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Home My WebLink AboutDERR-2024-012991LUST Correspondence Sign-Off Sheet ERRL# ___________ Author Subject File Name on Google Drive Enclosures Attached Specify Special Instructions PM verified site status module in database is current Draft Approval Process Project Manager Section Manager Branch Manager Final Approval Process Section Secretary Author Branch Secretary Administrative Secretary Section Secretary Certified Mail Enclosures Included ccs Mailed Mailed By ' : Alex Thompson Inability to Pay Oversight Costs Letter 4000381 NOU Inability to Pay for Oversight Costs Letter Letter in Gdrive. Also PST Fund Claims Packet dated February 27, 2017 None n Yes No 11/20/2024 P 12/0х/2024 12/0ш/2024 T 04ш7Ҋ24 12/0ш/2024 AT AT 12/0ш/2024 SS 12/10/2024 12/10/2024 SS Attach Signed Letter Yes Yes Yes 12/18/2024 195 North 1950 West • Salt Lake City, UT Mailing Address: P.O. Box 144840 • Salt Lake City, UT 84114-4840 Telephone (801) 536-4100 • Fax (801) 359-8853 • T.D.D. (801) 536-4284 www.deq.utah.gov Printed on 100% recycled paper State of Utah SPENCER J. COX Governor DEIDRE HENDERSON Lieutenant Governor Department of Environmental Quality Kimberly D. Shelley Executive Director DIVISION OF ENVIRONMENTAL RESPONSE AND REMEDIATION Brent H. Everett Director ERRL-0497-24 December 16, 2024 CERTIFIED MAIL RETURN RECEIPT REQUESTED Asanfar Joseph Ameen Alpha & Omega Business Acquisitions 2824 West Ivory Way West Jordan, Utah 84084 Re: Exemption Application for Recovery of Management and Oversight Expenses West Valley Sinclair, located at 1950 West 3500 South, West Valley City, Utah Facility Identification No. 4000381, Release Site NOU Dear Mr. Ameen: For releases not covered by the Petroleum Storage Tank (PST) Fund, the Director of the Division of Environmental Response and Remediation (DERR) may recover expenses incurred by the Division for management and oversight of the release (Utah Code Ann. 19-6-420 (10)). On September 23, 2024 you informed Alex Thompson of the DERR that you could not pay for these expenses associated with your leaking underground storage tank release site based on an inability to pay. Utah Administrative Code R311-209-4 allows the Division Director to consider certain factors to determine whether he may grant an exemption from paying these expenses. As such, you will need to complete the enclosed Financial Data Application worksheet so your financial status can be reviewed. To properly assess your financial status, the enclosed form should be fully completed and submitted with copies of your tax returns for the last three (3) years. Your financial information, along with other relevant factors, will be used by the Division Director to make your exemption determination. Additionally, it is recommended that you submit the PST Fund Eligibility Application included with this email within 30 days of receiving this letter. Facility ID# 4000381 Page 2 If you have any questions regarding this matter, please contact Alex Thompson, the DERR project manager, at (801) 536-4100. Sincerely, Brent H. Everett, Division Director Division of Environmental Response and Remediation BHE/MAT/stt Enclosure: PST Fund Claims Packet dated February 27, 2017 Exemption Application for Recovery of Management and Oversight Expenses Financial Data Request Form cc: Dorothy Adams, Executive Director, Salt Lake County Health Department Ron Lund, Environmental Health Director, Salt Lake County Health Department 1 Exemption Application for Recovery of Management and Oversight Expenses Financial Data Request Form You have indicated interest in applying for an exemption from paying management and oversight expenses, as outlined in Utah Code Ann. 19-6-420 (10) and Utah Admin. Code R311-209-4, based on an inability to pay. This form requests information regarding your financial status. In order to process your application to be considered unable to pay, you must provide the information requested in this form along with copies of your last three Federal income tax returns. The data will be used to evaluate your ability to pay for management and oversight cost associated with your underground storage tank release not covered by the Petroleum Storage Tank Fund. If there is not enough space for your answers, please use additional sheets of paper. Note that we may request further documentation of any of your responses. We welcome any other information you wish to provide supporting your case, particularly if you feel your situation is not adequately described through the information requested here. 2 Name: Spouse's Name: Address: County of Residence: Certification Under penalties of perjury, I declare that this statement of assets, liabilities, and other information is true, correct, and complete to the best of my knowledge and belief. I further declare that the copies of Federal income tax returns I have enclosed for the years , , and are true and accurate copies of those returns actually filed with the United State Internal Revenue Service. I further understand that I will be subject to prosecution by the Utah Department of Environmental Quality to the fullest extent possible under the law should I provide any information that is not true, correct, and complete to the best of my knowledge. __________________________________ __________________ Signature Date STATE OF UTAH ss. COUNTY OF SALT LAKE SUBSCRIBED AND SWORN to before me, a notary public, on this day of , ____. 3 NOTARY PUBLIC PART I. BACKGROUND INFORMATION 1. MEMBERS OF HOUSEHOLD (List the head of the household and all persons living with you) Name Age Relationship to Head of Household Currently Employed? 2. EMPLOYMENT (List all jobs held by persons in household) Name Employer Length of Employment Annual Salary 4 3. INCOME (List all income earned by persons in household. If members of the household other than the applicant and spouse earn income, please itemize on separate page) Source Gross (Pre-Tax) Period of Payment (check one) Applicant Spouse Weekly Monthl y Quarte rly Yearl y Wages/Salaries Sales Commissions Investment Income (interest, dividends, capital gains, etc.) Net Business Income Rental Income Retirement Income (Pension, Social Security, etc.) Child Support Alimony Other Income (Please Itemize) 5 PART II. CURRENT LIVING EXPENSES Please list personal living expenses which were typical during the last year and indicate if any of these values are likely to change significantly in the current year. Please do not include business expenses. If you are the owner of an operating business, please attach any available financial statements. Period of Payment (check one) For Agency Use Only Expense Amount Weekly Monthly Quarterly Yearly A. Living Expenses 1. Rent 2. Home maintenance 3. Auto fuel maint./other transp. other transportation 4. Utilities a. Fuel (gas, oil, wood) b. Electric c. Water/sewer d. Telephone 5. Food 6. Clothing, personal care 7. Medical costs B. Debt Payments 6 1. Mortgage payments 2. Car payments 3. Credit card payments 4. Educational loan payments C. Insurance 1. Household insurance 2. Life insurance 3. Automobile insurance 4. Medical insurance D. Taxes 1. Property taxes 2. Federal income taxes 3. State income taxes 4. FICA E. Other Expenses 1. Child care 2. Current School tuition/expenses 3. Legal or 7 professional services 4. Other (itemize on separate page if necessary) PART III. NET WORTH Please provide the following information to the best of your ability. Data should be as current as possible. Estimates are acceptable; if you wish note such items with an "E". If you are the sole proprietor of a business, please list business assets and liabilities, in addition to personal assets and liabilities. Please mark these entries with a "B" to identify them as business assets and liabilities. 1. BANK ACCOUNTS (Checking, NOW, Savings, Money Market, CDs, etc.) Name of Bank or Credit Union Type of Account Current Balance 2. INVESTMENTS (Stocks, Bonds, Mutual Funds, Options, Futures, Real Estate Investment Trusts (REIT), etc.) Investment Number of Shares or Units Current Market Value 3. RETIREMENT FUNDS AND ACCOUNTS (IRA, 401(k), Keogh, vested interest in company retirement fund, etc.) Description of Account Estimated Market Value 4. LIFE INSURANCE POLICIES (Whole Life, Universal Life, etc.) Policy Holder Issuing Company Policy Value Cash Value 5a. VEHICLES USED FOR COMMUTING PURPOSES (Cars, Trucks, Motorcycles, etc.) Only list up to two vehicles used for communized purposes) Model Year Estimated Market Value 5b. OTHER VEHICLES (Cars, Trucks, Motorcycles, Recreational Vehicles, Motor Homes, Boats, Airplanes, etc.) Model Year Estimated Market Value 6. VEHICLE LOANS (Cars, Trucks, Motorcycles, Recreational Vehicles, Motor Homes, Boats, Airplanes, etc.) Vehicle (Model and Year) Owed To Balance Due Start Date End Date 7a. REAL ESTATE-PRIMARY RESIDENCE (Home-List only one such residence) Location Description of Property Estimated Market Value 7b. OTHER REAL ESTATE (Land, Buildings, Land with Buildings) Location Description of Property Estimated Market Value 8. MORTGAGES AND REAL ESTATE LOANS Type of Loan Owed To Property Secured Against Balance Due Start Date End Date 9. PERSONAL PROPERTY (Household Goods and Furniture, Jewelry, Art, Antiques, Collections, Precious Metals, etc.) Only list items with a value greater than $500.00) Type of Property Estimated Market Value 10. FURNITURE AND HOUSEHOLD GOODS LOANS List Item Owed To Balance Due Start Date End Date 11. OTHER ASSETS Type of Asset Estimated Market Value 12. CREDIT CARDS AND LINES OF CREDIT Credit Card/Line of Credit (Type) Owed To Balance Due 13. OTHER DEBT (Amounts due to individuals, Fixed Obligations, Taxes Owed, Overdue Alimony or Child Support, etc.) Type of Debt Owed To Balance Due Start Date End Date PART IV. ADDITIONAL INFORMATION Please respond to the following questions. For any question that you answer "Yes," please provide additional information on separate pages or at the bottom of this page. QUESTION YES NO 1. Do you have any reason to believe that your financial situation will change during the next year? 2. Are you currently selling or purchasing any real estate? 3. Is anyone (or any entity) holding real or personal property on your behalf (e.g. a trust)? 4. Are you a party in any pending lawsuit? 5. Have any of your belongings been repossessed in the last three years 6. Are you a Trustee, Executor, or Administrator? 7. Are you a participant or beneficiary of an estate or profit sharing pla 8. Have you declared bankruptcy in the last seven years? 9. Do you receive any type of federal aid or public assistance? Petroleum Storage Tank Trust Fund Claim Information Packet Department of Environmental Quality Division of Environmental Response and Remediation 195 North 1950 West, 1st Floor P.O. Box 144840 Salt Lake City, Utah 84114-4840 Telephone: (801) 536-4100 Fax: (801) 359-8853 TABLE OF CONTENTS Introduction ......................................................................................................................................1 PST Trust Fund Eligibility ...............................................................................................................1 PST Trust Fund Deductible and Coverage ......................................................................................1 Environmental Consultants and Subcontractors ..............................................................................2 Work Plans and Budgets ..................................................................................................................2 PST Trust Fund Reimbursement Documentation ............................................................................3 Third Party Claims ...........................................................................................................................3 Other Information Eligibility Application Work Plan Approval Application and Agreement Standardized Invoice Request for Payment Voucher Proof of Payment Introduction The Division of Environmental Response and Remediation (DERR) established the Petroleum Storage Tank Trust Fund (PST Fund) to help underground storage tank (UST) owners/operators meet U.S. Environmental Protection Agency financial assurance requirements and to help pay the costs of abatement, investigation, and remediation of releases from leaking underground storage tanks (LUSTs). This claim information packet summarizes the procedures and requirements for obtaining PST Fund assistance for the investigation and remediation of releases from PST Fund-covered LUSTs. This claim information packet is not all-inclusive, therefore, one should review the Underground Storage Tank Act 19-6-401 and the Underground Storage Tank Rules R311 for more detailed information. PST Fund Eligibility Known or suspected releases (leaks) from petroleum UST systems (USTs, associated piping, and dispensers) must be reported to the DERR within 24 hours of occurrence. To be eligible for reimbursement from the PST Fund, the UST system must have a valid UST Certificate of Compliance and must be covered by the PST Fund at the time of the release. A ³PST Trust Fund Eligibility ApplicaWion´ oU claim mXVW be UeceiYed b\ Whe DERR dXUing Whe period under which the UST system was covered by the PST Fund, or within one year after the UST system was properly closed, or within six months after the end of the period under which the UST was covered by the PST Fund. Following a review of your PST Fund Eligibility Application, the DERR will provide written notification regarding eligibility for reimbursement from the PST Fund. There are time constraints provided by law that may cause an otherwise eligible release to become ineligible. Therefore, it is important to file a PST Trust Fund Eligibility Application promptly. PST Fund Deductible and Coverage Deductible: Releases that occurred and were reported before July 1, 1994 have a $25,000 deductible. Releases that occurred and were reported after July 1, 1994 have a $10,000 deductible. Coverage: For releases reported before May 11, 2010, the PST Fund may reimburse up to $990,000 ($490,000 for non-marketer facilities) of the investigation and remediation costs. For releases reported after May 11, 2010, the PST Fund may reimburse up to $1,990,000 ($990,000 for non-marketer facilities) of the investigation and remediation costs. All costs, including the deductible amount, must be for customary, reasonable, and legitimate work as determined by the DERR. Expenses that are eligible for reimbursement from the PST Fund include costs for vapor abatement, subsurface investigation, soil and groundwater sampling, corrective action, and provision for alternative drinking water supplies. 1 Expenses that are not eligible for reimbursement by the PST Fund include costs to achieve compliance with UST system leak detection requirements, upgrading of an UST system, removal or installation of an UST system, loss of business, and legal fees. If a facility has a current PST Fund-eligible release and a subsequent PST Fund-eligible release occurs at that facility, the PST Fund allowable coverage for the subsequent release will be limited to the amount required to investigate and remediate only the subsequent release. Additional PST Fund monies cannot be obtained for the investigation and remediation of the original release through the coverage of a subsequent release, i.e., the maximum coverages for each release cannot be aggregated. The DERR will determine the coverage based on the magnitude of the subsequent release. In addition, a $10,000 deductible will apply to the subsequent release. Environmental Consultants and Subcontractors Environmental consultants overseeing and directing work at LUST sites must be DERR- Certified UST Consultants in accordance with UST Rule R311-201-2. The Certified UST Consultant must have a current and approved PST Fund Statement of Qualification (SOQ) on file with the DERR in accordance with UST Rule R311-207-3. Consulting firms must update their PST Fund SOQs each year and the SOQs must be approved by the DERR before PST Fund money is expended. Environmental consultants must obtain a minimum of three bids from qualified subcontractors for subcontracted work (drillers, excavation contractors, etc.) in accordance with UST Rule R311-207-4(e). The requirement to obtain three bids for subcontracted work is waived if the subcontracted work is expected to cost, and actually does cost, less than $5,000. Work Plans and Budgets Work Plans and Budgets (WP&B) for work required to investigate and remediate a release must be pre-approved by the DERR and the PST Fund claimant. The claimant and their environmental consultant must complete, sign, and submit a Work Plan Approval Application and Agreement (WPAA&A) form for each WP&B before the work is performed. If the claimant does not want to sign a WPAA&A form for each individual WP&B, the claimant may complete and sign one form that will cover all subsequent work plans with the same environmental consultant. However, the claimant must submit a cover letter with the form to document that this is what they want to do. This authorization will remain in effect until the claimant notifies the DERR otherwise in writing. An approved work plan may be changed and the budget may be exceeded only after obtaining approval from the DERR. Emergency work (work that prevents or abates substantial danger to public health or the environment) can be approved verbally (with a written follow-up submitted within 48 hours requesting an amendment and explaining the need for the change in the scope- of-work and budget). 2 Reimbursement amounts are determined by the actual time and material costs expended for the work, up to but not exceeding the approved budget amount for each task. PST Fund Reimbursement Documentation In accordance with UST Rule R311-207-4, all expenses must be documented on a monthly basis and submitted on Whe ³SWandaUdi]ed InYoice´ or equivalent. Information from invoices must be compiled on the PST Trust Fund, Request for Payment Voucher. PST Fund reimbursement requests that do not comply with UST Rule R311-207 will be returned to the claimant for correction. The costs for correction of reimbursement requests will not be reimbursable by the PST Fund. Requests for PST Fund reimbursement must be received by the DERR within one year of the date that the work was performed or reimbursement will be denied. The following information is required for PST Fund reimbursement: Ɣ Employee name, labor category (e.g., P102-Project Geologist or P104-Field Geologist, etc.), date of work, task or description of work (e.g., groundwater sampling, operation and maintenance, report preparation, etc.), hourly labor rate, and the number of hours spent on each task; Ɣ Laboratory analytical costs; Ɣ Equipment rental and materials costs; Ɣ Utility costs; Ɣ Other direct costs; Ɣ Invoices from general contractors, subcontractors, and suppliers with a work description and listing of price and quantity of labor, equipment, and materials used; and, Ɣ Proof of Payment. If reimbursement is to be made to the PST Fund claimant, proof of payment to the consultant must be provided. If reimbursement is to be made directly to Whe conVXlWanW, When pUoof of pa\menW Wo Whe conVXlWanW¶V VXbconWUacWoUV and VXppliers is required. Proof of payment may be in the form of canceled checks, lien waivers, or affidavits from the entity that is owed the money. PST Fund claimants are primarily liable for all costs incurred and should obtain lien releases or lien waivers from the companies, contractors, and subcontractors providing materials or performing services associated with the release. Third Party Claims If a third party claim resulting from the release is brought against a PST Fund claimant, or if any action or situation is likely to result in a third party claim, the PST Fund claimant must immediately report it to the Department of Administrative Services, Risk Manager at (801) 538-9560 and to the DERR Project Manager. 3 PST Trust Fund Eligibility Application 2/24/17 Utah Department of Environmental Quality Division of Environmental Response and Remediation Petroleum Storage Tank Trust Fund Were tanks in compliance when leak was detected? Yes No LUST Release Number: Facility ID Number: Applicant Name (please print) Signature Date Mailing Address City State Zip Telephone ( ) Applicant is a: Tank System Owner Facility Owner Tank System Operator Land Owner (Must demonstrate authority to file claim) If the tank system owner or operator, the facility owner, or owner of the land on which the tank system is located is different than the applicant shown above, complete the appropriate spaces in this portion of the form. Tank System Owner Facility Owner Tank System Operator Land Owner Mailing Address Telephone Dates of Ownership From To Name of facility where the release occurred: Facility Address: Contact person at the facility: Telephone ( ) Date Release occurred or was discovered: Date release was reported to the DERR: Number of tank systems that contributed to the release at the site (attach additional sheets if needed). Tank Number Tank Volume Product Installation/Closure Date Is this release covered under independent insurance? Yes (if yes, please submit a copy of your insurance policy) No Number of tank systems that were or will be removed during the course of this site cleanup? How was the release confirmed? (Attach a brief summary that includes laboratory analysis, field instrument readings, visual observations, tank tightness test results, etc.) Is there evidence of a previous release? If so, describe how the release was determined. Was the release caused by a third party? If so, explain the circumstances and provide the name, address, and telephone number of Whe Whird parW\ and Whe Whird parW\¶V inVXrance compan\. HaYe \oX receiYed an\ reimbXrVemenW or offerV of reimbXrVemenW from a Whird parW\ or a Whird parW\¶V inVXrance c ompany? If so, how much and when was it received? Have you signed a release? Utah Code Ann. 19-6-426(7) prohibits responsible parties from doing anything that may prejudice the right of the State to recover from third parties. Petroleum Storage Tank Trust Fund Work Plan Approval Application and Agreement Work Plan No. __________, Amendment No. __________ Facility Name: ____________________________________ Address: _________________________________________ Facility ID No.: ____________________________________ Release ID: _______________________________("Release") Owner/Operator, responsible party, or other person seeking PST Trust Fund Reimbursement: _________________________________________________________________________("Claimant") Utah-Certified UST Consultant: ______________________________________________("Contractor") In submitting Work Plans_______________________ and amendments thereto for the above referenced Release ___________ for approval, the Claimant and the Contractor collectively, the "Parties," represent and agree to the following: Definitions: "Contractor" means the person identified as such above. "Claimant" means the person identified as such above. ³PaUWieV´ meanV ClaimanW and ConWUacWoU. "Division Director" means the Division Director of the Division of Environmental Response and Remediation. ³PST FXnd" meanV Whe PeWUoleXm SWoUage Tank TUXVW FXnd. "Release" means the release identified above. "State" means the State of Utah including its agencies, officers, employees, volunteers and specifically, the Division of Environmental Response and Remediation (DERR), the Division Director of the Division of Environmental Response and Remediation, and the Petroleum Storage Tank Trust Fund. "Work Plan" means the work plan identified above. 1. The key personnel, for which qualifications are submitted under R311-207-3(c), are: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 2. The Claimant acknowledges that the Claimant is required to obtain a payment bond from the Contractor under Section 14-2-1 of the Utah Code. If the Claimant fails to do so, the Claimant is liable to each person who performed labor or services or supplied equipment or materials ("Subcontractors") in the event the Contractor does not pay the subcontractors, even if the Claimant has paid the Contractor (Utah Code Section 14-2-2). The Claimant acknowledges and agUeeV WhaW Whe PST FXnd Zill noW UeimbXUVe Whe ClaimanW foU VXch SXbconWUacWoUV¶ claimV foU payment against the Claimant if the PST Fund has already made payment to the Claimant or Contractor. The Claimant understands that the premium paid for a payment bond is reimbursable. Therefore, the Claimant: a. Has required the Contractor to obtain 100 percent payment bond through a United States Treasury-listed bonding company, and attached a copy, or; b. Has obtained other equivalent assurance and waives all claims and remedies against the State if the equivalent assurance does not adequately protect the Claimant. The equivalent assurance is described as follows: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 3. The Parties agree that the Contractor shall have no cause of action against the State for payment. The Parties acknowledge and agree that the State is not a party to any contract with the Claimant or the Contractor for reimbursement from the PST Fund in the execution of this Work Plan, except to the extent provided by a contract signed by the Division Director. Instead, the ClaimanW¶V UeimbXUVemenW iV goYeUned b\ Whe UWah UndeUgUoXnd SWoUage Tank AcW and Whe UWah Underground Storage Tank Rules. The Contractor is entitled to reimbursement solely under his/her contract with the Claimant. 4. The Parties agree that they will use a subcontracting method consistent with the requirements of R311-207. 5. The Parties agree that, as a condition of performing the work under the work plan, the Contractor shall carry the insurance specified in R311-207-3(c)(4). The Contractor represents that the Certificate of Insurance documenting the required insurance is attached or that a current certificate is on file with the Division Director and has been provided to the Claimant. The Parties assume the risk and responsibility of ensuring that the app ropriate insurance coverage is in place. 6. The Parties agree that payments from the PST Trust Fund shall be limited to amounts that are customary, legitimate, reasonable and consistent with R311-207. Unless the Parties and the Division Director have entered into a written Pay-for-Performance agreement, the Parties acknowledge that payments will be for actual time and materials expended up to, but not exceeding, the amount of the Division Director approved work plan and Division Director approved change orders, if any. 7. The Parties shall maintain financial and operation records in sufficient detail to document all transactions relating to PST Fund reimbursement for the execution of this work plan. The Parties shall make available for audit and inspection all such records relating to the completion of the work plan and related services, requirements, and expenditures until all audits initiated by State auditors are completed, or for a period of five years from the date of PST Fund reimbursement related to the execution of this work plan. Records which relate to disputes, litigation, or the settlement of claims arising out of the performance of this work plan, or to cost and expenses of this work plan as to which exception has been taken by the Division Director, shall be retained by the Parties until disposition has been made of such disputes, litigation, claims, or exceptions. 8. The Parties certify that there is a contract between the Claimant and the Contractor for the performance of work under the work plan for which approval is sought ("Contract") and incorporate the provisions herein into that Contract. To the extent that the Contract or amendments thereto conflict with any provisions herein, the provisions herein govern. The Parties shall provide the Contract to the Division Director upon request. 9. The Division Director is a third party beneficiary of this Petroleum Storage Tank Trust Fund Work Plan Approval Application and Agreement and may enforce its provisions. 10. This Petroleum Storage Tank Trust Fund Work Plan Approval Application and Agreement does not limit the Division Director¶V rights and remedies under applicable law. Contractor_____________________________________________________________________ Signature, Printed Name, and Date Claimant______________________________________________________________________ Signature, Printed Name, and Date Revised 5/11/12 PROFESSIONAL SERVICES DERR LABOR CATEGORY DERR LABOR CODE TASK HOURS RATE THIS INVOICE TOTAL PREVIOUS TOTAL NEW TOTAL APPROVED BUDGET REMAINING BUDGET SubTotal DIRECT CHARGES DESCRIPTION TASK QUANTITY RATE THIS INVOICE TOTAL PREVIOUS TOTAL NEW TOTAL APPROVED BUDGET REMAINING BUDGET SubTotal OUTSIDE SERVICES DESCRIPTION TASK QUANTITY RATE THIS INVOICE TOTAL PREVIOUS TOTAL NEW TOTAL APPROVED BUDGET REMAINING BUDGET SubTotal BUDGET HISTORY SUMMARY TASK TOTAL TASK BUDGET APPROVED AMOUNT PREVIOUS INVOICES AMOUNT THIS INVOICE TOTAL INVOICE TO DATE TOTAL TASK BUDGET REMAINING %BUDGET REMAINING % OF WORK REMAINING 1 2 3 4 5 6 7 8 WORK PLAN TOTAL STANDARDIZED INVOICE Utah State Petroleum Storage Tank Fund FACILITY ID. # E INVOICE # LOCATION ADDRESS INVOICE DATE LOCATION NAME RELEASE ID. REMIT PAYMENT TO FROM WORK PLAN APPROVED BUDGET INVOICE FOR SERVICES PERFORMED TO DERR WORK PLAN NO. WORK PLAN DESCRIPTION PE T R O L E U M S T O R A G E T A N K T R U S T F U N D RE Q U E S T F O R P A Y M E N T V O U C H E R DE R R Pr o j e c t M a n a g e r : Da t e : SU B M I T T E D B Y : BI L L T O : PA Y E E : RE L E A S E N U M B E R : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ UT A H D E P T . O F E N V I R O N M E N T A L Q U A L I T Y AD D R E S S : FA C I L I T Y NU M B E R : _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___ _ DI V . O F E N V I R O N M E N T A L R E S P O N S E & RE M E D I A T I O N TY P E O F B U S I N E S S : SI T E N A M E : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 19 5 N O R T H 1 9 5 0 W E S T - PO B O X 1 4 4 8 4 0 SO L E P R O P R I E T O R _ _ _ _ _ P A R T N E R S H I P _ _ _ _ _ C O R P O R A T I O N _ _ _ _ _ SI T E LO C A T I O N : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ SA L T L A K E C I T Y , U T A H 8 4 1 1 4 -48 4 0 PH O N E : PH O N E N O . ( 8 0 1 ) 5 3 6 -41 0 0 DA T E WO R K P L A N SE R V I C E S R E N D E R E D : DE S C R I P T ION MU S T I N C L U D E C O P I E S O F I N V O I C E S , C H E C K S & B A C K -UP D O C U M E N T A T I O N IN V O I C E # AM O U N T I, t h e u n d e r s i g n e d , c e r t i f y t h a t t h e a b o v e l i s t e d i t e m s o r s e r v i c e s w e r e r e q u i r e d f o r a n d u s e d a t t h i s s i t e , t h a t t h e c h a r g e s ap p e a r i n g h e r e o n a r e c o r r e c t , a n d t h a t n o p a r t o f t h e s a m e h a s b e e n p a i d f o r b y t h e P S T Fu n d . T h e p r e s e n t a t i o n o f a c l a i m b a s e d o n m a t e r i a l l y f a l s e i n f o r m a t i o n i s s u b j e c t t o c r i m i n a l p e n a l t i e s . Ut a h C o d e A n n . § 1 9 -6-42 9 . TO T A L S U B M I T T E D : $ SI G N A T U R E O F R E S P O N S I B L E P A R T Y D A T E SI G N A T U R E O F C O N S U L T A N T F O R P R O J E C T D A T E CL A I M # 1 LE S S D I S A L L O W E D CO S T S : NO T E : Si g n a t u r e s o f B O T H R e s p o n s i b l e P a r t y A N D C o n s u l t a n t r e q u i r e d f o r D i r e c t R e i m b u r s e m e n t t o t h e C o n s u l t a n t . On l y o n e s i g n a t u r e r e q u i r e d f o r r e i m b u r s e m e n t t o o w n e r . PM T # ST A T E U S E : SU B -TO T A L A P P R O V E D : $ LE S S D E D U C T I B L E : $ PR O J E C T M A N A G E R D A T E AC C O U N T A N T D A T E DIV I S I O N DIR E C T O R DA T E TO T A L T O R E I M B U R S E : $ PS T S E C T I O N M A N A G E R DA T E MS C D A T E DE Q / F I N A N C E D A T E FU N D AG E N C Y LO W O R G AP P R SO U R C E PR O G R A M FU N C T I O N AM O U N T RE V D A T E : 2/27/1 7 FI N A N C I A L C O D I N G 72 2 0 48 0 47 3 1 72 2 0 61 3 7 $ Petroleum Storage Tank Trust Fund AFFIDAVIT: PROOF OF PAYMENT This form should be used when a claimant submits an affidavit from the consultant as proof of payment for costs claimed for reimbursement. See R311-207-4(d) Utah Admin. Code ClaimanW¶V Name ______________________________________________________________________ Site Name and Address _________________________________________________________________ _________________________________________________________________ Facility Identification No. __________________________________ Release Site___________________ STATE OF UTAH ) : ss COUNTY OF ______________________ ) I, being first duly sworn upon oath and being of lawful age, state that the following invoices relative to the refere nced application for reimbursement from the Utah Petroleum Storage Tank Trust Fund have been paid in full through the execution of a promissory no te by the claimant. INVOICE # INVOICE DATE AMT. PAID INVOICE # INVOICE DATE AMT. PAID I further state that there is no relationship or affiliation between myself and the claimant. I hereby certify that the foregoing information is correct to the best of knowledge, information, and belief. I understand there are severe civil and/or criminal penalties for any false statement or misrepresentation of a material fact, knowing it to be false, or failing to disclose a material fact with the intent to defraud. Signature: Date: Print Name: Title: Phone: Consultant Company Name: Consultant Company Mailing Address: Subscribed and sworn to before me in the county of _______________________, Utah, this _____ day of _________________(month), __________(year). My commission expires ________________________. ______________________________________________ Notary Public Signature SUBCONTRACTORS¶/MATERIALMENS¶ LIEN :AIVER For valuable consideration, the receipt and sufficiency whereof is hereby acknowledged, the undersigned Subcontractor/Materialman having performed services or furnished materials for that certain project known as ___________________________________________________, located at ___________________________________________________________________, heUeb\ UeleaVeV, UelinqXiVheV, and ZaiYeV an\ and all mechanic¶V lienV, maWeUialman¶V lienV, and all other liens of every nature and kind, and/or the right to file any such lien, against said project for labor, services, equipment, and material supplied and performed through ________________, 201____. The undersigned certifies that: 1. Full payment, less retainage if any, has been received for all invoices submitted through ___________________________, 201____; and 2. The undersigned has paid all of its subcontractors for work and services performed and all of its materialmen for materials furnished to said date. DATED this _______ day of _______________________, 201____. ___________________________________ Authorized Representative of: ___________________________________