Draft UST RF Preapproval applicationstatic.azdeq.gov/forms/ust_preapproval_exp_app.pdf · 2020. 7....

ADEQ UNDERGROUND STORAGE TANK (UST) EXPEDITED PREAPPROVAL APPLICATION FORM

Expedited Preapproval Application – FAC ID:______________________________ 49-1051(K) Revised Feb 2021 Page 1

UST PROGRAM EXPEDITED PREAPPROVAL APPLICATION UNDER ARIZONA REVISED STATUTES (A.R.S.) 49-1051(K)

General Eligibility Requirements –

Check one:

☐ Newly confirmed release requires urgent action

☐ Existing confirmed release – contamination represents an imminent threat to human health and the environment(this must be demonstrable to ADEQ)

Additional requirements –

☐ Owner and Operator (Applicant) must be able to demonstrate compliance with financial responsibility (FR) at thetime of the release

☐ If Applicant relies on UST insurance to demonstrate compliance with FR, policy notice and other associatedrequirements must be met

Note: Expedited preapproval requires rapid initiation of corrective actions. Therefore, the proposed schedule is an important part of this submittal.

If you have certain time-sensitive standard corrective actions that are more appropriately submitted under the standard preapproval process, please use that process instead and contact ADEQ to explain why you are requesting a faster review.

Please contact ADEQ if you need assistance in completing this submission: call 602-771-0333 or email - [email protected]

SECTION 1.1 - FACILITY INFORMATION

ADEQ assigned Facility ID Number: _0-0______________

Facility Name: ___________________________________________________________________________

Facility Address: _________________________________________________________________________

City: _____________________ State: ____________ Zip Code: ___________

1.2 - APPLICANT INFORMATION

Name of Applicant: ________________________________________________________________________

Name of Applicant must match the information provided on the Arizona Corporation Commission (ACC) Website. ACC File Number:____________________________

Name/Title of Applicant’s Authorized Individual (leave blank if same as above):

____________________________________________________________________________________

Verification of Authority: Unless the applicant is an individual - Please attach (Attachment A) documentation, on Applicant letterhead, showing that the Authorized Individual may act for the Applicant on this application. The consultant conducting corrective actions is not eligible to be the Authorized Individual. The Authorized Individual must be able to legally represent the Applicant.

Date Stamp – for internal use only

mailto:[email protected]



Applicant Mailing Address: _____________________________________________________________________

City: _____________________________ State: __________ Zip Code: _______________

Primary Phone: ____________________ Secondary Phone: _____________________

Email: ________________________________________

Check all that apply to Applicant: ☐ UST Owner ☐ UST Operator ☐ Property Owner

SECTION 2 – FINANCIAL RESPONSIBILITY (FR)

2.1 – FINANCIAL ASSURANCE MECHANISM REFERENCE TABLE Identify the financial assurance mechanism(s) relied upon for compliance with A.R.S. 49-1006 (as applicable to the release(s) included in this submittal).

For more information on FR requirements, please refer to Arizona Administrative Code (A.A.C.) R18-12-300 through R18-12-323 and 40 C.F.R. § 280, subpart H.

☐ UST Insurance Coverage 40 C.F.R. § 280.97 A.A.C. R18-12-307

☐ Risk Retention Group Coverage 40 C.F.R. § 280.97 A.A.C. R18-12-307

☐ Financial Test of Self-Insurance 40 C.F.R. § 280.95 A.A.C. R18-12-305

☐ Guarantee 40 C.F.R. § 280.96 A.A.C. R18-12-306

☐ Surety Bond 40 C.F.R. § 280.98 A.A.C. R18-12-308

☐ Letter of Credit 40 C.F.R. § 280.99 A.A.C. R18-12-309

☐ Trust Fund 40 C.F.R. § 280.102 A.A.C. R18-12-312

☐ Standby Trust Fund 40 C.F.R. § 280.103 A.A.C. R18-12-313

☐ Certificate of Deposit 40 C.F.R. § 281.37 A.A.C. R18-12-310

☐ Local Government Bond Rating Test 40 C.F.R. § 280.104 A.A.C. R18-12-314

☐ Local Government Financial Test 40 C.F.R. § 280.105 A.A.C. R18-12-315

☐ Local Government Guarantee 40 C.F.R. § 280.106 A.A.C. R18-12-316

SECTION 2.2 – PREAPPROVAL FR ELIGIBITY CATEGORY

Please refer to Arizona Revised Statutes (A.R.S.) § 49-1006.02(A), (B) and (C). Select the category that corresponds to your eligibility category (this will identify which actions are needed for you to demonstrate preapproval program eligibility):

☐ Category A: Financial assurance mechanism is UST insurance with a deductible less than $50,000 (no $50,000cost share obligation)

Attach (Attachment B) documentation demonstrating a timely claim was filed with your insurance

provider

Attach (Attachment B) correspondence between you and your insurance provider including a copy of

any preapproval related information and costs



☐ Category B1: Financial assurance mechanism is UST insurance with a deductible of $50,000 or more – requires$50,000 cost share obligation. Note: preapproval for costs within the cost share obligation is not required.

☐ Category B2: Reliance upon a financial assurance option other than UST insurance – requires $50,000 costshare obligation. Note: preapproval for costs within the cost share obligation is not required.

☐ Category C: Financial assurance mechanism is UST insurance with release reported between July 1, 2006 andDecember 31, 2015 (with no evidence of filing a timely claim against its insurance provider – requires $50,000cost share obligation. Note: maximum amount of preapproval funding available is $500,000.

SECTION 3 – BASIS FOR REQUESTING EXPEDITED PREAPPROVAL Describe (use additional space as needed or attach)

SECTION 3.1 – UST RELEASE INFORMATION

If needed, attach the information below for additional releases.

RELEASE NUMBER

RELEASE CONFIRMATION

DATE

RELEASE REPORTED

DATE

MEDIA IMPACTED (Select all that apply)

☐ Soil ☐ Groundwater ☐ Vapor

☐ Other (describe)



SECTION 3.2 – ANALYTICAL RESULTS (attach and complete table(s) below) Attach (Attachment C) complete laboratory report(s) and site map(s). Provide summary details below for results that are being relied upon to demonstrate applicability for expedited preapproval process. An example table template is located here: http://static.azdeq.gov/ust/24hour_notification_table.xlsx

Soil:

Chemicals of Concern (Identify) VOCs PAHs

various Sample ID # Location of Sample Depth (bgs) Soil Type mg/kg (ppm) mg/kg (ppm)

Water: If water has documented impacts – please summarize below:

☐ Surface Water - describe: _________________________________________________________________

☐ Groundwater – Depth to water: ___________________

☐ Grab sample(s)

☐ Compliance sample(s)

Chemicals of Concern (list with concentration(s) in g/L (ppb):

Sample ID # Chemicals of Concern (Identify)

Chemicals of Concern (Identify)

Chemicals of Concern (Identify)

☐ Known receptor impact - identify receptor(s): _________________________________________________

http://static.azdeq.gov/ust/24hour_notification_table.xlsx



Drilling Method

SECTION 3.3 – PROPOSED CORRECTIVE ACTION SCHEDULE (Attachment D) Expedited preapproval requires rapid initiation of corrective actions. Therefore, the proposed schedule is an important part of this submittal.

SECTION 4 – PROPOSED EXPEDITED CORRECTIVE ACTIONS SECTION 4.1 - Complete the Preapproval Application Cost Sheet (sample image below) to identify proposed actions and costs| Download Cost Sheet Excel document >

https://azdeq.gov/node/6833



Soil Borings and Monitoring Wells Borings that become wells are accounted for in the monitoring wells section only. For example, if 6 borings were drilled and 4 were completed as wells, the table below would show 2 borings and 4 monitoring wells.

Excavation Over-excavation initiated under the Tank Site Improvement Program is only eligible for expedited preapproval to the extent that reasonable and necessary costs exceed the amount allowable under the Tank Site Improvement program.

Additionally, samples must be collected from the investigation derived waste at appropriate intervals to document the claimed soil disposal volume accurately represents the volume of contaminated soil that required removal and disposal.

Remediation If expedited actions include remediation activities – demonstrate how the selected remedial method was determined (next, plan for continued remedial efforts - outside of expedited process).

If you believe additional site-specific information directly related to completion of this section is necessary for the technical evaluator to consider, please attach (Attachment E) to the submittal and identify which actions and costs may be impacted by this information.

SECTION 5 – CERTIFICATION STATEMENTS

5.1 - APPLICANT CERTIFICATION STATEMENT This certification statement, in its entire ADEQ prescribed form, must be signed by the Applicant or the

Authorized Individual. Please fill in costs and check boxes to confirm understanding.

Applicant Certification: All facts and statements set forth in this application are true and correct;

Under penalty of perjury, I hereby certify that I have reviewed the proposed corrective action work and costs in the amount of $ ______________._____. The amount requested for expedited preapproval is $_____________.______. To the best of my knowledge, information, and belief:

☐ Conducting corrective actions outside of the standard preapproval process is necessary to address newlydiscovered contamination that is currently a risk to public health and the environment.

☐ I believe that these actions meet the requirements for expedited preapproval and I understand theimportance of quick response to address this contamination.

☐ I understand that the Department may conduct site visits and I have confirmed with the on-site propertyowner and any off-site property owners, if applicable, that ADEQ is permitted access to the sites.

☐ I understand that if the preapproved scope of work cannot be implemented as approved, I am required toreceive approval from the Department through a change notice prior to implementing the change notice.

☐ I understand that I am responsible for paying for all work prior to requesting reimbursement from theDepartment.

☐ I certify that neither my consultant, representative, agent nor I have been reimbursed by insurance oranother financial assurance mechanism for the corrective action activities that are the subject of thisApplication.

☐ I certify none of the costs included in this submittal have been previously paid by or submitted to theDepartment for payment or reimbursement.

☐ I understand that I am required to remit to the Department within thirty days any amounts that have beenpaid to me, my consultant, representative or agent by the Department that have also been recovered frominsurance, my financial responsibility mechanism, or any settlement for the corrective action costs included inthis Application.

☐ I understand that the Department may compel the production of documents to determine the existence,amount and type of insurance or alternative coverage available and to whom payment was made or may bemade, and that I must report to the Department any payment of corrective actions costs through insuranceand alternative mechanisms.



SECTION 5 – CERTIFICATION STATEMENTS (continued)

5.1 - APPLICANT CERTIFICATION STATEMENT (continued) This certification statement, in its entire ADEQ prescribed form, must be signed by the Applicant or the

Authorized Individual. Please fill in costs and check boxes to confirm understanding.

Applicant Certification (continued):

Check the statement below that is applicable for your submittal:

☐ I certify, in accordance with A.R.S. 49-1006.02.A, that I have filed a timely claim with my insurer, and that Iam pursuing the claim. I understand that if I fail to pursue an insurance claim, I am no longer eligible for thisprogram.

☐ I certify, in accordance with A.R.S. 49-1006.02.B, that I have filed a timely notice with my insurer under apolicy that had at least a $50,000 deductible before April 1, 2015. I understand that I am not eligible forreimbursement from the state until I have demonstrated that I’ve expended or become responsible for atleast $50,000 of eligible corrective action costs per facility for work conducted on or after January 1, 2016. Iunderstand that the $50,000 is not eligible for reimbursement from the UST Revolving Fund.

☐ I am applying under A.R.S. 49-1006.02.B and I have relied upon a mechanism other than insurance tosatisfy financial responsibility requirements. I understand that I am not eligible for reimbursement from thestate until I have demonstrated that I’ve expended or become responsible for at least $50,000 of eligiblecorrective action costs per facility for work conducted on or after January 1, 2016. I understand that the$50,000 is not eligible for reimbursement from the UST Revolving Fund.

☐ I am applying under A.R.S. 49-1006.02.C and the UST release occurred between July 1, 2006 and December31, 2015. I understand that I am not eligible for reimbursement from the state until I have demonstrated thatI’ve expended or become responsible for at least $50,000 of eligible corrective action costs per facility forwork conducted on or after January 1, 2016. I understand that the $50,000 is not eligible for reimbursementfrom the UST Revolving Fund. I understand that reimbursement is limited to $500,000 per facility.

☐ I am applying for a release that occurred when financial responsibility was not required.

☐ I am applying under A.R.S. 49-1016.C and I am neither an UST owner nor operator under A.R.S. 49-1001.01.I have demonstrated compliance with requirements to notify the department in writing of the tank’sexistence, including, if known, its location, size and use if the UST owner failed to do so.

________________________________________

Signature of Applicant/Authorized Individual

________________________________________ Printed Name/Title

________________________________ Company Name

_________________________ Date




5.2 – CONSULTANT CERTIFICATION STATEMENT

Company Name: _______________________________________________________________________

Individual Name: _________________________________________

AZ professional registration is required. Certification/Registration No.: ___________________________

Address: _______________________________________________________________________

City: __________________________ State: __________ Zip Code: _________

Primary Phone: ________________ Secondary Phone: _________________

Fax: _______________________ Email: ________________________________________

I, the Primary Service Provider, am responsible for preparing the proposed scope of work and costs and declare that I will be responsible for the management and supervision of the corrective actions included in this application.

I affirm that the included activities will be conducted in accordance with A.R.S. § 49-1005 and 18 A.A.C. 12, Article 2.

☐ Conducting urgent corrective actions outside of the standard preapproval process is necessary to addresscontamination that is currently a risk to public health and the environment.

☐ The proposed corrective actions meet the requirements for expedited preapproval and I understand theimportance of quick response to address this contamination.

☐ I do not believe that the costs included in this submittal have been previously paid by or submitted to theDepartment for payment or reimbursement.

☐ Neither I nor this company have been reimbursed by insurance for the corrective actions that are the subjectof this application.

(Notarized Signature)

_______________________________________________________________________________________ Signature

_______________________________________________________________________________________ Printed Name/Title

_______________________________________________________________________________________ Company Name



UST Program Submittal Instructions A complete application includes:

☐ Application Form with signed certification statements (pages 1 through 9)☐ Attachment A: Documentation for Authorized Individual

☐ Attachment B: FR/Insurance Documentation

☐ Attachment C: Documentation Demonstrating Basis for Expedited Preapproval including Analytical results and Site Plan

☐ Attachment D: Proposed Corrective Action Schedule

☐ Attachment E: Additional Information for Proposed Expedited Corrective Actions (if applicable)

ADEQ encourages you to email a complete application and any attachments to [email protected] and in the “RE” line – indicate that this is a request for “Expedited Preapproval for FAC ID No: 0-0XXXXX”

Additional submittal options: Mail or hand-deliver one original and all attachments to the below address: Attention: UST Preapproval Program – Expedited Preapproval Arizona Department of Environmental Quality 1110 West Washington Street Phoenix, AZ 85007

Submittal of a complete and accurate application (with attachments) will allow for more timely review of your submittal.

mailto:[email protected]

Zip Code: Name of Applicant: ACC File Number: NameTitle of Applicants Authorized Individual leave blank if same as above: Secondary Phone: Email: undefined: UST Owner: OffUST Operator: OffProperty Owner: OffCategory A Financial assurance mechanism is UST insurance with a deductible less than 50000 no 50000: OffCategory B1 Financial assurance mechanism is UST insurance with a deductible of 50000 or more requires: OffCategory B2 Reliance upon a financial assurance option other than UST insurance requires 50000 cost: OffCategory C Financial assurance mechanism is UST insurance with release reported between July 1 2006 and: OffDescribe use additional space as needed or attach: NUMBER: DATE: DATE_2: Soil: OffGroundwater: OffVapor: OffOther describe: OffKnown receptor impact identify receptors: VOCs: mgkg ppm: mgkg ppm_2: mgkg ppm_3: mgkg ppm_4: mgkg ppm_5: mgkg ppm_6: mgkg ppm_7: mgkg ppm_8: mgkg ppm_9: mgkg ppm_10: mgkg ppm_11: mgkg ppm_12: mgkg ppm_13: mgkg ppm_14: Chemicals of Concern Identify: Chemicals of Concern Identify_2: Chemicals of Concern Identify_3: Chemicals of Concern Identify_4: Chemicals of Concern Identify_5: Chemicals of Concern Identify_6: Zip Code_2: Secondary Phone_2: Email_2: Conducting urgent corrective actions outside of the standard preapproval process is necessary to address_2: OffThe proposed corrective actions meet the requirements for expedited preapproval and I understand the: OffI do not believe that the costs included in this submittal have been previously paid by or submitted to the: OffNeither I nor this company have been reimbursed by insurance for the corrective actions that are the subject: OffPrinted NameTitle: Company Name: Application Form with signed certification statements pages 1 through 8: OffAttachment A Documentation for Authorized Individual: OffAttachment B FRInsurance Documentation: OffAttachment C Documentation Demonstrating Basis for Expedited Preapproval including Analytical results and: OffAttachment D Proposed Corrective Action Schedule: OffAttachment E Additional Information for Proposed Expedited Corrective Actions if applicable: OffCheck Box1: OffCheck Box2: OffCheck Box3: OffCheck Box4: OffText5: Text6: Text7: Text8: Text9: AZText10: Text11: Text12: Text13: Check Box14: OffCheck Box15: OffCheck Box16: OffCheck Box17: OffCheck Box18: OffCheck Box19: OffCheck Box20: OffCheck Box21: OffCheck Box22: OffCheck Box23: OffCheck Box24: OffCheck Box25: OffText26: Text27: Text28: Text29: Text30: Text31: Text32: Text33: Text34: Text35: Text36: Text37: Text38: Text39: Text40: Text41: Text42: Text43: Text44: Text45: Text46: Text47: Text48: Text49: Text50: Text51: Text52: Text53: Text54: Text55: Check Box56: OffCheck Box57: OffCheck Box58: OffCheck Box59: OffCheck Box60: OffText62: Text63: Text64: Text65: Text66: Text67: Text68: Text69: Text70: Text71: Text72: Text73: Text74: Text75: Text76: Text77: 2019 Expedited Preapproval Application FAC ID: Printed Name: Relationship to Applicant if applicable: Text1: Group2: OffCheck Box5: OffCheck Box6: OffCheck Box7: OffCheck Box8: OffCheck Box9: OffCheck Box10: OffCheck Box11: OffCheck Box12: OffCheck Box13: Off

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