DEP Form 62-761.900(3) Part A "Storage Tank Financial Test (Self Insurance) (Letter From Chief Financial Officer)" - Florida

What Is DEP Form 62-761.900(3) Part A?

This is a legal form that was released by the Florida Department of Environmental Protection - a government authority operating within Florida.The document is a supplement to DEP Form 62-761.900(3), Storage Tank Certificate of Insurance. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2019;
  • The latest edition provided by the Florida Department of Environmental Protection;
  • 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 DEP Form 62-761.900(3) Part A by clicking the link below or browse more documents and templates provided by the Florida Department of Environmental Protection.

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Download DEP Form 62-761.900(3) Part A "Storage Tank Financial Test (Self Insurance) (Letter From Chief Financial Officer)" - Florida

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PRINT
CLEAR
A copy of financial instruments kept off-site shall be made
DEP Form 62-761.900(3) Part A
available for inspection upon five business days notice.
Form Title: Financial Mechanisms for Storage Tanks
Part A: ST Financial Test (Self Insurance)
Form Effective Date October 2019
Incorporated in Rules 62-761.420 and 62-762.421, F.A.C.
STATE OF FLORIDA
STORAGE TANK FINANCIAL TEST (SELF INSURANCE)
(Letter from Chief Financial Officer)
Reference: 40 CFR 280.95(d)
Sunbiz
I am the chief financial officer of
, herein
[Name of firm: the owner or operator, or guarantor]
referred to as the “firm”,
.
[Address of the firm]
This letter is in support of the use of the
to demonstrate financial
[Insert "financial test of self insurance" and/or "guarantee"]
responsibility for
[Insert "taking corrective action" and/or "compensating third parties for bodily injury and property damage caused by"]
in the amount of at least:
[Insert “accidental releases” or “sudden accidental releases” or “nonsudden
accidental releases” or leave blank if only corrective action is covered]
Per Occurrence: $
Annual Aggregate: $
arising from operating (a) storage tank(s) [underground storage tanks (UST) and/or aboveground storage tanks (AST)].
Storage tanks at the following facilities are assured by this financial test or a financial test under an authorized State
program by this firm:
[List information for each facility. See Instruction #6 on page i for details. Indicate “See attachment” if required.]
FDEP FacID
Facility Name and Site Address
Number of Tanks
(for sites in Florida)
(for all sites covered)
or Tank I.D. Nos.
Part A page 1 of 4
DEP Form 62-761.900(3)
Entire form page 1 of 42
SAVE
PRINT
CLEAR
A copy of financial instruments kept off-site shall be made
DEP Form 62-761.900(3) Part A
available for inspection upon five business days notice.
Form Title: Financial Mechanisms for Storage Tanks
Part A: ST Financial Test (Self Insurance)
Form Effective Date October 2019
Incorporated in Rules 62-761.420 and 62-762.421, F.A.C.
STATE OF FLORIDA
STORAGE TANK FINANCIAL TEST (SELF INSURANCE)
(Letter from Chief Financial Officer)
Reference: 40 CFR 280.95(d)
Sunbiz
I am the chief financial officer of
, herein
[Name of firm: the owner or operator, or guarantor]
referred to as the “firm”,
.
[Address of the firm]
This letter is in support of the use of the
to demonstrate financial
[Insert "financial test of self insurance" and/or "guarantee"]
responsibility for
[Insert "taking corrective action" and/or "compensating third parties for bodily injury and property damage caused by"]
in the amount of at least:
[Insert “accidental releases” or “sudden accidental releases” or “nonsudden
accidental releases” or leave blank if only corrective action is covered]
Per Occurrence: $
Annual Aggregate: $
arising from operating (a) storage tank(s) [underground storage tanks (UST) and/or aboveground storage tanks (AST)].
Storage tanks at the following facilities are assured by this financial test or a financial test under an authorized State
program by this firm:
[List information for each facility. See Instruction #6 on page i for details. Indicate “See attachment” if required.]
FDEP FacID
Facility Name and Site Address
Number of Tanks
(for sites in Florida)
(for all sites covered)
or Tank I.D. Nos.
Part A page 1 of 4
DEP Form 62-761.900(3)
Entire form page 1 of 42
A
is also used by this firm to demonstrate evidence of financial responsibility in the
[
Insert "financial test" and/or "guarantee" or leave blank if EPA Regulations section does not apply]
following amounts under other EPA regulations or state programs authorized by EPA under 40 CFR Parts 271 and 145:
EPA Regulations
Amount
Closure (§§ 264.143 and 265.143)
$
Post
-Closure Care (§§ 264.145
and
265.145)
$
Liability Coverage ( §§ 264.147 and 265.147)
$
Corrective Action (§ 264.101(b))
$
Plugging and Abandonment (§ 144.63)
$
Closure
$
Post-Closure Care
$
Liabi
lity
Coverage
$
Corrective Action
$
Plugging and Abandonment
$
Total
$
This firm has not received an adverse opinion, a disclaimer of opinion or a "going concern" qualification from an
independent auditor on its financial statements for the latest completed fiscal year ended
.
[Date]
The figures for the following items marked with an asterisk (*) are derived from these audited financial statements and
footnotes.
[Fill in the information for Alternative I if the criteria of paragraph (b) of § 280.95 (as adopted) are being used to demonstrate compliance with the
financial test requirements. Fill in the information for Alternative II if the criteria of paragraph (c) of § 280.95 (as adopted) are being used to demonstrate
compliance with the financial test requirements.]
Check either the box by Alternative I (here) or Alternative II (next page). The
Alternative I
fields for the appropriate section will then be visible and some will auto calculate.
1. Amount of annual UST and AST aggregate coverage being assured by a
financial test, and/or guarantee [from Page 1]
$
2. Amount of corrective action, closure and post-closure care costs,
liability coverage, and plugging and abandonment costs covered by
a financial test, and/or guarantee [from EPA Regulations section]
$
3. 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 and add that amount to line 6]
0.00
6. Tangible net worth [subtract line 5 from line 4]
$
Yes
No
7. Is line 6 at least $10 million?
8. Is line 6 at least 10 times line 3?
9. Have financial statements for the latest fiscal year been filed
with the Securities and Exchange Commission (SEC)?
Part A page 2 of 4
DEP Form 62-761.900(3)
Entire form page 2 of 42
Yes
No
10. Have financial statements for the latest fiscal year been filed
with the Energy Information Administration?
11. Have financial statements for the latest fiscal year been filed
with the Rural Utilities Service?
12. Has financial information been provided to Dun and Bradstreet,
and has Dun and Bradstreet provided a financial strength rating
of 4A or 5A?
[Answer "Yes" only if both criteria have been met]
Check either the box by Atlernative I (previous page) or Alternative II (here). The
Alternative II
fields for the appropriate section will then be visible and some will auto calculate.
1. Amount of annual UST and AST aggregate coverage being assured by
a financial test and/or guarantee
$
[from Page 1]
2. Amount of corrective action, closure and post-closure care costs,
liability coverage, and plugging and abandonment costs covered
by a financial test and/or guarantee
$
[from EPA Regulations section]
3. 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 and add that amount to line 6]
0.00
6. Tangible net worth [subtract line 5 from line 4]
$
* 7. Total assets in the U.S.
$
[Required only if less than 90 percent of assets are located in the U.S.]
Yes
No
X
8. Is line 6 at least $10 million?
9. Is line 6 at least 6 times line 3?
10. Are at least 90 percent of assets located in the U.S.?
[If "No", complete line 11.]
11. Is line 7 at least 6 times line 3?
[Fill in either lines 12-15 or lines 16-18:]
* 12. Current assets
$
* 13. Current liabilities
$
0.00
14. Net working capital [subtract line 13 from line12]
$
Yes
No
15. Is line 14 at least 6 times line 3?
16. Current bond rating of most recent bond issue
17. Name of rating service
18. Date of maturity of bond
Part A page 3 of 4
DEP Form 62-761.900(3)
Entire form page 3 of 42
Yes
No
19. Have financial statements for the latest fiscal year been filed with
the SEC, the Energy Information Administration, or the Rural
Utilities Service?
[If "No", attach a report from an independent certified public accountant certifying that there are no material differences between the data as
reported in lines 4-18 above and the financial statements for the latest fiscal year.]
[For both Alternative I and Alternative II complete the certification with this statement.]
Certification
The person whose signature appears below hereby certifies that the wording of this instrument is identical to the wording
as adopted and incorporated by reference in Rule(s) 62-761.420 and/or 62-762.421, F.A.C.
[Signature of Chief Financial Officer]
[Name and Title]
[Date]
[Owner or Operator Storage Tanks Program Contact]
[Owner or Operator Contact Phone Number]
[Owner or Operator Contact Email Address]
Part A page 4 of 4
DEP Form 62-761.900(3)
Entire form page 4 of 42
Page of 4