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        Petroleum Fund Forms

        Forms for Changes to Petroleum Fund Claimant

        The following templates were developed by Petroleum Fund staff to encourage proper notification for a change in claimant and/or associated authorized representative for corrective action efforts at a facility receiving State Petroleum Fund reimbursement. Each template serves a different purpose, so please review the description below each to ensure proper use. The language in these documents should not be changed. Please fill in the editable fields with the applicable information, print the template on company letterhead, and include actual inked signatures of the people named on the letter. Note, you must contact the remediation case officer in addition to the below Petroleum Fund notice if the responsible party has changed for an ongoing corrective action.

        Change of Operator/Claimant
        This document should be used when a property transaction has occurred and/or a new party is accepting responsibility as the claimant of an existing Petroleum Fund case. This includes information regarding the company relinquishing control and the company assuming liability. This document should be printed on the new company’s letterhead and signed by both parties.

        Change of Authorized Representative
        This document should be used to designate a new authorized representative for an existing Petroleum Fund case. This includes acknowledgement of the duties of the new authorized representative. This document should be printed on the company’s letterhead and signed by the new representative.

        CEM Payment Affidavit for Subcontractor Costs      
        This document should be used for proof of payment(s) when a CEM has received payment, and will apply it to subcontractor invoices, on a claimant’s behalf. This document must be printed on the consulting firm’s letterhead and physically signed by the CEM, before scanning and uploading it to the Nevada Environmental Activities system. If this letter is not provided, the CEM must provide receipts for each contractor, vendor, or piece of equipment billed through their CEM invoices.


        Claim/Bid Forms

        2015-01 Form I - Contractor Certification
        2015-01 Form II - Vendor Certification
        2015-01 Form III - Bid Request
        2015-01 Form IV - Bid Summary
        2015-01 Form V - CEM & Contractor
        2015-01 Form VI - Owner & Contractor

        Bid Excess Justification/Concurrence

        Invoice Breakdown Sheet


        Petroleum Fund Enrollment Forms

        Operators of underground storage tank (UST) systems must register with NDEP's UST Program using the below form prior to enrollment in the Petroleum Fund. USTs will be enrolled in the Fund upon receipt of this form, the enrollment payment ($100 per tank system), and demonstration of system tightness (tanks and associated product piping).
        UST Notification Form (7530-1)

        Enrollment coverage for aboveground storage tanks (ASTs) begins 6 months from date of receipt of this application and payment unless this is a continuing enrollment (NRS 445C.410.2). All operators of AST systems enrolled in the Fund must visually inspect their systems monthly (NAC 445C.250). The below inspection form may be used to meet this requirement. Note, any operator with an aboveground storage tank that uses underground delivery piping that cannot be visually inspected, must have the piping tested prior to enrollment (and annually thereafter) for tightness by a certified tester. Any underground delivery piping that is constructed of steel, must also have a corrosion prevention system installed that must also be tested annually (Fund Policy Resolution #2017-01).
        Aboveground Storage Tank Enrollment Form
        Aboveground Tank Inspection Form


        Tax Documentation for Fund Reimbursements

        Nevada operators that had a petroleum release from their storage tank and have received reimbursement claim payment(s) from the Nevada Petroleum Fund may receive tax form 1099-MISC from the State of Nevada Controller’s office. The Board to Review Claims and NDEP have received a determination from the US Department of Agriculture, Natural Resources Conservation Service that Fund reimbursement payments (i.e. cost-share payments) may be eligible for exclusion from an operator’s reported gross income under Section 126 of the Internal Revenue Code of 1954, as amended. If you have received tax form 1099-MISC for the current tax year, download the below Record of Decision to submit to your tax professional along with claim payment documents received from NDEP.

        Record of Decision from US Department of Agriculture, Natural Resources Conservation Service 

        To review the Secretary of Agriculture’s Determination of the Primary Purpose of the Nevada Petroleum Claims Fund for the Cleanup of Petroleum Discharge From Storage Tanks (federal register), click the following link:



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