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

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

Claim Eligibility

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

Budget

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

Reimbursement

• GeoTracker Supplemental Information Form for Hard-Copy Reimbursement Request
• Reimbursement Request Information Checklist
  • Reimbursement Request Spreadsheet (Sample)
  • Reimbursement Request Spreadsheet (Excel)
• Proof of Payment Affidavit - This form can be submitted via mail, email, or fax (Rev. date 4/17)
• Proof of Payment Certification - This form can be submitted via mail, email, or fax (Rev. date 4/17)
• Provider’s Complaint Form for Claimant’s Nonpayment of Eligible Costs Form - This form can be submitted via mail, email, or fax

Technical

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

Publications

• Commingled Plume Account Application Package
• Financial Responsibility
• Legislation
• Newsletter Archive