Department of
Environmental Protection
Bob Martinez Center 2600 Blair Stone Road Tallahassee, Florida 32399-2400
FLORIDA PETROLEUM RESTORATION INSURANCE PROGRAM CLAIM
Please Print or Type - Review Instructions Before Completing Form 1. DEP Facility ID Number_______________________________________ Discharge Date_______________________
2.
Facility Name Tank(s) Address City/State/Zip Contact Person Financial Responsibility Type
Telephone
(
)
3.
Tank(s) Owner Owner Mailing Address City/State/Zip Contact Person
Telephone
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)
4.
It is the understanding of the facility owner/operator that appropriate action has been taken to meet the Petroleum Insurance/Financial Responsibility requirements pursuant to Section 376.3072, Florida Statutes. Therefore, the facility owner/operator elects to remediate the subject discharge in the following manner (check one): The owner/operator will proceed with cleanup according to Section 376.30711, F.S. (pre-approval). will cleanup the site pursuant to Rule 62-770, F.A.C., and will not seek State funding assistance for the cleanup. Other:
5.
(Check All Applicable Boxes) Discharge reported within 24 hours to DEP District Office or contracted county representative. Attach copy of Discharge Report Form Petroleum storage system tested or emptied within 3 days of discharge discovery. Leaking petroleum storage system removed from service within 3 days until it has been repaired or replaced. Free product recovery initiated. To the best of my knowledge and belief all information submitted on this form is true, accurate and complete.
Print name & title of owner or authorized person
Signature
Date
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CLAIM INSTRUCTIONS
All owners or operators who are enrolled in the Florida Petroleum Liability and Restoration Insurance Program (FPLRIP) and have had a release from an eligible petroleum storage system or have discovered petroleum contamination should complete this form. Completion of this form is necessary to file a claim under FPLRIP. Submission of this form does not guarantee that you will receive state assistance. 1. DEP facility ID number. Only registered sites enrolled in FPLRIP are eligible. Date of subject discharge. Fill in the name and physical address of the facility, name of contact person and telephone number. Financial responsibility should be: A) B) C) D) 3. FPLIPA/State Fund Self Insured/State Fund Other Insurance/State Fund Other method. Explain.
2.
Fill in the name and address of the tank owner, if different from above. Name of contact person and telephone number. Check the method of cleanup assistance the owner/operator desires for site remediation.
4. 5.
Check each item that applies relative to compliance with Rule 62-761, Florida Administrative Code and Section 376.3072(2), F.S. . Fill in the name of the person authorized to represent the owner/operator, or the owner/operator, the individual's title, and obtain the appropriate signature. Submit Claim Form and Discharge Reporting Form to: Contracted County Storage Tank Inspector See the attached list for the correct county representative A completed claim package must include: 1) Claim Form 2) Discharge Reporting Form 3) Pollutant Storage Tank System Inspection Report Form 4) Florida Petroleum Liability and Restoration Insurance Program Checklist If you have any questions, please call (850) 245-8839.
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