Form 9310-1 Application Package for Reimbursement to Local Governmen

APPLICATION PACKAGE
for
REIMBURSEMENT TO LOCAL GOVERNMENTS

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Line-By-Line Instructions for Completing Application

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Application Filing Instructions

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Application Checklist

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LGR Application Form (EPA Form 9310-1) (Duplicate as Needed)

LINE-BY-LINE INSTRUCTIONS
FOR EPA FORM 9310-1,
APPLICATION FOR REIMBURSEMENT TO LOCAL GOVERNMENTS
Please type or print all sections of the application. If you need more space, please attach
additional pages and clearly identify the corresponding line number.

1.

Local Government Identification

This section requests basic information about your local government.
Line 1a: Identify the name of your local government (e.g., town, city, county, Indian Tribe).
Line 1b: Indicate the name and daytime telephone number (including area code) of the contact person
for this request.
Line 1c: Indicate the official mailing address of your local government. (EPA will use this address
for all correspondence related to this reimbursement.)
Line 1d: Identify the date that the application for reimbursement is being filed. (Note: If you are
submitting an application more than one year after completing the response, you must attach an
explanation.)

2.

Release Description

This section requests basic information about the release incident.
Line 2a: Indicate the date and approximate time the release occurred or was discovered.
Line 2b: Identify the location where the release occurred. (If a street address is not applicable,
please reference major landmarks, surface or drinking water sources, cross streets, or prominent
geographic features, as appropriate.)
Line 2c: Briefly describe the source or cause of the release. (For example, overturned truck,
building or tire fire, abandoned waste, clandestine drug lab.)
Line 2d: Identify the hazardous substance(s) released and the estimated quantity. (Be sure to
indicate chemical names, when known, and units of measure.)
Line 2e: Briefly describe the specific threat(s) to human health and the environment represented by the
incident. (For example: health threat posed by leaking cylinders of hydrogen fluoride, a highly

Have questions about the program or the application process? Call the LGR HelpLine at 800-431-9209.

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corrosive and fatal hazardous substance when inhaled.)
Line 2f: Attach any additional materials (e.g., police or fire department reports, or sampling results)
pertinent to the release. (This information is not required; however, please attach if readily
available.)

3.

Response Description

This section requests basic information about your local government’s response to the release
incident.
Line 3a: Indicate the date and approximate time when the response was initiated.
Line 3b: If known, please indicate with a check mark whether EPA, the National Response Center,
or another agency was notified of the incident. Otherwise, leave this section blank.
Line 3c: If EPA was notified, indicate which Regional Office was contacted. Otherwise, leave this
section blank.
Line 3d: Indicate the date and approximate time when the agency identified in Line 3b was contacted.
Line 3e: Indicate the date of response completion. (An applicant may consider a response
complete when all field work has been completed and the local government has received all
reports and invoices.)
Line 3f: Indicate the jurisdiction (e.g., town, city, county, or Indian Tribe) in which the emergency
response occurred.
Line 3g: Indicate with a check mark whether your government is a participant in the Title III
Emergency Response Plan.
Line 3h: Identify ALL agencies involved with the response and their jurisdictions. (Include any
responders from neighboring communities.)
Line 3i: Briefly summarize all response actions related to the emergency response.
Line 3j: Briefly summarize the temporary emergency response measures that your local government
would like to have reimbursed.

4.

Cost Information

Have questions about the program or the application process? Call the LGR HelpLine at 800-431-9209.

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This section requests specific information about the costs incurred during the incident.
Line 4a: Indicate the total amount of local funds spent for the overall response. (Include all labor,
special services, overtime, supplies, and equipment costs incurred by all local responders.)
Line 4b: Indicate the total amount of funds that your local government is requesting EPA to reimburse.
Line 4c: On Table 1 of the application, provide a detailed breakdown of costs that your local
government is requesting EPA to reimburse. In the first column, describe the temporary emergency
measures. (These entries should mirror those identified on Line 3j.) In the second column, identify
the agency that incurred the cost. Use the cost element codes provided in
Attachment 1 to complete the third column. In the fourth column, indicate the total dollar amount
requested. Please note that supporting documentation (e.g., invoices, sales receipts, rental agreements)
must be attached to support each cost provided in Table 1.
Line 4d: On Table 2 of the application, provide a brief summary of your efforts to recover costs from
potentially responsible parties, your state, and your local government insurance. In the first column,
provide the name and title of the source contacted. In the second column, identify the date(s) those
sources were contacted. Provide a brief summary of the response in the third column. In column four,
indicate (Yes or No) if you have attached details related to the cost recovery.
Line 4e: Provide any additional financial data that will help EPA in determining your local
government’s financial burden resulting from the incident. (This information is not required;
however, please attach if readily available.)

5.

Certifications and Authorization

This section requires an authorized signature to certify the information provided on the
application.
Your local government’s highest ranking official (e.g., mayor, county executive) is required to sign the
application. By signing the form, this official certifies that: all costs are accurate and were incurred
specifically for this response; this reimbursement request does not supplant local funds normally
provided for response; cost recovery was pursued; and if funds received from EPA are later
recovered, the reimbursement will be returned to the Agency. (The highest ranking official of the
local government may delegate the authority to sign the application. If a delegate is used, you
must enclose a letter of delegation.)

Have questions about the program or the application process? Call the LGR HelpLine at 800-431-9209.

3

FILING INSTRUCTIONS
When should I submit my application?
A request for reimbursement must be received by EPA within one year of the date of completion of
the response. If you submit your application late, you must include an explanation for the delay.
Late applications will be considered on a case-by-case basis.
Where should I send my application?
Completed applications and supporting documentation should be sent to:
U.S. Environmental Protection Agency
Local Governments Reimbursement (LGR) Program
Attn: Lisa Boynton, Mail Code 5104-A
1200 Pennsylvania Avenue
Washington, D.C. 20460
What can I do if my application needs to be amended?
If you file your reimbursement application and later become aware of any changes you must make
to the incident or response description or costs incurred, you can send amended information to the
address listed above.
What records must I keep?
If you receive a reimbursement from the Superfund, you must keep all records of costs, response
activities, and release notifications shown on your application, as well as any worksheets used to
figure these costs and the original costs documentation, for a period of three years from the date the
reimbursement was made. After three years from the date of reimbursement, if EPA has not begun
a cost recovery action against a PRP, you may dispose of your records. You must notify EPA of
your intent to dispose of the records 60 days before you do so.
What should I do if my address changes?
If the address provided on Line 1b of the application form changes after you file, please notify the
EPA Reimbursement Officer as soon as possible of your address change. This will enable EPA to
reach you if additional information or clarification is needed to evaluate your application and will
ensure timely receipt of a reimbursement if your application is approved.
Who can I contact if I need more information or help in completing my application?
You can call the LGR Helpline at 800-431-9209.

Have questions about the program or the application process? Call the LGR HelpLine at 800-431-9209.

4

APPLICATION CHECKLIST
Before you send this application:
• Make sure that your application form is correct and complete.
• Include receipts, invoices, or other documents to support ALL costs being
requested for reimbursement.
• Attach all necessary supporting documentation or additional information you want
considered.
• Coordinate your application with all other responding agencies and local
governments involved in the incident. Remember, EPA will award only one
reimbursement request per incident.
• Provide an explanation if your request is being filed more than one year after the
response was completed.
• Make sure that the highest ranking local government official (or a delegate) signs
and dates the application.
• Attach documentation (e.g., a letter of delegation) if the highest ranking local
government official delegates the authority to sign the application.
• Make a copy of the completed application (including any attachments) for your
files.

Have questions about the program or the application process? Call the LGR HelpLine at 800-431-9209.

5

EPA Form 9310-1, Application for Reimbursement to Local Governments
Please type or print all information
United States Environmental Protection Agency
Washington, D.C. 20460

Form Approved
OMB No. 2050-0077

Application for Reimbursement
to Local Governments for
Emergency Response to Hazardous
Substance Releases Under CERCLA Sec. 123

Approval expires

1. Local Government Identification
a. Name of Local Government

b. Contact Name and Telephone Number

c. Official Address

d. Date of Application

2. Release Description
a. Date and Time of Occurrence or Discovery

b. Location

c. Source or Cause of Release

d. Hazardous Substances Released and Quantity (Petroleum, crude oil, or any unspecified fractions thereof are excluded)

e. Threats to Human Health and Environment

f. Attach any additional material pertinent to the release

3. Response Description
a. Date and Time of HazMat

b. Was anyone notified of the response?

☐ EPA

Response Initiation

c. EPA Region

☐ NRC

☐ Other

d. Date and Time Contact Made

f. Jurisdiction in Which Response Occurred

e. Date of Response Completion
(Local government has received
all data, reports, and charges for
response)

g. Is your local government a participant in the Title III
Emergency Response Plan?
(Check one)

h. Responding Agencies and Jurisdictions

EPA Form 9310-1

☐ Yes

☐ No

i. Summary of Response Actions

j. Temporary Measures for Which Reimbursement is Sought

4. Cost Information
a. Total Response Cost

b. Total Reimbursement Requested

$

$

c. Complete and attach Table 1, “Detailed Cost Breakdown”
d. Complete and attach Table 2, “Cost Recovery Summary”
e. Attach other pertinent financial information

5. Certification and Authorization (To be completed by highest ranking official of applying local government)
I hereby certify that:
1)
2)
3)
4)

All costs are accurate and were incurred specifically for the response for which reimbursement is being requested;
Reimbursement for costs incurred for response activities does not supplant local funds normally provided for response;
Cost recovery was pursued as presented in the attached Table 2; and
Reimbursement funds for which costs are later recovered will be returned to EPA.

I further certify that I am authorized to request this reimbursement and to receive funds from the Federal Government.
Printed or Typed Name of Highest Ranking Local
Government Official or Authorized Representative

Signature of Highest Ranking Local Government Official or
Authorized Representative

Title

Date

Burden Statement:
The public reporting and recordkeeping burden for this collection of information is estimated to average approximately 9 hours per application.
Burden means the total time, effort, or financial resources expended by persons to generate, maintain, retain, or disclose or provide information to
or for a Federal agency. This includes the time needed to review instructions; develop, acquire, install, and utilize technology and systems for the
purposes of collecting, validating, and verifying information, processing and maintaining information, and disclosing and providing information;
adjust the existing ways to comply with any previously applicable instructions and requirements; train personnel to be able to respond to a
collection of information; search data sources; complete and review the collection of information; and transmit or otherwise disclose the
information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. This collection is a mandatory collection under CERCLA Section 123 and 40 CFR Part 3 10. The OMB
control numbers for EPA’s regulations are listed in 40 CFR Part 9 and 48 CFR Chapter 15.
Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates, and any suggested methods for
minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S.
Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460; and to the Office of Information and
Regulatory Affairs, Office of Management and Budget, 725 17 th Street, NW, Washington, DC 20503, Attention: Desk Officer for EPA. Include
the EPA ICR number and OMB control number in any correspondence.

EPA Form 9310-1

* Form 9310-1 is not considered complete unless it is signed by the highest ranking official of
the local government requesting reimbursement or signed by the authorized representative
indicated in an enclosed letter delegating signature authority for this application process.

ATTACHMENT 1 TO FORM 9310-1 COST ELEMENT CODES AND COMMENTS
[Cost Element Codes for use in Table 1]
Code

Cost category

Cost element

Comments

PC ......

Personnel Compensation.

PC1: Overtime—for services in excess of the Compensation of overtime costs incurred
local agency’s standard work day or work
specifically for a response will be
week.
considered only if overtime is not
PC2: Experts and consultants—for services
otherwise provided for in the applicant’s
rendered on a per diem or fee basis or for
operating budget.
services of an intermittent, advisory nature.

TR ......

Transportation ..................

TR1: Passenger vehicle rental—for
transportation of persons during evacuation.
TR2: Nonpassenger vehicle rental—for transportation of equipment or supplies.

RC ......

Utilities ...............................

RC1: Utilities—for power, water, electricity Utility costs will be considered for private
and other services exclusive of transportation
utilities not owned or operated by the
and communications.
applicant or other unit of local
government.

OS ......

Other Contractual
Services.

OS1: Contracts for technical or scientific
analysis—for tasks requiring specialized
hazardous substance response expertise.
OS 2:D ec o nta min atio n
services —for
specialized cleaning or decontamination
procedures and supplies to restore clothing,
equipment or other serviceable gear to
normal functioning.

SM ......

Supplies and Materials.

SM1: Commodities—for protective gear and May include such items as chemical foam
clothing, cleanup tools and supplies and to
suppress a fire; food purchased
similar materials purchased specifically for,
specifically for an evacuation; air
and expended during, the response.
purifying canisters for breathing
apparatus; disposable, protective
suits and gloves; and sampling
supplies.

EQ ......

Equipment .........................

EQ1: Replacement—for durable equipment Equipment replacement costs will be
declared a total loss as a result of
considered if applicant can demonstrate
contamination during the response.
total loss and proper disposal of
EQ2: Rent—for use of equipment owned by
contaminated equipment.
others.
Equipment rental costs will be considered
for privately owned equipment not
owned or operated by the applicant or
other unit of local government.

Passenger and nonpassenger vehicle
rental costs will be considered for private
vehicles not owned or operated by
the applicant or other unit of local
government.

May include such items as specialized
laboratory analyses and sampling.

Table 1
Detailed Cost Breakdown
Temporary Emergency Measure

EPA Form 9310-1

Cost Incurred By

Cost Element
(See Attachment 1)

Amount

Attach supporting documentation (e.g., invoices, sales receipts, rental
agreements)

Table 2
Cost Recovery Summary
Note: This “Cost Recovery Summary” must accompany each request for reimbursement.
You Must Fill Out Each Section Of This Form.
Name and Title of
Source Contacted
Attempts to Recover Costs from
Potentially Responsible Parties
(including PRP insurance)

Attempts to Recover Costs from State
Funding Sources

Attempts to Recover Costs from Local
Government Insurance

EPA Form 9310-1

Date(s)
Contacted

Brief Summary of Response

Details
Attached