All owners or operators who are enrolled in the Florida
Petroleum Liability and Restoration Insurance Program (FPLRIP) and have had a
release from an eligible petroleum storage system or have discovered petroleum
contamination should complete this form.
Completion of this form is necessary to file a claim under
FPLRIP. Submission of this form does not guarantee that you will receive state
- DEP facility ID number. Only registered sites enrolled in FPLRIP are
eligible. Date of subject discharge.
- Fill in the name and physical address of the facility, name of contact
person and telephone number. Financial responsibility should be:
- FPLIPA/State Fund
- Self Insured/State Fund
- Other Insurance/State Fund
- Other method. Explain.
- Fill in the name and address of the tank owner, if different from above.
Name of contact person and telephone number.
- Check the method of cleanup assistance the owner/operator desires for site
- Check each item that applies relative to compliance with Rules 62-761,
62-762 and/or 62-769, Florida Administrative Code.
Fill in the name of the person authorized to represent the
owner/operator, or the owner/operator, the individual's title, and obtain the
Submit Claim Form and Discharge Reporting Form to: Contracted
County Storage Tank Inspector See the attached list for the correct county
A completed claim package must include:
- Claim Form
- Discharge Reporting Form
- Pollutant Storage Tank System Inspection Report Form
- Florida Petroleum Liability and Restoration Insurance Program Checklist
If you have any questions, please call (850) 245-8839.
If you are having problems downloading documents from this website, adjust the security settings in your browser. For example, in Internet Explorer, go to Tools > Internet Options > Security - and set the Internet zone to Medium level.