Underground Storage Tank Cleanup Fund (USTCF)
Forms and Publications
Quick Links
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
- Request to Reopen a Closed UST Cleanup Fund Claim – submit this form to request to reopen an existing closed claim
- Fraud Reporting Complaint
- 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
These forms can only be submitted via US Mail with original signature
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
- Budget Change Request Form – submit this form to request a budget increase/decrease for the current fiscal year
- Remediation Information Form
- 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
