PART 5 EVENT SUMMARY SHEET – APPLICATION GRAND TOTAL AIN: RAC Name: Emergency/Initial Investigation Work 3. Monitoring/Interim 4. Corrective 5. Report Work (Field Work) Work Action Plan Work Preparation Work DEQ DEQ DEQ DEQ DEQ Charges Adjusted Charges Adjusted Charges Adjusted Charges Adjusted Charges Adjusted Charges Charges Charges Charges Charges A. Personnel Soil/Water Disposal Equipment Travel Transportation Drilling & P & A Analysis Miscellaneous (Includes Unit Pricing) Subtotals Beginning Ending 7. Application addresses invoices to the owner dated: (Select quarter by entering year) 6. Dates work performed in application: July 1 September 30 _______ January 1 March 31 _______ – – 8. DEQ Fiscal Year (July June) _____________ – October 1 December 31 _______ April 1 - June 30 ______ – The area below is for DEQ Trust Fund use only: Incident Information: DEQ Comments, Notations for Program Task Total $ Deductibles , Treatment Units, & Last Incident No. Release Date Substance Applications Trust Fund No. CAP Amount LDEQ Adjustments Deductible Amount ($) Reviewer LDEQ Reimbursement $ Name Trust Fund Annual Aggregate $1 million $2 million Number Payment RAC (ROG Aprvd.) ICAP Charges $ ICAP Balance $ To: CAP Balance $ Owner
PART 5 – EVENT SUMMARY SHEET APPLICATION GRAND TOTAL AIN: RAC Name: Emergency/Initial Work Investigation Work (Field Work) 3. Monitoring/Interim Work 4. Corrective Action Plan Work 5. Report Preparation Work Charges DEQ Adjusted Charges Charges DEQ Adjusted Charges Charges DEQ Adjusted Charges Charges DEQ Adjusted Charges Charges DEQ Adjusted Charges A. Personnel Soil/Water Disposal Equipment Travel Transportation Drilling & P & A Analysis Miscellaneous (Includes Unit Pricing) Subtotals 6. Dates work performed in application: Beginning Ending 7. Application addresses invoices to the owner dated: (Select quarter by entering year) July 1 – September 30 _______ January 1 – March 31 _______ 8. DEQ Fiscal Year (July – June) _____________ October 1 – December 31 _______ April 1 - June 30 ______ The area below is for DEQ Trust Fund use only: Incident Information: Program Task Total $ DEQ Comments, Notations for Deductibles , Treatment Units, & Last Applications Incident No. Release Date Substance LDEQ Adjustments Trust Fund No. CAP Amount Deductible Amount ($) Reviewer Name LDEQ Reimbursement $ Trust Fund Number Annual Aggregate $1 million $2 million ICAP Charges $ ICAP Balance $ (ROG Aprvd.) CAP Balance $ Payment To: RAC Owner