Form IL532 3059 (LPC712) "Drycleaner Environmental Response Trust Fund Claim Form" - Illinois

What Is Form IL532 3059 (LPC712)?

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

Form Details:

  • Released on December 1, 2020;
  • The latest edition provided by the Illinois Environmental Protection Agency;
  • 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 Form IL532 3059 (LPC712) by clicking the link below or browse more documents and templates provided by the Illinois Environmental Protection Agency.

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Download Form IL532 3059 (LPC712) "Drycleaner Environmental Response Trust Fund Claim Form" - Illinois

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Illinois Environmental Protection Agency
1021 North Grand Avenue East
P.O. Box 19276
Springfield
Illinois
62794-9276
(217) 782-3397
Drycleaner Environmental Response Trust Fund
Claim Form
As soon as you have a known or suspected release from your drycleaning facility, please fill our this form as completely as you
can. Note: This form should be completed within Acrobat before being printed, signed, and submitted.
1. Claimant
Name:
Address:
City:
State:
ZIP:
Phone:
ext:
Claimant is:
the owner/operator of the drycleaning facility.
a third party affected by a release at an insured facility.
2. Authorized Agent
(if applicable)
Name:
Address:
City:
State:
ZIP:
Phone:
ext:
3. Facility Information
Drycleaning Facility
Name:
Address:
City:
State:
ZIP:
Tax Parcel ID:
Third Party Facility
Name:
Address:
City:
State:
ZIP:
Tax Parcel ID:
4. Claim is for:
Remedial benefits (i.e. historical solvent release, one occurring before the insurance policy effective date)
Insurance benefits (i.e. current solvent release, one occurring after the insurance policy effective date)
5. Policy number:
IL 532 3059
Drycleaner Claim Form
Page 1 of 3
LPC 712 Rev. 12/2020
Illinois Environmental Protection Agency
1021 North Grand Avenue East
P.O. Box 19276
Springfield
Illinois
62794-9276
(217) 782-3397
Drycleaner Environmental Response Trust Fund
Claim Form
As soon as you have a known or suspected release from your drycleaning facility, please fill our this form as completely as you
can. Note: This form should be completed within Acrobat before being printed, signed, and submitted.
1. Claimant
Name:
Address:
City:
State:
ZIP:
Phone:
ext:
Claimant is:
the owner/operator of the drycleaning facility.
a third party affected by a release at an insured facility.
2. Authorized Agent
(if applicable)
Name:
Address:
City:
State:
ZIP:
Phone:
ext:
3. Facility Information
Drycleaning Facility
Name:
Address:
City:
State:
ZIP:
Tax Parcel ID:
Third Party Facility
Name:
Address:
City:
State:
ZIP:
Tax Parcel ID:
4. Claim is for:
Remedial benefits (i.e. historical solvent release, one occurring before the insurance policy effective date)
Insurance benefits (i.e. current solvent release, one occurring after the insurance policy effective date)
5. Policy number:
IL 532 3059
Drycleaner Claim Form
Page 1 of 3
LPC 712 Rev. 12/2020
6. Drycleaning Units
Number of units at this location:
Are they still in use?
Yes
No
If No, as of what date were the drycleaning units no longer in use?
What drycleaning solvents are/were stored in the drycleaning units?
7. Are there any other machines, equipment, or tanks (underground or aboveground) located at this facility that contain any
product that is chlorine-based or petroleum-based besides the drycleaning units that store drycleaning solvent?
Yes
No
If Yes, please explain.
8. Who owns the land that the drycleaning units are located on?
Does anyone lease the land?
Yes
No
If Yes, who?
9. Who owns the facility / drycleaning units?
10. Who owns and / or operates the the business at this location, if any?
How long has this person or company operated it?
How long has the business with drycleaning units been at this location?
Release Information
11. When did you first learn a release (e.g. spill or leak) had occurred?
12. How was it discovered (e.g. accidental spill, soil testing, etc.)?
13. When and how was the problem reported to the Illinois EMA or Illinois EPA?
14. Identify the source of the contamination (e.g. the unit, spill, etc.), if known:
15. Are you aware of any person who has a bodily injury or property damage claim from the release?
Yes
No
If Yes, list their names and phone numbers.
16. Do you think contamination has migrated beyond your property?
Yes
No
If Yes, list names, addresses, and phone numbers of affected persons.
17. Has a "site investigation" or report been prepared?
If Yes, list the date of the report and enclose a copy with this form.
Yes
No
18. Have activities commenced to clean up the contamination?
Yes
No
If Yes, briefly describe.
19. Your Licensed Professional Engineer's name and company:
IL 532 3059
Drycleaner Claim Form
Page 2 of 3
LPC 712 Rev. 12/2020
20. Has this site received a "No Further Remediation" letter?
Yes
No
If Yes, please provide a copy.
Other Insurance
21. Have you ever had any other insurance policy specifically providing pollution liability coverage for this property?
If Yes, provide the name of the company, the policy number, and a copy of the policy:
Yes
No
22. Has the incident been reported to this insurance company?
Yes
No
23. Have you received or are you requesting payment from anyone else for costs associated with this claim?
If Yes, whom?
Yes
No
Certification
(Must be notarized)
I hereby certify and understand that, in addition to all other civil and criminal penalties provided by law, any person who
knowingly makes to the Agency an oral or written statement that is false, fictitious, or fraudulent and that is materially related to
or required by the DERT Fund Act or 35 Ill. Adm. Code 890 commits a Class 4 felony, and each such statement or writing shall
be considered a separate Class 4 felony.
Printed Name
Title
Signature
Date
Notarization
State of Illinois, County of
Signed before me on
by
date
(name of person)
Seal
Signature of Notary Public
Attachments: Please provide copies of any and all of the following for this facility which exist at the time of filing this claim form.
site investigation reports
remediation objectives reports
remedial action plans
remedial action completion reports
Return this form (original and one copy) and any attachments to:
Illinois EPA
Mail Code 24
P.O. Box 19276
1021 North Grand Avenue East
Springfield, Illinois 62794-9276
.
Questions or concerns? Please email
EPA.DrycleanerFund@illinois.gov
IL 532 3059
Drycleaner Claim Form
Page 3 of 3
LPC 712 Rev. 12/2020
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