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 [and/or] property damage caused by an accidental release arising from operating [owner's or operator's] underground storage tank should be paid in the amount of $[___].

[Signatures]

Owner or Operator

Attorney for Owner or Operator

(notary)

Date

[Signature(s)]

Claimant(s)

Attorney(s) for Claimant(s)

(notary)

Date