Department of Natural Resources and Environmental Control
Tank Management Section
1351 Underground Storage Tank Systems
The undersigned, as principals and as legal representatives of [Owner or Operator] and [insert name and address of third-party claimant] hereby certify that the claim of Bodily Injury [and/or] Property Damage caused by an Accidental Release arising from operating [Owner or Operator] Underground Storage Tank System should be paid in the amount of $[ ______________ ].
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[Signature of Owner or Operator]
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[Signature of Attorney for Owner or Operator]
(Notary)________________ Date ________
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