are notfor corrective action in excess

of the minimum

requirements

of 415

ILCS

5/57.

1 further certify

that costs

ineligible for payment form the Fund pursuant

Illinois Administrative Code Section 732.606 are not included in theis billing package.

Such

ineligible costs include but are not limited to:

Costs

associated with ineligible tanks.

Costs associated with siterestoration (e.g., pump islands, canopies).

Costs associated

with utility replacement (e.g. sewers, electrical,

telephone, etc.).

Costs incurred prior to IRMA notification.

Costs associated with planned tank pulls.

Legal defense costs.

Costs incurred prior to July 28,

1989.

Costs associated

with installation of new liSTs or the repair of existing USTs.

I further certify that

this billing

and all

attachments thereto were prepared under my direction or

supervision in

accordance with a system designed toassure that qualified personnel properly gathered and evaluated

the

information submitted

therein.

I affirm that the information

is, to the best

of my knowledge

and belief, true,

accurate and complete and the costs

for remediating said LUST

site are correct and reasonable.

Such

affirmation

is made under penalty of perjury as defined in Section 32.2 of the Criminal

Code of 1961, III.

Rev.

Stat.

1991, ch.38, par.32.2.

lam

aware the

there are significant penalties for submitting false information,

including the possibility of fine and

imprisonment for knowingly

committ’mg violations.

Owner/Operator:

______________________________________________________Title:

_______________________

Signature:

________________________________________________________________ Date:

________________

Subscribed

and sworn to before me the

______________________

day of

__________________

(Budget Proposals

anti

Budget Amendments mustbe notarized when the

certification is signed.)

_________________________________________________________

Seal:

(Notary Public)

________________________________________________

Seal:

P.E. Signature:

_____________________________________________________ Date:

__________________

Subscribed

and sworn to before me the

___________________day of

(Budget Proposals and Budget

Amendments

must be notarized

when the certification

is signed.)

______________________________________________

Seal:

(Notary Public)

The Agency

is authorized to require

this

information under 415 ILCS

5/1.

Disclosure of this

information is

required.

Failure to do

so may

result

in the delay or denial of any budget or payment requested

hereunder.

This form has been approved by the Forms Management Center

532-2273

LPC

495

Feb-99

ELECTRONIC FILING,

RECEIVED, CLERKS

OFFICE, SEPTEMBER 23, 2005

***USL

~(PC#68)***

Phase

Summary

Sheets

(Includes

the

Standard task

list for each phase

and

to be used to

summarize

the costs

either

proposed

or incurred)

ELECTRONIC FILING,

RECEIVED, CLERK’S OFFICE, SEPTEMBER 23, 2005

***~~

~(PC#68)***

Incident #

________________

EARLY ACTION

TOTAL

734.210(a,b)

732.202(a,b)

Initial Response & Abatement

734.210(c,d,e,g)

732.202(c,d,e,g)

20&45DayReporting

734.210(1)1

732.202(1)1

Tank Removal

734.210(1)2

732.202(1)2

Tank Abandonment

734.2 10(1)3

732.202(1)3

LA ETD&B

734.210(1)4

732.202(1)2

Ex-situ Treatment

734.210(h)

732.202(h)

Collect & Malyze Soil Samples

734.210(h)(3)

732.202(h)(3)

Prepare & Submit report for EA Closure, ifTier

Objectives are met

734.2

15(a)( 1)

732.203(a)(l)

Perform 45

day Free Product Removal

734.21 5(a)(4)

732.203(a)(4)

Prepare & Submit 45 day Free Product

Removal Report

Non-Phase Specific Task(s) Completed during

EARLY

ACTION

734.605

732.601

Prepare & Submit Application for Pa~nt

734.350

723.411

Negotiate Off-Site Access

Subtotal

EARLY ACTION

Handling

Charges

Total EARLY

ACTION

LA-Summary

ELECTRONIC

FILING,

RECEIVED, CLERK’S OFFICE, SEPTEMBER 23, 2005

***USI(PC#65)***

Pelt 4SdiyFRfl

PRODUCT REMOVAL

734.215(c)

732.203(c)

Prepare & Submit Post 45 day Free Product Removal Plan

734.215(d)

732.203(d)

Prepare & Submit Post 45 day Free Product Removal

Budget

734.215(e)

732.2O3(e)

Perform Free Product Removal

734.215(g)l 732.203(g)1

Prepare

& Submit Plan Amendments as Necessary

734.21 5(g)2 732.203(g)2

Prepare & Submit BudgetAmendments as

Necessary

Rcqu

App

flted for

rent

Requestd

tot

Approial

Subtotal Post 45day

FREE

PRODUCT REMOVAL

Handling Charges

Total Post 45day

FREE

PRODUCT REMOVAL

ELECTRONIC

FILING,

RECEIVED, CLERK’S OFFICE, SEPTEMBER 23, 2005

Stage

734.3 15(b)

734.3 10(b)

734.315(a)

***~~

~(PC#68)***

Subtotal

SITE INVESTIGATION

Handling

Charges

Total SITE INVESTIGATION

TOTAL SITE INVESTIGATION

Prepare & Submit Work Plan (Stage

Prepare & Submit SIBudget

Perform Stage

Investigation

Stage 2

734.320(b)

Prepare & Submit WorkPlan (Stage 2)

734.310(b)

Prepare

& Submit SI Budget

734.320(a)

Perform Stage

2 Investigation

Stage 3

325(b)

Prepare

& Submit Work Plan

(Stage

734.310(b)

Prepare & Submit SI Budget

734.325(a)

Perform Stage

2 Investigation

3 10(d);

Prepare & Submit SC/SI

Plan Amendments

as Necessary

310(d)2

Prepare &

Submit SC/SI Budget

Amendments as Necessary

734.330

Prepare

and

Submit Completion Report

734.605

Prepare & Submit Application for Payment

734.350

Negotiate Off-Site Access

SI-Summary

ELECTRONIC FILING, RECEIVED,

CLERK’S OFFICE,

SEPTEMBER 23,

2005

***~JS~ ~(PC#68)***

SIItttASSII!WATION

Method

1 and Metbod

PreviOusly

sporavS

Requested

for

Approval

732.305 (a)

Prepare & Submit A Method

or Method 2

Site Classification

WorkPlan

732.305 (b)

Prepare & Submit A Method

or Method

Site Classification Work Plan Budget

732.305 (e)

Prepare & Submit Method

or Method

2 Amended SCWPs

as Necessary

732.305

(e)

Prepare & Submit Method

or Method 2

Amended SCWP Budgets as Necessary

732.309

Prepare & Submit A Method

or Method 2 Site Classification Completion Report

Exposure Pathway Exclusion

732.312(b)

Prepare & Submit Site Classification Work Plan (Classi~’in~g

Under 732.312)

732.312(e)

Prepare & Submit Site Classification Work Plan

Budget (Classi~ingUnder 732.312)

732.312(k)l

Prepare & Submit Amended SCWPs

as Necessary(Classif~ing

Under 732.312)

732.3 12(k)2

Prepare & Submit Amended SCWP Budgets as Necessary (Classi~ngUnder 732.312)

732,312(h)

Prepare & Submit A Site Classification Completion Report

(Classif~’ingUnder 732.312)

Other

732.306

Deferred

Site Classification Activities

732.307(c) Perform Method One Soil Classification

732.307(d)

Perform Method Two Soil Classification

732.307(f)

Conduct Water Supply Well Survey

732.307(s)

Investigation of Migration Pathways

732.307(h,i, Surface and Groundwater Investigation

Non-Phase Specific Task(s) Completed during SITE CLASSIFICATION

734.605

Prepare & Submit Application for Payxxtnt

734.350

Negotiate Off-Site Access

Subtotal SITE

CLASSIFICATION

Handling

Charges

TOTAL SITE

CLASSIFICATION

ELECTRONIC FILING,

RECEIVED,

CLERK’S OFFICE,

SEPTEMBER 23, 2005

***USI(PC#68)***

Incident #

Conventional

734.335(a)

Prepare&SubmitWorkPlan

734.335(b)

Prepare & Submit Budget

734.335(c)

Preform Corrective Action After Approval

Alternative

734.340(a)

Prepare & Submit Work Plan

734.340(b)

Prepare & Submit Budget

734.340(c)

Preform Corrective Action After Approval

734.340(d)

Agency Required Remote Monitoring

734.335(e)I Prepare & Submit Plan Amendments

as Necessary

734.335(e)2 Prepare & Submit Budget Amendments as Necessary

734.345(a)

Prepare & Submit Corrective

Action Completion Report

734.355(a)

Prepare and Submit Status Report within 4 years

Non-Phase

Specific Task(s) Completed ~

734.605

Prepare & Submit Application for Payntnt

734.350

Negotiate Off-Site Access

________________$

________________

Other

Subtotal

CORRECTIVE ACTION

Handling

Charges

Total CORRECTWE ACTION

CA-Summary

ELECTRONIC

FILING, RECEIVED,

CLERKS OFFICE, SEPTEMBER 23, 2005

***(JSI(PC#68)***

Detail

Sheets

(To

completed for each

Standard

Task utilized,

listing

all Products

and

Services

proposed or

incurred

relative to

the

specified task)

ELECTRONIC FILING,

RECEIVED, CLERKS

OFFICE,

SEPTEMBER 23, 2005

Task:

***~J~j

~(PC#68)***

Task:

TOTAL:

Unit of

Handling

Section

Product

Service

Quantity

Measure

Unit Rate

Total

Section

Product

or Service

Quantity

Unit

Measure

Unit Rate

Total

Handling

or N)

TOTAL:

ELECTRONIC FILING, RECEIVED, CLERKS

OFFICE,

SEPTEMBER 23,

2005

Task:

u.s.I.

Section

Product or Service

Quantity

Unit of

Measure

UnitRate

Total

Handling

(Y or N)

TOTAL:

ELECTRONIC FILING,

RECEIVED, CLERK’S

OFFICE, SEPTEMBER 23, 2005

***USL

~(PC#68)***

Example

Corrective

Action

Budget

ELECTRONIC FILING,

RECEIVED, CLERK’S OFFICE,

SEPTEMBER 23, 2005

***~~

~(PC#68)***

BUDGET

ANI~

BILLING

FORM FOR

LEAKING UNDERGROUND STORAGE

TANKS SITES

SITE INFORMATION

Site Name:

any site

Site

Address:

any

where

City:

any city

Zip:

_____________________________

County:

any county

IEPA Generator No.:

IEMA Incident No.:

2004####

IEMA Notification Date:

January

I, 2004

Date this form

was Prepared:

August 15, 2005

This form is being submitted

Budget Proposal

_________

Budget Amendment (Budget

Amendments must include only the cost

over the previous budget.)

Amendment Number:

________________________

__________

Billing Package for costs

incurred

Name(s) of report(s) documenting the

costs

requested:

______________

Corrective Action Plan

Date(s):

Aug-05

EXPIDITED

____NON-EXPEDITED

This form

is being submitted for the

Site Activitiesindicated below (check one):

Site Investi2ation

__________

Early Action

__________

Site Classification

_______

Stage

_________

Low Priority Corrective Action

High

Priority

Corrective Action

______

Stage

Other (indicate activities)

_______________________________________________

_______

Stage

DO NOT SUBMIT “NEW PROGRAM” COSTS AND “OLD PROGRAM”

COST AT THE

SAME TIME, ON THE SAME FORMS.

A-i

This

form must

be submitted

in duplicate.

The

Agency h amhorized

requu-r

this frfförmlaion

under 415

ILCS

SI!.

flbck,sureofahis iafonnaaion

required.

Failure

It, It’ sri

nay result

in the

delay or denitsl 0!

nay bud~eiorpa)meea

equeg

hereunder.

ELECTRONIC FILING,

RECEIVED, CLERKS

OFFICE, SEPTEMBER 23, 2005

***~JS~

~(PC#68)***

Incident #

_______________

If eligible for reimbursement, where

should reimbursement checks be sent?

Please note that only owners or operators

of USTs may be eligible for reimbursement.

Therefore, payment can only be

made to an owner or operator

Pay to the order of:

Any site

Send

in care of:

Any site

Address:

Any where

City:

Any where

State:

Illinois

Zip:

_________________

Number of Petroleum USTs in illinois presently owned or operated by

the owneror operator, any subsidiary,

parent

or joint stock company of the owner

or operator; and

any company owned by any

parent,subsidiary

joint stock company of the owner or operator:

Fewer than

101:

101

Numberof USTs at the

site:

(Number of USTs includes USTs presently at the

siteand USTs that

have

been removed)

Number of incidents reported to IBMA:

Incident Numbers assigned to the site due to releases from

USTs:

20044t###

Please list

all

tanks which have ever been located at the site and are presently located at the site.

Size

Did UST

Type of

Product Stored

(gallons)

have a release?

IncidentNo.

Release

Gasoline

10,000

2004##fl

Tank

Gasoline

10,000

2004####

Line

Used Oil

500

2004##fl

Over-fill

_______

Yes

_______

Yes

_______

Yes

_______

Yes

_______

Yes

_______

Yes

_______

Yes

________

Yes

A-2

This form must be submitted in duplicate.

ELECTRONIC FILING, RECEIVED, CLERKS

OFFICE, SEPTEMBER 23, 2005

***(JS~~(PC#68)***

incident

________________

Conventional

734.335(a)

Prepare & Submit Work Plan

4,559.91

734.335(b)

Prepare

& Submit Budget

591.62

734.335(c)

Preform Corrective Action

After Approval

337,481.24

Alternative

Other

734.340(a)

Prepare & Submit Work Plan

734.340(b)

Prepare & Submit Budget

734.340(c)

Preform Corrective Action

After Approval

734.340(d)

Agency Reguit-ed Remote Monitoring

734.335(e)1 Prepare & Submit Plan Amendments as

Necessary

734.335(e)2 Prepare & Submit Budget Amendments

as Necessary

734.345(a)

Prepare & Submit Corrective Action Completion

Report

4,079.35

734.355(a)

Prepare and Submit Status Report

within 4 years

734.605

Prepare & Submit Application for Payment

~..

868.82

734.350

Negotiate Off-Site Access

Subtotal

CORRECTIVE ACTION

Handling

Charges

Total

CORRECTIVE

ACTION

347,580.94

338.80

347,919.74

CA-Summary

ELECTRONIC FILING,

RECEIVED, CLERKS OFFICE, SEPTEMBER 23, 2005

***(J~~

~(PC#68)***

isk:

734.335(a)

Prepare & Submit Work Plan

Section

Product or Service

Quantity

Unit of

Measure

Unit Rate

Total

Handling

(Y or N)

3.!

Project Manager

Hour

$103.65

$1,762.05

3.1

Scientist

Hour

$83.00

$1,660.00

3.1

Administrative Assistant

Hour

$49.79

$298.74

3.1

Drafts~rson/CAD

Hour

$65.52

$262.08

3.1

Professional Engineer

Hour

$126.76

$507.04

3.3

B&W Copies

450

Each

$0.10

$45.00

3.3

ColorCopies

Each

$1.25

$25.00

TOTAL:

4,559.91

isk:

734.335(bli

Prepare& Subrnit~4get

Section

Product or Service

Quantity

Unit of

Measure

Unit Kate

Total

Handling

3.1

Project Manager

3.5

Hour

$103.65

$362.78

3.1

Administrative Assistant

Hour

$49.79

$99.58

3.1

Professional Engineer

Hour

$126.76

3.3

B&W Copies

Each

$0.10

$2.50

CA-i

TOTAL:

59L62

ELECTRONIC FILING,

RECEIVED, CLERK’S

OFFICE, SEPTEMBER 23, 2005

***~JS~

~(PC#68)***

Task:

734.335(c)

Preform Corrective Action After

Approval

Section

Product or Service

Unit of

Quantity

Measure

Unit Rate

Total

Handling

(V or N)

1.4

Removal, Transportation, &

Disposal of Contaminated

Soil

4000

Cubic Yard

$57.00

$228,000.00

1.4

Purchase, Transportation&

Placement of Backfill

4000

Cubic Yard

$20.00

$80,000.00

1.4

Removal and Replacement of

Overburden

2000

Cubic Yard

$6.50

$13,000.00

1.7 Field Crew Per Diem (8

x 7)

Each

$28.00

$1,568.00

1.7 Field CrewLodging

Night

$100.00

$2,800.00

1.7

Tractor with Lowboy Trailer

Hour

$55.00

$330.00

1.7

Driver hA

Overized Loads

Hour

$55.00

$330.00

2.1

BETX

soil

with MTBE

Each

$85.00

$2,125.00

2.1

PNA soil

Each

$152.00

$3,800.00

2.!

FlashPoint

Each

$15.00

2.!

FOC

Each

$33.00

2.1

Paint Filter

Each

$14.00

2.1

Each

$14.00

2.1

Reactivity

Each

$68.00

2.3

Sample Shipping

Day

$50.00

$100.00

1.6

Asphalt Replacement

1548

Sq Foot

$2.38

$3,684.24

.3 Well Abandonment

160

Foot

$10.00

$1,600.00

CA-2

TOTAL:

-4

337,481.24

ELECTRONIC

FILING,

RECEIVED, CLERKS OFFICE, SEPTEMBER 23,

2005

***~~

~(PC#68)***

Task:

734.335(c)

Preform

Corrective Action After Approval

Section

Product or Service

Quantity

Unitof

Measure

Unit Rate

Total

Handling

or N)

3.1

Engineer

Hour

$103.00

$824.00

3.!

ProjectManager

Hour

$103.65

$1,658.40

3.1

Technician

Hour

$64.17

$4,171.05

3.2

Photolonization Detector

Day

$105.00

$735.00

3.2

Site

Survey Equipment

Day

$250.00

$500.00

3.2 Environmental

Utility Vehicle

Day

$60.00

$600.00

3.3

Manifests

112

Each

$3.00

$336.00

3.3 Disposable Camera

Each

$10.00

3.4

Per Diem

Each

$28.00

$224.00

3.4 Lodging

Night

$100.00

$800.00

TOTAL:

9,858.45

CA-2

ELECTRONIC FILING,

RECEIVED,

CLERK’S OFFICE,

SEPTEMBER 23,

2005

***~~

~(PC#68)***

isk:

734,345(a)

Prepare

& Submit Corrective Action Completion Report

Section

Product or Service

Quantity_j

Unit of

Measure

Unit Kate

Total

Handling

or N)

3.1

Project

Manager

Hour

$103.65

$1,554.75

3.1

Scientist

Hour

$83.00

$830.00

3.1

Administrative Assistant

Hour

$49.79

$597.48

3.1

Draftspersort/CAD

Hour

$65.52

$196.56

3.1

Professional

Engineer

Hour

$126.76

$760.56

3.3

B&W Copies

1200

Each

$0.10

$120.00

3.3

Color Copies

Each

$1.25

$20.00

isk:

734.605

Prepare & Submit Application for Payment

TOTAL:

TOTAL:

4,079.35

868.82

Section

Product or Service

Quantity

Unit ofl

Measure

Unit Rate

Total

Handling

or N)

3.!

Account Technician

Hour

$49.79

$298.74

3.1

PrOject

Manager

Hour

$65.52

$196.56

3.!

Professional

Engineer

Hour

$126.76

$253.52

3.3

B&W Copies

1200

Each

$0.10

$120.00

CA-$

ELECTRONIC

FILING,

RECEIVED,

CLERKS OFFICE, SEPTEMBER 23,

2005

***~

3~~(PC#68)***

isk:

734.335(e)1

Prepare

& Submit Plan Amendments

Necessary

Unit of

Handling

Section

Product or Service

Quantity

Measure

Unit Rate

Total

(V or N)

TOTAL:

isk:

734.335(e)2

Prepare & Submit Budget Amendments

as Necessary

Section

Product or Service

Quantity

Unit of

Measure

Unit Rate

Total

Handling

or N)

TOTAL:

CA-4

ELECTRONIC FILING, RECEIVED, CLERKS

OFFICE,

SEPTEMBER 23,

2005

isk:

734.350

Negotiate Off-Site Access

***USI(PC#65)***

TOTAL:

isk:

734.355(a)

Prepare and Submit Status Report

within 4

years

Section

Product or Service

Quantity

Unitof

Measure

Unit Rate

Total

Handling

or N)

TOTAL:

Unit of

Handling

Section

Product or Service

Quantity

Measure

UnitRate

Total

(Y or

CA-S

ELECTRONIC FILING, RECEIVED,

CLERK’S OFFICE,

SEPTEMBER 23, 2005

* *

HANDLING CHARGES

Incident#

Handling Charges are eligible for payment on subcontractor billings

andlor field purchases

only if they are

equal toor less

than the amounts determined

by the following table:

Subcontractor or Field

Purchase Cost

-$5,000

$5,001

$15,000

$15,001

$50,000

$50,001

$100,000

$100,001

$1,000,000

Eligible Handling Charges as a

Percentage of Cost

$600

of amt. over $5,000

$1,600

of amt. over

15,000

$4,400

of amt. Over $50,000

$6,900

of amt. over $100,000

Total. Subcontractor

and Filed Purchases:

2,800.00

HANDLING CHARGES:

336.00

Section in these

Forms

where

Subcontractor Name or Field Purchase

Cost is Listed

Subcontract Amount

Holiday Imi Express (Lodging)

734.335(c)

$2,800.00

Handling

ELECTRONIC

FILING,

RECEIVED, CLERKS

OFFICE, SEPTEMBER 23,

2005

***u~I ~(Pç#68)***

Illinois

nvirônme

tal

rotectio

Agency

Owner/Operator and Professional Engineer Budget Certification Form for

Leaking Underground Storage Tanks Sites

In accordance with

415

ILCS 5/5.7,

if an owner or operator

intends to seek payment from

the UST Fund,

owner or operator must

submit to the Agency, for the Agency’s

approval or modification, a budget which

includes an accounting of all costs

associated

with the implementation of the investigative,

monitoring

and/or corrective action plans.

I hereby certify that

intend

to seek payment from

the UST FUND for performing

____________________________

Corrective Action Activities

activities at

any site

LUST site.

I further certify

that the costs set forth in this budget are

necessary activities and

are reasonable

and accurate to the

best of my knowledge and belief

I also

certify

that the costs

included in this

budget are

notfor corrective action in excess

of the

minimum requirements of 415

ILCS 5/57 and

no costs are

included in this budget which are not described in the correctiveaction plan. I

further certify

that costs

ineligible for payment from the Fund pursuant to 35

Illinois Administrative

Code Section 732.606

are

not

included in the budget proposal or

amendment.

Such

ineligible costs

include but are not limited

to:

Costs

associated

with ineligible tanks.

Costs

associated with siterestoration (e.g.,

pump islands, canopies).

Costs associated

with utility replacement (e.g. sewers, electrical,

telephone,

etc.).

Costs

incurred prior to IEMA notification.

Costs associated

with planned tank pulls.

Legal defense costs.

Costs incurred prior to July 28,

1989.

Costs associated

with installation of new USTs or the

repair of existing USTs.

Owner/Operator:

______________________________________________________ Title:

_________________________

Signature:

________________________________________________________________ Date:

__________________

Subscribed

and sworn to before me

the

______________________

day of

___________________

2001

(Budget Proposals and

Budget Amendments must

be notarized

when

the certification

is signed.)

_____________________________________________________

Seal:

(Notary Public)

FE.:

____________________________________________________Seal:

P.E. Signature:

_____________________________________________________ Date:

__________________

Subscribed

and sworn to before

me the

___________________

day of

___________________

200!

(Budget Proposals and Budget Amendments must be notarized when the certification is

signed.)

_________________________________________________________

Seal:

(Notary Public)

The

Agency is authorized

to require this

information

under 415

ILCS 5/I.

Disclosure of this

information

required.

Failure to do so may result in the delay

or denial of any budget or payment requested

hereunder.

This form has been approved by the Forms Management Center

532-2273

LPC

495

Feb-99