PETROFUND REIMBURSEMENT APPLICATION GUIDE

Transcription

1 MINNESOTA PETROLEUM TANK RELEASE COMPENSATION BOARD PETROFUND REIMBURSEMENT APPLICATION GUIDE This guide applies to the initial and supplemental reimbursement application forms that are effective July 1, June 30, This guide follows the arrangement of the application section by section and provides information about items that are not self-explanatory. It covers both the 7-page initial reimbursement application form and the 4-page supplemental application form and their attachments. If you are filling out a supplemental application, however, you will see that some items do not apply to the shorter form. If you have questions about anything not covered in these pages, please call the Petrofund Information Line at or Before filling out your application, assemble the following items: Invoices you received for cleanup work ( corrective action ). All bids and proposals you received from contractors and consultants. All the information you have concerning the petroleum storage tanks and piping at this site and any associated leak detection equipment, tank tightness testing, and inventory control To avoid delays in the processing of your application, do not leave any question blank. If an item doesn t apply to you, write not applicable. APPLICANT INFORMATION Check RESPONSIBLE PERSON if you owned or operated the tank(s) at any time during or after the release. Check VOLUNTEER if you did not own or operate the tank(s) but did own the property where the release occurred. Check OTHER if you did not own or operate the tank(s) or own the property, but took the corrective action in response to a request or order of the Minnesota Pollution Control Agency (MPCA). Page 1 of 7

2 LEAK SITE INFORMATION MPCA Leak Number. Enter the Leak# or Site ID# used on correspondence regarding this site sent to you by the MPCA. If you are applying for reimbursement of agricultural storage tank removal costs and no release has been discovered at this site, enter Not Applicable ( N/A ). MPCA Project Manager. If you are unsure about the correct name to enter, please contact the MPCA at or for assistance, or visit Tank Facility Name. Enter the name of the site where the release occurred. Total amount of contaminated soil excavated at this site. Enter the amounts listed in Item D of Part IV of the General Excavation Report (see MPCA Guidance Document 3-02) and in Item F of Section 1 of the Corrective Action Excavation Report Worksheet (see MPCA Guidance Document 3-02a). If no contaminated soil was excavated at this site, enter 0. MULTIPARTY CHECK REQUEST If you have requested the issuance of a multiparty check for this application by completing and signing a Petrofund Multiparty Check Request form, the reimbursement check will be issued in the names of all the parties that signed the form. Page 2 of 7

3 SOURCE AND CAUSE What was the source and cause of the petroleum release at this site? Indicate which tank(s) the petroleum release originated from and the factors that caused the release (such as overfills, corrosion, loose fittings, etc.). If the release was a sudden spill or was caused by a specific incident, describe the circumstances in detail on a separate sheet. Do not enter unknown. How was the release discovered? Specify the field instrument(s), analytical procedure(s), or other method used to confirm that a petroleum release occurred at this site. COMPETITIVE BIDDING Competitive bidding has been required for most Petrofund work since December 16, In the space provided, list all the written bids or proposals that you obtained from consultants or contractors to perform corrective action services at your site. Attach additional sheets if necessary. Be sure to submit with your application the original forms (not photocopies) for all bids and proposals that you received. If you did not select the low-cost bid or proposal for some or all of the work, explain that decision on a separate sheet. If you did not obtain any written bids or proposals to perform corrective action at this site, write None in the Name column. MPCA TANK INFORMATION AND COMPLIANCE Have you submitted an underground storage tank audit? If you are unsure whether an optional self-audit for this site has been submitted to the MPCA, or if you would like more information about the self-audit program, please contact the MPCA at or for assistance. Underground Storage Tanks and Aboveground Storage Tanks. Enter as much of the requested information as possible for (a) all the petroleum storage tanks and piping that were in place at this site at the time the release was discovered, and (b) all the petroleum storage tanks that have been installed at this site since the release was discovered. This information will be reviewed by the MPCA to determine your compliance with state and federal rules and regulations applicable to the condition or operation of petroleum storage tanks. Page 3 of 7

4 ELIGIBLE COSTS Dates of work covered by invoices submitted with this application. If you are uncertain of the dates the work was performed, list the dates of the earliest and latest invoices submitted with this application. Are any of the costs included in this application in dispute? Check Yes if there is any disagreement about how much should be paid for any cost included in this application or if there is any disagreement about who should pay any cost included in this application. INSURANCE Because costs payable under an applicable insurance policy generally are not eligible for reimbursement, all insurance issues should be resolved before you submit an application for Petrofund reimbursement. CONSULTANTS/CONTRACTORS All consultants and contractors who perform corrective action services after August 1, 1992, must register with the Petrofund board. Reimbursement for corrective action services performed by an unregistered consultant or contractor is subject to reduction. Petrofund Registration Number. If you do not know a particular person s or firm s registration number, call the Petrofund at or Page 4 of 7

5 CERTIFICATION PAGE For this applicant category... Individual Sole proprietorship Partnership Municipality or State, federal, or other public agency Corporation...the application must be signed by: The applicant The proprietor A general partner (1) A principal executive officer or ranking elected official, or (2) The duly authorized representative or agent of the principal executive officer if the representative or agent is responsible for the overall operation of the facility that is the subject of the application. (1) A principal executive officer of at least the level of vice-president, or (2) The duly authorized representative or agent of the executive officer if the representative or agent is responsible for the overall operation of the facility that is the subject of the application, or (3) A person whom the board of directors designates by a corporate resolution. Consultant Signature. The application must be signed by a representative of each consulting firm that performed work included on invoices submitted with this application. Application Preparer s Signature. You should sign this section if you filled out the application. Otherwise, it should be signed by the person who prepared the application for you. Note: The certification page submitted with your application must contain original signatures. Photocopies will not be accepted. Page 5 of 7

6 ATTACHMENTS As the forms indicate, you do not need to submit all the attachments with your application. Please submit only those that are applicable. Reimbursement rate. Generally, applicants may receive reimbursement for up to 90 percent of the total reimbursable costs incurred at the site, but a different reimbursement rate applies in some circumstances. Consult the following chart to determine whether you qualify for a higher rate of reimbursement. If more than one rate applies, use the higher rate to calculate your reimbursement request. If the following applies to you for this site... You did not own or operate the tank(s) or own the property, but took the corrective action in response to a request or order of the Minnesota Pollution Control Agency You are requesting reimbursement for costs associated with corrective action at a bulk plant located on what is or was railroad right-of-way, and more than one bulk plant was operated on the same section of right-of-way (see the Railroad Right-of-Way Bulk Plant attachment) You are requesting reimbursement for costs associated with a release from a tank in transport (see the Tank in Transport Release attachment) You submitted a previous application prior to June 30, 2001, and received reimbursement for costs associated with corrective actions performed at a residential site used as a permanent residence at the time the release was discovered You submitted a previous application prior to June 30, 2001, and received reimbursement as a small gasoline retailer who dispensed less than 250,000 gallons of motor fuel to the public during the most recent calendar year that petroleum products were dispensed at the location You submitted a previous application prior to June 30, 2001, and received reimbursement for 100 percent of the cumulative total reimbursable costs in excess of $250,000 for all sites in which you had an interest...calculate at this rate of reimbursement 100 percent 90 percent of the total reimbursable costs on the first $40,000 of reimbursable costs 100 percent of any remaining reimbursable costs 90 percent of costs over $10, percent if you most recently received reimbursement at that rate 100 percent if you most recently received reimbursement at that rate 95 percent 100 percent Page 6 of 7

7 Not more than $1,000,000 may be reimbursed for costs associated with a single release, regardless of the number of persons eligible for reimbursement, and not more than $2,000,000 may be reimbursed for costs associated with a single tank facility. Agricultural Storage Tank Removal attachment Railroad Right-of-Way Bulk Plant attachment If you submitted these attachments and supporting documentation with a previous application, then you do not need to submit them again. This document is available in alternative formats to individuals with disabilities by calling , or (TTY). Page 7 of 7

8 DO NOT STAPLE OR BIND APPLICATION MATERIALS CLIP OR RUBBER BAND ONLY OFFICE USE ONLY LEAK # PHASE ENTERED MINNESOTA PETROLEUM TANK RELEASE COMPENSATION BOARD APPLICATION FOR REIMBURSEMENT This document is available in alternative formats to individuals with disabilities by calling , or (TTY). I. APPLICANT INFORMATION Name Mailing Address City State Zip Address Contact Person (if different from above Name") Day Phone Ext Fax Check One Responsible Person [list dates applicant owned or operated tank(s): / / to / / ] Volunteer (list dates applicant owned property: / / to / / ) Other (see Application Guide) Check One Corporation Partnership Individual Sole Proprietorship Municipality State, federal, or other public agency II. LEAK SITE INFORMATION MPCA Leak Number MPCA Project Manager Tank Facility Name Address City MN Zip Day Phone Ext / / Date petroleum leak detected / / Date petroleum leak reported to the MPCA cubic yards Total amount of contaminated soil excavated at this site III. MULTIPARTY CHECK REQUEST (if applicable) If you have requested the issuance of a multiparty check for this application, attach the original request form(s) and list each associated lender, contractor, and consultant below. This application is effective JULY 1, 2011 JUNE 30, 2012 PAGE 1 OF 7

9 IV. CHRONOLOGY Please provide a chronological description (including dates) of the clean-up activities covered on this application (attach additional sheets if necessary). For each drilling or sampling event, list the date and number of borings and wells installed or sampled. V. SOURCE AND CAUSE What was the source and cause of the petroleum release at this site? (see Application Guide) How was the release discovered? If the release was not reported to the MPCA within 24 hours of discovery, state the reason why. To the best of your knowledge, list all persons other than the applicant who were owners or operators of the tank during or after the petroleum release. Yes No Did any of the persons listed above incur corrective action costs related to this petroleum release? If yes, list name(s) and address(es) if known. VI. COMPETITIVE BIDDING List all of the written bids and proposals that you obtained for corrective action services at this site (attach additional sheets if necessary). Attach the originals (not copies) of all signed and dated bids and proposals. Bidder Amount Name Selected* of Bid Consultants Contractors *If the lowest bid or proposal was not selected, explain that decision on a separate sheet. Date of Bid Task PAGE 2 OF 7

10 VII. Yes MPCA TANK INFORMATION AND COMPLIANCE No Have you submitted an underground storage tank audit? Underground Storage Tanks Enter the requested information for (a) all underground petroleum storage tanks and piping that were in place at this site at the time the release occurred, and (b) all underground petroleum storage tanks that have been installed at this site since the release occurred (attach additional sheets if necessary). Refer to the MPCA documents Do Underground Storage Tank and Piping Requirements Apply to Your Petroleum Tank?" and What Do You Have to Do?/When Do You Have to Act? to determine the applicability of leak detection, corrosion protection, and spill/overfill protection requirements. If you are unsure how tank rules apply to your tanks, please call the UST Compliance and Assistance Unit at (651) and tell the receptionist that you have questions about this form. Tank # Petroleum Product Capacity Tank Material Date Installed Date Removed (if applicable) Tank # Tank Leak Detection (select method below) Leak detection method (select all that apply) 1. None 2. Inventory control plus annual tightness testing 3. Inventory control plus tightness testing every 5 years 4. Manual tank gauging 5. Manual tank gauging plus annual tightness testing 6. Manual tank gauging plus tightness testing every 5 years 7. Statistical inventory reconciliation (SIR) 8. Automatic tank gauging 9. Interstitial monitoring 10. Vapor monitoring 11. Ground water monitoring 12. Other (specify) Tank Corrosion Protection (select method below) Spill Bucket (Yes/No) Corrosion protection method 1. None 2. Fiberglass, jacketed steel or composite tank 3. STI-P 3 tank 4. Anodes installed 5. Impressed current system 6. Lined tank 7. Other (specify): Overfill Protection (select method below) Overfill protection method 1. None 2. Ball float valve 3. Automatic shutoff 4. Audible alarm 5. Other (specify): If tank tightness tests were performed, indicate dates of all tests. PAGE 3 OF 7

11 Tank # Continuous Leak Detection (select method below) Continuous method 1. None 2. Automatic flow restrictor 3. Automatic shutoff device 4. Continuous alarm Piping Leak Detection (fill out the section applicable to your piping) Pressurized Piping Suction Piping Check valve located at: Periodic Leak Detection Tank Pump (select method below) (select method below) Periodic method 1. None 2. Annual tightness test 3. Statistical inventory reconciliation (SIR) 4. Electronic line leak detector 5. Interstitial monitoring 6. Groundwater monitoring Suction leak detection method 1. None 2. Tightness test every 3 years 3. Statistical inventory reconciliation (SIR) 4. Interstitial monitoring 5. Vapor monitoring 6. Groundwater monitoring Piping Corrosion Protection (select method below) Corrosion protection method 1. None 2. Steel with anodes 3. Coated steel with anodes 4. Impressed current 5. Fiberglass or flexible piping If piping tightness tests were performed, indicate dates of all tests. Identify MPCA-certified tank removal contractor who performed tank excavation # Tank removal contractor s MPCA certification number Aboveground Storage Tanks Enter the requested information for (a) all aboveground petroleum storage tanks that were in place at this site at the time the release was discovered, and (b) all aboveground petroleum storage tanks that have been installed at this site since the release was discovered (attach additional sheets if necessary). In describing your secondary containment, specify: the materials used to construct both the base and the walls, including the type and thickness of materials (e.g., 6" compacted clay; 30 mil HDPE; reinforced concrete slab floor/concrete block walls; none) how the material specifications are known (e.g., permeability tests/dates, installation specifications) whether the volume of the secondary containment area is adequate for the contents of the largest tank Tank # Contents Capacity Date Installed Date Removed Description of Secondary Containment Walls Base Verification Volume (Yes/No) PAGE 4 OF 7

12 VIII. ELIGIBLE COSTS / / to / / Dates of work covered by invoices submitted with this application Yes No Are any of the costs included in this application in dispute? If so, describe the disputed issue(s) on a separate sheet. Yes No Are any of the costs included with this application subject to bankruptcy proceedings? If so, please describe the nature of the proceedings on a separate sheet. Yes No Has the applicant filed a lawsuit or made a claim against any third party for costs for which the applicant is seeking reimbursement or for any costs associated with this release? If so, attach a separate sheet identifying all third parties and provide copies of all correspondence between the applicant and third parties. Yes No Is the applicant aware of any action the applicant committed or of any action committed by a consultant or contractor which may have caused or aggravated the contamination at this site? If so, please explain. Yes No Are ongoing corrective action costs expected at this site? If so, explain briefly below. Type of Work Approximate Cost $ $ $ Attach a copy of a site map that shows the former tank basin, the excavation area, and any on-site structures. If new tanks were installed, the map also should show their sizes and location(s). The site map should also identify the location of any soil borings and monitoring wells on the property. IX. INSURANCE A. Yes No Did the applicant have in effect one or more insurance policies at the time of the release? If No, skip to question D. If Yes, proceed to the next question. B. Yes No Was a claim filed for coverage of any of the costs for which the applicant is seeking reimbursement in this application? If Yes, skip to question C. If No, please explain why no claim was filed. (Skip to question D.) C. Yes No Did the insurer agree to cover your claim? If Yes : State the amount of benefits received (or to be received). $ Provide a copy of the insurance policy and the insurer s explanation of benefits. If No : Provide a copy of the insurance policy and the insurer s letter explaining the reasons for denying your claim. D. Yes No Is the applicant aware of any other insurance policy, whether held by the applicant or another person, that could cover any of the eligible costs in this application? If so, please explain. PAGE 5 OF 7

13 X. CONSULTANTS/CONTRACTORS Complete the following for ALL contractors, subcontractors, consultants, engineering firms, or others who performed corrective actions at this site and whose work is covered by invoices included in this application (see Application Guide). Landfarm/Compost Site or Thermal Treatment Facility # Petrofund Registration Number County Name of individual or firm Mailing Address City State Zip Contact Person Phone Consultants/Contractors (ATTACH ADDITIONAL PAGES IF NECESSARY) Address # Petrofund Registration Number Name of individual or firm Mailing Address City State Zip Contact Person Phone Address # Petrofund Registration Number Name of individual or firm Mailing Address City State Zip Contact Person Phone Address # Petrofund Registration Number Name of individual or firm Mailing Address City State Zip Contact Person Phone Address # Petrofund Registration Number Name of individual or firm Mailing Address City State Zip Contact Person Phone Address XI. ATTACHMENTS The following attachments are included with this application (see Application Guide): Either A, B, or C must be included. Check any that apply. Attachment A Standardized Invoice Summary (current rules) Agricultural Storage Tank Removal attachment Attachment B Standardized Invoice Summary (former rules) Railroad Right-of-Way Bulk Plant attachment Attachment C Itemized Cost Worksheet (pre-10/6/95 rules) Tank in Transport Release attachment PAGE 6 OF 7

14 XII. CERTIFICATION PAGE* (see Application Guide) APPLICANT SIGNATURE and NOTARIZATION (SIGNATURE AND NOTARIZATION REQUIRED) If information contained in this application changes in any material way after this application is submitted to the Petrofund, I will immediately notify the Petrofund in writing of those changes. I understand that the information used to support this application is subject to audit by the Minnesota Pollution Control Agency and the Minnesota Department of Commerce. I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I certify that if I have submitted invoices for costs that I have incurred but that remain unpaid, I will pay those invoices within 30 days of receipt of reimbursement from the board. I understand that if I fail to do so, the board may demand return of all or a part of reimbursement paid to me and that if I fail to comply with the board's demand, that the board may recover the reimbursement, plus administrative and legal expenses in a civil action in district court. I understand that I may also be subject to a civil penalty. I further certify that I am authorized to sign and submit this application on behalf of Corporation / Partnership / Municipality / Public Agency Signature NOTARIZATION Subscribed and sworn to before me this day Name (print/type) of, 20. Title Date Signed Notary Public [Stamp] My commission expires CONSULTANT SIGNATURE (SIGNATURE REQUIRED) I,, confirm that all costs claimed by as a part of this (Individual name) (Consultant company) application are a true and accurate account of services performed. I further confirm that no costs included in this application that were invoiced by my consulting company are ineligible as listed in Minnesota Rules, Chapter / Consultant Signature Title Date Duplicate this section if more than one consultant signature is required. APPLICATION PREPARER S SIGNATURE (SIGNATURE REQUIRED) (Preparer s name) / Preparer s Signature Title Date *NOTE: SUBMIT CERTIFICATION PAGE CONTAINING ORIGINAL SIGNATURES. Please send this application and accompanying documents to: MINNESOTA DEPARTMENT OF COMMERCE PETROFUND 85 SEVENTH PLACE EAST, SUITE 500 ST. PAUL, MN OR This application is effective JULY 1, 2011 JUNE 30, 2012 PAGE 7 OF 7

15 AN IMPORTANT NOTICE REGARDING INTEREST COSTS The 2002 Minnesota Legislature added a provision to Minn. Stat. 115C that allows some applicants, if certain conditions are met, to receive partial reimbursement of up to 180 days of interest costs associated with the financing of corrective action. If you qualify, you may receive reimbursement of interest costs only when all of the following are true: You incurred interest costs in a written extension of credit or loan from a financial institution. (Interest charged by consultants or contractors is not eligible for reimbursement because they do not qualify as financial institutions as defined by law.) You signed and executed the written extension of credit or loan from a financial institution after July 1, Your complete application for reimbursement was not considered within 60 days (if it is an initial application) or within 120 days (if it is a supplemental application). Two important notes: 1. The 60- and 120-day deadlines are measured from the time that your complete application is received by the Department of Commerce. An application is complete when the information reasonably required or requested from you by the Petrofund staff has been received by the Petrofund staff. 2. Considered does not mean paid. Your complete application has been considered when a Petrofund analyst has reviewed it and notified you of a reimbursement determination. The law also provides that interest costs meeting the requirements above are eligible only when they are incurred between the date that a complete application is received by the Department of Commerce and the date that the Petrofund staff first notifies you of its reimbursement determination. In addition, interest costs are not eligible for reimbursement to the extent they exceed two percentage points above the adjusted prime rate charged by banks, as defined in Minn. Stat , subd. 5, at the time the extension of credit or loan was executed. If you believe that you would qualify for reimbursement of interest costs, please include a copy of your executed extension of credit or loan from a financial institution in your reimbursement application. If you do qualify to receive reimbursement of interest costs, and if your complete application for reimbursement is not considered within the required time frame, Petrofund staff will calculate the amount of reimbursement for interest costs that you are eligible to receive, and the additional amount will be included in your reimbursement check.

16 ATTACHMENTS A, B, AND C How to determine which you should use Significant changes to the rules that govern Petrofund reimbursement took effect on October 6, These changes apply to costs incurred on or after that date with the exceptions noted below. Use Attachment A to request reimbursement for costs incurred on or after October 6, 2003, that are not covered by either of the exceptions. Exception #1: 1995 steps The changes to the rules do not apply to costs incurred for work performed as part of one of the steps of consultant services listed on Attachment B if you began incurring costs for that step before October 6, (These steps will be referred to here as 1995 steps. ) Use Attachment B to request reimbursement for these costs. No 1995 steps could begin after October 5, As of October 6, 2003, once a 1995 step ends, costs for any additional work performed are subject to the changes to the rules. Exception #2: Pre-10/6/95 contracts The changes to the rules do not apply to costs incurred for work performed at any time up to the leak reporting date in 2004 as part of a contract entered into before October 6, Leak reporting date means the month and day that the leak was reported to the state. Use Attachment C to request reimbursement for these costs. As of January 1, 2004, costs for any work performed on or after the anniversary of the leak reporting date are subject to the changes to the rules.

17 ATTACHMENT A STANDARDIZED INVOICE SUMMARY (CURRENT RULES) Please use this attachment for costs you are submitting for reimbursement that are subject to the current rules. For each standardized invoice form you are submitting with this application, enter the total invoice amount on the corresponding line in the box below. Add the numbers on each line, subtract the amount of insurance reimbursement you have received, and multiply the resulting total by the appropriate reimbursement rate. COST SUMMARY Tank in Transport Release: Use Tank in Transport Release Attachment Excavation and Soil Disposal Oversight Before Investigation... $ Limited Site Investigation or Full Remedial Investigation... $ Active Remediation initial field testing... $ Active Remediation site-specific system design... $ Active Remediation system installation, start-up, and operation & maintenance... $ Active Remediation system decommissioning... $ Contractor Services... $ Agricultural Tank Removal... $ Permits, utilities, and public safety access fees (invoiced directly to the applicant)... $ Emergency response costs... $ TOTAL ELIGIBLE COSTS... $ Insurance Reimbursement (subtract) $( ) = $ x 90%* TOTAL REIMBURSEMENT REQUEST = $ * If a different reimbursement rate applies, calculate at that rate. See Application Guide.

18 ATTACHMENT B STANDARDIZED INVOICE SUMMARY (FORMER RULES) Please use this attachment for any costs you are submitting for reimbursement that are (1) not subject to the current rules, and (2) associated with work that was performed under a contract you entered into after October 5, For each standardized invoice form you are submitting with this application, enter the Grand Total from the Actual Invoice Amount column on the corresponding line in the box below. Add the numbers on each line, subtract the amount of insurance reimbursement you have received, and multiply the resulting total by the appropriate reimbursement rate. STANDARDIZED INVOICE SUMMARY Tank in Transport Release: Use Tank in Transport Release Attachment Underground Storage Tank Removal Assessment... $ Initial Site Assessment... $ Additional Site Assessment... $ Remedial Investigation / Corrective Action Design Report... $ Remedial Design / Maintenance... $ Contractor Services... $ Agricultural Tank Removal... $ Permits, utilities, and public safety access fees (invoiced directly to the applicant)... $ Emergency response costs... $ TOTAL ELIGIBLE COSTS... $ Insurance Reimbursement (subtract) $( ) = $ x 90%* TOTAL REIMBURSEMENT REQUEST = $ * If a different reimbursement rate applies, calculate at that rate. See Application Guide.

19 ATTACHMENT C ITEMIZED COST WORKSHEETS (PRE-10/6/95 RULES) Please use this attachment for any costs you are submitting for reimbursement that are (1) not subject to the current rules, and (2) associated with work that was performed under a contract you entered into on or before October 5, Enter the total of each itemized cost worksheet on the corresponding line in the box below. Add the numbers on each line, subtract the amount of insurance reimbursement you have received, and multiply the resulting total by the appropriate reimbursement rate. ITEMIZED COST WORKSHEET SUMMARY A $ B $ C $ D $ E $ F $ G $ H $ I $ J $ K $ TOTAL ELIGIBLE COSTS... $ Insurance Reimbursement (subtract) $( ) = $ x 90%* TOTAL REIMBURSEMENT REQUEST = $ * If a different reimbursement rate applies, calculate at that rate. See Application Guide. Please note the following before completing the itemized cost worksheets: Invoices must be submitted for each cost listed on the itemized cost worksheets. In the Description column, enter a word or phrase that specifically describes the work performed. Employee titles alone will not suffice.

20 A. SOIL BORINGS/MONITORING WELLS Specific Task Description Firm Name Invoice Number or Date Total Units Unit Costs Subtotal Total B. LABORATORY TESTS AND ANALYSIS Specific Task Description Firm Name Invoice Number or Date Total Units Unit Costs Subtotal Total C. EXCAVATION Specific Task Description Firm Name Invoice Number or Date Total Units Unit Costs Subtotal Total D. SOIL DISPOSAL Specific Task Description Firm Name Invoice Number or Date Total Units Unit Costs Subtotal Total

21 E. WATER TREATMENT Specific Task Description Firm Name Invoice Number or Date Total Units Unit Costs Subtotal Total F. TRUCKING Specific Task Description Firm Name Invoice Number or Date Total Units Unit Costs Subtotal Total G. EMERGENCY and TEMPORARY HAZARD CONTROL Specific Task Description Firm Name Invoice Number or Date Total Units Unit Costs Subtotal Total H. SITE RESTORATION and CLOSURE Specific Task Description Firm Name Invoice Number or Date Total Units Unit Costs Subtotal Total

22 I. OTHER CLEAN-UP COSTS Specific Task Description Firm Name Invoice Number or Date Total Units Unit Costs Subtotal Total J. REPORT PREPARATION; DATA COLLECTION; OPERATION OVERSIGHT AND MAINTENANCE; SYSTEM MONITORING; CORRESPONDENCE; MILEAGE; POSTAGE; PER DIEM Specific Task Description Firm Name Invoice Number or Date Total Units Unit Costs Subtotal Total K. MARK-UP Specific Task Description Firm Name Invoice Number or Date Total Units Unit Costs Subtotal Total

23 Agricultural Storage Tank Removal attachment The 2000 Minnesota Legislature, under Minn. Stat. 115C, added a provision that allows reimbursement of up to $7,500 per tank for the costs associated with removing an underground agricultural petroleum storage tank. This form will help you to determine whether you are eligible for additional reimbursement. Please read each question and check Yes or No for each tank that you own (attach additional sheets if necessary). Tank 1 Tank 2 Tank 3 Did this underground petroleum storage tank have a capacity of more than 1,100 gallons? Was the underground petroleum storage tank registered with the Minnesota Pollution Control Agency by January 1, 2000? Was the underground petroleum storage tank located on a farm at which the contents of the tank were used by the tank owner or operator predominantly for farming purposes and not commercially distributed? Was the underground petroleum storage tank removed prior to January 1, 2001? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No You may apply for up to 90% reimbursement of the eligible costs (with a maximum of $7,500 per tank) associated with each tank for which you were able to answer Yes to all four questions above. Please submit this form and a site map with your reimbursement application if you are applying for reimbursement of costs associated with removing an agricultural storage tank.

24 Railroad Right-of-Way Bulk Plant attachment The 2001 Minnesota Legislature added a provision [Minn. Stat. 115C.09, subd. 3h (c)] that allows a higher reimbursement rate for a portion of the costs associated with corrective action at a bulk plant located on what is or was railroad right-of-way. This form will help you to determine whether you are eligible for the higher rate. Please read each question and check Yes or No. Are the costs for which you are requesting reimbursement associated with corrective action at a bulk plant located on what is or was railroad right-of-way? Yes No Was more than one bulk plant operated on the same section of right-of-way? Yes No To apply for reimbursement of 90% of the total reimbursable costs on the first $40,000 of reimbursable costs and 100% of any remaining reimbursable costs, you must have responded Yes to both questions above. In addition, you should submit the following documents with your application: This form; A copy of your lease agreement with the railroad; and A site map that shows the applicable section of right-of-way and the locations of all bulk plants that are or were located on the same section of right-of-way.

25 Tank in Transport Release attachment The 2003 Minnesota Legislature amended Minn. Statute 115C to allow for partial reimbursement of costs associated with a release from a tank in transport. This form will help you to document your eligibility to receive this reimbursement. TANK INFORMATION Enter the requested information for each tank in transport involved in the release. Type of Tank Petroleum Product Capacity REIMBURSEMENT REQUEST CALCULATION Fill out Worksheet A if this is your first application for reimbursement of costs associated with this release. Otherwise, fill out Worksheet B. Worksheet A Costs associated with release... $ Deductible (subtract) $ 10, = $ x 90% Worksheet B Costs associated with release that were not previously claimed... $ x 90% TOTAL REIMBURSEMENT REQUEST = $ TOTAL REIMBURSEMENT REQUEST = $ By law, reimbursement for costs associated with a release from a tank in transport is limited to $100,000.