Technical Assistance Program Application Form – Gasoline/Diesel Step 1 of 8 12% Under the Technical Assistance Program (TAP), the Pollution Liability Insurance Agency (PLIA) may provide informal site-specific technical consultations and issue written opinion letters to persons conducting independent remedial actions at qualifying petroleum cleanup sites. PLIA may provide the described services under the authority of RCW 70A.330.040 (9) and the Model Toxics Control Act (MTCA), Chapter 70A.305 RCW and 173-340 WAC. It is PLIA’s goal to issue a written opinion letter within 45 days of receiving a request and all other required documentation. PART 1 - ELIGIBILITYFor a site to qualify for service under TAP, certain qualifying conditions must be met. PLIAs eligibility factors can be found here. If the site does not meet the criteria for TAP, please refer to the Department of Ecology’s Voluntary Cleanup Program.A. Funding FactorsIs the site funded by a PLIA Loan or Grant and/or insured by either Colony Group, Crum and Forster Specialty Insurance Company or Great American E&S Insurance Company?* Yes No Unknown If "No" or "Unknown" to the above, is the site remediation funded by The Department of Ecology?* Yes No Unknown The site is not eligible for TAP. Please refer to the Department of Ecology’s Voluntary Cleanup Program. B. Site Type FactorsWas heating oil or gasoline stored on the property?* Heating Oil Gasoline Both Is surface water or sediment contamination present?* Yes No Unknown The site is not eligible for TAP. Please refer to the Department of Ecology’s Voluntary Cleanup Program.If "No" or "Unknown" to the above, are co-mingled, non-petroleum contaminants present at the site?*Your site may be eligible if the presence of co-mingled contaminants is incidental. For clarification click here. Yes No, or only incidental non-petroleum contaminants The site is not eligible for TAP. Please refer to the Department of Ecology’s Voluntary Cleanup Program. C. Location FactorsPlease select all that apply. The site is within the bounds of or impacts the following:* A Dangerous Waste site managed by the Department of Ecology’s Hazardous Waste Toxics Reduction Program. A Nuclear Waste Program. A Superfund Site. An Industrial Section Site. None of the above apply. Based on your selections, the site is not eligible for TAP. Please refer to the Department of Ecology’s Voluntary Cleanup Program.D. Legal FactorsPlease select all that apply. The following legal factors apply to the site:* A Potentially Liable Party (PLP) dispute about liability is in progress. Litigation regarding the site, court supervision or agreed order is in progress. Remediation is occurring under an active contract between the Department of Ecology and the PLP. None of the above. Based on your selections, the site is not eligible for TAP. Please refer to the Department of Ecology’s Voluntary Cleanup Program. PART 2 - ADMINISTRATIONA. Customer Information.The Customer is the person or organization requesting services from PLIA under TAP, and is responsible for paying the $9,500 program fee. The authority and duty of the Customer are explained in the Agreement.Name* First Last Title*Mr.Mrs.Ms.Dr.Ind.OtherCompany Name Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Code Phone*FaxEmail* What is the Customer’s relationship to the Site? (Please check all that apply)* Property owner Property lessee Past property owner Attorney Consultant Mortgage holder Other If Other, please specify* Who will be the Primary Contact? All official correspondence will be addressed to the Primary Contact.* Customer Property owner Project Manager B. Project Manager InformationPLIA will send this person a copy of all official correspondence. This person must be either the Customer or hired by the Customer. Please enter the required information below. Same as above Name* First Last Title*Mr.Mrs.Ms.Dr.Ind.OtherCompany Name Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Code Phone*FaxEmail* C. Property Owner Information Same as above Name* First Last Title*Mr.Mrs.Ms.Dr.Ind.OtherCompany Name Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Code PhoneFaxEmail What type of entity is the property owner?*PrivateTribalFederalStateCountyMunicipalMixedPublic SchoolOtherIf Other, please specify* Add additional property owner?” Name* First Last Title*Mr.Mrs.Ms.Dr.Ind.OtherCompany Name Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Code PhoneFaxEmail What type of entity is the property owner?*PrivateTribalFederalStateCountyMunicipalMixedPublic SchoolOtherIf Other, please specify* PART 3 – DESCRIPTION OF SITEA. Name of the SiteIf the site has already been identified by the state of Washington, enter the name provided by PLIA or the Department of Ecology. Otherwise, enter a suggested name for the site. ( e.g. Xyz Deli).Name* If known, enter the following site identification numbers.Facility Site ID # UST Site ID # B. Location of Property where the Release(s) Occurred (Source Property and/or Property Where Cleanup Will Occur)Do you know on which property the release(s) occurred?* Yes No Physical Address of PropertyPlease refer to the source property when answering the following questions.Please refer to the property addressed by your cleanup when answering the following questions.Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Code Geographic Position Please enter the geographic position of the property below. CoordinatesLatitude* Longitude* Legal DescriptionsTax Parcel #(s)* County* Identification of Properties Affected by the Release(s)Does the release(s) affect any properties adjacent to the source property?* Yes No Unknown If "Yes" to the above, please enter the county and tax parcel information of properties affected by the release.CountyTax Parcel #(s) C. Identification of Public Right-of-Ways Affected by the Release(s)Does the release(s) affect any public right-of-ways (for example, streets)* Yes No Unknown If "Yes" to the above, please specify*D. Hazardous Substances and Affected MediaPlease identify in the following table the hazardous substance(s) released and the affected media (soil, ground water, and/or air).*Hazardous Substance Soil Ground Water Air Petroleum-GasolinePetroleum-OtherBenzeneHalogenated SolventsLeadMetals - OtherMethyl tertiary-butyl etherNon-Halogenated SolventsPolychlorinated biPhenyls (PCB)Polynuclear Aromatic HydrocarbonsArsenicAsbestosBenthic FailuresBioassay FailureConventional Contaminants, InorganicConventional Contaminants, OrganicCorrosive WastesHalogenated PesticidesMercuryNon-Halogenated PesticidesOther Deleterious SubstancesOther Halogenated OrganicsOther Non-Halogenated OrganicsOther Reactive WastesPBDEPhenolic CompoundsRadioactive WastesTributyltinUnExploded OrdnanceConfirmed, Above Cleanup Level Confirmed, Below Cleanup Level Confirmed, Not Present Suspected Not Suspected Unknown Confirmed, Above Cleanup LevelConfirmed, Below Cleanup LevelConfirmed, Not PresentSuspectedNot SuspectedUnknownConfirmed, Above Cleanup Level Confirmed, Below Cleanup Level Confirmed, Not Present Suspected Not Suspected Unknown E. Indoor AirAre contaminant odors present in any buildings, manholes, or other confined spaces?* Yes No Unknown If "Yes" to the above, please specify, including distance from contamination.* PART 4 – DESCRIPTION OF INDEPENDENT REMEDIAL ACTIONS AT THE SITEA. Scope of Remedial ActionsBriefly describe your proposed remedial actions and clean up goals at the site PART 5 - ATTACHMENTSPlease attach to this application a report that includes the information below. Use the headings provided. Download a printable version of these requirements. Description of the Site Describe the source(s), circumstances and discovery of the release. Operational History of the Site Remedial Actions Describe the current status of remedial actions at the site. Complete a terrestrial ecological evaluation (TEE) or document an exclusion from further evaluation using the criteria in WAC 173-340-7491. Maps Please follow the reporting requirements below when requesting written opinions on planned or completed remedial actions: Licensing. Documents submitted containing geologic, hydrologic or engineering work must be under the seal of an appropriate licensed professional, as required by Chapters 18.43 and 18.220 RCW. Data Submittal. Environmental sampling data must be submitted in both a printed format and an electronic format capable of being transferred into the Department of Ecology’s data management systems. Please attach to this application a report that includes the information described here. Please use the headings provided. Failure to follow these requirements may result in unnecessary delays. PLIA will not issue a No Further Action (NFA) opinion unless these requirements are satisfied. Note: You will be uploading your files to a third-party secure file storage service.A. Documentation of Remedial ActionsPlease list all known remedial action plans or reports produced for the site in the table below, and note whether or not they are being uploaded along with this formTitleAuthorDateSubmitted to PLIA (Yes/No)? Upload your files for TAP IMPORTANT FILE NAMING REQUIREMENTS: Please include your site’s FSID# at the beginning of all filenames for files uploaded to PLIA. This will ensure that your files remain associated with your application. If you do not know the FSID# for your site, please include the property/site address at the beginning of all filenames. If you do not see the Box.com upload form below, or if you are having trouble uploading your file(s), please contact PLIA at (800) 822-3905 or by email. PART 6 - TERMS OF AGREEMENT AND SIGNATURE The Washington State Pollution Liability Insurance Agency (PLIA) provides informal site-specific technical consultations and written opinion letters under the Technical Assistance Program (PTAP). The Customer is entering into this Agreement under the authority of RCW 70.149.040 (9) and the Model Toxics Control Act (MTCA), Chapter 70.105D RCW, and its implementing regulations, Chapter 173-340 WAC. Services Provided by PLIA Under TAP, PLIA provides the Customer informal site-specific advice and assistance on the administrative and technical requirements of MTCA consistent with WAC 173-340-515(5). Consultations may include assistance in identifying applicable regulatory requirements and opinions on whether the remedial actions proposed for or conducted at the Site meet those requirements. All opinion letters are based on an analysis of whether the remedial action meets the substantive requirements of MTCA, Chapter 70.105D RCW, and it’s implementing regulations, Chapter 173-340 WAC (collectively “substantive requirements of MTCA”). Payment for Services by the Customer The Customer agrees to pay the one-time program fee of $9,500 prior to receiving services provided under the TAP. The Customer may pay the required fee prior to, at or after the intake meeting. The program fee is non-refundable. Intake Meeting The Customer agrees to schedule an intake meeting. The Customer must choose a date that does not exceed three months from the date of application submittal. All intake meetings are held virtually. Electronic copies of relevant reports and maps should be provided to PLIA ahead of the intake meeting. The agenda will include, but is not limited to, a discussion of the following items: Customer goals for the project (site or property opinion letter). History and future use of the site. Any proposed or completed cleanup activities. The Conceptual Site Model for the site. Current remedial plan. Identification of data gaps, if any. Setting milestones for cleanup. Establishing a timeline commitment that includes quarterly progress reports. PLIA will provide written notice of formal acceptance into the program within 5 business days after the payment has processed that includes: the TAP project identification number, the assigned Site Manager, and important dates. Progress Reports The Customer agrees to submit a progress or status report, in alignment with the intake meeting timeline, to the Site Manager every 90 days. Failure to submit scheduled reports may result in project termination. Project Termination This Agreement may be terminated by either party without cause by sending written notice to the other party. The effective date of termination will be the date PLIA sends notice to the Customer or the date PLIA receives notice from the Customer. Unless otherwise directed, issuance of a No Further Action opinion, either for the Site as a whole or for a portion of the real property located within the Site, shall constitute notice of termination by PLIA. Reservation of Rights/No Settlement This agreement does not constitute a settlement of Liability to the state under MTCA. This Agreement also does not protect a liable person from contribution claims by third parties for matters addressed by the agreement. The state does not have the authority to settle with any person potentially liable under MTCA except in accordance with RCW 70.105D.040(4). PLIA reserves all rights under MTCA, including the right to require additional or different remedial actions at the Site should it deem such actions necessary to protect human health and the environment, and to issue orders requiring such remedial actions. Liability The state of Washington and/or the Pollution Liability Insurance Agency accepts no liability, nor portion of liability, from the Customer. The state of Washington, PLIA, and its officers and employees are immune from all liability, and no cause of action arises from any act or omission in providing, or failing to provide, advice, opinion, conclusion, or assistance under this program. Statement and Signature The undersigned affirms that the information contained in this application is true and accurate to the best of my knowledge and I understand and agree to the terms of this Agreement as specified above. Your application is not complete until you schedule your intake meeting. Formal acceptance into PTAP follows the intake meeting. Upon submitting this form, you will be directed to an e-signature page, attesting and affirming that you understand and agree to the Terms of this Agreement, and that the information contained in this application is true and accurate to the best of your knowledge. IMPORTANT: After you've uploaded your files and submitted your application, you'll be forwarded to a confirmation screen to schedule your your REQUIRED intake meeting . Your application is not complete until you schedule your intake meeting. Formal acceptance into TAP follows the intake meeting.Name* First Last Submitter/Signatory Email* What is the signatory’s involvement at the site? Please check all that apply. Customer Property Owner Consultant Attorney Other If Other, please specify* CAPTCHA
