Request for UST Removal Reimbursement

1
Colorado Department of Labor and Employment
Division of Oil and Public Safety – Petroleum Storage Tank Fund
633 17th Street, Suite 500, Denver, CO 80202-3610
Phone: 303-318-8525
Fax: 303-318-8488
Email: cdle_pstreimbursementapps@state.co.us
Web: www.ops.colorado.gov

__________________________________________________________________________

This form should be used when an applicant is applying for reimbursement for UST removal in accordance with PSTC Policy 29. Cost should not exceed $1 per gallon of UST volume removed, up to a maximum of $30,000 per facility.
Conditions of UST Removal Reimbursement are as follows:
• The Division of Oil & Public Safety (OPS) will determine the total UST volume removed based on the tank registration or other records.
• UST(s) must have been installed prior to August 2008
• Reimbursement is only available to owners or operators of active UST systems, and property owners with abandoned or orphaned tanks, who are eligible to participate in the Fund.
• Applications for UST Removal reimbursement must be submitted within 90 days of tank closure.

Document Information
• The applicant must be in compliance with permanent tank closure requirements, including notification and assessment.
2
Applicant Information

Any information provided in the application and W-9 should match IRS records. If unsure, request a 147C from the IRS. The W-9 must be state-approved. You may request a blank W-9 by clicking here. For more information, you can see the Guidance for UST Removal Reimbursement Application here.
3
Applicant Name* This field is required.This is the name of the owner or operator of active UST systems or property owners with abandoned or orphaned tanks. The Applicant can be a sole proprietor or individual, a corporation, a partnership, or a Limited Liability Company.
4
Account Name* This field is required.Account Name replaces the "Owner ID". This is the number established by OPS at either registration or when OPS became aware that an owner has Fund eligible tanks. (IE: ACCT-00123). It can be found in COSTIS-IA. The website can be accessed by clicking here. On the website, you can use the search box by using any known information, i.e. Facility Name, Facility ID, etc. Open the facility and hover over/ click on Facility Owner to find the information.
ACCT-
5
Applicant Contact Name* This field is required.This is the name of the owner or operator of active UST systems or property owners with abandoned or orphaned tanks. The Applicant can be a sole proprietor or individual, a corporation, partnership, or a Limited Liability Company.
The is an individual associated with facility or tank ownership.
6
Applicant Contact Email* This field is required.This is the method of communication for Acknowledgement and Deficiency Letters and the Incentive Payment Report. This is usually the owner/applicant contact who is knowledgeable with or accountable for the application.
This is the applicant contact who is knowledgeable with or accountable for the application.
7
Applicant Contact Phone Number* This field is required.
Please enter a valid phone number.
8
Applicant Representative NameIf applicable, this is the individual who represents the interests of the applicant. In some instances, they actually assemble and complete the application. A Representative can be a Consultant or Contractor, someone other than the applicant.
9
Applicant Representative Company NameIf applicable, this is the company of the individual who represents the interests of the applicant.
10
Applicant Representative EmailIf applicable, this is the email address of the individual who represents the interests of the applicant.
example@example.com
11
Applicant Representative Phone Number
Please enter a valid phone number.
12
Applicant Mailing Address* This field is required.This is location where applicant’s business mail is received.
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Country
13
Facility Name* This field is required.This is the facility’s name as per OPS records.
14
Facility ID* This field is required.This is the facility number established by OPS at either registration or when OPS became aware that there is a facility with Fund eligible tanks. You can find the facility information in COSTIS-IA. The website can be accessed by clicking here. On the website, you can use the search box by using any known information, i.e. Facility Name, Facility ID, etc.
15
Facility Address* This field is required.This is the physical location where the Fund eligible tanks are located.
Street Address
Street Address 2
City
Please Select
Please Select
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State
Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
16
Tank Tag* This field is required.This information can be found in COSTIS-IA. The website can be accessed by clicking here. On the website, you can use the search box by using any known information, i.e. Facility Name, Facility ID, etc. The tank list will show up on the right-hand side, click view all and then click on each tank, the Tank Tag will appear under the Facility ID. You can also see on this page installation and closure date.
17
Tank Capacity* This field is required.This information can be found in COSTIS-IA. The website can be accessed by clicking here. On the website, you can use the search box by using any known information, i.e. Facility Name, Facility ID, etc. The tank list will show up on the right-hand side, click on view all and the information will appear.
Gallons
18
Was the tank removed orphaned/abandoned?* This field is required.For more information about orphaned/abandoned tanks click here
YESNO
19
Installation Date* This field is required.Tanks installed after August 2008 are not eligible. This information can be found in COSTIS-IA. The website can be accessed by clicking here . On the website, you can use the search box by using any known information, i.e. Facility Name, Facility ID, etc. The tank list will show up on the right-hand side, click on view all to see the installation date. You can also click on each tank to see the installation and closure date
Tanks installed after August 2008 are not eligible
Month
Day
Year
20
Closure Name* This field is required.This information can be found in COSTIS-IA. The website can be accessed by clicking here. On the website, you can use the search box by using any known information, i.e. Facility Name, Facility ID, etc. The closure list will show up on the right-hand side, click on each closure and you will be able to see the Closure Name at the top.
Closure Name
21
Removal Date* This field is required.This information can be found in COSTIS-IA. The website can be accessed by clicking here. On the website, you can use the search box by using any known information, i.e. Facility Name, Facility ID, etc. The tank list will show up on the right-hand side, click on view all and use the Date of Closure here.
Tanks removed prior to 1/1/2019 are not eligible
Month
Day
Year
22
Do you want to add another tank?
Yes
No
23
Tank Tag
24
Tank Capacity
Gallons
25
Was the tank removed orphaned/abandoned?For more information about orphaned/abandoned tanks click here
YESNO
26
Installation DateTanks installed after August 2008 are not eligible
Tanks installed after August 2008 are not eligible
Month
Day
Year
27
Closure NameThis information can be found in COSTIS-IA. The website can be accessed by clicking here. On the website, you can use the search box by using any known information, i.e. Facility Name, Facility ID, etc. The closure list will show up on the right-hand side, click on each closure and you will be able to see the Closure Name at the top.
Closure Name
28
Removal Date
Tanks removed prior to 1/1/2019 are not eligible
Month
Day
Year
29
Do you want to add another tank?
Yes
No
30
Tank Tag
31
Tank Capacity
Gallons
32
Was the tank removed orphaned/abandoned?For more information about orphaned/abandoned tanks click here
YESNO
33
Installation DateTanks installed after August 2008 are not eligible
Tanks installed after August 2008 are not eligible
Month
Day
Year
34
Closure NameThis information can be found in COSTIS-IA. The website can be accessed by clicking here. On the website, you can use the search box by using any known information, i.e. Facility Name, Facility ID, etc. The closure list will show up on the right-hand side, click on each closure and you will be able to see the Closure Name at the top.
Closure Name
35
Removal Date
Tanks removed prior to 1/1/2019 are not eligible
Month
Day
Year
36
Do you want to add another tank?
Yes
No
37
Tank Tag
38
Tank Capacity
Gallons
39
Was the tank removed orphaned/abandoned?For more information about orphaned/abandoned tanks click here
YESNO
40
Installation DateTanks installed after August 2008 are not eligible
Tanks installed after August 2008 are not eligible
Month
Day
Year
41
Closure NameThis information can be found in COSTIS-IA. The website can be accessed by clicking here. On the website, you can use the search box by using any known information, i.e. Facility Name, Facility ID, etc. The closure list will show up on the right-hand side, click on each closure and you will be able to see the Closure Name at the top.
Closure Name
42
Removal Date
Tanks removed prior to 1/1/2019 are not eligible
Month
Day
Year
43
Invoice#* This field is required.This is the number on the tank removal invoice. This is important when there are several invoices or partial tank removal costs on several invoices. It helps identify and clarify invoices, creating an audit trail.
44
Vendor Name* This field is required.
45
Amount Paid* This field is required.This is the total dollar amount of the actual tank removal costs. If tank removal costs were $50,000. This is the amount to be entered in “Amount Paid”, regardless if only $30,000 is eligible because three 10,000-gallon tanks were removed. Conversely, if allowable tank removal costs were $25,000 and three 10,000-gallon tanks were removed. $25,000 is the amount to be entered in “Amount Paid”.
46
Invoice Date* This field is required.This is the date on the tank removal invoice. It helps as same as noted in Invoice #
Month
Day
Year
47
Would you like to add another invoice?
Yes
No
48
Invoice#
49
Vendor Name
50
Amount Paid
51
Invoice Date
Month
Day
Year
52
Would you like to add another invoice?
Yes
No
53
Invoice#
54
Vendor Name
55
Amount Paid
56
Invoice Date
Month
Day
Year
57
Would you like to add another invoice?
Yes
No
58
Invoice#
59
Vendor Name
60
Amount Paid
61
Invoice Date
Month
Day
Year
62
Would you like to add another invoice?
Yes
No
63
Invoice#
64
Vendor Name
65
Amount Paid
66
Invoice Date
Month
Day
Year
67
Would you like to add another invoice?
Yes
No
68
Invoice#
69
Vendor Name
70
Amount Paid
71
Invoice Date
Month
Day
Year
72
Printed Name* This field is required.
73
Title* This field is required.
74
Signatory authority* This field is required.The Applicant’s signer must be a proper signatory, legally binding themselves and/or the organization to the “Applicant Certification”. These signatory requirements are the same as completing an Original or Supplemental Reimbursement Application. In order to allow the consultant to attest on the applicant's behalf, a letter on the company's letterhead must be submitted with the application as an attachment and it must be signed by a proper signatory authority.
Clear
75
Date* This field is required.
Date
Month
Day
Year
76
Please make sure these documents are attached to this application* This field is required.Sending copies of the closure acknowledgement letter is not necessary. The Applicant’s compliance regarding the closure notice and assessment will be of record.
77
Back-Up Documentation

Acceptable forms of Proof of Payments are a copy of a canceled check (both sides); Proof of Electronic Funds Transfer from the financial institution; or fully executed Affidavit: Proof of Payment (found on the OPS website). OPS needs to be able to tie the payment to the tank removal costs, i.e. if tank removal costs are $26,000 which is part of a larger invoice of $58,000, the proof of payment could be for $58,000, with an audit trail depicting that the $26,000 being paid. For more information, you can see the Guidance for UST Removal Reimbursement Application here.
78
Upload* This field is required.
79
UploadUpload more files here if needed. Otherwise, click next.
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Colorado Department of Labor and EmploymentDivision of Oil and Public Safety – Petroleum Storage Tank Fund633 17th Street, Suite 500, Denver, CO 80202-3610Phone: 303-318-8525Fax: 303-318-8488Email: cdle_pstreimbursementapps@state.co.usWeb: www.ops.colorado.gov

__________________________________________________________________________

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Colorado Department of Labor and Employment
Division of Oil and Public Safety – Petroleum Storage Tank Fund
633 17th Street, Suite 500, Denver, CO 80202-3610
Phone: 303-318-8525
Fax: 303-318-8488
Email: cdle_pstreimbursementapps@state.co.us
Web: www.ops.colorado.gov