Underground Storage Tank Cleanup Fund (USTCF)

Forms and Publications

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Forms

These forms are presented in PDF format.

General Use

These forms can be submitted via mail, email, or fax
• Claimant Contact Information Form - use to change address with Fund.
• Fraud Reporting Complaint
• Power of Attorney - REV. 10/15
• Project Execution Plan (PEP) Excel Workbook (2.1-10/14/18)
• Request for Change in Claimant or Joint Claimant Identification
  • Process of Transferring a Claim Upon a Claimant or Joint Claimant Death
  • Supporting Documents Checklist
• Request to Reopen a Closed UST Cleanup Fund Claim – submit this form to request to reopen an existing closed claim

Claim Eligibility

• Certificate of Compliance with Health & Safety Code Section 25299.54(h)
• Commingled Plume Account Application Package
• Permit Waiver (for claims filed after 1/1/08)
• Permit Waiver Pursuant to Kelsoe Opinion
• Request for Assignment of Claim to Priority Class B
• USTCF Claim Application
• Worksheet for Priority Class B Claimants

Budget

• Budget Change Request Form – submit this form to request a budget increase/decrease for the current fiscal year
• Remediation Information Form

Reimbursement

• Claimant (Payee) Data Record (Std. 204) - Submit when the entity's tax status or address changes.
  • STD. 204 Form Review Process Flowchart
  • Government Agency Taxpayer Identification Form - Government Agencies only
• Proof of Payment Affidavit - This form can be submitted via mail, email, or fax (Rev. date 5/20/2020)
• Proof of Payment Certification - This form can be submitted via mail, email, or fax (Rev. date 5/20/2020)
• Provider’s Complaint Form for Claimant’s Nonpayment of Eligible Costs Form - This form can be submitted via mail, email, or fax
• Request for Appeal
• Request for Extension - submit this form to request an extension to submit first reimbursement request or to request extension to submit final reimbursement request

These forms can only be submitted via US Mail with original signature
• Certification of Non-Recovery - This form can only be submitted by mail.
• Conditions of Payment – this form is a required supplement to your Reimbursement Requests

Technical

• Bid Summary Sheet
• Cost Guidelines
• Cost Guidelines Errata Sheet

Publications

• Financial Responsibility