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 Form
• 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

• Payee Data Record (STD 204) – Form is required for each entity that is receiving funding from the State Water Board. Submit this form when the entity’s name, tax status or mailing address for receiving the Form 1099 changes. (NOTE: Mailing address supplied on this form is where the entity will receive their potential Form 1099 at the end of each tax year.) (Link to Form: https://www.documents.dgs.ca.gov/dgs/fmc/pdf/std204.pdf)
  • STD. 204 Form Review Process (Link to File: https://www.waterboards.ca.gov/water_issues/programs/ustcf/docs/forms/form_review_process_flowchart.pdf
    
• Payee Data Record Supplement (STD 205) – Form only is required for an entity that is receiving funding from the State Water Board to mailing addresses that are different than the one listed on the STD 204. (NOTE: Mailing address supplied on this form is where the entity will receive payments from the State Water Board.) (Link to Form: https://www.documents.dgs.ca.gov/dgs/fmc/pdf/std205.pdf)
  
  
• Government Agency Taxpayer ID Form – This form is required to be on file for any government agency that is receiving funding from the State Water Board. Submit this form when the mailing address changes. (NOTE: This form can only be used by government agencies).  (Link to Form: https://fiscal.ca.gov/wp-content/uploads/2019/08/GovtTINForm_000.pdf)
  
  
• 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