U nderground

S torage

T ank

I ndemnification

F und

 USTIF Logo

Commonwealth of Pennsylvania

Insurance Department

Underground Storage Tank

Indemnification Fund

901 North 7th Street

Harrisburg, PA 17102-1414

Telephone: (717) 787-0763

FAX: (717) 705-0140

APPLICATION

 

 


Tank Owner/Operator Name
Facility Name

DEP Owner/Operator # If Known
DEP Facility ID # If Known

Address
Address

City, State, Zip
City, State, Zip

County
County

Phone Number
Phone Number
Type of Facility:
(Church, School, Fire Station, etc...)
Tax ID #

PLEASE ATTACH:

    
  • A COPY OF A TANK TIGHTNESS TEST - Done within the past 30 days
    •     
  • $50 DEPOSIT FEE - which will be returned if coverage is rejected.
    •     
  • IF ACCEPTED, coverage will be effective on the date the completed application is received by the Fund.

    • UNDERGROUND HEATING OIL STORAGE TANK INFORMATION

    Tank

    Date
    Installed

    Size
    (Gallons)

    Construction
    Material

    Type of
    Product
    Stored

    (1) CONSTRUCTION MATERIAL
    DW   =  Double-Walled/Secondary Containment F         =  Single-Wall Fiberglass
    F/S    =  Fiberglass/Steel Composite S         =  Coated or Bare Steel
    STI    =  STI-P3 CP/S   =  Cathodically Protected Steel

     

    1.    List date and results of all previous tank tightness tests on this heating oil tank.
          
          
    2.    Have you, during the past five years, had any reportable releases or spills of heating oil from this tank?
           If yes, provide details, if no, so indicate.
          
          
    3.    Is there any history of leaks or releases from this tank at this facility not stated above?
           If yes, provide details, if no, so indicate.
          
          
    4.    At the time of the signing of this application, do you know of any facts or circumstances which may reasonably be expected to result
           in a claim or claims being asserted against your company for environmental cleanup or response, or release of pollutants into the
           environment from this tank?
           If yes, provide details, if no, so indicate.
          
          
     
     
    Completion of this form does not bind coverage. Applicant's acceptance by theFund is required prior to binding coverage.

    FOR FUND USE ONLY

    		  
     
    ACCEPTED BY FUND:

    DATE

    SIGNATURE

     
    OWNER/OPERATOR # FACILITY ID#    
    APPLICANT

    Signature of Owner

    Print Name

    Contact Person & Phone #

    Date