9 Va. Admin. Code § 25-590-260:10
Current through Register Vol. 41, No. 4, October 8, 2024
[Note: The instructions in brackets are to be replaced by the relevant information and the brackets deleted.]
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] [Signature(s)]
Owner or Operator Claimant(s)
Attorney for Attorney(s) for
Owner or Operator Claimant(s)
(Notary) Date (Notary) Date
9 Va. Admin. Code § 25-590-260:10