PTRCB Forms and Worksheets

The forms below can be filled out on-line, saved, printed, signed, notarized and sent to the Petroleum Tank Release Compensation Board. A W-9 may be necessary for processing some of our forms or for updating our data base - click here for a blank W-9 form.

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Forms

Form Title Format
Application for Petroleum Release Eligibility
Use this form to apply for eligibility to receive reimbursement of costs associated with a release from a petroleum storage tank and/or associated piping.
Transfer of Release Eligibility
Complete this form to advise the Board a new owner/operator is assuming responsibility for the release.
Application for Voluntary Registration
Use this form to determine potential eligibility for reimbursement from the Petroleum Tank Release Cleanup Fund prior to a release.
Assent to Audit
Use this form to indicate assent to an audit of time sheets, payroll records, purchase orders, and other documents. Required for payment of claim.
Claim for Reimbursement–Corrective Action
Instructions and form necessary to file a claim for reimbursement.
Claim for Reimbursement–Third Party
Instructions and form necessary to file a third party claim.
Designation of Representative
Use this form to designate another person to receive reimbursement.
Acknowledgment of Payment
Use this form to acknowledge payment of invoice(s).
Owner/Operator's Report of Insurance
Use this form to identify insurance information and to subrogate and assign certain rights to the board.
Corrective Action Plan Modification Form
Use this form to obtain approval of changes to Corrective Action Plan.
Equipment Policy Acknowledgement
Use this form to document disposition remediation equipment at a facility.
Multiple Funding Source Template
Use this Microsoft Excel spreadsheet for allocation of costs among funding sources
Request for Allocation of Costs to Co-Pay
Use this form to allocate corrective action costs from grants or insurance payments toward copay.
  • Here is a link of interest for your information and use.
DNRC Well Abandonment Form

Unit Cost Worksheets

Form Title Format
Soil Boring/ Monitoring Well Installation
Use this form to provide unit cost for tasks associated with boring and well installation.
Groundwater Monitoring and Sampling
Use this form to provide unit cost for tasks associated with monitoring and sampling.
Bulk Soil Excavation -
Use this bulk estimator, in Microsoft Excel format, to provide unit cost for excavation based upon banked cubic yards (BCY) removed for multiple bulk categories.

Checklists

Form Title Format
Aboveground Storage Tank Self-Inspections
For use by owners and operators of aboveground storage tank facilities.