Form Un 049 PDF Details

Form Un 049 is an IRS form that businesses use to request a tax exemption for their products. The form is used to document the business's history, products, and sales data. Filling out Form Un 049 can be complicated, so it's important to consult with an accountant or tax specialist before submitting the form. Thankfully, there are many online resources available that can help you understand what information is required on Form Un 049. By taking the time to research and complete the form correctly, you can save yourself from potential penalties and taxes down the road.

This information will allow you to grasp better the details of the form un 049 before you start filling it out.

Form NameForm Un 049
Form Length2 pages
Fillable fields46
Avg. time to fill out9 min 46 sec
Other namesCFR, selfinsurance, CFO, unidocs

Form Preview Example

State of California

State Water Resources Control Board

Division of Financial Assistance

P.O. Box 944212

Sacramento, CA 94244-2120

For State Use Only



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


1 million dollars annual aggregate



1 million dollars per occurrence


2 million dollars annual aggregate




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









Third Party


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


Name and Title of Tank Owner or Operator

Signature of Witness or Notary


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

Rev. 10/16/06


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:




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


“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.


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:

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

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

Rev. 10/16/06

How to Edit Form Un 049 Online for Free

This PDF editor allows you to create the certificate of financial responsibility cers 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 certificate of financial responsibility cers 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 UN-049

Complete the Note, Facility, Name Facility, Name Facility, Name Facility, Name Facility, Name Facility, Name Facility, Address Facility, Address Facility, Address Facility, Address Facility, Address Facility, Address and Facility, Address section with all the details asked by the software.

Filling out UN-049 part 2

Outline the essential information in the Signature, of, Witness, or, Notary Date, Date, Name, and, Title, of, Tank, Owner, or, Operator Name, of, Witness, or, Notary Instructions, on, Next, Page www, uni, docs, org and Rev area.

Filling out UN-049 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.

Watch Form Un 049 Video Instruction

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .