Petroleum Tank Release Compensation Forms
The following forms and instructions can be downloaded in Microsoft Word
or PDF format.*
* You will need Adobe 5.0 or higher to use online
input forms properly. The forms below can be filled out on-line, then
printed, signed, notarized and sent to the Petroleum Tank Release Board.
Petroleum Tank Release Compensation Forms
| Form Title |
Format |
Application for Petroleum
Release Eligibility
Use this form to apply for eligibility to receive reimbursement of
costs associated with a release from a petroleum storage tank
and/or associated piping. |
FORM
1R (Word)
FORM 1R (PDF)* |
Transfer of Release
Eligibility
Complete this form to advise the Board a new owner/operator is
assuming responsibility for the release. |
FORM 1T (Word)
FORM 1T (PDF)* |
Application for Voluntary
Registration
Use this form to determine potential eligibility for reimbursement
from the Petroleum Tank Release Cleanup Fund prior to a release. |
FORM 1V (Word)
FORM 1V (PDF)* |
Assent to Audit
Use this form to indicate assent to an audit of time sheets,
payroll records, purchase orders, and other documents. Required for
payment of claim. |
FORM
2 (Word)
FORM 2 (PDF)* |
|
Claim for Reimbursement–Corrective Action
Instructions and form necessary to file a claim for reimbursement.
|
FORM
3 (Word)
Form 3
Instructions
FORM 3 (PDF)* |
Claim for
Reimbursement–Third Party
Instructions and form necessary to file a third party claim. |
FORM
3T (Word)
Instructions
(Word)
FORM 3T
(PDF)*
Instructions
(PDF) |
Designation of
Representative
Use this form to designate another person to receive
reimbursement. |
FORM
5 (Word)
FORM 5 (PDF)* |
Acknowledgment of Payment
Use this form to acknowledge payment of invoice(s). |
FORM
6 (Word)
FORM 6 (PDF)* |
Owner/Operator's Report of
Insurance
Use this form to identify insurance information
and to subrogate and assign certain rights
to the board. |
FORM
7 (Word)
FORM 7 (PDF)* |
Corrective Action Plan
Budget Modification Form -DRAFT
Use this form to obtain approval of changes to Corrective Action
Plan. |
FORM
8 (Word)
FORM 8 (PDF)* |
Standard Corrective Action
Task Names
The Board asks that these names be utilized to describe corrective
action plan tasks. Updated 10/5/07 |
Standard
Corrective Action Task Names |
Unit Cost Worksheets
| Form Title |
Format |
Soil Boring/ Monitoring
Well Installation
Use this form to provide unit cost for tasks associated with
boring and well installation. |
Soil
Boring (MS Word)
Soil Boring
(PDF)* |
Groundwater Monitoring and
Sampling
Use this form to provide unit cost for tasks associated with
monitoring and sampling. |
GW
Monitoring (MS Word)
GW Monitoring
(PDF)* |
Soil Excavation
Use this form to provide unit cost for
excavation based upon banked yards removed. |
Soil
Excavation (MS Word)
Soil
Excavation (PDF)* |
