ADEM Form 32 "Alabama Tank Trust Fund Payment Request" - Alabama

What Is ADEM Form 32?

This is a legal form that was released by the Alabama Department of Environmental Management - a government authority operating within Alabama. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2022;
  • The latest edition provided by the Alabama Department of Environmental Management;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of ADEM Form 32 by clicking the link below or browse more documents and templates provided by the Alabama Department of Environmental Management.

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Download ADEM Form 32 "Alabama Tank Trust Fund Payment Request" - Alabama

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This form is now available for electronic submittal using the
Alabama Environmental Permitting and Compliance System or
AEPACS.
[Note: The program encourages the use of an electronic form
submittal rather than a paper form submittal.]
Please click the link below to submit this form electronically
using AEPACS.
https://aepacs.adem.alabama.gov/nviro/ncore/external/home
This form is now available for electronic submittal using the
Alabama Environmental Permitting and Compliance System or
AEPACS.
[Note: The program encourages the use of an electronic form
submittal rather than a paper form submittal.]
Please click the link below to submit this form electronically
using AEPACS.
https://aepacs.adem.alabama.gov/nviro/ncore/external/home
PR
Alabama Tank Trust Fund
Payment Request
Part I
1.1 Payment Request Information:
Payment Request Number:
Date of Payment Request (mm/dd/yy):
UST or AST Incident Number:
Facility 1.0. Number:
1.2 Facility Information
Site Name:
Site Address:
1.3 Owner Information:
Owner Name:
Owner Email:
Owner Address:
Employer Tax Number (IRS):
1.4 Response Action Contractor Information:
Approved Response Action Contractor Name:
Approved Response Action Contractor
Address:
Project Contact:
Project Contact phone#
Project Contact E-mail:
Employer Tax Number (IRS)
1.5 Designation of Payment:
Name of Person or Firm to whom Payment is to be made:
Email:
Address & Phone #:
M3
(Revised 06/22 m4)
PR
1.6 Activity Information:
Indicate below the activities for which the Payment Request is submitted
:
Site Stabilization/Initial Abatement
Preliminary Investigation
Secondary Investigation/ Additional Well Installation
Alabama Risk Based Corrective Action (ARBCA)
Groundwater Sampling
Free Product Removal/Mobile Enhanced Multiphase Extraction (MEME)
Corrective Action Plan Evaluation
Develop Corrective Action Plan
Corrective Action
Stockpile Sampling / Management/ Disposal
Provision of Alternate Water Supply
Pilot Test
Monitoring Well Abandonment
System Decommissioning/Removal
Activities/Other/Brief Summary of Activities:
Provide completion date for this phase of work activities:
Provide proposed completion date for all site activities:
1.7 Subcontractor Information:
Indicate Subcontractors used during this phase of work:
Name & Address
Service Provided
ADEM Form 32
08/2019
M3
Revised 06/22 m4)
PR
1.8 Certification of Payment:
Signature must be provided below for this request to be processed
0
1. I certify that
all costs
incurred under this
payment request
have been
paid to
the
contractor.
Check to
The above certification will result in a check written to the owner or operator.
owner
0
2.
I
certify
that
all costs
incurred under this
payment
request
have
NOT been paid to
the contractor.
Check to
Contractor
The above certification will result in a check written to the contractor.
Typed or Printed Name and
Title:
Owner Operator
Signature:
Date:
The
signature above
is to
certify
that
either option
1 or
option
2
above applies, and
I
certify
that
an
unintentional
release has
occurred
from
a
motor fuel underground
storage
tank
system or aboveground storage
tank
system
at the site and
I
certify
that to
the
best
of my
knowledge
and
belief: that
the costs
presented herein represents
actual costs incurred
in the performance
of response actions
at this
site
during the period
of
time
indicated on
this
application; and
that no
charges
are presented
as
part
of
this application that
did
not result from the
performance
of response
actions which
were necessary
due to
the release of motor fuels
at
this
site.
1.9 Certification of Payment Request Information:
Signature must be dated with an original signature by a responsible corporate official or a person to which
signature authority has been delegated in writing
.
Documentation of such delegation should be maintained on
record by each
company,
and shall be made available to the Department upon request.
I
certify
that to the
best of
my knowledge and belief: that
the
costs presented herein represents
actual costs
incurred in the performance
of
response
actions at
this
site
during the period
of time
indicated on
this
application;
and
that no
charges are
presented
as
part
of
this
application
that
did
not result from the performance
of
response
actions which were
necessary due to the release
of
motor fuels
at
this
site.
I certify under penalty
of
law that I have personally
examined and
am
familiar
with
the information
submitted
in
this payment request and
all attachments and
that, based on my
inquiry of
those persons immediately
responsible for
obtaining
the information
contained
in
this
payment
request,
I
believe
that
the
information is
true,
accurate,
complete, and
that this payment request does
not
duplicate
any
request for payment for any charge
previously
submitted
to the Department.
Contractor's Signature:
Typed or printed name and title:
Date:
Sections 1.8 and 1.9 must be signed by appropriate person for Request to be processed
ADEM
Form
32
08/2019
M3
Revised 06/22 m4)
1.10 Trust Fund Obligation Information:
Total of Previously Approved Payment Requests:
Total of Payment Requests to Date:
(Approved
Payment Requests plus amount proposed in this
request)
Estimate Percent Completion of Entire Project to Date:
1.11 Payment Request Amount:
Payment Request
Amount from Forms:
Owners Required Contribution for UST
Release($5
,000):
Applicable for
CP#1
Only
Owners Required Contribution for AST
Release($10 ,000): Applicable for CP#1
Only
Total of This Payment Request:
CP approved amount
Proposed
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This Payment Request exceeds the approved Cost Proposal by
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-------------1
Please describe the cause of the exceedance below and include appropriate invoices
1.12 ADEM Approval Signatures:
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ADEM
Form
32
08/2019
M3
Revised 06/22 m4)
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