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 assistance.
 

1. DEP facility ID number. Only registered sites enrolled in FPLRIP are eligible. Date of subject discharge.
2. 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.
3. Fill in the name and address of the tank owner, if different from above. Name of contact person and telephone number.
4. Check the method of cleanup assistance the owner/operator desires for site remediation.
5. 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 appropriate signature.

Submit Claim Form and Discharge Reporting Form to: Contracted County Storage Tank Inspector See the attached list for the correct county representative
A completed claim package must include:

1. Claim Form
2. Discharge Reporting Form
3. Pollutant Storage Tank System Inspection Report Form
4. Florida Petroleum Liability and Restoration Insurance Program Checklist

If you have any questions, please call (850) 245-8839.