Section R18-12-603. General Application and Direct Payment Request Requirements

A.      Department Form. An eligible person or the designated repre- sentative of an owner or operator shall submit a reimburse- ment and preapproval application and direct payment request on a form provided by the Department.

B.       Application and Direct Payment Request Contents. An appli- cation or direct payment request shall include the following:

1.        Information on the eligible person, as follows:

a.         Name and any contact person with a description of the relationship of the contact person to the eligible person, and address, daytime telephone number, fax number, if any, and e-mail address, if any, for both the eligible person and the contact person;

b.        Status as an owner of an UST system that is a sub- ject of the application, an operator of an UST system that is a subject of the application, a political subdi- vision described at A.R.S. § 49-1052(H), or a volun- teer; and

c.         The Department-assigned identification number of the eligible person;

2.        For a designated representative of an owner or operator, a copy of the written assignment to the designated repre- sentative of any rights, title, and interest the owner or operator may have in the proceeds of a reimbursement from the assurance account;

3.        Information on the facility that is the subject of the appli- cation or direct payment request, as follows:

a.         The facility name; address; daytime telephone num- ber; fax number, if any; and e-mail address, if any;

b.        The Department-assigned facility identification number; and

c.         The Department-assigned LUST file number for each release that is the subject of the application or direct payment request;

4.        Identification of the phase or phases of corrective action that are the subject of the application or direct payment request;

5.        Information on the corrective action service provider per- forming eligible activities that are the subject of the appli- cation or direct payment request, as follows:

a.         Name and  contact  person, address, daytime tele- phone number, fax number, and e-mail address of the corrective action service provider and the contact person;

b.        Identification of the corrective action service pro- vider as a licensed contractor or consultant;

c.         As applicable, the seal number assigned to the regis- trant by the Board of Technical Registration; and

d.        As applicable, the license number issued by the Reg- istrar of Contractors;

6.        For owners and operators, all of the following on a sepa- rate form provided by the Department:

a.         For claims that when combined with all other approved  costs  associated   with  a  release  exceed

$500,000 for a release, documentation demonstrat- ing that any insurance or alternative financial assur- ance mechanism required for coverage under A.R.S.

§ 49-1052(F)(5) has been utilized to the maximum extent possible. Failure to provide documentation that meets the requirements of this subsection shall result in denial of the portion of the application or direct payment request that exceeds $500,000 for a release;

b.        A statement of the amount of any benefits received from any insurance coverage or alternative financial assurance mechanism relating to the costs of the cor- rective action that is a subject of the application or direct payment request and any claims against insur- ance or alternative financial assurance mechanism relating to corrective action costs associated with the

UST that is the source of any release that is the sub- ject of the application or direct payment request;

7.        A statement that, in the event ranking is required under R18-12-612, either the eligible person waives financial need priority points or the eligible person requests direct written notice of ranking under R18-12-612(A);

8.        A signed and notarized statement of the eligible person, with the eligible person’s original signature, certifying that:

a.         The eligible person has paid or has agreed to pay the copayment;

b.        For a reimbursement application or direct payment request, the eligible person has incurred the claimed costs and is seeking payment for work actually per- formed;

c.         For the eligible person who is an owner or operator, the eligible person’s consultant, representative, or agent has not and will not receive payment from insurance or any alternative financial assurance mechanism for the claimed costs of the corrective actions;

d.        Naptha-type jet fuel or kerosene-type jet fuel were not placed in the UST system that is the subject of the application;

e.         A substance described under A.R.S. § 49-1001(14)(b) was not placed in the UST system on or after July 1, 1997, unless the owner or operator paid the excise tax before July 1, 1997, elected to continue to pay the excise tax, and is not delinquent in paying the excise tax;

f.         The eligible person has not been convicted of fraud relating to performance of eligible activities or any claim to the assurance account; and

g.        The application or direct payment request and its contents are true, accurate, and complete to the eligi- ble person’s best information and belief;

9.        A signed and notarized statement, with original signature of the eligible person or the designated representative of the owner or operator identifying by name, address, day- time telephone number, fax number, and federal employer identification (tax) number or social security number of the person that is to appear on the payment warrant. A completed Internal Revenue Service form W- 9 for the person that is to appear on the payment warrant shall be included with the reimbursement application or direct payment request, unless the applicable Internal Revenue Service form W-9 has been on file with the Department for less than one year. If the eligible person is the person identified to appear on the payment warrant, the reimbursement application or direct payment request shall include proof, consisting of copies of cancelled checks or financial institution statements, that the eligible person paid the costs. If neither copies of cancelled checks nor financial institution statements are available, a sworn statement, by individual invoice, from the correc- tive action service provider.

10.     A signed and notarized statement of the corrective action service provider supervising, managing, or performing the eligible activities that are the subject of the applica- tion or direct payment request, with the original signature of the corrective action service provider, certifying that:

a.         The corrective action service provider supervised, managed, or performed the corrective actions, or in a preapproval application, prepared the work plan, in accordance with R18-12-605;

b.        For consultants, the corrective actions were per- formed in accordance with the requirements of the Arizona Board of Technical Registration, as applica- ble;

c.         For licensed contractors, the eligible activities were performed in accordance with the requirements of the Registrar of Contractors;

d.        The corrective action service provider or the individ- ual registrant have not been convicted of fraud relat- ing to performance of any eligible activities or any claim to the assurance account; and

e.         The invoices submitted with the reimbursement application or direct payment request include only costs for actual work performed;

11.     Other documentation as necessary to demonstrate that any claimed costs are eligible; and

12.     If applicable, a statement notifying the Department of any agreement demonstrating the eligible person has agreed to pay the copayment, and a copy of the agreement, if a copy is requested by the Department pursuant to R18-12- 609(A).

Historical Note

Adopted effective September 21, 1992 (Supp. 92-3). Sec- tion repealed; New Section made by final rulemaking at 12 A.A.R. 1611, effective June 4, 2006 (Supp. 06-2).