Financial Assurance Program Enrollment Application

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Introduction

Thank you for your interest in the Washington State Financial Assurance Program (FA Program).

Please review the application checklist prior to applying. This list shows required information and documentation for program enrollment. 

Please note that all information submitted in your application is subject to public disclosure. For information containing personal identification such as social security numbers or bank account numbers, we require you to black out this information prior to submission.

If you cannot complete your application in one sitting, you can select the ‘Save my progress and resume later’ box at the top of the screen. We will save your application for 90 days.

You may wish to save a copy of the completed application for your records. For assistance or questions about this application, please call 360-407-0520 or email pliamail@plia.wa.gov.

For more information on Washington State’s Financial Assurance Program, visit https://plia.wa.gov/financial-assurance-program/ 

SECTION A: Applicant Information

The applicant must be the owner or operator of the facility at the time PLIA accepts the application and enrollment in the program begins.














Best Contact Person for Program Communication


If not, please provide contact information for the person we should communicate with regarding this application. 












Owners/Operators


If not, please provide contact information for all property owners, UST owners and UST operators.




Provide contact information for a designated agent at the company above.                            










Add another owner/operator


Please upload any branding or multiple owner agreement(s) listing the lessee(s) to this folder:  https://plia.app.box.com/f/56461681c578478e977b46530f3c8fdd.

Please Note: Failure to upload applicable leasing documents will lead to increased review time for your application.

SECTION B: Facility Information










To look up your UBI #, select Business Lookup at: https://secure.dor.wa.gov/gteunauth/

*Enter the tax parcel number(s) associated with your facility.
**For properties with multiple tax parcels, please separate parcel numbers with a comma. 

MM/DD/YYYY


MM/DD/YYYY







SECTION B: Facility Information cont.

Prior Petroleum Cleanup


If yes, please upload any environmental reports or documentation associated with the release and provide documentation of financial responsibility valid at the time of each release to this folder:  
https://plia.app.box.com/f/56461681c578478e977b46530f3c8fdd.







If yes, upload the No Further Action documentation to this folder:
https://plia.app.box.com/f/56461681c578478e977b46530f3c8fdd.



If yes, provide the following information for each business or person(s) who are involved:



Provide contact information for a designated agent at the company above.                            







Add another response

SECTION C: Tank Information

For each Underground storage tank (UST) you wish to enroll, please upload a copy of the following documents:
  • Most recent compliance status / Department of Ecology inspection report; 
  • Most recent compliance leak test checklist; and 
  • Most recent corrosion protection records for each UST 
Upload link: https://plia.app.box.com/f/56461681c578478e977b46530f3c8fdd.



In addition, please provide the following information for each UST:
UST for Enrollment





*Temporary closure is defined by Washington State Department of Ecology as when the tank is taken out of service and no longer dispensing regulated petroleum products.
















   




Compartments: for each compartment in this UST, please provide the following information. 





Add another compartment
Add another UST for enrollment

SECTION C: Tank Information cont.

Provide the following information for the UST system.



SECTION D: Financial Information

Provide the following information related to financial responsibility for any UST(s) at the facility, as required by Chapter 173-360A WAC, Part 10 Financial Responsibility.








SECTION E: Inspection Safety Plan Information


Emergency Information

Please provide the physical addresses and phone numbers information for the following emergency services:









Next Steps

Annual Enrollment Fee

Annual Enrollment Fee Costs:
  • UST is 0-10 years old: $1,000 per UST.
  • UST is 11-20 years old: $1,500 per UST.
  • UST is 21-30 years old: $2,000 per UST.
  • UST is 30+ years old: $2,500 per UST.

You must certify and submit on the next page. After application submittal, the Financial Assurance Program enrollment process includes the following steps:
  • PLIA will assign a project manager to your application and begin an internal review on the application.
    • If the application is incomplete, your assigned PLIA project manager will reach out to discuss any missing or incomplete information.
  • If the application is complete, PLIA will notify applicants and send the following documents for applicant review and signature:
    • Facility access agreement
    • Enrollment contract
    • Payment plan request form (if applicable)
  • Applicant submits payment after receiving the enrollment contract.
    • Payment is due in full prior to enrollment, unless a signed payment plan is received and agreed to by PLIA.
    • If a payment plan is approved, the first payment is due before the Facility is enrolled
    • Please note, payments submitted before you receive your enrollment contract will be returned.
  • Once all documents have been received, and payment has been received, PLIA will finalize enrollment of the facility by:
    • Signing the enrollment contract
    • Providing applicant with a Certification of Coverage

IMPORTANT: If historical contamination is found to be present at the time of enrollment, cleanup actions related to that release are subject to cost recovery.

Conclusion


Applicant Certification
I certify to the following:
  • The information provided in my Financial Assurance (FA) Program Application is  accurate to the best of my knowledge.
  • I have reviewed the FA Program rules found under WAC 173-350-600 and understand my obligations.
  • I have reviewed the FA Program Guidance and understand that the Guidance informs and controls my application. 
  • I understand that submitting an incomplete application and/or not responding to requests for information may result in enrollment delay or denial. 
  • If a Financial Assurance Request is made to address a release from my enrolled UST, I agree to enroll in the Technical Assistance Program (TAP) and pay the required program fee. 
  • If I am an owner and have a lessee, I acknowledge that I have spoken with the lessee, and they are willing to sign an access agreement and understand that they have to allow cleanup on the property.
  • If I am a lessee, I acknowledge that I have spoken with the owner and they are willing to sign an access agreement and understand that they have to allow cleanup on the property.
  • I understand that if my application is accepted, I will receive an enrollment contract. Coverage will not begin until both the applicant and PLIA have signed the enrollment contract. 
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