1. UNDERGROUND HEATING OIL TANK CLEANUP REIMBURSEMENT PROGRAM
    2. APPLICATION FOR REIMBURSEMENT
      1. PA Department of Environmental Protection
      2. Bureau of Environmental Cleanup and Brownfields
      3. Site Remediation Division
      4. P. O. Box 8471
      5. Harrisburg, PA 17105-8471

2620-FM-BECB0249 Rev. 5/2015  COMMONWEALTH OF PENNSYLVANIA
Instructions  DEPARTMENT OF ENVIRONMENTAL PROTECTION

 BUREAU OF ENVIRONMENTAL CLEANUP AND BROWNFIELDS

 
 
 
2620-FM-BECB0249 Rev. 5/2015
Instructions
 
 
 
 
 
 
2620-FM-BECB0249 3/2012
Form
 
 
 
 
 
2620-FM-BECB0249 Rev. 5/2015
Form
 
 
 
 
 
 
2620-FM-BECB0249 Rev. 5/2015
Form
 
 

UNDERGROUND HEATING OIL TANK CLEANUP REIMBURSMENT PROGRAM INFORMATION AND INSTRUCTIONS

Please read ALL of the information below before completing the Application for Reimbursement.
Basic Provisions

The program provides reimbursement of environmental cleanup costs resulting from a release of heating oil from an underground tank system. The applicant must pay the first $1,000 of eligible costs. Remaining eligible costs may be reimbursed up to a maximum of $4,000. For additional program requirements see Am I Eligible for Reimbursement? below. If the heating oil release has contaminated or could potentially contaminate groundwater or surface water, it must be reported to the local Department of Environmental Protection (DEP) regional office. Since the potential to contaminate groundwater or surface water is often difficult to assess, DEP recommends that all heating oil releases to the environment be reported. The DEP regional office can help with information on cleaning up a heating oil release and obtaining cleanup liability protection. A list of DEP regional offices, including contact information and counties served, appears on page 2.

Am I Eligible for a Reimbursement?

Answering the following questions will help to determine your eligibility for reimbursement.

Are/were you the tank owner?

Was the heating oil tank an underground (buried) tank?

Was the tank capacity 3,000 gallons or less?

Did the tank store fuel that was used for heating on the premises?

Was there a release of heating oil to the environment from the tank, the associated lines/pipes, or as a result of a spill or overfill due to a failure of the tank system?

Did the release occur, or was it discovered, on or after January 30, 1998?

Has an environmental cleanup been completed, or is one in progress?

Yes   No

Yes   No

Yes   No

Yes   No

Yes   No

Yes   No
Yes   No

If you answered "YES" to ALL of the above, you may be eligible for reimbursement.

Heating oil tanks located on or above the surface of the floor in an underground area, such as a basement or cellar, are not eligible for this program.

What Costs Are Eligible for Reimbursement?

Eligible costs include, but are not limited to:
·   Excavating, emptying, cleaning, removing, transporting and disposing of a leaking underground storage tank.
·   Excavating contaminated soil.
·   Recovering free product.
·   Transporting and disposing of wastes (e.g. in-tank materials, contaminated soil, contaminated groundwater).
·   Determining the extent of contamination, including conducting soil borings or installing wells.
·   Designing and implementing groundwater and surface water abatement systems (e.g. installation and maintenance of well water treatment systems and placement of absorbent booms in streams, lakes, or ponds).
·   Restoring disturbed or contaminated areas by backfilling, grading, and basic re-vegetation.
·   Sampling and analytical costs associated with disposal of wastes, determining the extent of contamination, evaluating the progress of the cleanup, and confirming that a cleanup is complete.
·   Preparing and submitting required reports, such as those required by the municipality or those submitted to DEP.

·   Permit and inspection fees associated with tank removal or closure or environmental cleanup.

What Costs Are Not Eligible for Reimbursement?

Ineligible costs include, but are not limited to:
·   Excavating, emptying, cleaning, removing, transporting and disposing of a non-leaking tank.
·   Repairing a heating oil tank.
·   Installing a new heating oil tank.
·   Repairing or replacing a heating system.
·   Replacement fuel.
·   Inspection and permit fees not associated with tank removal or closure or environmental cleanup, such as permit fees for installing a new tank or heating system.
·   Preparing and submitting the reimbursement application and preparation of reports solely for the tank owner’s use.

·   Activities eligible for reimbursement under other assistance programs or those covered by private insurance.

How Do I Apply?

1.  Complete and sign the Application for Reimbursement. An original signature is required on the application form.

2.  Attach original itemized contractor invoices for the work performed. We cannot accept contractor estimates or proposals.

3.  Attach proof of payment of at least $1,000 of eligible cleanup costs. Proof of payment may include a copy of the front and back of a canceled check, a paid contractor invoice, or other paid receipt.*

*  Releases from two (2) or more tanks at the same address are subject to the same provisions as releases from a single tank. You must pay the first $1,000 of eligible cleanup costs for each tank that has experienced a release. The maximum reimbursement allowed is $4,000 per tank. You must provide information about each tank in Section D of the application.

4.  Attach a completed and signed W-9 form, Request for Taxpayer Identification Number and Certification, available from the U.S. Internal Revenue Service (IRS) at www.irs.gov or by calling the IRS at 1-800-829-3676. An original signature is required on the W-9 form.

Reimbursement you receive will be reported to the IRS and may be subject to taxes. Consult the IRS for additional information.

5.  Mail the completed application and attachments to:
PA Department of Environmental Protection
Bureau of Environmental Cleanup and Brownfields
Site Remediation Division
P.O. Box 8471

Harrisburg, PA 17105-8471

Where Can I Get Help?

If you have questions or need additional information about this reimbursement program, call the DEP Site Remediation Division at 717-787-0886 or email tankcleanup@pa.gov. Information and application forms are also available on the DEP website at www.dep.state.pa.us , keyword: Tank Cleanup. For information on cleaning up a home heating oil release contact your DEP regional office or consult the DEP publication entitled Home Heating Oil Releases available at the web address above.

DEP Regional Offices and Counties Served

 


Southeast Region
2 E. Main Street
Norristown, PA 19401-4915
Phone:  484-250-5900 (24 hours/day)

Counties: Bucks, Chester, Delaware, Montgomery and Philadelphia
Northeast Region
2 Public Square
Wilkes-Barre, PA 18701-1915
Phone:  570-826-2511 (24 hours/day)

Counties: Carbon, Lackawanna, Lehigh, Luzerne, Monroe, Northampton, Pike, Schuylkill, Susquehanna, Wayne and Wyoming
South-central Region
909 Elmerton Avenue
Harrisburg, PA 17110
Phone:  717-705-4700 (8 a.m. to 4 p.m.)
 866-825-0208 (24 hours/day)

Counties: Adams, Bedford, Berks, Blair, Cumberland, Dauphin, Franklin, Fulton, Huntingdon, Juniata, Lancaster, Lebanon, Mifflin, Perry and York

 
North-central Region
208 West Third Street
Suite 101
Williamsport, PA 17701
Phone:  570-327-3636 (24 hours/day)

Counties: Bradford, Cameron, Centre, Clearfield, Clinton, Columbia, Lycoming, Montour, Northumberland, Potter, Snyder, Sullivan, Tioga and Union
Southwest Region
400 Waterfront Drive
Pittsburgh, PA 15222
Phone:  412-442-4000 (24 hours/day)

Counties: Allegheny, Armstrong, Beaver, Cambria, Fayette, Greene, Indiana, Somerset, Washington and Westmoreland
Northwest Region
230 Chestnut Street, Meadville, PA 16335
Phone:  814-332-6945 (8 a.m. to 4 p.m.)
 800-373-3398 (after hours)
Counties: Butler, Clarion, Crawford, Elk, Erie, Forest, Jefferson, Lawrence, McKean, Mercer, Venango and Warren

2620-FM-BECB0249 Rev. 5/2015

Form
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF ENVIRONMENTAL CLEANUP AND BROWNFIELDS
For Department Use Only

Application No.        


UNDERGROUND HEATING OIL TANK CLEANUP REIMBURSEMENT PROGRAM



APPLICATION FOR REIMBURSEMENT

Carefully review the Information and Instructions before completing this form. Be sure to complete all sections and include supporting documentation. Type or print all information, except for required signatures. Submit the completed application package to:



PA Department of Environmental Protection



Bureau of Environmental Cleanup and Brownfields



Site Remediation Division



P. O. Box 8471


Harrisburg, PA 17105-8471

SECTION A – TANK OWNER INFORMATION

Name         
 

Mailing Address         
 Street

       
 P.O. Box

                          -        
 City  State  Zip Code

County           Telephone  (     )        -       

 

Municipality         
 Township, Borough or City

Federal Tax ID or Social Security Number         

Reimbursement you receive will be reported to the U.S. Internal Revenue Service (IRS) and may be subject to taxes.

DEPARTMENT USE ONLY
Supplier Invoice #:        

 
VID #:           Invoice Date:           

 
SAP Fund
General Ledger
Cost Center
Internal Order
Budget Period
 
 

 
2008200000
6602014
3522609000
3526046270
20  
 
 
 

Total Amount Approved for Payment: $           

 
Approved for Payment:          Date:           
                       

  Technical Review  Date  Administrative Review  Date
All supporting documentation for the application is on file in the Bureau of Environmental Cleanup and Brownfields.

SECTION B – TANK LOCATION
Provide information about the location of the tank(s).
Street Address         
City           State           ZIP Code           County         
Municipality         

 Township, Borough or City

Contact Person Name           Telephone  (     )        -       

E-mail         
SECTION C – CLEANUP CONTRACTOR(S)
Provide information about the contractor(s) who performed the work. Attach additional sheets if necessary.
Name         
Mailing Address (Street, P.O. Box)         
       
City           State           Zip Code         
Contact Person Name           Telephone  (     )         -       
SECTION D – DESCRIPTION OF THE TANK, THE RELEASE, AND THE COSTS
Attach additional sheets if more than one tank has experienced a release.
Did the tank last store fuel that was used for heating on the premises?   Yes   No

Was the tank an underground (buried) tank?   Yes   No


Was the release reported to the DEP Regional Office?   Yes   No

See the Information and Instructions for a list of DEP regional offices.

Size (capacity) of the underground tank         gallons.

Type of fuel stored in tank (check all that apply)

Fuel Oil No. 2 (heating oil)   Kerosene   Used Oil   Other (specify)        
Rele ase occurrence/discovery date           (mo, day, yr)

If the date the release occurred is unknown, provide the date that the release was discovered.

Source of the release (check all that apply)

Tank   Line (pipe)   Spill/Overfill*   Other (specify)        

*Only spills or overfills that are due to a failure of the tank system are eligible. Spills or overfills that are the result of improper fuel delivery are not eligible. If a spill or overfill results from improper fuel delivery, contact the heating oil distributor and ask them to perform the cleanup.

Approximate amount of fuel released         gallons. If amount released is unknown, write "unknown."
Total eligible costs you paid.  $       

See the Information and Instructions for a list of eligible costs. Costs paid by insurance are not eligible for reimbursement.

SECTION E – SIGNATURE & DECLARATION
Signature      Date        
 
"By signing and submitting this Application for Reimbursement, I assert that the information contained in the application and supporting documentation is true and correct to the best of my knowledge and belief, subject to punishment under 18 PA. C.S. 4904 relating to unsworn falsification to authorities."

Reimbursements and reimbursement applications are public documents and subject to disclosure to the public upon request.

To ensure timely processing of your application, be sure to include:

 
 

 Completed and signed Application for Reimbursement.

 Proof of payment of at least $1,000 of eligible cleanup costs for each tank release.
 
 Original itemized invoices.

 Completed and signed W-9 form.
 

See the Information and Instructions for additional information. Keep a copy of your completed application for your records.
 
 
 
 
 
 
 
 

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