9 Va. Admin. Code § 20-170-400:9

Current through Register Vol. 40, No. 22, June 17, 2024

Section 9VAC20-170-400:9 - APPENDIX IX

(NOTE: Instructions in brackets are to be replaced with the relevant information and the brackets deleted.)

CERTIFICATION OF VALID CLAIM

The undersigned, as principals and as legal representatives of [insert vessel 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 a sudden and/or nonsudden accidental occurrence arising from a waste deposit from [owner or operator] vessel into state waters should be paid in the amount of $[ ].

[Signatures]

Vessel Owner or Operator

Attorney for Owner or Operator

[Notary] [Date]

[Signature(s)]

Claimant(s)

Attorney(s) for Claimant(s)

[Notary] [Date]

9 Va. Admin. Code § 20-170-400:9

Derived from Virginia Register Volume 19, Issue 19, eff. July 2, 2003

Statutory Authority

§§ 10.1-1402 and 10.1-1454.1 of the Code of Virginia.