Section 260:11. APPENDIX XI. LETTER FROM CHIEF FINANCIAL OFFICER (SHORT FORM)

APPENDIX XI. LETTER FROM CHIEF FINANCIAL OFFICER (SHORT FORM).

[Note: This Appendix may only be used by owners or operators who do not own or operate hazardous waste facilities, or underground injection control wells.]

[Note: The instructions in brackets are to be replaced by the relevant information and the brackets deleted.]

I am the chief financial officer of [insert: name and address of the owner or operator or guarantor]. This letter is in support of the use of [insert "the financial test of self-insurance," and/or "Guarantee"] to demonstrate financial responsibility for [insert: "taking corrective action" and/or "compensating third parties for bodily injury and property damage"] caused by [insert "sudden accidental releases" and/or "nonsudden accidental releases"] in the amount of at least $[insert dollar amount] corrective action per occurrence, $[insert dollar amount] third party liability per occurrence, and $[insert dollar amount] annual aggregate arising from operating (an) underground storage tank(s).

Underground storage tanks at the following facilities are assured by this financial test by this [insert: "owner or operator," and/or "guarantor"]: [List for each facility the name and address of the facility where tanks assured by this financial test are located, and whether tanks are assured by this financial test. If separate mechanisms or combinations of mechanisms are being used to assure any of the tanks at this facility, list each tank assured by this financial test by the tank identification number provided in the notification submitted pursuant to 9VAC25-580-70 (Underground Storage Tanks: Technical Standards and Corrective Action Requirements)].

I am not required to demonstrate evidence of financial responsibility for any other EPA regulation or state programs authorized by EPA.

This [insert: "owner or operator," or "guarantor"] has not received an adverse opinion, a disclaimer of opinion, or a "going concern" qualification from an independent auditor on the financial statements for the latest completed financial reporting year.

[Fill in the information below to demonstrate compliance with the financial test requirements.]

1. Amount of annual UST aggregate coverage being assured by a financial test, and/or guarantee...$__________

2. Amount of annual aboveground storage tank (AST) aggregate coverage being assured by a financial test and/or guarantee...$__________

3. Total UST/AST financial responsibility obligations assured by a financial test and/or guarantee (sum of lines 1 and 2)...$__________

4. Total tangible assets...$__________

5. Total liabilities [if any of the amount reported on line 3 is included in total liabilities, you may deduct that amount from this line or add that amount to line 6]...$__________

6. Tangible net worth [subtract line 5 from line 4]...$__________

7. Is line 4 at least equal to line 3 above? Yes... No...

8. Have financial statements for the latest financial reporting year been filed with the Securities and Exchange Commission? Yes... No...

9. Have financial statements for the latest financial reporting year been filed with the Energy Information Administration? Yes... No...

10. Have financial statements for the latest financial reporting year been filed with the Rural Utilities Service? Yes... No...

11. Has financial information been provided to Dun and Bradstreet, and has Dun and Bradstreet provided a financial strength rating at least equal to the amount of annual UST aggregate coverage being assured according to the table below?

	Annual Aggregate Requirement	Dun and Bradstreet Rating
	$20,000	EE ($20,000 to $34,999)
	$40,000	DC ($50,000 to $74,999)
	$80,000	CB ($125,000 to $199,999)
	$150,000	BB ($200,000 to $299,999)
	$200,000	BB ($200,000 to $299,999)
	$300,000	BA ($300,000 to $499,999)
	$500,000	1A ($500,000 to $749,999)
	$750,000	2A ($750,000 to $999,999)
	$1,000,000	3A ($1,000,000 to $9,999,999)

[Answer "Yes" only if BOTH criteria have been met.] Yes... No...

12. If you did not answer yes to one of lines 8 through 11, please attach a report from a certified public accountant certifying that there are no material differences between the data reported in lines 4 through 7 above and the financial statements for the latest financial reporting year.

I hereby certify that the wording of this letter is identical to the wording specified in Appendix XI of this chapter as such regulations were constituted on the date shown immediately below.

[Signature]

[Name]

[Title]

[Date]

Historical Notes

Amended, Volume 21, Issue 08, eff. January 26, 2005.

Statutory Authority

§§ 62.1-44.34:9 and 62.1-44.34:12 of the Code of Virginia; 40 CFR Part 280.