Administrative Code

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Virginia Administrative Code
Title 9. Environment
Agency 25. State Water Control Board
Chapter 590. Petroleum Underground Storage Tank Financial Responsibility Requirements

9VAC25-590-260:10. Appendix X. Certification of Valid Claim.

[Note: The instructions in brackets are to be replaced by the relevant information and the brackets deleted.]

The undersigned, as principals and as legal representatives of [insert 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 an accidental release arising from operating [owner's or operator's] underground storage tank should be paid in the amount of $[.....]

[Signatures] [Signature(s)]

Owner or Operator Claimant(s)

Attorney for Attorney(s) for

Owner or Operator Claimant(s)

(Notary) Date (Notary) Date

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