Figure 30 TAC 37.880(b)(2)(A)

CERTIFICATION OF VALID CLAIM

The undersigned, as principals and as legal representatives of (insert owner or operator) and (insert name and address of third-party claimant), hereby certify that the claim of bodily injury (insert and/or) property damage caused by an accidental release arising from operating (insert owner's or operator's) underground storage tank should be paid in the amount of ${_____}.

(Insert signatures)                                                          (Insert signature(s)}
(Insert owner or operator)                                             (Insert claimant(s))
(Insert attorney for owner or operator)                          (Insert attorney(s) for claimant(s))

(Insert notary)                              (Insert date)                              (Insert notary)                                 (Insert date)
; or