Virginia Administrative Code
Title 9 - ENVIRONMENT
Agency 25 - STATE WATER CONTROL BOARD
Chapter 590 - PETROLEUM UNDERGROUND STORAGE TANK FINANCIAL RESPONSIBILITY REQUIREMENTS
Section 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