DHEC Form 3244 "Owner/Operator Contractor Selection Form" - South Carolina

What Is DHEC Form 3244?

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

Form Details:

  • Released on October 1, 2020;
  • The latest edition provided by the South Carolina Department of Health and Environmental Control;
  • 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 fillable version of DHEC Form 3244 by clicking the link below or browse more documents and templates provided by the South Carolina Department of Health and Environmental Control.

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Download DHEC Form 3244 "Owner/Operator Contractor Selection Form" - South Carolina

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Owner/Operator Contractor Selection Form
Underground Storage Tank (UST) Management Division
1. CONTRACTOR OF CHOICE
As the current or former UST Owner/Operator and the designated
Release Report Date:
Permit Number:
party responsible for the confirmed release reported on the date
and permit number provided.
I would like to use the contractor listed below to conduct all site rehabilitation work for the referenced release reported above:
Name of Contractor:
Address:
City:
State:
Zip:
Telephone Number:
Certification Number:
NOTE: Site rehabilitation activities must be performed by a S.C. Certified Site Rehabilitation Contractor per Section
44-2-120(A) of the SUPERB Act and Section IV(A) of the S.C. DHEC SUPERB Site Rehabilitation and Fund Access Regulation R.61-98.
2. FINANCIAL OR FAMILIAL RELATIONSHIP
Does a financial or familial relationship, as defined below, exist
Yes
No
O/O Initial:
q
between you and the contractor/person that you listed above?
FINANCIAL RELATIONSHIP: A connection or association through a material interest of sources of income which exceed five percent of
annual gross income from a business entity.
FAMILIAL RELATIONSHIP: A connection or association by family or relatives, in which a family member or relative has a material interest.
Family or relatives include: father, mother, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, husband, wife, father-in-law,
mother-in-law, son-in-law, daughter-in-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half brother, half sister,
grandparent, grandchild, great-grandchild, step-grandparent, step-great-grandparent, step-grandchild, step-great-grandchild or fiancée.
3. PAYMENT
A.
The first $25,000.00 in eligible site rehabilitation costs for releases reported subsequent to July 1, 1993 will be applied against the
applicable SUPERB deductible per Section 44-2-40(D) of the SUPERB Act, upon submittal of the canceled check (front and back) or a
notarized statement from the contractor verifying payment.
B.
For eligible costs exceeding the $25,000.00 deductible, you can pay the contractor and, upon the submittal of the canceled check
(front and back) or a notarized statement from the contractor verifying payment, be compensated from the SUPERB Account, or have
payment issued directly from the SUPERB Account to the contractor. (Check one.)
For eligible costs exceeding the deductible, I request that payment be made to me after I have
q
O/O Initial:
paid the contractor.
– OR –
For eligible costs exceeding the deductible, I request that payment be made directly to the
q
O/O Initial:
contractor.
C. If the release qualifies under amnesty (reported prior to July 1, 1993) per Section 44-2-40(B) of the SUPERB Act, you can pay the
contractor and be compensated from the SUPERB Account, or have payment issued directly from the SUPERB Account to the
contractor. (Check one.)
For eligible costs, I request that payment be made to me after I have paid the contractor.
O/O Initial:
q
– OR –
For eligible costs, I request that payment be made directly to the contractor.
O/O Initial:
q
NOTE: As required by the SUPERB Act, all costs must receive prior financial approval from DHEC regardless of payment option.
4.
UST OWNER/OPERATOR OR PARTY RESPONSIBLE FOR ABOVE REFERENCED RELEASE
Signature:
Date Signed:
Printed Name:
Telephone Number: (
)
Affiliation (if applicable):
Email Address:
SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
DHEC 3244 (10/2020)
Owner/Operator Contractor Selection Form
Underground Storage Tank (UST) Management Division
1. CONTRACTOR OF CHOICE
As the current or former UST Owner/Operator and the designated
Release Report Date:
Permit Number:
party responsible for the confirmed release reported on the date
and permit number provided.
I would like to use the contractor listed below to conduct all site rehabilitation work for the referenced release reported above:
Name of Contractor:
Address:
City:
State:
Zip:
Telephone Number:
Certification Number:
NOTE: Site rehabilitation activities must be performed by a S.C. Certified Site Rehabilitation Contractor per Section
44-2-120(A) of the SUPERB Act and Section IV(A) of the S.C. DHEC SUPERB Site Rehabilitation and Fund Access Regulation R.61-98.
2. FINANCIAL OR FAMILIAL RELATIONSHIP
Does a financial or familial relationship, as defined below, exist
Yes
No
O/O Initial:
q
between you and the contractor/person that you listed above?
FINANCIAL RELATIONSHIP: A connection or association through a material interest of sources of income which exceed five percent of
annual gross income from a business entity.
FAMILIAL RELATIONSHIP: A connection or association by family or relatives, in which a family member or relative has a material interest.
Family or relatives include: father, mother, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, husband, wife, father-in-law,
mother-in-law, son-in-law, daughter-in-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half brother, half sister,
grandparent, grandchild, great-grandchild, step-grandparent, step-great-grandparent, step-grandchild, step-great-grandchild or fiancée.
3. PAYMENT
A.
The first $25,000.00 in eligible site rehabilitation costs for releases reported subsequent to July 1, 1993 will be applied against the
applicable SUPERB deductible per Section 44-2-40(D) of the SUPERB Act, upon submittal of the canceled check (front and back) or a
notarized statement from the contractor verifying payment.
B.
For eligible costs exceeding the $25,000.00 deductible, you can pay the contractor and, upon the submittal of the canceled check
(front and back) or a notarized statement from the contractor verifying payment, be compensated from the SUPERB Account, or have
payment issued directly from the SUPERB Account to the contractor. (Check one.)
For eligible costs exceeding the deductible, I request that payment be made to me after I have
q
O/O Initial:
paid the contractor.
– OR –
For eligible costs exceeding the deductible, I request that payment be made directly to the
q
O/O Initial:
contractor.
C. If the release qualifies under amnesty (reported prior to July 1, 1993) per Section 44-2-40(B) of the SUPERB Act, you can pay the
contractor and be compensated from the SUPERB Account, or have payment issued directly from the SUPERB Account to the
contractor. (Check one.)
For eligible costs, I request that payment be made to me after I have paid the contractor.
O/O Initial:
q
– OR –
For eligible costs, I request that payment be made directly to the contractor.
O/O Initial:
q
NOTE: As required by the SUPERB Act, all costs must receive prior financial approval from DHEC regardless of payment option.
4.
UST OWNER/OPERATOR OR PARTY RESPONSIBLE FOR ABOVE REFERENCED RELEASE
Signature:
Date Signed:
Printed Name:
Telephone Number: (
)
Affiliation (if applicable):
Email Address:
SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
DHEC 3244 (10/2020)
SOUTH CAROLINA DEPARTMENT OF
HEALTH AND ENVIRONMENTAL CONTROL
DHEC FORM 3244
Instructions for Completing
Form’s title - Owner/Operator Contractor Selection Form
Form’s purpose – The purpose of this form is for the tank owner, operator, or authorized agent of
a confirmed UST release to select a South Carolina certified site rehabilitation contractor.
Who will complete the form (audience) – The tank owner, operator, or authorized agent.
Enough instruction to guide the person completing the form.
Fill in all boxes with correct information.
Address all statements and answer all questions by recording information in the appro-
priate blanks or check boxes.
The tank owner, operator, or authorized agent must sign/initial and date the form where
appropriate.
As the UST Owner/Operator at the time of the referenced release, you must resubmit this form if
there is a change in site rehabilitation contractors.
Form is scanned and saved electronically - Record Group Number 169, Retention Schedule
13300
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