PTRCB Equipment Policy Acknowledgement

I, the undersigned, have read and understand the conditions of the
Petroleum Release Compensation Board Equipment Policy regarding
reimbursement for the cost of equipment.

Owner Name:  
Owner Address:



Phone:  
Facility ID Number:  
Facility Name:  
Facility Address:



DEQ Release Number:  
Equipment Model Purchase Date
Owner Signature:   Date:

Please complete and return to:

Petroleum Tank Release Compensation Board
PO Box 200902
Helena, MT  59620