Petroleum Fund Forms

Forms for Changes to Petroleum Fund Claimant

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.

Bid Forms

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

Claim Forms

Daily Field Activity/Equipment Log (Excel)
Daily Field Activity/Equipment Log (PDF)
Invoice Breakdown Sheet
Mileage Log (PDF)

Petroleum Fund Enrollment Forms

Operators of underground storage tank (UST) systems must register with NDEP's UST Program using the below UST notification form prior to enrollment in the Petroleum Fund. USTs will be enrolled in the Fund upon receipt of this form, the enrollment payment ($100 per tank system), and demonstration of system tightness for the 6 months prior to enrollment (tanks and associated product piping).
UST Notification Form (7530-1)
What leak detection must I provide when enrolling an underground storage tank in the Nevada Petroleum Fund?

Enrollment coverage for aboveground storage tanks (ASTs) begins 6 months from date of receipt of an AST enrollment form (below) and enrollment payment unless this is a continuing enrollment (NRS 445C.410.2).

All operators of AST systems enrolled in the Fund must visually inspect their systems monthly (NAC 445C.250). The below inspection form may be used to meet this requirement. In addition to visual inspections, any operator with an aboveground storage tank that uses underground distribution piping that cannot be visually inspected, must have the piping tested prior to enrollment (and annually thereafter) for tightness by a certified tester. Any underground delivery piping that is constructed of steel, must also have a corrosion prevention system installed that must also be tested by a qualified corrosion tester annually (Fund Policy Resolution #2017-01).
Aboveground Storage Tank Enrollment Form
Aboveground Tank Inspection Form

Tax Documentation for Fund Reimbursements

Nevada operators that had a petroleum release from their storage tank and have received reimbursement claim payment(s) from the Nevada Petroleum Fund may receive tax form 1099-G from the State of Nevada Controller’s office. The Board to Review Claims and NDEP have received a determination from the US Department of Agriculture, Natural Resources Conservation Service that Fund reimbursement payments (i.e. cost-share payments) may be eligible for exclusion from an operator’s reported gross income under Section 126 of the Internal Revenue Code of 1954, as amended. If you have received tax form 1099-G for the current tax year, download the below Record of Decision to submit to your tax professional along with claim payment documents received from NDEP.
Record of Decision from US Department of Agriculture, Natural Resources Conservation Service 

To review the Secretary of Agriculture’s Determination of the Primary Purpose of the Nevada Petroleum Claims Fund for the Cleanup of Petroleum Discharge From Storage Tanks (federal register), click the following link:


Newsletter Signup: Water Pollution

Success! Thank you for signing up. Check your email to complete your subscription.