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
Owner or Operator
Attorney for Owner or Operator
Notary
Date
[Signature(s)]
Claimant(s)
Attorney(s) for Claimant(s)
Notary
Date_________or
N.D. Admin Code 33-24-08-102
General Authority: NDCC 23-20.3-03, 23-20.3-04.1
Law Implemented: NDCC 23-20.3-04.1