PART 5.G ANALYSIS SUPPLEMENTARY SHEET Check Event: Emergency/Initial Work Investigation Monitoring/Interim Work Corrective Action Plan Work Do not address RAC markups on this sheet. RAC markups should be shown on the Miscellaneous Supplementary Sheet. Charges for analyzing samples will only be reimbursed at the intervals designated by DEQ. If the owner is directly billed for analysis, no markup allowed. Rush charges assessed by the laboratory to analyze a sample will not be paid when not required by DEQ. (No. of Tests) X (Cost Per Test) = Total See Appendix B, Table 4 of the Trust Fund Cost Control Guidance Document for rates. Purchase of sampling equipment (EnCores, preserved vials, etc.) should be addressed on the Part 5.H (1). RAC LAB PARAMETER METHOD MEDIUM NO. OF COST INVOICE INVOICE (Ex: BTEX, TPH-G, USED ANALYZED TESTS PER TOTAL NO. NUMBER etc.) TEST SUBTOTAL OF THIS PAGE $ TOTAL ANALYSIS COSTS $ Page________of_______ (Analysis Supplementary Sheet)
PART 5.G ANALYSIS SUPPLEMENTARY SHEET Check Event: Emergency/Initial Work Investigation Monitoring/Interim Work Corrective Action Plan Work Do not address RAC markups on this sheet. RAC markups should be shown on the Miscellaneous Supplementary Sheet. Charges for analyzing samples will only be reimbursed at the intervals designated by DEQ. If the owner is directly billed for analysis, no markup allowed. Rush charges assessed by the laboratory to analyze a sample will not be paid when not required by DEQ. (No. of Tests) X (Cost Per Test) = Total See Appendix B, Table 4 of the Trust Fund Cost Control Guidance Document for rates. Purchase of sampling equipment (EnCores, preserved vials, etc.) should be addressed on the Part 5.H (1). RAC INVOICE NO. LAB INVOICE NUMBER PARAMETER (Ex: BTEX, TPH-G, etc.) METHOD USED MEDIUM ANALYZED NO. OF TESTS COST PER TEST TOTAL SUBTOTAL OF THIS PAGE $ TOTAL ANALYSIS COSTS $ Page________of_______ (Analysis Supplementary Sheet)
3-25-14-2013-MFTF-Reimbursement-App.docx