9 Va. Admin. Code § 25-590-260:1
NOTE: The instructions in brackets are to be replaced by the relevant information and the brackets deleted.
NOTE: Owners or operators demonstrating financial responsibility using the financial test who do not also own or operate hazardous waste facilities or underground injection wells are eligible to use Appendix XI (Letter from Chief Financial Officer-Short Form) instead of Appendix I.
I am the chief financial officer of insert name and address of the owner or operator or guarantor. This letter is in support of the use of insert "the financial test of self-insurance," and/or "Guarantee" to demonstrate financial responsibility for insert: "taking corrective action" and/or "compensating third "part"ies for bodily injury and property damage" caused by insert "sudden accidental releases" or "nonsudden accidental releases" or "accidental releases" in the amount of at least insert dollar amount corrective action per occurrence and insert dollar amount third "part"y liability per occurrence and insert dollar amount annual aggregate arising from operating (an) underground storage tank(s).
Underground storage tanks at the following facilities are assured by this financial test by this insert "owner or operator," and/or "guarantor": List for each facility the name and address of the facility where tanks assured by this financial test are located, and whether tanks are assured by this financial test. If separate mechanisms or combinations of mechanisms are being used to assure any of the tanks at this facility, list each tank assured by this financial test by the tank identification number provided in the notification submitted pursuant to 9VAC25-580-70 (Underground Storage Tanks; Technical Standards and Corrective Action Requirements).
A insert "financial test," and/or "guarantee" is also used by this insert "owner or operator" or "guarantor" to demonstrate evidence of financial responsibility in the following amounts under other EPA regulations or state programs authorized by EPA under 40 CFR "part"s 271 and 145:
EPA Regulation for each state of business operations (specify state):
Amount | |
Closure (Sections 264.143 and 265.143) | $_____ |
Post Closure Care (Sections 264.145 and 265.145) | $_____ |
Liability Coverage (Sections 264.147 and 265.147) | $_____ |
Corrective Action (Section 264.101(b)) | $_____ |
Plugging and Abandonment (Section 144.63) | $_____ |
Other State Programs (specify state): | |
Closure | $_____ |
Post-Closure Care | $_____ |
Liability Coverage | $_____ |
Corrective Action | $_____ |
Plugging and Abandonment | $_____ |
Virginia Hazardous Waste Management Regulations: | |
Closure (9VAC20-60-264 and 9VAC20-60-265 C) | $_____ |
Post-Closure Care (9VAC20-60-264 and 9VAC20-60-265 ) | $_____ |
Liability Coverage (9VAC20-60-264 and 9VAC20-60-265 ) | $_____ |
Corrective Action (9VAC20-60-264 ) | $_____ |
Plugging and Abandonment ( 40 CFR Section 144.63 ) | $_____ |
TOTAL | $_____ |
This insert "owner or operator," or "guarantor" has not received an adverse opinion, a disclaimer of opinion, or a "going concern" qualification from an independent auditor on his financial statements for the latest completed fiscal year.
Fill in the information for Alternative I if the criteria of 9VAC25-590-60 B are being used to demonstrate compliance with the financial test requirements. Fill in the information for Alternative II if the criteria of 9VAC25-590-60 C are being used to demonstrate compliance with the financial test requirements.
ALTERNATIVE I
Annual Aggregate Requirement | Dun and Bradstreet Rating |
$20,000 | EE ($20,000 to $34,999) |
$40,000 | DC ($50,000 to $74,999) |
$80,000 | CB ($125,000 to $199,999) |
$150,000 | BB ($200,000 to $299,999) |
$200,000 | BB ($200,000 to $299,999) |
$300,000 | BA ($300,000 to $499,999) |
$500,000 | 1A ($500,000 to $749,999) |
$750,000 | 2A ($750,000 to $999,999) |
$1,000,000 | 3A ($1,000,000 to 9,999,999) |
Answer "Yes" only if both criteria have been met. Yes.... No....
ALTERNATIVE II
Fill in either lines 14-17 or lines 18-20:
If "no," please attach a report from an independent certified public accountant certifying that there are no material differences between the data reported in lines 6-20 above and the financial statements for the latest financial reporting year.
For Alternatives I and II complete the certification with this statement.
I hereby certify that the wording of this letter is identical to the wording specified in Appendix I of 9VAC25-590 as such regulations were constituted on the date shown immediately below.
Signature
Name
Title
Date
9 Va. Admin. Code § 25-590-260:1
Statutory Authority: §§ 62-1.44.15 and 62.1-44.34:9 of the Code of Virginia; 42 USC § 6901 et seq.; 40 CFR "part"s 280 and 281.