Administrative Code

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Virginia Administrative Code
Title 9. Environment
Agency 20. Virginia Waste Management Board
Chapter 170. Transportation of Solid and Medical Wastes on State Waters

9VAC20-170-400:9. APPENDIX IX..


(NOTE: Instructions in brackets are to be replaced with the relevant information and the brackets deleted.)


The undersigned, as principals and as legal representatives of [insert vessel owner or operator] and [insert name and address of third party claimant] hereby certify that the claim of bodily injury [and/or] property damage caused by a sudden and/or nonsudden accidental occurrence arising from a waste deposit from [owner or operator] vessel into state waters should be paid in the amount of $[ ].


Vessel Owner or Operator

Attorney for Owner or Operator

[Notary]                        [Date]



Attorney(s) for Claimant(s)

[Notary]                        [Date]

Statutory Authority

§§ 10.1-1402 and 10.1-1454.1 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 19, Issue 19, eff. July 2, 2003.

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