Form Un 049 PDF Details

In the State of California, ensuring the financial capacity to manage potential risks and liabilities associated with underground storage tanks (USTs) containing petroleum is a critical concern for owners and operators. The Certification of Financial Responsibility for Underground Storage Tanks, known as the UN-049 form, serves as a vital tool in this process. Mandated by the State Water Resources Control Board's Division of Financial Assistance, this certification requires tank owners and operators to demonstrate their ability to cover cleanup costs and compensate third parties in the event of a petroleum release. The form outlines specific coverage amounts, ranging from half a million to two million dollars, based on per occurrence and annual aggregate figures. Moreover, it details various mechanisms approved for demonstrating financial responsibility, including insurance policies, letters of credit, and participation in the State UST Cleanup Fund. Importantly, the form facilitates comprehensive reporting, allowing multiple UST sites to be listed under a single certification. This streamlined approach, combined with stringent compliance requirements, underscores California's commitment to environmental protection and public safety in the management of petroleum underground storage tanks.

QuestionAnswer
Form NameForm Un 049
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesIssuer, unidocs, UN-049, find certificate of financial responsibilty form

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State of California

State Water Resources Control Board

Division of Financial Assistance

P.O. Box 944212

Sacramento, CA 94244-2120

For State Use Only

CERTIFICATION OF FINANCIAL RESPONSIBILITY

FOR UNDERGROUND STORAGE TANKS CONTAINING PETROLEUM

A. I am required to demonstrate Financial Responsibility in the required amounts as specified in CCR, Title 23 Division 3, Chapter 18, Section 2807:

500,000 dollars per occurrence

AND

1 million dollars annual aggregate

or

or

1 million dollars per occurrence

 

2 million dollars annual aggregate

B.

 

 

hereby certifies that it is in compliance with the requirements of California Code of

 

 

Regulations, Title 23, Division 3, Chapter 18, Article 3, Section 2807.

 

 

 

 

 

(Name of tank Owner or Operator)

 

The mechanisms used to demonstrate financial responsibility as required by Section 2807 are as follows:

C.Mechanism Type

Name and Address of Issuer

Mechanism

Number

Coverage

Amount

Coverage

Period

Corrective

Action

Third Party

Compensation

Note: If you are using the State Fund as any part of your demonstration of financial responsibility, your execution and submission of this certification also certifies that you are in compliance and shall remain in compliance with all conditions for participation in the Fund.

D. Facility Name

Facility Name

Facility Name

Facility Name

Facility Name

Facility Name

Facility Name

Facility Address

Facility Address

Facility Address

Facility Address

Facility Address

Facility Address

Facility Address

E. Signature of Tank Owner or Operator

Date

Name and Title of Tank Owner or Operator

Signature of Witness or Notary

Date

Name of Witness or Notary

Submit original to local UST regulatory agency. Keep a copy at each UST facility.

(Instructions on Next Page)

UN-049 - 1/2

www.unidocs.org

Rev. 10/16/06

INSTRUCTIONS FOR CERTIFICATION OF FINANCIAL RESPONSIBILITY

Please type or print information clearly. All underground storage tank (UST) sites owned or operated may be listed on one form, therefore a separate certification is not required for each site. For questions regarding required coverage amounts or approved financial responsibility mechanisms, please refer to the State Water Resources Control Board’s publication, “Petroleum Underground Storage Tank Financial Responsibility Guide” or call the UST Cleanup Fund at (800) 813-3863.

A.Coverage Required Check one box on the left side of the form to indicate coverage per occurrence (i.e., $500,000 or $1,000,000) and one box on the right side of the form to indicate annual aggregate coverage (i.e., $1,000,000 or $2,000,000).

B.Name of Tank Owner Provide the full legal name of either the tank owner or the tank operator. or Operator

C.Mechanism Type Indicate which approved mechanism(s) are being used to show financial responsibility either as contained in the federal regulations (40 CFR, Part 280, Subpart H, Sections 280.93 through 280.107) or CCR, Title 23, , Division 3, Chapter 18, Section 2808.1.

Name of Issuer

List the names and addresses of companies and/or individuals issuing coverage. If you use

 

the State UST Cleanup Fund as a mechanism, use the following information:

 

d”

 

e UST Cleanup Fund, P.O. Box 944212, Sacramento, CA 94244-2120”.

Mechanism Number

List the identifying number for each mechanism used (e.g. insurance policy number, letter

 

of credit number, etc.). If using the State Cleanup Fund and/or a financial test of self-

 

insurance (e.g. CFO letter), enter “N/A”.

Coverage Amount

Indicate the per occurrence and annual aggregate coverage amount provided by each listed

 

mechanism. If more than one mechanism is indicated, aggregate coverage must equal

 

100% of required financial responsibility amounts.

Coverage Period

Indicate the effective date of each mechanism. State Cleanup Fund coverage is continuous

 

as long as you maintain compliance and remain eligible for participation.

Corrective Action

Does the specified mechanism provide coverage for corrective action? Indicate “Yes” or

 

“No”. If using the State Cleanup Fund, indicate “Yes.”

Third Party

Does the specified mechanism provide coverage for third party compensation? Indicate

Compensation

“Yes” or “No”. If using the State Cleanup Fund, indicate “Yes.”

D.Facility Information List the name and site address of each UST facility covered by this Certification.

E.

Signature Block

The tank owner or operator must sign and date the Certification. Print or type the owner or

 

 

operator’s name and title in the space provided. The owner or operator’s signature must be

 

 

witnessed. The witness or notary must sign and date the Certification. Print or type the

 

 

witness’ name in the space provided. Anybody may sign as witness; however, if a notary

 

 

signs, please attach documentation.

Send the original completed form to the local agency(ies) that issue the UST permit(s) for the listed site(s). Keep a copy of the certification at each UST site. Local agency contact information is available at: www.calcupa.net/cupacontactlist.xls.

If you have questions about financial responsibility requirements or about the Certification of Financial Responsibility form, please contact the State Water Resources Control Board, Underground Storage Tank Cleanup Fund at 1-800-813-FUND (3863) or refer to www.waterboards.ca.gov/cwphome/ustcf/howtocontactus.htm.

Νοτε: Per Health and Safety Code §25299.76(a), failure comply with UST Financial Responsibility requirements can result in civil penalties of up to $10,000 per day, per UST, for each day of violation. Eligibility for reimbursement of claims submitted to the State Cleanup Fund may also be jeopardized.

UN-049 - 2/2

www.unidocs.org

Rev. 10/16/06

How to Edit Form Un 049 Online for Free

This PDF editor allows you to create the ies file. It will be easy to create the file efficiently by using these simple actions.

Step 1: This page contains an orange button saying "Get Form Now". Click it.

Step 2: The moment you access our ies editing page, there'll be each of the actions you can take regarding your form in the upper menu.

You have to provide the following information if you would like prepare the document:

portion of fields in calcupa

Complete the Note, If you are using the State Fund as, D Facility Name, Facility Name, Facility Name, Facility Name, Facility Name, Facility Name, Facility Address, Facility Address, Facility Address, Facility Address, Facility Address, and Facility Address section with all the details asked by the software.

Filling out calcupa part 2

Outline the essential information in the Facility Name, Facility Name, Facility Address, Facility Address, E Signature of Tank Owner or, Signature of Witness or Notary, Date, Date, Name and Title of Tank Owner or, Name of Witness or Notary, Submit original to local UST, Instructions on Next Page, wwwunidocsorg, and Rev area.

Filling out calcupa stage 3

Step 3: Choose "Done". It's now possible to export your PDF file.

Step 4: To prevent yourself from any sort of headaches in the long run, be sure to generate no less than several copies of your file.

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