7 Del. Admin. Code § 1352-D-29.0
The undersigned, as principals and as legal representatives of [Owner or Operator] and [insert name and address of third-party claimant] hereby certify that the claim of Bodily Injury [and/or] Property Damage caused by an Accidental Release arising from operating [Owner or Operator] aboveground storage tank should be paid in the amount of $[______________].
Signature(s) of Owner or Operator: ______________________________________________
Name of Owner or Operator: ____________________________________________________
Print legibly or type
Name of Attorney for Owner or Operator: _________________________________________
Print legibly or type
Signature of Attorney for Owner or Operator: ____________________________________
Notary:_____________________________________ Date: __________________
Signature of Claimant: __________________________________________________________
Name of Claimant: ____________________________________________________________
Print legibly or type
Name of Attorney for Claimant: ________________________________________________
Print legibly or type
Signature of Attorney for Claimant: ________________________________________________
Notary_____________________________________ Date ___________________
7 Del. Admin. Code § 1352-D-29.0