Petroleum Fund Forms

The following templates were developed by Petroleum Fund staff to encourage proper notification for a change in claimant and/or associated authorized representative for corrective action efforts at a facility receiving State Petroleum Fund reimbursement. Each template serves a different purpose, so please review the description below each to ensure proper use. The language in these documents should not be changed. Please fill in the editable fields with the applicable information, print the template on company letterhead, and include actual inked signatures of the people named on the letter. Note, you must contact the remediation case officer in addition to the below Petroleum Fund notice if the responsible party has changed for an ongoing corrective action.

Change of Operator/Claimant
This document should be used when a property transaction has occurred and/or a new party is accepting responsibility as the claimant of an existing Petroleum Fund case. This includes information regarding the company relinquishing control and the company assuming liability. This document should be printed on the new company’s letterhead and signed by both parties.

Change of Authorized Representative
This document should be used to designate a new authorized representative for an existing Petroleum Fund case. This includes acknowledgement of the duties of the new authorized representative. This document should be printed on the company’s letterhead and signed by the new representative.

CEM Payment Affidavit for Subcontractor Costs      
This document should be used for proof of payment(s) when a CEM has received payment, and will apply it to subcontractor invoices, on a claimant’s behalf. This document must be printed on the consulting firm’s letterhead and physically signed by the CEM, before scanning and uploading it to the Nevada Environmental Activities system. If this letter is not provided, the CEM must provide receipts for each contractor, vendor, or piece of equipment billed through their CEM invoices.



2015-01 Form I - Contractor Certification
2015-01 Form II - Vendor Certification
2015-01 Form III - Bid Request
2015-01 Form IV - Bid Summary
2015-01 Form V - CEM & Contractor
2015-01 Form VI - Owner & Contractor
Bid Excess Justification/Concurrence
Aboveground Tank Inspection Form
Invoice Breakdown Sheet

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