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.
| 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. |
|
| Application for Voluntary Registration Use this form to determine potential eligibility for reimbursement from the Petroleum Tank Release Cleanup Fund prior to a release. |
|
| 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 |
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)* |
| Equipment Policy Acknowledgement Use this form to document remediation equipment at a facility. New 12/3/09 | FORM 9 (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 |
| Maximum Reimbursable Costs for Corrective Action Plans and Reports Provided to assist with costs of plans and reports. Updated 1/6/10 |
Maximum Reimbursable Costs |
| 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)* |
| Form Title | Format |
|---|---|
| Aboveground Storage Tank Self Inspection For use by owners and operators of aboveground storage tank facilities. New 9/30/09 |
Checklist (Printable PDF only - not a form) |
