N.H. Admin. Code § Odb 403.02

Current through Register No. 50, December 12, 2024

Section Odb 403.02 - Reimbursement Authorization Form

An owner submitting a reimbursement request shall provide the following information on a "Reimbursement Authorization Form" obtained from the board:

(a) Authorization information including the type of facility or project and whether reimbursement is sought for corrective action costs or third-party damages;

(b) Facility, property, and project information including:

(1) Facility and property name, as applicable;

(2) Address;

(3) Location town;

(4) The department facility identification number if applicable;

(5) The department project number;

(6) For an initial authorization, the date of discharge discovery; and

(7) A statement indicating whether the facility is active or permanently closed;

(c) Owner and insurance information including:

(1) Owner name;

(2) Mailing address;

(3) Daytime phone number;

(4) Whether the owner is a new owner since the last authorization;

(5) Number of facilities owned if more than one; and

(6) If an initial authorization for a discharge, whether other insurance coverage is available; and

(d) The owner's or corporate officer's signature and date certifying the following liability statement and affirmation:

"I hereby certify that the facility referenced above is currently in compliance, or I am the owner of land where a compliant facility was located, or I am a duly authorized officer of the entity that owns the compliant facility or land where a compliant facility was located. I understand that a 'deductible' or deductible balance may be applied against any amounts reimbursed from the fund. If reimbursement is made to an 'applicant', I understand that the deductible or deductible balance amount may be billed and that said amount is due within 30 days of the billing date, unless the board approves periodic payments. I understand the funds under RSA 146-D:6, IV (b-d) only provide excess insurance coverage. I declare that the representations made in this reimbursement authorization are to the best of my knowledge true and correct, and agree to reimburse the fund for any payments made based upon incorrect information on this form, or incorrect reimbursement submittal information. If an officer of the owner, I affirm that I have been duly authorized by the corporation, LLC, LLP, or other corporate entity to bind the corporation, LLC, LLP, or other corporate entity, and to make the above declarations. I also affirm that the corporation, LLC, LLP, or other corporate entity has made all filings and paid all fees required by the New Hampshire Secretary of State."

N.H. Admin. Code § Odb 403.02

#8491, eff 11-22-05; ss by #9935-B, eff 9-1-11

Amended by Volume XL Number 2, Filed January 9, 2020, Proposed by #12941, Effective 12/15/2019, Expires 12/15/2029