Spreadsheet: 5a06640a-947e-4e51-9243-0a2dcdae2a6b
Sheet: Sheet1

Unnamed: 0 | Unnamed: 1 | Unnamed: 2 | EXCESS LIABILITY TRUST FUND | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10 | Unnamed: 11 | TO BE COMPLETED BY IDEM | Unnamed: 13 | Unnamed: 14 | Unnamed: 15 | Unnamed: 16 | Unnamed: 17 | Unnamed: 18 | Unnamed: 19 | Unnamed: 20 | Unnamed: 21 | Unnamed: 22 | Unnamed: 23 | Unnamed: 24 | Unnamed: 25 | Unnamed: 26 | Unnamed: 27 | Unnamed: 28 | Unnamed: 29 | Unnamed: 30 | Unnamed: 31 | Unnamed: 32 | Unnamed: 33 | Unnamed: 34 | Unnamed: 35 | Unnamed: 36 | Unnamed: 37 | Unnamed: 38 | Unnamed: 39 | Unnamed: 40 | Unnamed: 41 | Unnamed: 42 | Unnamed: 43 | Unnamed: 44 | Unnamed: 45 | Unnamed: 46 | Unnamed: 47 | Unnamed: 48 | Unnamed: 49 | Unnamed: 50 | Unnamed: 51 | Unnamed: 52 | Unnamed: 53 | Unnamed: 54 | Unnamed: 55 | Unnamed: 56 | Unnamed: 57 | Unnamed: 58 | Unnamed: 59 | Unnamed: 60 | Unnamed: 61 | Unnamed: 62 | Unnamed: 63 | Unnamed: 64 | Unnamed: 65 | Unnamed: 66 | Unnamed: 67 | Unnamed: 68 | Unnamed: 69 | Unnamed: 70 | Unnamed: 71 | Unnamed: 72 | Unnamed: 73 | Unnamed: 74 | Unnamed: 75 | Unnamed: 76 | Unnamed: 77 | Unnamed: 78 | Unnamed: 79 | Unnamed: 80 | Unnamed: 81 | Unnamed: 82 | Unnamed: 83 | Unnamed: 84 | Unnamed: 85 | Unnamed: 86
 |  |  | ELIGIBILITY APPLICATION |  |  |  |  |  |  |  |  | Date submitted (month/day/year)
 |  |  | State Form 55459 (11-13) |  |  |  |  |  |  |  |  | ELTF control number
INSTRUCTIONS: This form should be submitted when applying for an eligibility determination. For detailed information on completing this form, please see the INSTRUCTIONS tab (located at bottom of Excel document).  Note:  Applications will not be processed that contain incomplete information (all fields on this application must be completed) or do not contain the required Power of Attorney forms.
TO BE COMPLETED BY APPLICANT
SECTION 1 - APPLICANT INFORMATION
Name of Applicant |  |  |  |  |  |  |  | [NAME] (Check all that apply.)
Mailing Address of Applicant (Number and Street) |  |  |  |  |  |  |  | City, State, ZIP Code
Name of Contact Person |  |  |  |  |  |  |  |  |  |  |  | Contact Telephone Number (with Area Code)
Contact Email Address
Was there private insurance that may cover this release? |  |  |  |  |  |  |  |  |  | Name of Insurance Company |  |  |  | Policy Number
SECTION 2 -SITE INFORMATION
Facility Identification Number |  |  |  |  | Date Incident Reported to IDEM (month/day/year) |  |  |  |  |  |  | LUST Incident Number
Name of Facility |  |  |  |  |  |  |  | IDEM Project Manager |  |  |  | County Where Facility is Located
Address of Facility (NOTE: enter 911 Street Address.) |  |  |  |  |  |  |  |  |  | City, State, ZIP Code
SECTION 3 - UNDERGROUND STORAGE TANK FEE PAYMENT INFORMATION
In accordance with 328 IAC 1-1-9(a)(2), a minimum of 50% of required UST fees must have been paid before the incident discovery.
Did the Claimant pay at least 50% of UST fees before the date of the release?
In accordance with 328 IAC 1-3-3(d) a person who acquires ownership or operation of an UST under IC 13-23-8-4.5(2) must submit an "Intent to Acquire UST and Reinstate Eligibility" form to IDEM at least sixty (60) days prior to the acquisition in order to become eligible for reimbursement from the ELTF.
Was an "Intent to Acquire UST and Reinstate Eligibility" form submitted sixty (60) days prior to aquiring the property?
In accordance with 328 IAC 1-3-3(a)(6), the claimant must pay all past and currently due fees under IC 13-23-12-1.
Did the Claimant pay all past and currently due fees?
Please list the years of payment (e.g. 1988-2010, 2012):  (Claimant should include available payment receipts for verification of payment.)
SECTION 4 - INCIDENT REPORTING INFORMATION
In accordance with 328 IAC 1-1-9, the release must be reported within fourteen (14) days of the date the release was required to be reported under the spill reporting rule in rules of the Solid Waste Management Board at 329 IAC 9-4-4.
Please list the date the contamination was discovered or suspected (month/day/year):
Please list the date the contamination was reported to IDEM (month/day/year):
SECTION 5 - INITIAL SITE CHARACTERIZATION, THIRD PARTY REPORTS, AND NO FURTHER ACTION INFORMATION
In accordance with 328 IAC 1-3-1 (b)(2), an Initial Site Characterization Report must be submitted to IDEM.
Has an Initial Site Characterization (ISC) report been submitted?
ISC due date (month/day/year): |  |  |  |  |  |  |  |  | ISC submission date (month/day/year):
In [NAME] with 328 IAC 1-3-3, the results of a third party investigation must be provided to the owner or operator within forty-five (45) days of sampling.  Have these sampling results and any notification of a potential release been sent to the owner or operator via certified mail?
In accordance with 328 IAC 1-3-1 (c), claims must be submitted nine months after the incident is granted No Further Action (NFA) status.
Has the incident received a No Further Action (NFA) letter?
 |  |  |  |  |  |  |  |  | NFA date (month/day/year):
 |  |  | EXCESS LIABILITY TRUST FUND |  |  |  |  |  |  |  |  | TO BE COMPLETED BY IDEM
 |  |  | ELIGIBILITY APPLICATION |  |  |  |  |  |  |  |  | Date submitted (month/day/year)
 |  |  | State Form 55459 (11-13) |  |  |  |  |  |  |  |  | ELTF control number
TO BE COMPLETED BY APPLICANT (continued)
SECTION 6 - UST COMPLIANCE INFORMATION PRIOR TO THE DATE OF THE SUSPECTED RELEASE
In accordance with 328 IAC 1-3-3 and 329 IAC 9-2-2,  an accurate and fully completed UST Notification form must have been submitted to IDEM.  Please submit copies of all past and present UST Notification forms.
If the facility has failed any of the previously conducted IDEM UST Inspections, please explain any new procedures, repairs, or maintenance completed to correct the issue(s):
Please identify the parts of the UST system that met the 1998 standards at the time the release was suspected.
 |  |  | Corrosion Protection |  |  |  |  | Leak Detection |  |  | Spill Protection |  |  | Overfill Protection
Were the USTs in Temporary Closure at the Time the Release was Suspected?
Was the Piping Double Walled at the Time the Release was Suspected?
Was the Tank Double Walled at the Time the Release was Suspected?
Please Submit Copies and Identify the Dates of the Last Testing Prior to the Date of the Suspected Release:
Tank Tightness Test: |  |  |  |  |  |  | Line Tightness Test: |  |  |  |  | [NAME] Test:
In Summary,  Claimant Should Submit Available: (Electronic PDF copies are acceptable.)
 |  |  | Copies of all UST Notification Forms
 |  |  | Copies of UST Fee Payment Receipts.
 |  |  | Most Recent Copies of Line Tightness, Tank Tightness, Corrosion, and Tank Lining Inspections.
 |  |  | Copies of Most Recent UST Repair Invoices with Description of Work Completed.
 |  |  | Copy of Initial Incident Report.
 |  |  | Power of Attorney (if signing for the owner/operator)
SECTION 7 - SIGNATURE OF OWNER/OPERATOR, ATTORNEY-IN-FACT OR ASSIGNEE
I swear or affirm to the best of my knowledge and belief that the costs presented herein represent the reimbursable costs actually incurred in the performance of site characterization or corrective action related to this site during the period of time indicated on this application. I also swear or affirm that all charges presented as part of this application were necessary to the performance of site characterization or corrective action.  I understand that pursuant to Indiana Code 13-23-9-6, I may be subject to criminal and civil penalties for submitting false and/or inaccurate information on this application.
Signature of Assignee of Rights |  |  |  |  |  |  |  |  |  |  |  | Date signed (month/day/year)
Mr./Ms. | Print Name |  |  |  |  |  |  |  |  | Title |  |  | Company
Signature of Owner/Operator or Attorney-In-Fact |  |  |  |  |  |  |  |  |  |  |  | Date signed (month/day/year)
Mr./Ms. | Print Name |  |  |  |  |  |  |  |  | Title |  |  | Company