40 C.F.R. § 280.95
Letter From Chief Financial Officer
I am the chief financial officer of [insert: name and address of the owner or operator, or guarantor]. This letter is in support of the use of [insert: "the financial test of self-insurance," and/or "guarantee"] to demonstrate financial responsibility for [insert: "taking corrective action" and/or "compensating third parties for bodily injury and property damage"] caused by [insert: "sudden accidental releases" or "nonsudden accidental releases" or "accidental releases"] in the amount of at least [insert: dollar amount] per occurrence and [insert: dollar amount] annual aggregate arising from operating (an) underground storage tank(s).
Underground storage tanks at the following facilities are assured by this financial test or a financial test under an authorized State program by this [insert: "owner or operator," and/or "guarantor"]: [List for each facility: the name and address of the facility where tanks assured by this financial test are located, and whether tanks are assured by this financial test or a financial test under a State program approved under 40 CFR part 281. If separate mechanisms or combinations of mechanisms are being used to assure any of the tanks at this facility, list each tank assured by this financial test or a financial test under a State program authorized under 40 CFR part 281 by the tank identification number provided in the notification submitted pursuant to 40 CFR 280.22 or the corresponding State requirements.]
A [insert: "financial test," and/or "guarantee"] is also used by this [insert: "owner or operator," or "guarantor"] to demonstrate evidence of financial responsibility in the following amounts under other EPA regulations or state programs authorized by EPA under 40 CFR parts 271 and 145:
| EPA Regulations | Amount |
| Closure (§§ 264.143 and 265.143 ) | $____ |
| Post-Closure Care (§§ 264.145 and 265.145 ) | $____ |
| Liability Coverage (§§ 264.147 and 265.147 ) | $____ |
| Corrective Action (§ 264.101(b) ) | $____ |
| Plugging and Abandonment (§ 144.63 ) | $____ |
| Closure | $____ |
| Post-Closure Care | $____ |
| Liability Coverage | $____ |
| Corrective Action | $____ |
| Plugging and Abandonment | $____ |
| Total | $____ |
This [insert: "owner or operator," or "guarantor"] has not received an adverse opinion, a disclaimer of opinion, or a "going concern" qualification from an independent auditor on his financial statements for the latest completed fiscal year.
[Fill in the information for Alternative I if the criteria of paragraph (b) of § 280.95 are being used to demonstrate compliance with the financial test requirements. Fill in the information for Alternative II if the criteria of paragraph (c) of § 280.95 are being used to demonstrate compliance with the financial test requirements.]
| Alternative I | |
| 1. Amount of annual UST aggregate coverage being assured by a financial test, and/or guarantee | $____ |
| 2. Amount of corrective action, closure and post-closure care costs, liability coverage, and plugging and abandonment costs covered by a financial test, and/or guarantee | $____ |
| 3. Sum of lines 1 and 2 | $____ |
| 4. Total tangible assets | $____ |
| 5. Total liabilities [if any of the amount reported on line 3 is included in total liabilities, you may deduct that amount from this line and add that amount to line 6] | $____ |
| 6. Tangible net worth [subtract line 5 from line 4] | $____ |
| Yes No | |
| 7. Is line 6 at least $10 million? | __ __ |
| 8. Is line 6 at least 10 times line 3? | __ __ |
| 9. Have financial statements for the latest fiscal year been filed with the Securities and Exchange Commission? | __ __ |
| 10. Have financial statements for the latest fiscal year been filed with the Energy Information Administration? | __ __ |
| 11. Have financial statements for the latest fiscal year been filed with the Rural Utilities Service? | __ __ |
| 12. Has financial information been provided to Dun and Bradstreet, and has Dun and Bradstreet provided a financial strength rating of 4A or 5A? [Answer "Yes" only if both criteria have been met.] | |
| Alternative II | |
| 1. Amount of annual UST aggregate coverage being assured by a test, and/or guarantee | $____ |
| 2. Amount of corrective action, closure and post-closure care costs, liability coverage, and plugging and abandonment costs covered by a financial test, and/or guarantee | $____ |
| 3. Sum of lines 1 and 2 | $____ |
| 4. Total tangible assets | $____ |
| 5. Total liabilities [if any of the amount reported on line 3 is included in total liabilities, you may deduct that amount from this line and add that amount to line 6] | $____ |
| 6. Tangible net worth [subtract line 5 from line 4] | $____ |
| 7. Total assets in the U.S. [required only if less than 90 percent of assets are located in the U.S.] | $____ |
| Yes No | |
| 8. Is line 6 at least $10 million? | __ __ |
| __ __ | |
| 9. Is line 6 at least 6 times line 3? | __ __ |
| 10. Are at least 90 percent of assets located in the U.S.? [If "No," complete line 11.] | __ __ |
| 11. Is line 7 at least 6 times line 3? [Fill in either lines 12-15 or lines 16-18:] | __ __ |
| Yes No | |
| 12. Current assets | $____ |
| 13. Current liabilities | $____ |
| 14. Net working capital [subtract line 13 from line 12] | $____ |
| Yes No | |
| 15. Is line 14 at least 6 times line 3? | __ __ |
| 16. Current bond rating of most recent bond issue | __ __ |
| 17. Name of rating service | __ __ |
| 18. Date of maturity of bond | __ __ |
| 19. Have financial statements for the latest fiscal year been filed with the SEC, the Energy Information Administration, or the Rural Utilities Service? | __ __ |
[If "No," please attach a report from an independent certified public accountant certifying that there are no material differences between the data as reported in lines 4-18 above and the financial statements for the latest fiscal year.]
[For both Alternative I and Alternative II complete the certification with this statement.]
I hereby certify that the wording of this letter is identical to the wording specified in 40 CFR 280.95(d) as such regulations were constituted on the date shown immediately below.
[Signature]
[Name]
[Title]
[Date]
40 C.F.R. §280.95