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Home My WebLink AboutInsurance - BOCC0 CU- - Lam. CRUM&FORSTEW $,-1822 AFAIRFAXCONIPANY STORAGE TANK POLLUTION APPLICATION PLEASE ANSWER ALL QUESTIONS COMPLETELY INSTRUCTIONS: This application is to be used when applying for Storage Tank Pollution coverage. Please complete all applicable sections of this application. Read all questions carefully and provide complete and accurate answers. Failure to provide complete or accurate information may result in delayed consideration of this application or denial of coverage. This application is not an insurance policy and the Company considering coverage reserves the right to reject any application for any reason. If additional space is needed, please attach details to this application on a separate piece of paper. All applicants must sign and date the application where indicated. NOTICE: For certain policies and coverage parts issued, the limits of liability available to pay judgments for settlements shall be reduced by amounts incurred for legal defense. Further note that amounts incurred for legal defense shall be applied against the deductible or self -insured retention amount. ALL APPLICANTS MUST SUBMIT THE FOLLOWING INFORMATION IN ADDITION TO THE COMPLETED APPLICATION: 1. Storage Tank Schedule Addendum must be completed for each location and tank seeking coverage. 2. Storage tank and line integrity test results dated within the last twelve (12) months; 3. Complete copies of any other storage tank or line testing or monitoring results; 4. Complete copies of any expiring storage tank policy, including unaltered declarations and all endorsements; 5. Detailed information regarding any prior releases, remediation or planned tank upgrades or replacement. ma`s pis" ��.��/ ,:sue„�� ..,�:�_ _ i y , P ICANT rN F :�:_ -��%ice �i%�� APPLICANT NAME: GRANT COUNTY DATE: MAY, 17, 2022 ADDRESS: P.O. BOX 37 CITY: EPHRATA STATE: WA I ZIP: 98823 ENTITY IS: ❑ Individual ❑ Partnership ❑ Corporation ❑ Joint Venture ❑ LLC 0 Other (Please Explain) Year Started: 1909 1 Any DBAs or other Named Insureds: PHONE: (509) 754-6082 EMAIL: lohl@grantcountywa.gov W E BS IT E : grantcountywa.gov / .: .......... ...... .... .: .. /ice.. � _- / � . . � _ - .. . � ...- /�`s4�1 .r .i _��:_ ..-/. /�.� ,y ,--"-•f/�.--/--.. ./ . i Requested Effective Date: 7/7i2022 Policy Term: 1 YEAR NDNEVIUM Requested Limits of Insurance: 1,000,000 Requested Deductible: SEE TANK SCHEDULE - Effective Date: 7/7/2021 Retroactive Date: SEE TANK SCHEDULE Carrier: CRUM & FORSTER Premium: 4,210.00 Limits: 1,000,000 Deductible: SEE TANK SCHEDULE Has the applicant, or have any of the subject facilities or storage tanks, ever had any type of storage tank insurance coverage cancelled for any reason, or has any application for such ❑ YES d NO insurance ever been denied? LOC T /.,. Facility Name Facility Address Number of USTs Number of ASTs Facility Operations I SEE TANK SCHEDULE *If additional facilities are seeking coverage, please continue this list with all required information on a separate sheet of paper. THE STORAGE TANK SCHEDULE ADDENDUM THAT IS ATTACHED TO THIS APPLICATION MUST RE COMPLETED IN ITS ENTIRETY SEPARATEL Y FOR EACH FACILITY SHOWN-AHOV.E, E �t �p�I..D .�.�-P !1 YS`� ii x, Storage Tank Application (1121) , 12 Page 1 of 4 V EST N G ' U -I-� S. 1. Are all tanks in compliance with all current state and federal regulations? ""No"" 0 YES ❑ NO (If please provide full details separately) 2. Does the applicant have any open or pending notifications to any local, state or federal implementing agency? ® YES IM NO (If "Yes'; please provide full details separately) 3. Do you own all of the tanks? "No'; IN YES ❑ NO (If please provide full details separately) 4. Are there any additional tanks at this location that are not described above or in attached schedules? "No'; ❑ YES 51 NO (If please provide full details separately) S. Were all storage tanks new at the time of their installation? "No'; 91 YES ❑ NO (If please provide full details separately) 6. Are there any plans to close in place, temporarily close, upgrade or remove any storage tanks at any facility in the next eighteen (18) months? ❑ YES M NO (If "Yes" please provide full details separately) 7. Have you received, requested or otherwise obtained any estimates, proposals or bids to replace, remove or close any storage tanks within the past twelve (12) months? ❑ YES 91 NO (If "Yes'; please provide full details separately) 8. Have there ever been any reportable releases, spills or other pollution events at this or any other owned/operated facility? ❑ YES R1 NO (If "Yes'; please provide full details separately) 9. Have any storage tanks been previously removed or closed in place at any of the subject facilities? "Yes'; ❑ YES L NO (If please provide full details separately) 10. Within the past twelve (12) months, has any on -site monitoring well or system shown an increase in contaminant levels? ❑ YES C1 NO (If "Yes'; please provide full details separately) 11. Within the past twelve (12) months, has any sheen or free product been observed in any sumps, collars, spill bucket, or other containment? ❑ YES IM NO (If "Yes'; please provide full details separately) 12. Within the past twelve (12) months, has any potential contamination been suspected by odor, vapor or vapor testing? ❑ YES IM NO (If "Yes'; please provide full details separately) 13. Are all storage tanks active and in use at the time of completing this application? "No", YES ❑ NO (If please provide a detailed explanation separately) • Jr .- %-- 1. Has the applicant, or any person or entity applying as an insured, ever filed or been the subject of any bankruptcy, receivership, or insolvency proceedings? ® YES 0 NO (If "Yes'; please provide full details separately) 2. At the time of signing this application, is the applicant aware of any incident, event, occurrence, fact, circumstance or situation that could reasonably result in a claim or suit, demand, or requirement for cleanup ❑ YES 0 NO being made against it or any other entity for which coverage is being sought? (If "Yes'; please provide full details separately) 3. Have any environmental or pollution claims or suits ever been made against the applicant or any other entity for which coverage is being sought? ❑ YES IN NO (If "Yes-, please provide full details separately) 4. Has the applicant, or any other entity for which coverage is being sought, ever had a reportable release or spill of any regulated substance, hazardous materials, or any other pollutant, as defined by local, state or ❑ YES 91 NO federal environmental statutes or regulations? (If "Yes', please provide full details separately) S. Has there ever been any violations, complaints, injunctions, contamination, remediation, corrective action or monitoring at any facility owned or operated by the applicant or any other entity for which coverage is ❑ YES 0 NO being sought? (If "Yes" please provide full details separately) Storage Tank Application (1121) Page 2 of 4 NOTICE TO APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or, conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to criminal and civil penalties. NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines or confinement in prison, or any combination thereof. NOTICE TO ARKANSAS, NEW MEXICO AND WEST VIRGINIA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit, or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NOTICE TO CALIFORNIA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a _ settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Authorities. NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree. NOTICE TO KANSAS APPLICANTS: Any person who knowingly and with intent to defraud, presents, causes to be presented or prepared with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain material false information concerning any fact material thereto; or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act. NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit fraud against an insurer is guilty of a crime. NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. . NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. NOTICE TO OKLAHOMA APPLICANTS: Warning: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony (365:15-1-10, 36 §3613.1). Storage Tank Application (1121) Page 3 of 4 NOTICE TO OREGON APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or, conceals, for the purpose of misleading, information concerning any fact materials thereto, may be guilty of a fraudulent act, which may be a crime and may subject such person to criminal and civil penalties. NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. NOTICE TO TENNESSEE, VIRGINIA AND WASHINGTON APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. NOTICE TO VERMONT APPLICANTS: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law. WARRANTY STATEMENT: This application does not bind the applicant to purchase, or the company to issue any insurance, but it is agreed that this application shall be, the basis of the contract should a policy be issued and it will be attached to and made part of the policy. The undersigned applicant declares that (s)he is authorized by the applicant to sign this application on behalf of all prospective insureds and that, to the best of his/her knowledge, the statements herein are true and accurate. The applicant agrees that if the information supplied in this application and the materials submitted therewith should change between the date this application is signed and the effective date of the proposed insurance, the signatory shall immediately notify the insurer of such and shall provide the insurer with information that would complete, update or correct the application and materials submitted therewith. The insurer may withdraw or modify any of the terms or conditions of coverage accordingly. Signature: 9 Date: Printed Name: Title: Danny E Stone Chair Storage Tank Application (1121) Page 4 of 4 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COVERED STORAGE TANK AND LOCATION ENDORSEMENT This Endorsement shall not serve to increase our limits of 'insurance, as described in SECTION V - LIMITS OF INSURANCE. In consideration of the payment of premiums, it is hereby agreed that the following are added to the policy as "scheduled storage tank system(s)". Covered Storage Tank Systems Tank# Insured Site Type Install Date Capacity Contents Deductible Metro Date UST/AST (Gallons) 1 Location #1 UST 1999 10,000 Gasoline $10,000 7/712006 124 Enterprise St. SE Ephrata, WA 98823 2 Location #1 UST 1999 10,000 Diesel $10,000 7/7/2006 124 Enterprise St. SE Ephrata, WA 98823 la Location #2 AST 2012 2000 Gasoline $5,000 7/7/2016 3803 Neva Lake Road Ephrata, WA 98823 1b Location #2 AST 2012 2000 Waste Oil $5,000 717/2016 3803 Neva Lake Road Ephrata, WA 98823 2 Location #2 AST 2012 4jOOO Diesel $5,000 7/7/2016 3803 Neva Lake Road Ephrata, WA 98823 la Location #3 AST 1999 8000 Diesel $53000 7/7/2016 232 Chelan St. Hartline, WA 99135 1 b Location #3 AST 1999 4000 Gasoline $5,000 7/7/2016 232 Chelan St. - Hartline, WA 99135 la Location #4 AST 1999 4000 Diesel $51000 717/2016 24378 Broadway St. Mattawa, WA 99344 1 b Location #4 - AST 1999 2000 Gasoline $5,000 7/7/2016 24378 Broadway St. Mattawa, WA 99344 I Location #5 AST 2009 10,000 Gasoline $5,000 717/2016 12171 Wheeler Rd. Moses Lake, WA 98837 2 Location #5 .... A .. ST 2009 10,000 - Diesel $5,000 7/7/201 Co CFSTP 00 525 05 16 CopyrightO 2016 Crum & Forster Specialty Insurance Company Page I of 2 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. 12171 Wheeler Rd. Moses Lake, WA 98837 1 a Location #6 AST 2005 8000 Diesel $5,000 7/7/2016 4718 Rd P-IVY Quincy, WA 98848 1 b Location #6 AST 2005 4000 Gasoline $5,000 7/7/2016 4718 Rd P-NW Quincy, WA 98848 la Location #7 AST 2003 8000 Diesel $5,000 7/7/2016 13766 Road E SW Royal City, WA 99357 1 b Location #7 AST 2003 4000 Gasoline $5,000 7/7/2016 13766 Road E SW Royal City, WA ----993-57--- All other terms, conditions and exclusions under the policy are applicable to this Endorsement and remain unchanged. CFSTP 00 525 05 16 Copyright@ 2016 Crum & Forster Specialty Insurance Company Page 2 of 2 is a UPSS Precision Test Reporl Date 07/20/2021 Report # US129688 Site Grant County Public Works 124 Enterprise St SE Ephrata, WA 98823 USA ----------- ........... ... .. Test Date(s) 07/1612021 Reason for Test Aninual Compliance V Leighton 0' den Field Services PTY LTD Phone: +61 3 9804 2201 „a: +613 9804 2299 USA' +1888 275 3781 Email: infoMeloghtonobrien.col Jill ��ilillill: rMIMM Glossanj of Terms Test tochnology used:. Leighton 0" Brien we test (mass based), Leighton 0' Brien u1jage test (pressure or vactium), Quantitative We Une Test PM2 and Qualitative Dry Line Test. PM2 OIW446ii Avc F' ity, E'Phm% Municipal ffi Are PIP 04 Airport Go% gle 04 Map data 02.021 Ephrata Grant County Public Works US9688 Diagnostic Report to 16-07-2021 Pag