Certification of Valid Claim
The undersigned, as principals and as legal representatives of [insert: 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's or operator"s] underground storage tank should be paid in the amount of $[___].
[Signatures]
[Tank system owner or operator]
[Attorney for tank system owner or operator]
(Notary)
Date
[Signatures]
Claimant(s)
Attorney(s) for Claimant(s)
(Notary)
Date
N.Y. Comp. Codes R. & Regs. Tit. 6 §§ 613-8.7