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- Form DEP0062 "Reimbursable Amount Re-evaluation Form" - Kentucky
Form DEP0062 "Reimbursable Amount Re-evaluation Form" - Kentucky
What Is Form DEP0062?
This is a legal form that was released by the Kentucky Energy and Environment Cabinet - a government authority operating within Kentucky. As of today, no separate filing guidelines for the form are provided by the issuing department.
Form Details:
- Released on April 1, 2011;
- The latest edition provided by the Kentucky Energy and Environment Cabinet;
- Easy to use and ready to print;
- Quick to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a printable version of Form DEP0062 by clicking the link below or browse more documents and templates provided by the Kentucky Energy and Environment Cabinet.
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2DEP0062 (April 2011)
401 KAR 42:250
REIMBURSABLE AMOUNT RE-EVALUATION FORM
All rates are subject to 401 KAR 42:250 Contractor Cost Outline
FOR STATE USE ONLY
Mail completed form to:
KENTUCKY
DIVISION OF WASTE MANAGEMENT
UNDERGROUND STORAGE TANK BRANCH
DEPARTMENT FOR
200 FAIR OAKS LANE, SECOND FLOOR
ENVIRONMENTAL
FRANKFORT, KENTUCKY 40601
PROTECTION
(502) 564-5981
http://waste.ky.gov/ust
GENERAL INFORMATION
Name of Applicant:
PSTEAF Application#:
Agency Interest #:
Date of Directive:
Total Estimate Cost:
Professional Engineer or Professional Geologist Certification Of Cost Estimate Re-Evaluation
I certify that the foregoing cost estimate requested amount is true and accurate, and is effective until
_____________________. I certify that the costs listed are reasonable and necessary to the performance of the
written directive. I understand that the Underground Storage Tank Branch may request additional information to
verify that the costs are reasonable and necessary for the completion of the written directive issued
________________________.
________________________________________________
___________________________
Signature of PE/PG
Date
GENERAL REQUIREMENTS
This request is for completion of the following activities and their expected costs per task directed in the scope of
work for directed on _________________. When determining the estimated costs, the following shall be used
and submitted with the Reimbursable Amount Re-Evaluation Form DEP0062:
a. The costs shall be calculated using the personnel and equipment rates established in the Contractor Cost
Outline, Section 3;
b. Include a cost itemization to complete the individual task if the task is being completed by the eligible
company or partnership;
c. Include three (3) itemized bids for each individual task if the task is being completed by a subcontractor on
behalf of the eligible company or partnership from the area in which the facility is located, if applicable;
d. If the “Cost Estimate Form” DEP6090 was completed for portions of the written directive those costs shall
again be submitted with the “Reimbursable Amount Re-Evaluation Form” DEP0062.
ESTIMATED COSTS
Include a description of the task directed and the estimated costs (attach additional sheets if necessary). Attach
to this form all required information as described in General Requirements.
1.
$
2.
$
3.
$
4.
$
5.
$
6.
$
1
DEP0062 (April 2011)
401 KAR 42:250
REIMBURSABLE AMOUNT RE-EVALUATION FORM
All rates are subject to 401 KAR 42:250 Contractor Cost Outline
FOR STATE USE ONLY
Mail completed form to:
KENTUCKY
DIVISION OF WASTE MANAGEMENT
UNDERGROUND STORAGE TANK BRANCH
DEPARTMENT FOR
200 FAIR OAKS LANE, SECOND FLOOR
ENVIRONMENTAL
FRANKFORT, KENTUCKY 40601
PROTECTION
(502) 564-5981
http://waste.ky.gov/ust
GENERAL INFORMATION
Name of Applicant:
PSTEAF Application#:
Agency Interest #:
Date of Directive:
Total Estimate Cost:
Professional Engineer or Professional Geologist Certification Of Cost Estimate Re-Evaluation
I certify that the foregoing cost estimate requested amount is true and accurate, and is effective until
_____________________. I certify that the costs listed are reasonable and necessary to the performance of the
written directive. I understand that the Underground Storage Tank Branch may request additional information to
verify that the costs are reasonable and necessary for the completion of the written directive issued
________________________.
________________________________________________
___________________________
Signature of PE/PG
Date
GENERAL REQUIREMENTS
This request is for completion of the following activities and their expected costs per task directed in the scope of
work for directed on _________________. When determining the estimated costs, the following shall be used
and submitted with the Reimbursable Amount Re-Evaluation Form DEP0062:
a. The costs shall be calculated using the personnel and equipment rates established in the Contractor Cost
Outline, Section 3;
b. Include a cost itemization to complete the individual task if the task is being completed by the eligible
company or partnership;
c. Include three (3) itemized bids for each individual task if the task is being completed by a subcontractor on
behalf of the eligible company or partnership from the area in which the facility is located, if applicable;
d. If the “Cost Estimate Form” DEP6090 was completed for portions of the written directive those costs shall
again be submitted with the “Reimbursable Amount Re-Evaluation Form” DEP0062.
ESTIMATED COSTS
Include a description of the task directed and the estimated costs (attach additional sheets if necessary). Attach
to this form all required information as described in General Requirements.
1.
$
2.
$
3.
$
4.
$
5.
$
6.
$
1
DEP0062 (April 2011)
401 KAR 42:250
BIDS
For work completed by a subcontractor on behalf of the eligible company or partnership, three (3) itemized bids
shall be submitted and the following shall be completed and submitted with this form.
BID #1
Subcontractor Name:
Description of work to be
completed:
Bid Amount:
$
BID #2
Subcontractor Name:
Description of work to be
completed:
Bid Amount:
$
BID #3
Subcontractor Name:
Description of work to be
completed:
Bid Amount:
$
NOTE:
Bids shall be obtained only from persons qualified and able to perform the work being bid. Bids shall not be
obtained from persons with whom the applicant or applicant’s primary contractor has a financial interest. The
lowest viable bid shall be the basis for final reimbursement.
“RETAIN A COPY OF THIS FORM FOR YOUR RECORDS”
2
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